Progress in Prevention (1996)

We are now slightly past the halfway point in the national health promotion and prevention agenda, set out in Healthy People 2000, with its major goals of increasing healthy life span, reducing health disparities among Americans, and achieving access to preventive services for all.1 The evaluation of mid-decade progress has suggested the need for correction in the strategies used to achieve the targeted goals. The areas of poor progress at mid-decade suggest that the nation needs a better approach to the modification of behavioral factors that shape personal health outcomes.2 These factors may be modified by education and motivational strategies that require lengthy and frequent contact with healthcare providers. Cost becomes important to further progress: one of the Health People 2000 goals that has been moving in the wrong direction since 1990 is the significance of the financial barrier to clinical preventive services. Consistent delivery of recommended preventive and counseling services has not been successfully achieved in the doctor's office.3–5 Even services with established effectiveness are often not provided. Barriers include insufficient reimbursement for counseling, provider uncertainty about how to deliver recommended services, lack of patient or provider interest in preventive services, and lack of organizational support to facilitate delivery.6 Another barrier is the size of the job at hand: a recent analysis of the US Preventive Services Guidelines found that the average patient who presented for outpatient care had 15.4 risk factors that required 24.5 recommendations for preventive services.7 Solutions to inadequate preventive care most often focus on improved providers' practice behavior in the delivery of effective preventive services. However, physicians already work hard in office practice to deliver the most appropriate health services within the time and resources available. The delivery of preventive services is a “poor fit” in office culture, where the primary focus is on responding to patient complaints with proper diagnosis and treatment. To the extent that the task of prevention is invested in the hands of the medical care system, it is accomplished inconsistently.8 [See also p 0000] Title III, part F of the Older Americans Act provides funding, administered by Area Agencies on Aging, for disease prevention and health promotion services at multipurpose senior centers, congregate meal sites, and through home delivered meal programs. Priority is given to areas that are medically underserved and those with higher concentrations of economically vulnerable older individuals. Applicable services include most of the recognized effective preventive services. Health risk assessment, clinical screening services, counseling about nutrition, alcohol use, smoking cessation, and stress management, and physical fitness programs are authorized for support. Home injury control programs, mental health screening, medication management screening, counseling for social risks, and providing information concerning diagnosis, prevention, treatment, and rehabilitation of age-related diseases and chronic disabling conditions are also supported. See also p 1394 In this issue of the Journal, Reuben and colleagues describe an ingenious partnership for prevention between an academic medical group and the local Area Agency on Aging. This partnership provided a computerized health risk assessment, administered at a community-based meal site by a student recruiter. A “Prescription for Prevention” was generated, which included both the recommendations and educational materials specific to the problems identified. The recommendations were then delivered to the patient by a health educator and also provided to the patient's physician. Thus, a critical step in the delivery of effective health promotion and disease prevention to a vulnerable population was accomplished in a setting that allowed repeated access to inexpensive providers. These investigators and the Los Angeles Area Agency on Aging are to be congratulated for providing a superb example of how creativity and cooperation can promote progress in the efficient delivery of health promotion and preventive services to a vulnerable population, even in these lean times. Creative solutions such as this are critical if we are to improve significantly the healthy life of older Americans during the remaining years of the twentieth century.