Case Studies of Exemplary Primary Care Practice Facilitation Training Programs

Strong training is key to developing effective practice facilitators or coaches to support improvements in primary care practices. This case study profiles Coach University, a training program offered by HealthTeamWorks, a nonprofit organization located in Lakewood, Colorado. Coach University has trained almost 100 coaches since it began in 2010 and is considered one of the leading medical-practice coach training programs in the country.

The program offers several lessons for others interested in developing and delivering training for practice facilitators, such as:

• Effective practice facilitator training relies not only on knowledge of practice transformation topics and techniques but also on skills related to relationship building, complex adaptive change (adapting to multiple changes occurring at the same time), and culture change.
• A practice facilitator training program requires full-time leadership and committed faculty, all of whom have real-world experience working with practices.
• Keeping a practice facilitator training curriculum current and reflective of policy shifts and industry changes is crucial.
• Practice facilitator training that includes both direct instruction and experiential learning methods has significant benefits.
• Using a variety of practice facilitators as faculty is important in order to expose the trainees to different perspectives and teaching styles.
• Delivering practice facilitator training at the right level for trainees of varying backgrounds often requires on-the-fly faculty adjustments to the content and delivery of the curriculum.
• Trainees have a wealth of knowledge and experience that provides opportunities for peer-to-peer learning.
• Offering ongoing support and networking opportunities to new coaches after training benefits their long-term development.
• Helping coaches work effectively within their specific contexts is an important part of helping trainees succeed.

I. Background and history of Coach University

Coach University is a coach training program created and run by HealthTeamWorks. Various organizations, including health plans, health care delivery systems, and practices send staff to the program to be trained as coaches. Staff trained through Coach University then return to their sponsoring organizations prepared to function as a practice facilitator or coach, with ongoing support from the HealthTeamWorks network of experienced coaches.

Since 2006, HealthTeamWorks has offered coaching services. Initially, the organization worked with the national boards and societies of primary care providers through a program called Improving Performance in Practice (IPIP), under the leadership of the American Board of Medical Specialties. Through grants from the Robert Wood Johnson Foundation, the Colorado Department of Public Health and Environment, and others, primary care practices in Colorado were able to work with trained facilitators from HealthTeamWorks who provided onsite help with quality improvement strategies. As HealthTeamWorks scaled up this program to offer coaching services to practices outside Colorado, the organization began to consider how to support sustained practice transformation after HealthTeamWorks staff left a particular practice. As a result, HealthTeamWorks developed a collaborative coaching model in which organizations send their own staff members to be trained as coaches in addition to receiving direct coaching from HealthTeamWorks coaches. As local coaches gained more experience and confidence under the guidance of HealthTeamWorks coaching, they would take on more responsibility until, eventually, they became the primary practice coach with less direct guidance needed.

In 2010, HealthTeamWorks developed Coach University to bring together groups of trainees for a weeklong educational program (referred to as boot camp) that focused on the knowledge and skills needed to be a successful practice facilitator. The development of Coach University allowed HealthTeamWorks to work with several trainees at once, which made it possible for trainees to benefit from the knowledge and experiences of the entire group. After boot camp, each trainee has access to 1 year of individualized support from HealthTeamWorks coaches, staff, and resources. This support is tailored to each trainee and can include mentoring by a HealthTeamWorks coach, participating in Webinars, and having access to the learning network of HealthTeamWorks coaches and other former students.

II. High-level design of Coach University

The mission of Coach University is to achieve sustainable practice transformation by teaching key people within health care organizations to facilitate continuous quality improvement. This educational process includes two main components:

1. Teaching the technical information necessary to facilitate transformation, including the principles of the patient-centered medical home (PCMH).
2. Developing the change management and relationship-building skills needed to successfully facilitate transformation to a culture of continuous quality improvement.

HealthTeamWorks leaders describe these two components as “the information side” and “the human side,” respectively, and consider Coach University to be successful if those who complete it not only are well informed about practice transformation and can convey information to others but also are skilled at working with people at every level of a practice. They note that knowledge alone won’t bring about practice transformation; rather, “transformation happens with people.”

Coach University trainees are trained in two stages. First, trainees attend a weeklong boot camp at HealthTeamWorks headquarters in Colorado. This stage includes classroom learning as well as visits to practices engaged in quality improvement initiatives. After boot camp concludes, trainees receive a year of followup support from HealthTeamWorks coaches while they are beginning the process of facilitating practice transformation within their organizations. This support can range from Webinars on new subjects in the field (such as updated clinical practice guidelines or details on new health information technologies [IT]) to more individualized support tailored to the needs of the trainee.

III. Training program description

A. Program content

HealthTeamWorks leaders consider the joint principles of the PCMH, along with other quality improvement methods, to be foundational subjects taught during Coach University. Within this broad subject area, key topics include care coordination, care management, population management, and use of evidenced-based guidelines. Other areas of focus vary by client needs. For instance, HealthTeamWorks incorporated information on behavioral health integration when it began working with trainees from a large behavioral health plan. In addition to deepening their knowledge in these foundational subjects, Coach University participants also undergo training in technical and interpersonal skills necessary for their work, such as effective meeting facilitation, problem solving, extracting data from health IT systems, using these data for quality improvement, conducting practice assessments, and engaging in process improvement.

Consistent with the idea that transformation happens with people, Coach University emphasizes the development of interpersonal and relationship-building skills. These skills include the ability to communicate and work with a wide range of people—everyone from the CEO of a hospital system to a front-desk staffer in a practice—to help engage the entire organization in the transformation process. Trainees must learn how to help both leadership and staff understand what practice transformation is, convey why and how a practice should transform, and provide them with the tools needed to undergo the transformation process and sustain the changes made. Interactive classroom exercises, as well as visits to practices engaged in quality improvement efforts, help trainees learn strategies to build multiple levels of relationships, including relationships with the wider organization or system (for example, a large hospital system), the practices within that organization or system, and individuals on the quality improvement team.

HealthTeamWorks primarily measures trainees’ learning through pre-training and post-training assessments of key competency areas at the start and end of boot camp. In addition, HealthTeamWorks staff members observe trainees in the field during their 1 year of followup support and make recommendations for professional development during this time.

B. Program delivery

Coach University begins with a 1-week boot camp, offered three to four times a year, in which 6 to15 trainees (ideally, 8 to 12) gather for intensive, in-person training. HealthTeamWorks leaders value the professional and life experiences each trainee brings to the training and aim to gather trainees from a range of backgrounds with a variety of skill sets so that trainees actively learn from each other within the classroom. To facilitate learning, HealthTeamWorks leaders encourage storytelling and interactive learning among the participants. Group size is a key ingredient in facilitating peer-to-peer learning. Large groups make it challenging for staff to engage in interactive classroom exercises while giving each trainee the individual attention he or she needs, and very small groups limit shared experiences. All Coach University faculty members are experienced coaches and bring a variety of perspectives to the classroom. HealthTeamWorks leaders note that the opportunity to interact with professional coaches with differing styles and perspectives allows trainees to see that there are many good approaches to coaching and that no one approach is the ideal.

Coach University’s boot camp includes classroom instruction along with visits to practices to illustrate real-world applications of lessons. Within the classroom, faculty members use a mix of direct instruction and experiential approaches designed for participants to apply newly acquired knowledge and build coaching skills. For example, role playing is used to help trainees apply new knowledge and develop relationship-building skills. Trainees simulate a quality improvement meeting with Coach University faculty, playing the roles of quality improvement team members to practice using meeting facilitation skills, such as bringing a disengaged person into the conversation and managing an individual who dominates a conversation. The boot camp also includes opportunities to shadow a HealthTeamWorks coach as he or she works within a practice. During these visits to practices, trainees are given a tour of the facility and observe and assess various quality improvement processes being used within the practice. While on site, trainees either observe a quality improvement team meeting facilitated by the HealthTeamWorks coach or have the opportunity to talk with various members of the practice staff (such as physicians, practice managers, nurses, and front-line staff) to hear their perspectives on practice transformation work.

After boot camp concludes, all Coach University trainees continue to receive some level of support throughout the year through the collaborative coaching model. HealthTeamWorks notes that the level of followup varies by trainee, with some speaking with HealthTeamWorks staff once a month and others wanting more intensive support. This support can include mentoring by a HealthTeamWorks coach as well as access to the broader HealthTeamWorks learning network of coaches and trainees. Through this learning network, trainees can pose questions by email or phone to the HealthTeamWorks coaching staff, who then reach out to others to locate answers if needed. In some cases, HealthTeamWorks coaches might put trainees in contact with other coaches who have experience working in similar practices and facing similar challenges. In this way, HealthTeamWorks coaches help trainees build their professional support networks. Recent trainees often tap into the learning network for specific needs—for example, advice before they go into a difficult meeting or more extensive information on a topic or skill covered during boot camp. Another form of ongoing support of recent trainees is HealthTeamWorks’ Webinars on specific skills or knowledge.

IV. Trainees

Trainees typically come to Coach University because their employer has a contract with HealthTeamWorks to provide assistance with practice transformation activities.¹ These organizations select the staff members that attend Coach University.

Trainees arrive at boot camp with a diversity of backgrounds and varied levels of experience with practice transformation concepts and facilitation skills. About one-quarter of trainees are nurses; another quarter have masters-level training; and the remainder have a mix of bachelor degrees, medical degrees, or doctorates. Approximately three-quarters of trainees are currently employed as coaches; others are part of a management or leadership team. Some trainees have coached practices for several years, though many are new to practice facilitation and the field of quality improvement and are unfamiliar with the elements of the PCMH and related concepts. While many participants have past experience in health care in some capacity, and some have worked for their employers for many years, many trainees are taking on coaching as a new role or as an additional responsibility.

V. Faculty

All Coach University faculty members are coaches themselves, working directly with practices as employees of HealthTeamWorks. Some are managers or regional directors within HealthTeamWorks but continue to work with practices to keep their practice facilitation skills and knowledge current. While all HealthTeamWorks coaches have significant field experience, they have a wide variety of clinical and nonclinical backgrounds, including business administration, nursing, mental health, and group practice management.

HealthTeamWorks leaders believe this diversity of skills and knowledge among the coaching faculty—or “depth on the bench,” as one coach called it—is a crucial element of Coach University’s success. This diversity benefits trainees, who are able to tap into the network during and after training as questions or challenges arise in the course of practice transformation work. Thus, while one coach may work in a specific practice, that person has 12 to 15 other coaches at HealthTeamWorks with wide-ranging backgrounds to assist with challenges that may arise.

HealthTeamWorks coaches all share a common set of knowledge and skills. Specifically, coaches must do the following:

√  Be strong presenters and storytellers to convey information to practice staff and facilitate change.

√  Be well versed in adult learning theory to effectively communicate with and train others in ways appropriate for adults.

√  Have excellent conflict resolution and interpersonal skills to facilitate getting others to recognize areas for improvement and make change.

√  Understand practice transformation tools and techniques to use them and teach to practice staff with whom they work.

√  Be efficient managers to coordinate work with several practices simultaneously (the typical panel size for a HealthTeamWorks coach is 10 to 25 practices).

Although Coach University faculty are experienced in practice facilitation when they become HealthTeamWorks employees, Coach University uses what one program leader described as “a robust orientation” to ensure new faculty have the knowledge base necessary to perform well. Many of the topic areas covered in this orientation mirror those covered in the training provided to trainees. In addition, new coaches have the opportunity to shadow more experienced HealthTeamWorks coaches before teaching a Coach University session for the first time.

Coach University faculty benefit from several types of ongoing training and support provided by HealthTeamWorks, including funds provided for coaches to attend continuing education classes. HealthTeamWorks also runs a monthly staff training meeting to discuss current and emerging topics in practice transformation and to share challenges and best practices. In addition, ad hoc training sessions address specific topics of interest to coaches using Webinars or in-person events that range from 1 hour to a full day in length.

HealthTeamWorks monitors coach effectiveness through a periodic review of performance. A yearly survey asks coaches to rank themselves on knowledge of different topics and requests feedback on what topics they feel they need to learn more about. Coaches also undertake a 360-degree annual review, during which they discuss feedback on their performance from supervisors, peers, and clients (those practices for which they have served as coaches).

VI. Program administration

Many HealthTeamWorks staff members work on Coach University in addition to other organizational activities. Given the broad involvement in Coach University among HealthTeamWorks employees, we will first describe the organizational structure of HealthTeamWorks and then detail the program administration of Coach University.

HealthTeamWorks organizational structure. HealthTeamWorks staff members are loosely divided by their roles as either administrators or those more directly involved in the delivery of program services, such as boot camp or coaching. However, these distinctions are not absolute; for example, HealthTeamWorks’ chief executive officer teaches a boot camp session in addition to her leadership responsibilities. The administrative staff of HealthTeamWorks includes:

• A chief executive officer
• A chief financial officer and two staff members involved in finance
• A sales and marketing team consisting of a vice president, a regional sales representative, and a marketing and Web specialist
• A data and guidelines department, which develops and updates evidence-based guidelines
• A human resources representative
• A health IT representative
• Four support specialists who help with the administrative tasks associated with practice support
• Two administrative assistants who support the executive team

The HealthTeamWorks program staff is led by three regional directors who oversee activities for a particular region of the United States: Colorado/Mountain, East and Southern Central time zone, and Pacific and Northern Central time zone. Under each regional director, there are three program managers, who manage projects with clients and supervise and assist three to five coaches each. There are also three project managers, who manage projects and supervise coaches in addition to being responsible for a particular HealthTeamWorks project area, such as education and training. Employees in all of these roles wear many hats, and all serve as coaches for Coach University.

Coach University administration. HealthTeamWorks’ manager of education and training oversees Coach University and is responsible for:

• Boot camp planning and logistics, with the help of administrative assistants.
• Curriculum development, with direction from a work group of HealthTeamWorks coaches, program managers, and regional directors.
• Program assessment and evaluation, with input from HealthTeamWorks coaches and leadership. This includes “after-action meetings” with all HealthTeamWorks staff involved with a particular Coach University course. The staff discusses how the course went, reviews participant feedback, and considers whether and how to make improvements for future courses.

Every coach, program manager, and regional director employed by HealthTeamWorks is expected to be able to present topics at Coach University, and all staff members currently in these roles have done so. HealthTeamWorks has a core team of coaches who typically serve as Coach University faculty, but any coach, program manager, or regional director can serve as faculty if needed.

Tuition. Tuition for Coach University varies according to the level of engagement and contract parameters the trainee’s organization has with HealthTeamWorks for practice transformation activities. If a contracted organization wishes to send more than one employee to Coach University, HealthTeamWorks adjusts unit costs downward to account for economies of scale.

VII. Evaluation and internal quality improvement of the training program

As a quality-focused organization, HealthTeamWorks pays close attention to its own monitoring and evaluation processes and uses feedback from Coach University coaches and trainees to inform development of new topic and skill areas to be added to the program curriculum. Prior to each session of Coach University, HealthTeamWorks sends trainees a survey of the topic areas the program aims to cover and asks them to rank their understanding of a range of topics related to practice facilitation. For example, a participant might be asked to rank her understanding of “the importance of primary care as part of the health care system” on a scale of no understanding, basic understanding, intermediate understanding, or advanced understanding. HealthTeamWorks incorporates survey results into the upcoming boot camp session by adapting discussions, examples, and classroom exercises to the participants’ levels of knowledge.

Over time, the Coach University curriculum has evolved to reflect trainees’ growing familiarity with basic PCMH tenets and to account for changes in the health care system and in health care policy. While there continue to be many trainees who are unfamiliar with the PCMH upon entering Coach University—which was common when the program first started in 2010—trainees now often come with basic knowledge of these concepts and seek a more in-depth understanding. In addition, recent trainees and their employers have expressed interest in pursuing more specialized topic areas such as behavioral health integration in primary care, cost reduction strategies, provider and staff satisfaction, and patient engagement or activation—all topics Coach University has incorporated or is considering how to incorporate in its training. Currently, Coach University is also focusing on helping trainees understand the ways in which the landscape of payment models is shifting. HealthTeamWorks leaders are also interested in developing an addition to the Coach University curriculum that addresses the need to move patient-centered health care beyond the medical home and into the entire health care system.

VIII. Outcomes and placements

Since August 2010, when HealthTeamWorks launched Coach University in its current form, more than 100 trainees have completed the boot camp. Almost all of these trainees have also completed the yearlong follow-up period. After completing the program, trainees return to their organizations and work to develop and implement practice transformation goals. HealthTeamWorks estimates that approximately half of its trainees work as coaches in large health systems, with smaller numbers employed in Federally Qualified Health Centers, Accountable Care Organizations, various grant-funded practice facilitation programs within Colorado, medical societies, educational institutions, or in medical residency programs. HealthTeamWorks leaders noted that most trainees take on coaching activities in addition to their other responsibilities, and HealthTeamWorks coaches often help trainees and their employers determine how to integrate these new activities with existing duties.

IX. Next steps

With very few exceptions, training at Coach University currently is offered only to staff from organizations that contract with HealthTeamWorks for other services. Moving forward, HealthTeamWorks plans to increase its capacity to train anyone willing or interested in receiving practice facilitator training. In addition, HealthTeamWorks is considering ways to provide education on PCMH principles to clinical or office staff who do not aim to become practice facilitators but would benefit from developing a familiarity with this information as their organization or system moves towards transformation.

Coach University is also planning to expand its curriculum to include information on securing buy-in at all levels of a health care system. HealthTeamWorks staff note that while many practices are interested in transformation work, they often have trouble convincing system-level leadership that the process is worth the investment. Alternately, the leadership of a large health system may want to engage in transformation work but has trouble convincing individuals within practices of the value of that work. Addressing the both sides of this issue is expected to be important future work for HealthTeamWorks.

X. Lessons learned

HealthTeamWorks leaders identified a number of key lessons learned in the process of developing and implementing Coach University:

• Effective practice facilitator training relies not only on knowledge of practice transformation topics and techniques, but also on skills related to relationship building, complex adaptive change (adapting to multiple changes occurring at the same time), and culture change. Knowledge of PCMH components, quality improvement techniques, and related core competencies is crucial to practice facilitation. Skills such as meeting facilitation, encouraging buy-in to an idea or process, and motivating people to achieve practice transformation goals are just as important. In addition, learning how to help practices adapt to multiple, simultaneous, complex changes, which can be overwhelming, is an important component of practice facilitator training.
• A practice facilitator training program requires full-time leadership and committed faculty, all of whom have real-world experience working with practices. This on-the-ground experience, when shared by faculty within the classroom setting, helps trainees absorb the content and process it in a way that makes it easier to apply later on.
• Keeping a practice facilitator training curriculum current and reflective of policy shifts and industry changes is crucial. HealthTeamWorks continuously gathers suggestions from trainees and clients, and the HealthTeamWorks sales and marketing team gathers input about new client needs.
• Practice facilitator training that includes both direct instruction and experiential learning methods has significant benefits. HealthTeamWorks leaders note that Coach University trainees appreciate the ability to engage in activities and exercises that help them apply their knowledge and develop the relationship-building and change management skills necessary to do their work well.
• Using a variety of practice facilitators as faculty is important in order to expose the trainees to different perspectives and teaching styles. There is no single, ideal type of faculty member. Trainees benefit from interactions with faculty who have different types of skills, knowledge, experience, and teaching styles.
• Delivering practice facilitator training at the right level for trainees of varying backgrounds often requires on-the-fly faculty adjustments to the content and delivery of the curriculum. A single group of trainees might include one person who has never heard of the PCMH and another who has several years of coaching experience. Coach University faculty assess each group of trainees to determine their level of knowledge and skill, and adjust lessons in real time to provide information at the right level.
• Trainees have a wealth of knowledge and experience that provides opportunities for peer-to-peer learning. HealthTeamWorks leaders note that when trainees have a variety of skills and experience levels, they benefit from teaching one another. Moreover, trainees often teach the faculty some new lessons, too.
• Offering ongoing support and networking opportunities to new coaches after training benefits their longer-term development. Since only a limited amount of material can be covered during boot camp, many Coach University trainees find they need additional support and information on specific topics. They may also require advice from a more seasoned coach when faced with difficult situations. For these new coaches, the ability to draw on a source of ongoing support can be instrumental to their success.
• Helping coaches work effectively within their specific contexts is an important part of helping trainees succeed. In some cases, practices or organizations may send a staff member to be trained in practice facilitation but do not alter the staff member’s existing job description or set aside time or resources for him or her to take on additional responsibilities. In such cases, HealthTeamWorks has helped coaches develop job descriptions and has worked with their employers to help them understand what new skills and benefits the coach can bring to the organization.

This case study was developed as part of a contract funded by the Agency for Healthcare Research and Quality and was authored by:

Tricia Collins Higgins, Ph.D., M.P.H., Researcher, Mathematica Policy Research
Lisa Schottenfeld, M.P.H., M.S.W., Analyst, Mathematica Policy Research
Jesse Crosson, Ph.D., Senior Researcher, Mathematica Policy Research
Erin Taylor, Ph.D., M.P.P., Associate Director of Health Research and Senior Researcher, Mathematica Policy Research
Deborah Peikes, Ph.D., M.P.A., Senior Fellow, Mathematica Policy Research

¹ HealthTeamWorks clients include organizations such as accountable care organizations, medical societies, residency programs, hospital groups that have purchased ambulatory care facilities, health care systems, and individual practices.