Healthcare -- putting prevention into practice

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This slidedeck is submitted by Zafar Hasan because one of the trends in medicine for the last 20 years isa focus on prevention and this deck is an outstanding practice primer.

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  • This presentation is created for a 60 minute class period. A longer form, consisting of twice as many slides, is also available through AHRQ.Definition of USPSTFHelp faculty to integrate prevention education Considerations:Healthcare providers, students and physicians can be overwhelmed with informationWhen providing care one must have a well defined objective(s)End result is a tool with recognizable utility to patient and practiceRecommend how to implement the processExercise to demonstrate simplicityPlan:Audience to download ePSS prior to presentationSuccinct presentation (30 minutes)Demonstrate utilityPractical exercise Request feedbackAfter presentationAfter use during rotationsAudience:3d year medical studentsPractitioners concernsCMEReimbursementSimple process (nurse during screening prints form from ePSS)Concise presentations to capture specific topics with exercises to point out utilityPart of the bigger wellness program
  • The following resource was created by the American Association of the Colleges of Osteopathic Medicine’s Task Force on Integrating Preventive Medicine into Medical and Health Professions CurriculaFunding for this resource was supported by the Agency for Healthcare Research and Quality (AHRQ) through a Knowledge Transfer contract with the Health Research and Educational Trust (HRET). HRET is a charitable and educational organization affiliated with the American Hospital Association.
  • This is the list of topics for today’s presentation. I will begin with prevention and screening principles and end with a discussion of federal initiatives and practical exercises that demonstrate the usefulness of a new tools for prevention.Helpful acronyms:USPSTF – U.S. Preventive Services Task Force AHRQ – Agency for Healthcare Research and QualityePSS – Electronic Preventive Services Selector
  • The goal of prevention is wellness for both individuals and a population. Public health is directed toward a population and providing information and interventions, to include screening for disease, to improve the health of the community or population as a whole. Specific recent federal legislation that will assist clinicians in providing prevention to individuals will be discussed later in this presentation.
  • The USPSTF guidelines are evidence based guidelines put into practice. Experts are brought together by AHRQ to review the literature and come up with determinations for practice that are evidence based.
  • http://www.uspreventiveservicestaskforce.org/uspstf/grades.htmThe USPSTF provides plain language text to explain their letter grades.Both A and B are recommended services. Services that are not recommended are graded D and I indicates insufficient evidence to provide a recommendation. C is of particular interest because it identifies a service that is not generally recommended but may apply to an individual patient, thus, requiring the healthcare provider to make a clinical decision concerning the benefit for the individual.
  • These are a few recommendations to initiate a wellness program. Engaging other healthcare professionals is beneficial and in wellness programs will improve the quality of counseling. Different providers or counselors will have different approaches which may be helpful for the patient to grasp the significance of maintaining an activity or making a lifestyle change. Pointing out that the body is capable of self-healing and making a change in a risky behavior may permit the body to recover could be an important factor in an individual’s decision to modify a behavior. The time required to address preventive services and reimbursement for these services have often been sited as obstacles for the busy clinician to adequately provide these services. However, both of these obstacles have been addressed through the ePSS and recent legislation.
  • PPP xxvBecause behavioral choice is critical to most of these risk factors, clinician counseling that leads to improved personal health practices may be more valuable to patients than conventional clinical activities such as diagnostic testing. The bullets on this slide are general guidelines to consider when providing clinical counseling.Frame teaching to patient’s perceptionsCounseling should be culturally appropriate. Present information and services in a style and format that are sensitive to the culture, values, and traditions of the patient and at a level of comprehension consistent with the age and learning skills of he patient. Use a dialect and terminology consistent with the patient’s language and communication style.Purpose, effects and when to expect effectsDescribe the purpose of the intervention, what effects are expected and when the effects may be anticipated.Suggest small changesAlthough desirable, dramatic changes should not be expected. Instead, changes such as weight loss occur slowly over time and require dedication and perseverance.Be specificThe physician should address explicit requirements for successful outcomes and to develop realistic patient expectations. Add new behaviors rather than change old ones It may be more acceptable to add a new behavior (fruits and vegetables to a diet) and not insist on eliminating red meat, eggs and other foods that contribute to cholesterol and therefore CHD and stroke.Link the new and old behaviors During the process of counseling it will be appropriate to link the new behavior with the old to demonstrate the beneficial effects of the changes in lifestyle with the changes.
  • New England Journal of Medicine, Promoting Prevention through the Affordable Care Act, 10.1056/NEJM1008560Reimbursement for services has been an impediment to consistently providing preventive/wellness services in a busy clinic environment. Recent legislation has removed this issue. Free Preventive Care Under Medicare—Eliminates co‐payments for preventive services and exempts preventive services from deductibles under the Medicare program.  Effective beginning January 1, 2011.Free Preventive Care Under New Private Plans—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles.  Effective 6 months after enactment [9/23/10].
  • Different people access information differently. There are electronic sources and booklets available as well as in-depth resources to provide background information. The recommendations are also put into lay terms in the form of handouts and brochures. Checklists are also available to monitor progress to assist both the clinician and the individual patient to measure progress.
  • Screen shot of the ePSS software for PDA, EMR or EHR.Emphasize the access points for the device you haveHave audience find same materials from other slide (About ePSS at http://epss.ahrq.gov/ePSS/index.jsp The ePSSis a quick, hands-on tool designed to help primary care clinicians identify and offer the screening, counseling, and preventive medicine services that are appropriate for their patients. The ePSS is based on the current, evidence-based recommendations of the USPSTF and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors. Available both as a Web-based selector and as a downloadable PDA application, the ePSS brings the prevention information clinicians need – recommendations, clinical considerations, and selected practice tools – to the point of care.
  • Patients are typically screened by a member of the health care team in initial portion of an encounterA nurse typically takes vital signs and measures the patient’s height and weight prior to seeing the provider.This provides an opportunity to complete a brief preventive medicine/wellness questionnairePrint for inclusion in the health record or electronic review by the healthcare providerReviewed by the healthcare providerConcurs or changes recommendationsBrief discussion with the patient for those answers or findings that require treatment or need to be addressed with a comment that a member of the clinic staff will address some concerns in more detail.
  • Designated member of the health care team reviews in greater detailFurther counseling is provided by a member of the clinic staffPrinted instructions should be provided to the patient for further reference and explanation of the healthcare team recommendations.The VA Model is a working example similar to what was just described.A member of the healthcare team completes an in-depth screening using the VA electronic medical records system. The patient answers are documented for the healthcare provider’s review. The healthcare provider reviews the patient responses and addresses the health risks with the patient, recommending lifestyle modification and/or treatment.When appropriate the patient returns to the nurse for further discussion and counseling. Referral is made as indicated to a specialist.
  • Have audience chose the case from the ePSS screen shots or from the written slides. A number of cases are included for the speaker to choose from.Have students enter the information for 3 of these ‘patients’ and view the results. You may also want to tgo to the tools tab to see the patient instructions, questionnaires and other information. It may be useful and students may be more likely to access the data while in a clinic after using it in this setting. It would be beneficial to access the program online and demonstrate on the first 1 or 2 ‘cases’ and website in general then have them input 2 or 3 ‘patients”. Have them complete an evaluation for the presentation and tell them that you will contact them in a couple of months to see if they have used it and their for preceptors impressions of ePSS.
  • This case represents different levels of prevention
  • Healthcare -- putting prevention into practice

    1. 1. Putting Prevention into Practice (Short Form) Using the United StatesPreventive Services TaskForce Recommendations
    2. 2. Acknowledgements Robert M. Gum, DO, MPH, FACPM, Statewide Campus Regional Assistant Dean, WVSOM James F. Cawley, MPH, PA-C, Professor and Vice Chair, Department of Prevention and Community Health School of Public Health and Health Services The George Washington University V. James Guillory, DO, MPH, FACPM, Professor of Public Health, Public Health Program, KUMC John C. Pellosie, Jr., D.O., MPH, FAOCOPM, Chair of Preventive Medicine, NSUCOM H.S. Teitelbaum, DO, PhD, MPH, Professor and Chair, Department of Preventive and Community Medicine, LMU-DCOM
    3. 3. Thoughts on Prevention "To find health should be the object of any doctor. Anyone can find disease.“ – ---Andrew Taylor Still, D.O. “Prevention is one of the few known ways to reduce demand for health and aged care services. “ – ---Julie Bishop, JD ―The purpose of risk assessment is not to categorize individuals according to a test result nor even as to their overall risk, but rather to identify those who can be helped, or helped most, by preventive action.”
 – ---Geoffrey Rose, MD, PhD
    4. 4. Objectives Slide # Encourage focus on prevention 05 Identify basic health screening principles 06 Discuss the role of evidence-based medicine 07 Define the USPSTF grading system 08 Implement wellness intervention 09 Discuss counseling and delivery to patients 10 Describe new federal initiatives 11 Demonstrate USPSTF-related Resources 12-28
    5. 5. Why Prevention? In prevention the goal is to preserve and promote health and well being Prevention in public health moves interventions from the individual level to a population level Effective prevention leads to a healthier community – Why Now?  Federal support exists for prevention
    6. 6. Levels of Prevention Primary Prevention  Avoidance/prevention of disease or injury (inclusive of mental health)  Immunizations Secondary Prevention  Early detection and treatment  Mammography Tertiary Prevention  Reduction of disability and prompt rehabilitation  Management of existing conditions.  End-stage renal failure
    7. 7. The Role of Evidence Based Medicine The USPSTF reviews the scientific evidence regarding the effectiveness, risks, and benefits of specific health care services. A conclusion that there is no evidence of the effectiveness of a service is different from a conclusion that the service is ineffective.
    8. 8. What the Grades Mean
    9. 9. Implementing Wellness Interventions Work interprofessionally Counsel patient effectively Recognize the body is capable of self- healing and health maintenance Using the ePSS program saves time and simplifies the task. Work with legislators to support wellness services
    10. 10. Counseling Strategies Tailor teaching to  Be specific patients needs  Add new behaviors rather Purpose, effects and than eliminate when to expect effects established behaviors Suggest small changes  Link the new to old behaviors Use influence of  Listening profession  Assess readiness Encourage comments for change from patient  Cultural sensitivity Combine strategies  Community resources Involve office staff  Refer appropriately Monitor progress
    11. 11. New Federal Initiatives Change in Reimbursements Reimbursement for services has been an impediment to consistently providing preventive/wellness services in a busy clinic environment. Recent legislation has removed this barrier. Free Preventive Care Under Medicare—Eliminates co‐payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011. Free Preventive Care Under New Private Plans—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles. Effective 6 months after enactment [9/23/10]. New England Journal of Medicine, Promoting Prevention through the Affordable Care Act, 10.1056/JEJM1008560
    12. 12. Tools for Different Audiences Physicians and healthcare providers  Electronic and print resources and tools  Downloadable point of care prompts – electronic Preventive Services Selector: www.epss.ahrq.gov  How to: www.uspreventiveservicestaskforce.org Patients  Explanation of recommendations  Checklists to monitor individual preventive needs  www.healthfinder.gov has tools for patients.
    13. 13. Download the ePSS
    14. 14. Using the ePSS in a clinical setting-an example:• Patients are typically screened by a member of the health care team in initial portion of an encounter • A nurse typically takes vital signs and measures the patient’s height and weight prior to seeing the provider • This provides an opportunity to complete a brief preventive medicine/wellness questionnaire • Print for inclusion in the health record or electronic review by the healthcare provider• Reviewed by the healthcare provider • Concurs or changes recommendations • Brief discussion with the patient for those answers or findings that require treatment or need to be addressed with a comment that a member of the clinic staff will address some concerns in more detail
    15. 15. Using the ePSS in a clinical setting-an example:• Designated member of the health care team reviews in greater detail • Further counseling is provided by a member of the clinic staff • Printed instructions should be provided to the patient for further reference and explanation of the healthcare team recommendations• The VA Model is a working example similar to what was just described. • A member of the healthcare team completes an in-depth screening using the VA electronic medical records system. The patient answers are documented for the healthcare provider’s review. • The healthcare provider reviews the patient responses and addresses the health risks with the patient, recommending lifestyle modification and/or treatment • When appropriate the patient returns to the nurse for further discussion and counseling. Referral is made as indicated to a specialist
    16. 16. Case 1: Male, 57 y/o, smoker, sexually active
    17. 17. Case 1: Male, 57y/o, smoker, sexually active
    18. 18. y/o, nonsmoker, sexually active
    19. 19. Case 2: Male, 77 y/o,nonsmoker, sexually active
    20. 20. y/o, nonsmoker, sexually active
    21. 21. y/o, nonsmoker, sexually active
    22. 22. Patient Case 1 Your physician assistant (PA) reports to you the story of a 45- year-old man seen in the practice for an annual examination. The patient’s only complaint is occasional elbow pain that he attributes to using a new tennis racquet. He reports no medical illnesses and his only prior surgery is a hernia repair 10 years ago. He takes one low-dose aspirin per day, does not smoke and reports having an occasional alcoholic beverage. He reports no family history of early heart disease or cancer. Last year, his total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) were normal. He is married and in a monogamous relationship. Since testing negative for STIs (including HIV) many years ago, he reports no potential for new exposures. On examination, he is not overweight and not hypertensive. The patient asked the PA about the recommended preventive services for a person at his age and your PA is unsure of the appropriate source of prevention guidelines.
    23. 23. Patient Case 1
    24. 24. Patient Case 1
    25. 25. Patient Case 2 A 40-year–old woman presents to your clinic for a periodic examination and its seen initially by the nurse practitioner (NP). The patient reports no medical illnesses and has had no prior surgeries. She does not smoke or drink any alcoholic beverages. Her paternal grandfather was a heavy smoker and died of lung cancer at age 65. Otherwise, she has no other family history of cancer. She is married and in a mutually monogamous relationship. A colleague at work was diagnosed with breast cancer 5 years before and since that time this patient has performed periodic self- breast examinations. She reports no changes in her breasts, but asks the NP if she should get a mammogram. The NP asks you about your interpretation of current USPSTF recommendations regarding screening mammography.
    26. 26. Patient Case 2
    27. 27. Patient Case 2
    28. 28. For More Information If you have any questions or would like more information please contact: – Barbara Kass, Health Communications Specialist, Office of Communications and Knowledge Transfer; AHRQ at barbara.kass@ahrq.hhs.gov Helpful URLs – AHRQ’s USPSTF website (http://www.preventiveservices.ahrq.gov) has downloadable electronic Preventive Services Selector (ePSS) app – Printable patient counseling information for clinicians and patients, available at http://epss.ahrq.gov/ePSS/Tools.do – Technical Assistance paper with patient cases for health professions education http://www.ahrq.gov/qual/kt/tfmethods/impuspstf.htm – PowerPoint slide deck for educators and clinicians: ―Understanding the Methods Used by the USPSTF in Developing Recommendations‖ http://www.ahrq.gov/qual/kt/tfmethods/tfmethods.htm

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