Process Measures SESSION 3: COLLABORATIVE LEARNING PROJECT Today

Process Measures SESSION 3: COLLABORATIVE LEARNING PROJECT Today

Process Measures SESSION 3: COLLABORATIVE LEARNING PROJECT Today We Will Describe process measures relevant to healthy weight program (HWP) evaluations Identify valid, reliable, and generalizable tools and/or methods to collect process measures Prioritize process measures to identify core measures to recommend for inclusion across programs SESSION 3: COLLABORATIVE LEARNING PROJECT

Process Measures Documenting & Enhancing Engagement Nancy Sherwood, PhD University of Minnesota SESSION 3: COLLABORATIVE LEARNING PROJECT What Are Process Measures? Process measures are measures that examine how your program activities are delivered. Examples of process measures include: Measures of participation Readiness to change Mastery of skills SESSION 3: COLLABORATIVE LEARNING

PROJECT Core Process Measures Program Enrollment Are you engaging the target audience? Are enrollment goals being met? Program Attendance How many sessions are people attending? What percent of families who start the program, finish the program? Program Activities: In-Session & Between Session What percent of planned session activities are completed? What percent of homework is completed (e.g., food/activity logs)? SESSION 3: COLLABORATIVE LEARNING PROJECT Core Process Measures

Program Enrollment Are you engaging the target audience? YES Are enrollment goals being met? YES Program Attendance How many sessions are people attending? 100% What percent of families who start the program, finish the program? 100% Program Activities: In-Session & Between Session What percent of session activities are completed? 100% What percent of homework is completed? 100% SESSION 3: COLLABORATIVE LEARNING PROJECT Using Process Data to Enhance Engagement: Example Source: French SA, Sherwood NE, Veblen-Mortenson S, et al. Multicomponent Obesity Prevention Intervention in Low-Income Preschoolers: Primary and Subgroup Analyses of the NET-Works Randomized

Clinical Trial, 2012-2017. Am J Public Health. 2018 Dec;108(12):1695-1706. SESSION 3: COLLABORATIVE LEARNING PROJECT Pediatric Primary Care Child Physical Activity & Screen Time Annual Well Child Visit Family Connector Home Visits 12 per year & Check-Ins

Parent/ Primary Caregiver 4 per year Parenting Classes 12 per year Neighborhood Physical Activity & Nutrition Resources Home Environment & Parenting Practices Food, Physical

Activity, Media, Parenting Child BMI Child Dietary Intake 3 Year NET-Works Intervention Goal: Keep parents actively engaged in all components of the intervention for a three year period. Two key process measures documented in study database Dose delivered, or amount and length of intervention sessions offered Dose received, or participant attendance and completion of the offered sessions Define At Risk families 30 days, 45 days, 60 days, 90+ days without participating in an intervention activity Implement re-engagement protocols SESSION 3: COLLABORATIVE

LEARNING PROJECT Engaged Contacts HV: CC: PEC: P: Disengaged 15 2 2 21 Engaged Contacts HV:

CC: PEC: P: Disengaged 24 14 8 15 Engaged Contacts HV: CC: PEC: P: Disengaged 0

2 4 6 8 10 12 14 16 18 20 22

24 26 28 30 32 34 36 Months of Intervention Contact Type Home Visit Connector Check-In Parenting Education classes

Packet 38 27 11 12 6 40 Summary Develop tracking systems and use process evaluation data to optimize engagement and participation Flexibility and responsiveness to the unique needs of families can enhance engagement Tracking systems & re-engagement strategies need to be tailored to specific contexts SESSION 3:

COLLABORATIVE LEARNING PROJECT A Path to Sustainability Creating and Demonstrating Value Chris Bolling, MD American Academy of Pediatrics SESSION 3: COLLABORATIVE LEARNING PROJECT What Do Stakeholders Want? SESSION 3: COLLABORATIVE LEARNING PROJECT

What Do Stakeholders Want? Before you figure what they want, there are some things to know: 1. 2. 3. 4. 5. Figure out who they are Ask what they want Know that there are different ways to ask Be aware that the answers will surprise You will need different messages for different stakeholders, BUT SESSION 3: COLLABORATIVE LEARNING PROJECT What Do Stakeholders Want?

Be true to your mission keeping your big picture in sight SESSION 3: COLLABORATIVE LEARNING PROJECT What Do Stakeholders Want? Return on Investment Financial Workforce productivity Healthy community Improved quality of life Something you didnt even think of!

SESSION 3: COLLABORATIVE LEARNING PROJECT What Do Stakeholders Want? And you thought BMI was hard to change SESSION 3: COLLABORATIVE LEARNING PROJECT What Do Stakeholders Want? Outcomes can look very different to them Do not underestimate the power of the subjective, especially early in the process Reasonable deliverables Patient satisfaction A timeline for when things will happen The overarching goal clearly stated Ongoing follow-up with stakeholders

SESSION 3: COLLABORATIVE LEARNING PROJECT What Does YOUR Community Want? SESSION 3: COLLABORATIVE LEARNING PROJECT What Does YOUR Community Want? As with stakeholders, ask first What they tell you, may surprise as well Who are the key players? Who are the ones who really get it and are prepared for the long haul? SESSION 3: COLLABORATIVE LEARNING

PROJECT What Does YOUR Community Want? Things to consider with your community Time expectations Again, keeping the big picture in view Being clear about roles Keeping commitments Being prepared to be the driver SESSION 3: COLLABORATIVE LEARNING PROJECT Making the Cost-Benefit Case Difficult to make on a purely monetary

basis Health care systems present special challenges The depressing lesson of tertiary obesity care centers SESSION 3: COLLABORATIVE LEARNING PROJECT Making the CostBenefit Case You have to think globally The value added is system and community wide SESSION 3: COLLABORATIVE LEARNING PROJECT

Making the Cost-Benefit Case The goal may be as revenue neutral as possible Think as infrastructure Value to other entities Speaks to community health where it is recognized as a public health crisis Breakdown occurs at patient level Weight bias at work (sorry to editorialize!) SESSION 3: COLLABORATIVE LEARNING PROJECT Making the Cost-Benefit Case

The importance of being a trusted expert Picking your battles Finding your sugar daddy Using your voice Prioritizing your efforts SESSION 3: COLLABORATIVE LEARNING PROJECT Process Measures Measuring Provider Communication Style and Skill Ken Resnicow, PhD University of Michigan SESSION 3: COLLABORATIVE LEARNING PROJECT

MEAUSURES OF PROVIDER SKILLS AND COMMUNICATION STYLE Objective Behavior Counts Subjective Rating Expert Rating of Provider Skill/Behavior MITI Count MISC Count ROTER (RIAS) MITI Global ONE-PASS MI COACH BECCI Patient Rating of Provider Skills/Behavior

Example: Did your Health Care Climate provider ask you about Questionnaire your weight during your (HCCQ) last visit? SESSION 3: COLLABORATIVE LEARNING PROJECT MEAUSURES OF PROVIDER SKILLS AND COMMUNICATION STYLE Expert Rating of Provider Measure Features Skill/Behavior Motivational Interviewing (MI) Motivational Interviewing

Treatment Integrity (MITI) (Codes provider) Motivational Interviewing Skills Code (MISC) (Codes provider/patient) Both counts of individual utterances and global subjective ratings Requires audio/video and transcript Requires highly trained coders Cost ~ $100 per session/encounter Widely used/gold standard Allows sequential analysis One Pass

MI Coach Behaviour Change Counseling Index (BECCI) Global subjective ratings Requires audio/video and transcript Requires less training/calibration Adaptable to different protocols Lower cost Less-widely used Medical Objective Structured Clinical Examination (OSCE)

Expert rating Live or taped encounter Extensive training Roter Interaction Analysis System (RIAS) Requires audio or videotape Both counts of utterances and global subjectives 68 weeks of practice Coding of a recording in about twice real time

Widely used/good psychometrics Universal skills CBT skills Universal ComOn Cogitative Behavioral Therapy (CBT) RAND Motivational Interviewing Treatment

Integrity Coding Manual 4.2.1 Moyers TB, Manuel JK, & Ernst D. Motivational Interviewing Treatment Integrity Coding Manual 4.1. Unpublished manual, 2014. SESSION 3: COLLABORATIVE LEARNING PROJECT MI Specific Universal Description of MITI Codes MITI Code Brief Description Globals Cultivating Change Talk (CC)

Encourages the clients own language in favor of the change goal and confidence for making that change. Softening Sustain Talk (SS) Avoids a focus on the reasons against changing or on maintaining the status quo. Partnership (P) Conveys an understanding that expertise and wisdom about change reside mostly within the client. Empathy (E) Understands or makes an effort to grasp the clients perspective and experience. Behavior Counts Giving Information (GI) Gives information, educates, provides feedback, or expresses a professional opinion without persuading, advising, or warning. Questions (Q) Questions (open or closed).

Simple Reflection (SR) Reflects a clients statement with little or no added meaning or emphasis. Complex Reflection (CR) Reflects a clients statement with added meaning or emphasis. Affirm (AF) States something positive about the clients strengths, efforts, intentions, or worth. Emphasize Autonomy (EA) Highlights a clients sense of control, freedom of choice, personal autonomy, ability, and obligation about change. Confront (C) Directly and unambiguously disagreeing, arguing, correcting, shaming, blaming, criticizing, labeling, warning, moralizing, ridiculing, or questioning a clients honesty.

Seek Collaboration (Seek) Attempts to share power or acknowledge the expertise of a client. Persuade with Permission (PwP) Emphasis on collaboration or autonomy support while using direct influence. Persuasion (Per) Overt attempts to change a clients opinions, attitudes, or behaviors using tools such as logic, compelling arguments, selfdisclosure, facts, biased information, advice, suggestions, tips, opinions, or solutions to problems. Summary Measures Total MI Non Adherent (MINA) MI-Non-adherent Behaviors= (Total Per) + (Total CO) Total MI Adherent (MIA) MI-Adherent Behaviors= (Total EA) + (Total Seek) + (Total AF) Reflection to Question Ratio

(R:Q) Reflections to Questions Ratio= (Total Reflections)/(Total Questions) Relational Relational= [(Partnership) + (Empathy)]/2 Technical Relational= [(Cultivating) + (Softening)]/2 %CR Percent Complex Reflections= CR/(SR + CR) Manual for Motivational Interviewing Skill Code (MISC) Version 2.1 Miller WR, Moyers TB, Ernst D, & Amrhein P. Manual for Motivational Interviewing Skill Code Version 2.1. University of New Mexico, 2008.

SESSION 3: COLLABORATIVE LEARNING PROJECT MISC: Coding Client Speech One Pass McMaster F & Resnicow K. Validation of the one pass measure for motivational interviewing competence. Patient Educ Couns. 2015 Apr;98(4):499-505. SESSION 3: COLLABORATIVE LEARNING PROJECT Behaviour Change Counseling Index (BECCI) Lane C, et al. Behaviour Change Counselling Index (BECCI). University of Wales College of Medicine, 2002.

SESSION 3: COLLABORATIVE LEARNING PROJECT SESSION 3: COLLABORATIVE LEARNING PROJECT MI Coach Rating Scale Naar, S. & Safren, S. (2017). Motivational Interviewing and Cognitive-Behavioral Interventions. Guilford Press, New York, NY. SESSION 3: COLLABORATIVE LEARNING PROJECT

MI Coach Rating Scale SESSION 3: COLLABORATIVE LEARNING PROJECT MI Coach Rating Scale: Scoring Rubric SESSION 3: COLLABORATIVE LEARNING PROJECT The Roter Interaction Analysis System (RIAS): Universal SESSION 3: COLLABORATIVE LEARNING PROJECT

RIAS: Universal Forty exclusive behavior categories: Socioemotional communication Positive, negative, emotional, partnership building, and social exchanges Task-focused communication Asking questions, giving instruction and direction, and giving information Grouped into four primary functions of the medical visit Data gathering Patient education and counseling Responding to patient emotions (rapport) Partnership building SESSION 3:

COLLABORATIVE LEARNING PROJECT RIAS Scoring Domains Cluster Categories Relationship building Personal remarks, social conversation, remediations, partnership statements, selfdisclosure statement Positive talk Laughing, telling jokes showing approval-direct, giving compliments-general, showing agreement or understanding, back-channel responses Negative talk Showing disapproval-direct, criticizing-general

Emotional expression Emphasizing statements, legitimizing statements, showing concern or worry, reassurance, encouragement or showing optimism, asking for reassurance Facilitative behaviors Giving orientation, instructing, paraphrasing/checking for understanding, asking for understanding, requiring repetition, asking for opinions, asking for permission, transition words, requesting services or medication Counseling/direction Counseling or direction about any topic Medical data gathering Open or closed questions regarding medical conditions or therapeutic regimen Psychosocial data gathering Open or closed questions regarding psychosocial or lifestyle issues

Dental data gathering Open or closed questions regarding current dental history a or past dental history a Data gathering about other issues Open or closed questions about other issues Medical information giving Information giving about medical conditions or therapeutic regimen Psychosocial information giving Information giving about psychosocial or lifestyle issues Dental information giving Information giving about current dental history a or past dental history a Information giving about other

issues Information giving about other issues a New category Source: https://doi.org/10.1371/journal.pone.0203970.t002 ComOn Check Radziej K, Loechner J, Engerer C, et al. 2017. How to assess communication skills? Development of the rating scale ComOn Check. Med Educ Online. 22:1. SESSION 3: COLLABORATIVE LEARNING PROJECT ComOn Check Scale Items

F Subjective Global Rating How do you assess the communication skills of the physician in this conversation? A1 Initiating a Conversation Does the physician initiate the conversation appropriately? A2 Patients Perception Does the physician manage to get an idea of the patients perception at the beginning of, or during consultation? B Structure of Conversation B1 Does the physician actively give structure to the conversation (set an agenda of central topics)? B2 Does the physician set sub-sections during the course of the conversation (in detail)?

C Patients Emotions C1 Does the physician recognize the patients emotions and do they name them; evaluation based on NURSE by Back (2008)? C2 Does the physician offer emotional support; evaluation based on NURSE by Back (2008)? D End of Conversation Does the physician summarize the content of the consultation and do they close the conversation appropriately? E Communication Skills E1 Does the physician use clear and appropriate words during the conversation? E2 Does the physician use appropriate non-verbal communication during the consultation? E3 Does the physician adjust their pace during the consultation and do they make appropriate pauses? E4 Does the physician offer the patient the chance to ask questions during the consultation?

E5 Does the physician check whether the patient has understood the consultation? Cognitive Behavioral Therapy Hepner KA, Howard S, Paddock SM, Hunter SB, Chan Osilla K, Watkins KE. A Fidelity Coding Guide for a Group Cognitive Behavioral Therapy for Depression. Santa Monica, CA: RAND Corporation, 2011. Sponsored by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse SESSION 3: COLLABORATIVE LEARNING PROJECT Measure of CBT Treatment Fidelity SESSION 3: COLLABORATIVE LEARNING PROJECT

CBT Fidelity Checklist Source: Johnson C, L. Handen B, Butter E, et al. Development of a parent training program for children with pervasive developmental disorders. Vol 222007. SESSION 3: COLLABORATIVE LEARNING PROJECT Objective Counts Subjective Rating Expert Rating of Provider Skills/Behavior

MITI Count MISC Count MITI Global ONE-PASS MI COACH Patient Rating of Provider Skills/Behavior Example: Did your Health Care Climate provider ask you about Questionnaire your weight in your last visit ? SESSION 3: COLLABORATIVE LEARNING PROJECT

Health Care Climate Questionnaire Patient self-report 6-18 items Little to no cost Subjective ratings Widely used Adaptable to different clinicians and health issues Strong validity and reliability The Health Care Climate Questionnaire

I feel that my physician has provided me choices and options. My physician conveys confidence in my ability to make changes. I feel that my physician accepts me. My physician has made sure I really understand about my condition and what I need to do. My physician encourages me to ask questions. My physician listens to how I would like to do things. My physician tries to understand how I see things before suggesting a new way to do things. 1. 2. 3. 4. 5. Williams, G. C., Freedman, Z. R., & Deci, E. L. (1998). Supporting autonomy to motivate glucose control in patients with diabetes. Diabetes Care, 21, 1644-1651. Williams, G. C., Grow, V. M., Freedman, Z. R., Ryan, R. M., & Deci, E. L. (1996). Motivational predictors of weight loss and weight-loss maintenance. Journal of Personality and Social Psychology, 70, 115-126. Williams, G. C., Gagn, M, Ryan, R, M., & Deci, E. L. (2002). Supporting autonomy to motivate smoking cessation: A test of selfdetermination theory. Health Psychology 21, 40-50.

Shumway D, Griffith KA, Jagsi R, Gabram SG, Williams GC, Resnicow K. Psychometric properties of a brief measure of autonomy support in breast cancer patients. BMC medical informatics and decision making. 2015;15:51. Martinez KA, Resnicow K, Williams GC, et al. Does physician communication style impact patient report of SESSION 3: decision quality for breast cancer treatment? Patient Educ Couns. 2016;99(12):1947-1954. COLLABORATIVE LEARNING PROJECT Psychometric Properties of a Brief Measure of Autonomy Support in Breast Cancer Patients I feel that my (insert breast cancer treatment doctors, surgeon, medical oncologist, or radiation oncologist) 1. provided me with choices and options for my breast cancer treatment. 2. understood how I saw things with respect to my breast cancer. 3. expressed confidence in my ability to make decisions. 4. listened to how I would like to handle my breast cancer treatment. 5. encouraged me to ask questions. 6. tried to understand how I saw things before offering an opinion.

Source: Shumway D, Griffith KA, Jagsi R, Gabram SG, Williams GC, Resnicow K. 2015. Psychometric properties of a brief measure of autonomy support in breast cancer patients. BMC Medical Informatics and Decision Making, 15:51. SESSION 3: COLLABORATIVE LEARNING PROJECT Patient Report of Physician Counseling for Pediatric Obesity: Adapted HCCQ How much do you agree or disagree with the following statements? My doctor asked my opinion about things. My doctor gave me choices about what to do. My doctor understands what I am saying. My doctor listened to me. My doctor rushed me through the interview. (REVERSE CODED) My doctor asked too many questions. (REVERSE CODED) My doctor asked permission before giving me information or advice. My doctor was supportive/ encouraging. My doctor and I discussed the values that are important to me. My doctor left it up to me to decide whether or not to make changes in

food or television viewing. My doctor helped me to think about why changing our food habits might be important to my family. My doctor helped me to think about why changing our television habits might be important to my family. My doctor helped me feel like we could make changes in our food or television habits, if I wanted to. I felt pressured by my doctor to make changes. (REVERSE CODED) Not at all A little Somewhat A lot Cant say

Patient Report of Physician Counseling for Pediatric Obesity: Brief Form How much do you agree or disagree with the following statements? My doctor asked my opinion about things. My doctor gave me choices about what to do. My doctor understands what I am saying. My doctor listened to me. My doctor was supportive/ encouraging. *This brief scale has an alpha of .82 Not at all A little Somewhat A lot Cant

say Patient Report of Registered Dietitian Counseling for Pediatric Obesity: Adapted HCCQ How much do you agree or disagree with the following statements? My dietitian asked my opinion about things. My dietitian gave me choices about what to do. My dietitian understands what I am saying. My dietitian listened to me. My dietitian rushed me through the interview. My dietitian asked too many questions. My dietitian asked permission before giving me information or advice. The dietitian was supportive/ encouraging. The dietitian and I discussed the values that are important to me. The dietitian left it up to me to decide whether or not to make changes in food or television viewing. The dietitian helped me to think about why changing our food habits might be important to my family. The dietitian helped me to think about why changing our television habits might be important to my family. The dietitian helped me feel like we could make changes in our food or television habits, if I wanted to. I felt pressured by the dietitian to make changes.

Not at all A little Somewhat A lot Cant say Patient Report of Registered Dietitian Counseling for Pediatric Obesity: Brief Form Adapted HCCQ How much do you agree or disagree with the following statements? My dietitian asked my opinion about things. My dietitian gave me choices about what to do. My dietitian understands what I am saying.

My dietitian listened to me. My dietitian asked permission before giving me information or advice. he dietitian was supportive/ encouraging. he dietitian and I discussed the values that are important to me. This short form has an Alpha of .93 Not at all A little Somewhat A lot Cant say

Patient Report of Physician and Register Dietitian Counseling BMI2 Study: Scale Information Items Mean (0-3) Alpha MD COMMUNICATION (Year 1) 14 2.7 .74 RD COMMUNICATION (Year 1) 14

2.5 .89 MD COMMUNICATION (Year 2) 14 2.7 .79 RD COMMUNICATION (Year 2) 14 2.5 .91 SCALE

SESSION 3: COLLABORATIVE LEARNING PROJECT Objective Structured Clinical Examination (OSCE) SESSION 3: COLLABORATIVE LEARNING PROJECT General OSCE Skills

Initiative of interview Questioning skills Information-sharing skills Professional manner and rapport Listening skills Organization of interview closing Ethical conduct Compliance optimization SESSION 3: COLLABORATIVE LEARNING PROJECT OSCE Examiners Checklist Initiative of interview: acknowledgement of patient, introduces self, at ease, attentive to patient. Questioning skills: e.g., use of open-ended questions, transitional statements, confident and skillful

questioning, appropriate language, use of different types questions, or awkward, exclusive use of closed ended or leading questions, jargon, interrupts patient inappropriately. Information-sharing skills: e.g., none given, avoidance of jargon, responsiveness to patient questions or concerns, provision of counseling when appropriate, confident and skillful at giving information, attentive to patient understanding; truthful. Professional manner and rapport: e.g., condescending, offensive, aggressive, judgmental, negative attitude to patient, or polite and interested, warm, polite, empathic, concern for patients comfort and modesty, examinee's attention to personal hygiene, expression of interest in the impact of the illness. Listening skills: interrupts patient inappropriately, impatient, attentive to patients answers and concerns.

Organization of interview: scattered, shot-gun approach, logical flow, purposeful, integrated handling of encounter. Closing: abrupt, or acknowledges end of interview, or attempts closure, or clear closure, or organized, thoughtful closure. Ethical conduct: markedly inappropriate or awkward handling of ethical issues, or considers and responds to ethical issues with care and effectiveness. Compliance optimization: did the candidate do everything possible to optimize patients compliance? the SESSION 3: COLLABORATIVE LEARNING

PROJECT Discussion Questions 1. What process measures does your program evaluate and why? What process measures do you believe should be prioritized for HWP evaluation? 2. What tools and/or methods do you use to evaluate your programs process measures outlined in Q1? 3. How does your program use process evaluation data to enhance engagement and outcomes? COLLABORATIVE LEARNING PROJECT

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