Interview with the WI-INTUIT Project Team

Project Overview: The Wisconsin Improving Nonsurgical Treatment of Urinary Incontinence among Women in Primary Care (WI-INTUIT) team from the University of Wisconsin Madison is comparing streamlined practice facilitation (SPF) and SPF in combination with partnership building. WI-INTUIT is working across a wide variety of primary care practices across the state. For more information on WI-INTUIT, read their project’s executive summary (PDF, 203 KB).

Heidi Brown, MD, MAS, FACOG, Clinician Scientist, Kaiser Permanente Southern California and PI for the WI-INTUIT project responded to interview questions on behalf of her team. 

At a 30,000-foot view, what is most notable about your team’s approach to urinary incontinence (UI) screening and treatment implementation within primary care? What strategies were central to your project?

The most notable aspect of our team’s approach is that we enrolled primary care practices throughout our state, not just at our affiliated institutions. We supported implementation of UI screening and treatment in independent practices, federally qualified health centers, and tribal health clinics, as well as in practices affiliated with academic and non-academic health systems. We used streamlined practice facilitation (i.e., substituting email or phone calls in lieu of in-person and virtual meetings) when that better aligned with local context and practice workflows. We also employed partnership building to support practices in building local networks to help with urinary incontinence treatment.

What successes are you celebrating to date? 

We are thrilled that all enrolled practices have now implemented their UI screening and treatment workflows! We have not completed all data collection, but so far, rates of screening and treatment for UI have improved from pre- to post- implementation in almost all practices. 

Primary care providers are consistently challenged by the large number of topics that need to be addressed during short patient visits. How did you address this challenge in the primary care practices you worked with?

We suggested streamlined approaches for practices based on what they told us they already did well to minimize the additional time burden, but there is no way to overcome the fact that we are adding yet another task to their already overflowing to-do lists. We provided resource lists and tools to minimize the amount of additional time it took clinicians to address positive screens. Many providers set up workflows to address urinary incontinence outside of the visit during which screening was performed, and many engaged others in their practice (like advanced practice providers or nurses) to do some of the patient education. 

How did you address primary care provider education on UI? Were there any surprises or key takeaways from the training your team did with primary care providers?

We created streamlined educational materials, including a treatment algorithm and dot phrases that could be modified for notes and patient education, and we used videos to communicate information. We found that short and sweet videos were most effective, and so we found ourselves making shorter and shorter versions of materials to respond to time constraints. 

Screening and treatment for UI are often not prioritized because they do not have payment or accountability performance measures linked to them. How did you incentivize practices to include this important clinical issue in their workflows?

Because the practices we worked with volunteered to participate in our project, rather than being “voluntold,” we were fortunate to have their buy-in from the beginning. Many practices served predominantly female or older patient panels, for whom UI is an important issue. We made sure to offer maintenance of certification credit for busy clinicians who partnered with us on this quality improvement initiative, but their motivation to participate was really focused on helping their patients. 

What has been your biggest lesson learned to-date?

The landscape of primary care continues to evolve. Seven of our participating practices closed during implementation; some were acquired by other health systems and others were closed permanently. We realized how difficult it was for the clinicians, staff, patients, and communities within and surrounding those practices, and had to adjust our expectations for our research accordingly. We are very grateful to have been able to work with these practices and communities.

What advice would you have for primary care practices that may consider adopting interventions to screen and treat UI?

Many of our practices opted to model their UI screening and treatment practices after their existing practices for depression screening. Like UI, depression is a stigmatized condition for which we rely on patient questionnaires rather than clinical or laboratory tests. Most of our primary care practices already had awesome workflows for depression screening, so piggybacking UI screening onto those workflows made sense and was minimally disruptive.