About the Prescription for Health Program
Background
Physical inactivity, unhealthy diet, tobacco use and risky use of alcohol
are leading causes of disease, disability and premature death, and impose a
significant yet preventable burden on our healthcare system. The U.S. Preventive Services Task Force
concluded that "the most effective interventions available to clinicians for
reducing the incidence and severity of the leading causes of disease and
disability in the U.S. are those that address patients' personal health
practices."
In 2002, people in the United States made more than 480-million visits to
the offices of family physicians, general internists and general pediatricians
(Cherry
et al, 2003). At least 100 million people identify these primary care
clinicians as their usual source of care (Medical
Expenditure Panel Survey, 2001), value their advice, and are motivated to
act on that advice (Integration
of Health Behavior Counseling in Routine Medical Care Report, 2001). Many
proven approaches to health behavior counseling require several minutes of
clinician time in any single visit. These approaches often make strategic use
of full office practice teams that do not involve face-to-face
patient-clinician intervention, such as telephone counseling, Web sites,
follow-up through e-mail, expanded roles for office staff, or referral to community-based
clinics or services. Despite serious time constraints, many primary care
clinicians spend two or three minutes on health promotion and/or health
education during office visits (Stange et
al, 2002). However, few clinicians are able to go beyond a basic approach
of counseling patients to more complicated and effective brief behavior-change
counseling. Practical strategies are needed to tailor more complex and
multilevel interventions to the realities of primary care practice.
A body of evidence suggests that the following models and frameworks are
helpful in understanding the extent to which different interventions are
effective in improving patients? health behaviors and quality of life:
Prescription for Health projects
considered the domains and relationships in the 5As, CCM and RE-AIM when
designing, implementing, and evaluating interventions aimed at changing patient
and practice behavior.
The 5As is an evidence-based model that was
developed to describe a sequence of steps used in smoking cessation counseling
and has since been adopted to guide behavior change counseling for multiple
risk behaviors.
- Assess – Identify risk behavior(s)
- Advice – Give brief advice that includes a
personal message of encouragement to change
- Agree – Set goals based on the patient's readiness to change
- Assist – Use behavioral change techniques to
promote acquisition of skills, confidence and support for change/ Supplemented
by medical treatments when appropriate
- Arrange – Provide follow up and continued
support/ Referral to more intensive counseling when appropriate
The CCM provides a functional framework and set of organizational principles
for basic changes to support care that is evidence-based, population-based and
patient-centered. The model defines six broad dimensions that must be
considered when redesigning systems of care:
- Organization of Care
- Clinical Information Systems
- Delivery-System Design
- Decision Support
- Self-Management Support
- Community Resources
The model does not provide a specific set of interventions; rather, it acts
as a framework within which improvement strategies can be tailored to local
conditions. Prescription for Health
experience suggests that the same systems described in the CCM can be used to
support improvement efforts in health behavior counseling and chronic illness
care, possibly leading to practice efficiencies that will help achieve both
prevention and chronic care goals.
The REAIM framework offers a comprehensive way to evaluate health behavior
interventions. It can be used to estimate the intervention?s potential impact
on five elements:
- Reach the target population
- Efficacy or effectiveness
- Adoption by target settings or institution
- Implementation—consistency of delivery of intervention
- Maintenance of intervention effects in individuals and populations over time
|
