# Presentation: 278834

## 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

## Promoting Healthy Behaviors in Primary Care Practice-Based Research Networks

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

**Prescription for Health**

## 5-year National Program

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

**Prescription for Health**

- www.prescriptionforhealth.org

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

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

**Prescription for Health**

## 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.

## 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

## Practice-Based Research Networks

- Ask & answer important questions
- Translate research into practice and practice into research
- >111 active primary care PBRNs
- Nutting PA, editor. Contemporary Challenges for Practice-Based Research Networks. *Ann Fam Med*. 2005;3(suppl 1):S1-S60.
- Nutting PA, Beasley JW, Werner JJ. Practice-based research networks answer primary care questions. *JAMA*. 1999;281:686-688.
- Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks for research in primary health care. *BMJ*. 2001;322:588-590.
- Green LA, Dovey SM. Practice based primary care research networks.  They work and are ready for full development and support. *BMJ*. 2001;322:567-568.

## Slide 8

| The Ecology of Medical Care |
| --- |

## 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. *2002;22:320-323.
- Flocke SA, Crabtree BF, Stange KC.  Clinician-partner reflections on promotion of healthy behaviors. 2005 (under review).

## 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.shtml

**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.shtml

## 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.

## 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.

## 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.

## 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.

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

## 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.

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

## 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.

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

## 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.

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

## 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.

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

## 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.

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

## 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.

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

## 5 A’s Model Application

- 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.

**1. Assess**
- Identification of behaviors
-  and health conditions

## 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

## 2. Advise

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

## 3. Agree

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

## 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

## 5. Arrange

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

## 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.

## 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. 2005;*3(Suppl 2): S28-S32.

## 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. *2001;44:119-127.
- 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. *2001;79:579-612.
- 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. *2005;3:73-81.

## 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

## Extra Slides

- Do not print for handout

## 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.

## 1. Assess

**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)*

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

_**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)*

_**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)*

_**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)*

_**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)*

*1. Assess*

*2. Advise*

*3. Agree*

*4. Assist*

*5. Arrange*

## 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

## 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*. 1999;281:686-688.
- Thomas P, Griffiths F, Kai J, O'Dwyer A. Networks for research in primary health care. *BMJ*. 2001;322:588-590.
- Lanier D. Primary care practice-based research comes of age in the United States.  Ann Fam Med.  2005; 3(suppl 1):S2-S4.

## 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.*2001;322:567-568.
- Nutting PA, Beasley J, Werner JJ. Practice-based research networks answer primary care questions. *JAMA. *1999;281:686-688.

## 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. *1999;319:774-778.

## 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*.  1998;1:2-4.
- 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. *2001;79:579-612.

## 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. *2001;44:119-127.
- Glasgow R, Magid D, Beck A, Ritzwoller D, Estabrooks P. Practical clinical trials for translating research to practice: design and measurement recommendations. *Med Care. *2005;43:551-557.

## 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. *2004;82(4):581-629.

## 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