Early Insights from Prescription for Health

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Early Insights from Prescription for Health

• Kurt C. Stange, M.D., Ph.D.
• Chair, National Advisory Committee
• Prescription for Health
• Editor, Annals of Family Medicine
• Gertrude Donnelly Hess, MD Professor of Oncology
  Research
• Professor of Family Medicine, Epidemiology
  Biostatistics, Sociology and Oncology
• Case Western Reserve University
• Associate Director for Prevention Population
  Research
• Case Comprehensive Cancer Center

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Promoting Healthy Behaviors in Primary Care
Practice-Based Research Networks
Prescription for Health

• Robert Wood Johnson Foundation
• Agency for Healthcare Research and Quality

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5-year National Program
Prescription for Health

• To develop, evaluate disseminate practical
  strategies
• To promote healthy behaviors
• Physical activity
• Diet
• Tobacco cessation / avoidance
• Alcohol use

www.prescriptionforhealth.org
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Prescription for Health

• Round 1
• 17 PBRN Innovators
• Diverse approaches
• Round 2
• 10 PBRN Innovators
• Greater standardization
• Support
• National Program Office
• Independent Evaluation Unit
• PBRN Resource Center

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Evaluation Plan
From Cohen DJ, et al. Implementing Health
Behavior Change in Primary Care Lessons from
Prescription for Health. Ann Fam Med 3(Suppl 2)
S12-19, 2005.
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Practice-Based Research Networks

• "a group of ambulatory practices devoted
  principally to the primary care of patients,
  affiliated with each other (and often with an
  academic or professional organization) in order
  to investigate questions related to
  community-based practice. Typically, PBRNs draw
  on the experience and insight of practicing
  clinicians to identify and frame research
  questions whose answers can improve the practice
  of primary care. By linking these questions with
  rigorous research methods, the PBRN can produce
  research findings that are immediately relevant
  to the clinician and, in theory, more easily
  assimilated into everyday practice."
• http//ahrq.gov/research/pbrnfact.htm

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Practice-Based Research Networks

• Ask answer important questions
• Translate research into practice and practice
  into research
• gt111 active primary care PBRNs
• Nutting PA, editor. Contemporary Challenges for
  Practice-Based Research Networks. Ann Fam Med.
  20053(suppl 1)S1-S60.
• Nutting PA, Beasley JW, Werner JJ. Practice-based
  research networks answer primary care questions.
  JAMA. 1999281686-688.
• Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks
  for research in primary health care. BMJ.
  2001322588-590.
• Green LA, Dovey SM. Practice based primary care
  research networks. They work and are ready for
  full development and support. BMJ.
  2001322567-568.

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Pre Call for Proposals Conference

• PBRN
• Clinician
• Staff
• Leader / academic partner
• Community partner
• Potential of community-practice partnerships
• Potential is largely unmet
• Bridges needed between idealized models and
  practical realities

Stange KC, Gjeltema K, Woolf SH. One minute for
prevention the power of leveraging to fulfill
the promise of health behavior counseling. Am J
Prev Med. 200222320-323. Flocke SA, Crabtree
BF, Stange KC. Clinician-partner reflections on
promotion of healthy behaviors. 2005 (under
review).
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• Prescription for Health Changing Primary Care
  Practice to Foster Healthy Behaviors
• July/August 2005 Volume 3, Supplement
• www.AnnFamMed.org
• http//annfammed.org/content/vol3/suppl_2/index.sh
  tml

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Integration of Health Behavior Change Strategies
in Primary Care
From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Cross-cutting Lessons

• Health behavior change can be promoted in front
  lines primary care practice
• Increasing health behavior counseling requires
  substantive practice redesign
• System redesign may be needed for sustainable
  change
• Refinement of existing models based on front
  lines experience can guide implementation
• Supported co-evolution can create synergies

Cifuentes M, et al. Prescription for Health
Changing Primary Care Practice to Foster Health
Behaviors. Ann Fam Med 3(Suppl 2) S4-11, 2005.
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Implementation Lessons

• Health behavior change resources are
  enthusiastically received by practices
  patients Resources involving personal contact
  are preferred
• Practice extenders require training and support
  to avoid burnout
• Integrating behavior change tools into practice
  requires time, effort often special expertise
• Even simple interventions require operational
  change use of models often is helpful
• Sustainability should be considered at the outset

Cohen DJ, et al. Implementing health behavior
change in primary care Prescription for Health.
Ann Fam Med. 2005.3(Suppl 2) S12-S19.
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Strategies Implemented by Domain of the Chronic
Care Model

• Community resources
• Health care organization
• Self-management support
• Delivery system design
• Decision support
• Clinical information systems

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Community Resources

• Locally-based community health advisors
• Web-based directory of community resources
• Web links to information or resources outside the
  community

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Healthcare Organization

• Practice-wide assessments
• Evaluation of specific tools or techniques
• Negotiated support from insurers

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Self-Management Support

• Patient-centered goal setting and action plans
• Motivational interviewing
• Physical activity diet logs
• Community resource directories
• Local walking clubs
• Periodic follow-up
• Pedometers

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Delivery System Redesign

• Web-based pre-visit questionnaires
• Staff role changes education
• Health advisors, facilitators
• Brief interventions
• Periodic assessments
• Group visits
• Telephone email follow-up

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Decision Support

• Patient-reported health behavior info
• Relevant guidelines
• Readiness to change assessments
• Tailored scripts techniques
• Electronic (PDA, Web) support

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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Clinical Information Systems

• Patient registries
• Reminder systems
• Patient-completed screening tools
• Logs and behavioral questionnaires
• Expanding vital signs to include risky behaviors

From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
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5 As Model Application
1. Assess Identification of behaviors and health
conditions
From Woolf SH, et al. Putting It Together
Finding Success in Behavior Change Through
Integration of Services. Ann Fam Med 3(Suppl 2)
S20-27, 2005.
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1. Assess

• Identification of behaviors
• and health conditions
• In-office or pre-visit Web-based, touch-screen,
  or paper-based HRA surveys
• Staff screening
• Vital sign questions
• PDA screeners
• BMI
• Wall chart

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2. Advise

• Brief advice
• General advice
• PDA-guided advice
• Menu of options
• Brief motivational interviewing
• Behavior prescription
• Web-based counseling

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3. Agree

• Goal setting
• Action plans
• Weekly written goals
• PDA-guided goal setting
• Goals documented on prescription pads

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4. Assist

• Information
• Preprinted or computer-generated handouts,
  literature
• Educational bulletin board
• Mailed educational materials
• Website with community and behavior change
• Intensive Counseling
• Intensive individual counseling
• Group counseling
• Web-based counseling software
• Community services
• Self-management
• Self-management
• Self-help guidebook
• Feedback logs
• Quit kits
• Web-based problem-solving and feedback

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5. Arrange

• Reinforcement/Follow-up
• Health advisor personal follow-up
• Telephone follow-up
• E-mail follow-up
• Follow-up visits

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Community Linkages

• Complementary approaches
• Primary care practice
• Community agencies, groups, environment
• Integration has challenges
• Fragmentation
• Infrastructure
• Relationships
• Finances
• Knowledge

From Woolf SH, et al. Putting It Together
Finding Success in Behavior Change Through
Integration of Services. Ann Fam Med 3(Suppl 2)
S20-27, 2005.
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PBRNs as Laboratories

• IRB / HIPAA
• Conceptualization
• Short term study, vs.
• Sustained (quality improvement) change
• RE-AIM may be a useful framework
• Reach
• Efficacy/effectiveness
• Adoption
• Implementation
• Maintenance

Bodenheimer T, et al. Practice-based research in
primary care facilitator of, or barrier to,
practice improvement? Ann Fam Med. 20053(Suppl
2) S28-S32.
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P4H Round 2

• Chronic care model
• RE-AIM framework
• Pragmatic common measures
• Economic analyses
• Glasgow RE, McKay HG, Piette JD, Reynolds KD. The
  RE-AIM framework for evaluating interventions
  what can it tell us about approaches to chronic
  illness management? Patient Educ Couns.
  200144119-127.
• Glasgow RE, Orleans CT, Wagner EH, Curry SJ,
  Solberg LI. Does the chronic care model serve
  also as a template for improving prevention?
  Millbank Quarterly. 200179579-612.
• Glasgow RE, Ory MG, Klesges LM, Cifuentes M,
  Fernald DH, Green LA. Practical and relevant
  self-report measures of patient health behaviors
  for primary care research. Ann Fam Med.
  2005373-81.

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Promotion of Healthy Behaviors in Primary Care
Practice

• An important lever point
• Requires dedication innovation in the current
  (dysfunctional) health care system
• Great (unmet) potential of partnerships
• PBRNs are important laboratories
• Face challenges
• Ready to blossom with sufficient support

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Extra Slides

• Do not print for handout

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Round 1 Innovator PBRNs
From Cifuentes M, et al. Prescription for
Health Changing Primary Care Practice to Foster
Health Behaviors. Ann Fam Med 3(Suppl 2) S4-11,
2005.
34
4. Assist

• Information
• Preprinted or computer-generated handouts,
  literature (ACORN, APBRN, GRIN, MAFPRN, MNCCRN,
  NECF, PitNET, PPRG, PSARN, VaPSRN)
• Educational bulletin board (PSARN)
• Mailed educational materials (APBRN, KAN)
• Website with community and behavior change
  resources (ACORN, COOP, MAFPRN, RAP)

2. Advise
1. Assess

• Brief advice
• General advice (GRIN, MNCCRN, NECF, PPRG)
• PDA-guided advice
• (APBRN, NOPCRN, VaPSRN)
• Menu of options (CRN, HPRN)
• Brief motivational interviewing
• (MAFPRN, NECF, PitNET)
• Behavior prescription (GRIN, KAN, RAP)
• Web-based counseling message
• (ACORN)

• Identification of behaviors and health conditions
• In-office or pre-visit web-based, touch-screen or
  paper-based HRA surveys (ACORN, COOP, CRN, GRIN,
  HPRN, KAN, MAFPRN, MNCCRN, NOPCRN, PitNET)
• Staff screening (GRIN, MNCCRN, NECF)
• Vital sign questions
• (COOP, GRIN)
• PDA screeners (APBRN, CECH)
• BMI
• (APBRN, GRIN, MNCCRN, NOPCRN, PitNET, PSARN)
• Wall chart (GRIN, PPRG)

• Intensive Counseling
• Intensive individual counseling (CECH, COOP,
  MNCCRN, PSARN, PPRG??)
• Group counseling (COOP, MNCCRN, PitNET)
• Practice extender (APBRN)
• Telephone counseling (KAN, MAFPRN)
• Web-based counseling software (MAFPRN)
• Community services (COOP, GRIN, MAFPRN)

• Self management
• Self-management (COOP, MNCCRN, NOPCRN)
• Self-help guidebook (MAFPRN, PitNET, PSARN)
• Feedback logs (HPCRN, MNCCRN ,NOPCRN)
• Quit kits (GRIN)
• Web-based problem-solving and feedback (COOP,
  MAFPRN)

3. Agree

• Goal setting
• Action plans (APBRN, CECH, CRN, GRIN)
• Weeky written goals (MNCCRN)
• PDA-guided goal setting (APBRN, NOPCRN)
• Goals documented on prescription pads (HPRN)

5. Arrange

• Reinforcement/Follow-up
• Health advisor personal follow-up (APBRN, CECH,
  MAFPRN, MNCCRN, PSARN)
• Telephone follow-up (APBRN, CRN, COOP, GRIN,
  MAFPRN, MNCCRN, NOPCRN, PitNET, PSARN)
• Email follow-up (CECH, COOP, MAFPRN, PSARN)
• Follow-up visits (COOP, MAFPRN, MNCCRN, NECF,
  NOPCRN)

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PBRNs

• Affiliated practices devoted to patient care
• Often academic or other partners
• Engage frontlines wisdom to
• Develop or frame questions
• Gather data
• Interpret findings
• Implement findings
• More generalizable patient populations,
  theoretically, more transportable research
• http//ahrq.gov/research/pbrnfact.htm

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Primary Care PBRNs

• Laboratories for primary care research
• 111 networks in 44 states
• Translate research into practice
• Translate practice into research
• Nutting P, Beasley J, Werner J. Practice-based
  research networks answer primary care questions.
  JAMA. 1999281686-688.
• Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks
  for research in primary health care. BMJ.
  2001322588-590.
• Lanier D. Primary care practice-based research
  comes of age in the United States. Ann Fam Med.
  2005 3(suppl 1)S2-S4.

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Primary Care PBRNs

• Answer important questions
• Challenging current environment
• With support, ready for prime-time
• Answer to the call of the NIH Roadmap
• Contemporary Challenges for Practice-Based
  Research Networks. Ann Fam Med 2005 3 (suppl
  1). http//www.annfammed.org/content/vol3/suppl_1/
  index.shtml
• Nutting PA, Stange KC, eds. Prescription for
  Health Changing Primary Care Practice to Foster
  Healthy Behaviors. Ann Fam Med 2005 3 (suppl
  2). Full text free at http//annfammed.org/
  content/vol3/suppl_2/index.shtml
• Green LA, Dovey SM. Practice based primary care
  research networks. They work and are ready for
  full development and support. BMJ.2001322567-568
  .
• Nutting PA, Beasley J, Werner JJ. Practice-based
  research networks answer primary care questions.
  JAMA. 1999281686-688.

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Community Participatory Research

• Knowledge, resources, involvement of communities
  are key to success of research and its
  transportability sustainability
• 3 primary features
• Collaboration
• Mutual education
• Acting on results developed from research
  questions relevant to the community
• Macaulay AC, Commanda LE, Freeman WL, et al.
  Participatory research maximises community and
  lay involvement. BMJ. 1999319774-778.

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Chronic Care Model

• Community
• Health care system
• Resources, policies organization
• Self-management support
• Delivery system design
• Decision support
• Clinical information systems
• Interaction
• Informed, activated patient
• Prepared, proactive practice team
• Wagner EH. Chronic disease management What will
  it take to improve care for chronic illness
  Effective Clinical Practice. 199812-4.
• Glasgow RE, Orleans CT, Wagner EH, Curry SJ,
  Solberg LI. Does the chronic care model serve
  also as a template for improving prevention?
  Millbank Q. 200179579-612.

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Re-Aim

• Reach
• Efficacy/effectiveness
• Adoption
• Implementation
• Maintenance
• www.re-aim.org
• Glasgow RE, McKay HG, Piette JD, Reynolds KD. The
  RE-AIM framework for evaluating interventions
  what can it tell us about approaches to chronic
  illness management? Patient Educ Couns.
  200144119-127.
• Glasgow R, Magid D, Beck A, Ritzwoller D,
  Estabrooks P. Practical clinical trials for
  translating research to practice design and
  measurement recommendations. Med Care.
  200543551-557.

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Next Generation of Diffusion of Health Service
Innovations

• Theory-driven
• Process rather than package oriented
• Ecological
• Addressed with common definitions, measures,
  tools
• Collaborative coordinated
• Multidisciplinary multimethod
• Meticulously detailed
• Participatory
• Greenhalgh T, Robert G, Macfarlane F, Bate P,
  Kyriakidou O. Diffusion of innovations in service
  organizations systematic review and
  recommendations. Milbank Q. 200482(4)581-629.

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An Incremental Approach

• Work on or pay attention to multiple levels
• Pursue research, development shared learning
• Develop participatory relationships that
  transcend single projects
• Integrate qualitative quantitative methods
• Reconsider enabling the current dysfunctional
  system versus fostering its transformation