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Health Promotion and Disease Prevention Program VA Gulf Coast Health Care Systems Implementing a Behavioral Approach to Health Promotion and Disease Prevention.

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Presentation on theme: "Health Promotion and Disease Prevention Program VA Gulf Coast Health Care Systems Implementing a Behavioral Approach to Health Promotion and Disease Prevention."— Presentation transcript:

1 Health Promotion and Disease Prevention Program VA Gulf Coast Health Care Systems
Implementing a Behavioral Approach to Health Promotion and Disease Prevention Presenters: Kellee R. Bivens, PhD Sheila Phillips, RN, BSN

2 Objectives: Describe the TEACH patient education model and discuss its value to primary care staff and patients Describe how a behavioral approach facilitates patient centered care Describe the 9 Healthy Living Messages and how they are integrated into the Patient Centered Medical Home model

3 VHA Preventive Care Program
Core Elements: Infrastructure Integration with PACT Tools and Resources Annotations: a. Facility Level Activities • Program Development • Management • Evaluation • Reporting b. Support Clinical Care Activities • Promote HPDP Clinical Resources (e.g., Health Risk Assessment, VHA Clinical Preventive Services Guidance Statements) • Provide Staff Training and Mentoring for Healthy Lifestyle Coaching • Identify Community Resources/Partnerships c. Provide Clinical Care • Tobacco Cessation Counseling and Treatment • Weight Management • Other HPDP Services d. Other Suggested Staff Partners are representatives from • Women Veterans Program • OEF/OIF Program • Rural Health Program • Telehealth Program • Geriatric Program • Voluntary Service • Public Affairs • Social Work • Nutrition and Food Service • Veterans Canteen Service • Physical Activity • Quality Management • Employee Wellness • Flu Campaign • Others as desired

4 Vision of VHA Preventive Care Program
The Veteran will experience health promotion and disease prevention (HPDP) clinical interventions that are seamlessly integrated across the continuum of their health care and are delivered in a variety of modalities matched to the Veteran’s needs and preferences. VHA clinicians and clinical support staff will value and participate in the delivery of HPDP interventions for patients as appropriate to each Veteran’s priorities and overall plan of care.

5 A Model for Planned Care*
Health System Organization of Health Care Self- Management Support Decision Delivery System Design Clinical Information Systems Community Resources and Policies PACT Teamlet Briefly review Planned Care Model, emphasizing that research has determined that good functional and clinical outcomes occur as a result of productive interactions between a prepared, proactive practice team and an informed activated patient and family member. [For groups exposed to the model…no need to specify each of the elements below…just concentrate on SMS] How can we promote productive interactions? Research in the quality improvement arena has found that several elements within the health care system will support and promote productive interactions and improve health outcomes. These elements include: Self-management support….the focus of todays training. I will provide a definition and some examples of self-management support shortly Decision support, or guidelines…knowing the right thing to do for the right person at the right time. Delivery system design….how to organize care so that it is proactive and efficient. This might include group visits for patients with diabetes or planned follow-up calls to determine how folks are doing with their treatment plans. Clinical Information systems – like registries to track and remind clinicians and patients about key components of care Health system organization – this includes leadership and support And finally links to Community Resources Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Functional and Clinical Outcomes *E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

6 A Fundamental Shift in the Process of Care
PACT Transformation A Fundamental Shift in the Process of Care Traditional Care Collaborative Care Assumes knowledge + confidence drives change Patient sets agenda Goal is enhanced confidence Decisions made collaboratively Assumes knowledge drives change Clinician sets agenda Goal is compliance Decisions made by caregiver Tom Bodenheimer, in this graphic, depicts how care is transformed from the clinician or team-centered approach applied in traditional care settings to one that is more Veteran-centered, collaborative and empowering in the new PACT model. (Bodenheimer et al, CA Health Care Foundation, 2005)

7 Principles of PACT Patient-centered
Ongoing relationship with a primary care team Patient is full partner with team Comprehensive: whole person orientation Easier communication

8 Implementing PACT Principles
Staff training in patient-centered communication TEACH for Success course (health coaching) Facilitators: Health Behavior Coordinators and Veterans Health Education Coordinators Motivational Interviewing training Facilitators: Health Behavior Coordinators Follow-up mentoring and coaching

9 TEACH Philosophy Evidence-based best practice
. TEACH Philosophy Evidence-based best practice Holistic approach to patient care Patient-centered Patient self-management Partnerships with patients

10 TEACH Philosophy Shared decision making Interdisciplinary process
Practical, specific techniques Meets The Joint Commission standards Goal: improve competencies

11 TEACH Target Audience Clinical staff involved in educating patients:
PACT teamlets & expanded teams Nurses & advanced practice nurses Physicians & physician assistants Dietitians Pharmacists Psychologists Social workers Therapists—physical, occupational, speech, hearing

12 Premises of Course Health education makes a difference health outcomes
patient & clinician satisfaction Health education skills can be learned and mastered with practice

13 TEACH Goals Skills development—patient-centered health education, health coaching, partnering Mastery requires practice & feedback Follow-up: reinforcement & boosters Participants use strategies & techniques with Veterans

14 TEACH Course Units T Tune in to the Patient Preferences, and Needs
E Explore the Patient’s Concerns, Preferences, and Needs A Assist the Patient with Behavior Changes C Communicate Effectively H Honor the Patient as a Partner

15 Introduction Assess own patient education skills Course overview

16 Tune in to the Patient Most effective approaches to build rapport with patients How to quickly establish & maintain effective relationships with patients Clinician behaviors that help or hinder effective clinician-patient relationships Effective listening & questioning skills

17 Explore the Patient’s Concerns, Preferences and Needs
Components of a learning assessment How to assess a patient’s level of importance & confidence for a health behavior Quick needs assessment method How to detect limitations to learning

18 Assist the Patient with Behavior Change
Health coaching framework Elements Benefits Process Health coaching practice

19 Communicate Effectively
How to incorporate tailoring into communications with patients How to help patients deal with strong emotions such as fear How to deal with patient ambivalence How to deal with patient resistance

20 Honor the Patient as a Partner
Characteristics of effective clinician-patient partnerships How to assess clinician & patient preferences for partnering How to incorporate both clinician and patient perspectives in goal setting, decision making, treatment & learning activities

21 Definition of Health Coaching
Health coaching is the practice of health education and health promotion within a coaching context to enhance the well-being of individuals and to facilitate the achievement of their health-related goals. Palmer S, Tubbs I, and Whybrow A. (2003) Health coaching to facilitate the promotion of healthy behaviors and achievement of health-related goals. International Journal of Health Promotion & Evaluation, 41(3), pp

22 Health Coaching Characteristics
Collaborative, not directive Patient-centered Supports patient autonomy Empowers patient for self-management

23 Goals of Health Coaching
Help patients Clarify personal health goals Implement and sustain healthy behaviors Reduce negative impact of chronic disease Guide patients in self-management Skill development Problem solving

24 Importance for VHA Many Veterans have chronic diseases and the number is increasing. Poor health behaviors lead to and complicate chronic diseases. Improving poor health behaviors is key to improving health.

25 Benefits of Health Coaching
Consistent with PACT and Preventive Care Program Framework for making PACT principles and goals operational in practice Strategies are easy to learn and use Positive effects for both staff and patients Health outcomes Satisfaction

26 Who are the health coaches?
All PACT team members can coach patients Degree of involvement in health coaching may differ among team members Trained patients can coach other patients

27 Delivery Models Face to face during a clinic visit During group visits
In classes, especially self-management programs Over the telephone Via the Internet

28 Process of Health Coaching
Establish a positive relationship with the patient Develop a partnership with the patient Explain your role as a coach

29 Process of Health Coaching
Elicit the patient’s concerns and issues Use active listening skills Express empathy

30 Process of Health Coaching
Set an agenda with the patient for this session

31 Process of Health Coaching
Connect the coaching topic to the patient’s life goals and values Focus on the whole person, not just a specific diagnosis or behavior

32 Process of Health Coaching
Acknowledge the patient’s likes, dislikes and preferences Empower the patient by reminding him/her that the choices are his/hers to make Offer to help the patient find the answers that will work best for him/her

33 Process of Health Coaching
Ask before telling Ask what the patient already knows and what the patient wants to know Provide new information and clarify misperceptions as needed Invite the patient to consider a different perspective Confirm the patient’s understanding

34 Process of Health Coaching
Ask the patient how important he/she thinks it is to change

35 Process of Health Coaching
Help the patient set a goal Ask the patient to identify something he/she can do to improve his/her health

36 Process of Health Coaching
Help the patient create an action plan Ask the patient how confident he/she is to reach the goal Help the patient modify the action plan as needed

37 Process of Health Coaching
Develop a follow-up plan with the patient

38 Health Coaching Applications
Video Example

39 Motivational Interviewing
Intensive facilitator training with follow-up mentoring for: Health Behavior Coordinators Veterans Health Education Coordinators Health Promotion/Disease Prevention Program Managers Training/coaching by Health Behavior Coordinators for: PACT staff Other clinicians

40 Health Promotion and Disease Prevention Program VA Gulf Coast Health Care Systems
How the 9 Healthy Living Messages are integrated into the Primary Care Medical Home Model. Presenter: Sheila Phillips, RN, BSN

41 VA Mission Honor America’s Veterans by providing exceptional health care that improves their health and well being.

42 Health Promotion and Disease Prevention Ultimate Goal To create the best primary care delivery model in the world and thereby create one of the healthiest populations in the country!

43 Health Promotion and Disease Prevention (HPDP) Initiative
National 2010 Health Care Reform HPDP initiative provides two parts to the new bill. National Directive Joint Commission National Patient Safety Goals are integrated into HPDP. Evidence-based care – a systematic review capable of improving quality and consistency in healthcare.

44 - Healthy Living Messages for Veterans - Are actions taken to protect oneself or those you love from disease! Top five chronic diseases: Cardiovascular, Stroke, Cancer, Chronic Obstructive Pulmonary Disease & Diabetes. These account for 95 cents out of every dollar spent on health care and two out of three deaths. The World Health Organization estimates that 80% of heart disease, stroke and type 2 diabetes and > 40% cancers are preventable if you stop smoking, eat healthier and get physically active. The evidence has lead to the development of the 9 Healthy Living Messages and to encourage our Veterans to chose healthier lifestyles.

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46 1. Get Involved with Your Health Care
Getting involved in your health care. There are many ways to take an active role. Work with your Patient Aligned Care Team (PACT) to improve your health. is now available for veterans to access their health record. Please take advantage of this opportunity.

47 Meaningful Use means providers need to show they are using certified Electronic Health Record technology in ways that can be measured in quality and in quantity. According to Centers for and Medicare Services (CMS), the five broad goals of Meaningful Use are to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and families Improve care coordination Improve population and public health Ensure adequate privacy and security for personal health information The American Recovery and Reinvestment Act of 2009 describes Meaningful Use.

48 2. Be Tobacco Free Don’t use tobacco in any form. If you are using tobacco, the VA can help you quit. Avoid second hand smoke. If you are pregnant both you and your baby will benefit when you quit using tobacco. Tobacco use and exposure to secondhand smoke kill approximately 443,000 people in the United States each year. VA offers Tobacco Cessation groups, one on one appointments, follow up and medications to help stop tobacco use.

49 3. Eat Wisely Maximize your health by eating wisely. Eat a variety of foods including vegetables, fruits and whole grains. It is important to include fat-free or low-fat mild and milk products in your diet, and limit total salt, fat, sugar and alcohol. VHA offers nutrition counseling through it’s dietitians. It is easy to get a consult submitted by the RN Care Nurse assigned to your PACT teamlet. The VHA’s website is available to assist you with your nutritional, physical activity & healthy weight.

50 www.MyPyramid.gov, Steps to a Healthier You.

51 Physical activity will add:
4. Be Physically Active Avoid inactivity. Some activity is better than none. Aim for at least 2 ½ hours of moderate-intensity aerobic activity each week. Every 10 minute sessions counts. Do strengthening activities at least 2 days each week. Physical activity will add: YEARS TO YOUR LIFE and LIFE TO YOUR YEARS

52 5. Strive to Maintain a Healthy Weight
Losing even a little weight helps, if you need to lose weight. If you are at a normal weight, maintain it. Staying in control of your weight helps you be healthy now and in the future. A simple way to know if you are at a healthy weight is to know your body mass index (BMI). BMI Guidelines: Underweight = BMI less than 18.5 Normal weight = BMI of 18.5—24.9 Overweight = BMI of 25—29.9 Obesity = BMI of 30 or greater A reasonable and safe weight loss is 1-2 lbs per week. It might take 6 months to reach your ultimate goal, but making gradual lifestyle changes can help you maintain a healthier weight for life.

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54 6. Limit Alcohol Alcohol Misuse
If you choose to drink alcohol, drink in moderation (women no more than 1 drink a day; men no more than 2 drinks a day). Avoid “binge drinking.” If you are concerned about your drinking, talk to your VA health care team about getting help. Binge drinking is having more than 3 drinks on one occasion for women and adults over age 65. More than 4 drinks on one occasion for men. Alcohol Misuse Goal: Improve Detection and Management of Alcohol Misuse in Primary Care Clinical Implementation Improved efficiency and standardization of alcohol screening CPRS clinical reminder for brief alcohol counseling Participation in national efforts to integrate mental health care in primary care

55 7. Get Recommended Screening Tests and immunizations -
Get the right preventive services including vaccines, screening tests, and preventive medications. The pros and cons of receiving each service depend on your age, gender and health status. Find out which vaccines, screening tests and preventive medications are right for you! NCP website:

56 8. Manage Stress Pay attention to stress. Tools are available to help you manage and reduce your stress. If you or someone you know is in an emotional crisis call The Veterans’ Hotline at TALK and press 1 for Veterans. There are several strategies you can use to cope with or manage stress.

57 9. Be Safe Protect yourself and those you love from harm.
Common Safety issues – Prevent sexually transmitted infections Prevent Falls Prevent Motor Vehicle Crashes and Injury

58 Integrating the 9 Healthy Living Messages into the Patient Aligned Care Teams
Clinical Staff Guide for Healthy Living Messages Promotes an effective patient-centered interaction through evidence based in information about the HLM to initiate discussions or response to Veterans’ questions about healthy behaviors. My Health Choices (goal setting tool) - used to help Veterans choose an area of interest and for health behavior goal-setting and action planning.

59 Integrating Interventions in Patient Aligned Care Teams & Health Promotion/Disease Prevention
Program charter developed to create a purpose and designate committee members who implement the mission and vision of the program. HPDP Program goals were developed and initiated through a team effort . An internal resource scan is being developed, which lists available VA services. The HPDP Program is introduced in New Employee Orientation. HPDP team effort to ensure clinical reminders (screenings/immunizations, etc.) are aligned with VHA preventive clinical guidance statements.

60 HPDP Interventions in the planning phase:
Prevention visits by RN Care Coordinator Care Coordination/Home TeleHealth collaboration New Patient Orientation Action Plan - Management of Diabetes Mellitus in Primary Care

61 Health Promotion and Disease Prevention Benefits Everyone

62 Case Study of Health Coaching in the PACT Model
The next grouping of slides provides some background on the VHA Preventive Care Program, one of several sub-initiatives in the VHA’s New Models of Health Care Transformational Initiative. The role of the HBC within the context of the Preventive Care Program and the other New Models of Health Care initiative, particularly the primary care-based Patient Aligned Care Team initiative, is featured in this presentation

63 Karl 59 y/o Vietnam Veteran with  high BP
 poorly-controlled diabetes  poor diet, physical inactivity  depression  arthritis  stress Here is a case presentation to show how the Prevention Program can help address the care needs of a prototypical Veteran.

64 First VHA Contact Attends a Vietnam Veterans of America (VVA) meeting and hears a talk about health and well-being presented by VHA staff member. Picks up a brochure and information about services.

65 VA Medical Facility Contact
Calls for appointment While on hold briefly, hears a message promoting physical activity. Gets appointment for a New Patient Orientation group visit

66 New Patient Orientation group visit
Gets information about healthcare services offered by VA medical facility Learns about programs and educational resources to help him improve and maintain his health. Registers for My HealtheVet and gets “in-person authenticated” Karl’s engagement starts with his New Patient Orientation

67 My HealtheVet Goes to My HealtheVet website to:
Complete the online Health Risk Assessment and get feedback report Search for more health information in online Veterans Health Library Sign up for Secure Messaging My HealtheVet provides an opportunity for Karl to engage the VHA and interact with his team on his own time, at his own pace, in his own way.

68 HRA hosted by My HealtheVet
Demo only This slide includes a screen shot of the My HealtheVet website that was used in the usability testing of the prototype VHA HRA with the location of the HRA circled in red.

69 Next… Veterans Health Benefits Handbook
Appointment letter for visit with primary care team Brochure about healthy lifestyle

70 First Primary Care PACT Visit
At the medical center, he notices: Posters on walls with health promotion messages Video on CCTV in waiting room about healthy living Signs encouraging taking the stairs

71 In Primary Care PACT Clinic
Greeted by clerk Asks him how he’d like to be addressed Encourages him to write down any questions for the provider and other PACT team members Once Karl comes in for a visit, he has multiple opportunities to engage with his health care team in new ways. The Clerical Associate actively participates in the engagement and activation process.

72 In Primary Care PACT Clinic
Clinical Associate Explains concept of PACT care Begins completing clinical reminders, including depression, PTSD screening Asks about current meds and any changes Takes vitals Wears an “Ask Me about MOVE! button” The Clinical Associate interacts with Karl in ways that further prepare and activate him. Agenda setting can start here……Karl’s agenda, as well as the teams (prompted by clinical reminders).

73 In Primary Care PACT Clinic
RN Care Manager Addresses needed clinical preventive services Notes (+) screen for depression, follows up Utilizes MI to address obesity Offers options for self-management support: Group face-to-face sessions TeleMOVE support Telephone Lifestyle Coaching program Web-based weight management program Note all the opportunities for addressing clinical and behavioral issues and needs. Note the opportunities to use MI to elicit and support the Karl’s motivation. Not all of what is listed here and on the next slide need happen at a single visit.

74 In Primary Care PACT Clinic
RN Care Manager Uses MI to address physical activity and healthy eating Uses My Health Choices tool to help Karl set goals and develop an action plan Uses clinical reminder to document Follows up as requested

75 In Primary Care PACT Clinic
Provider Reviews current problems, medical history, meds, does exam Reviews HRA responses, feedback Addresses any complex issues related to clinical preventive services Discusses goals, action plan, supports behavior change Writes scripts Refer to individual/group wellness or disease management clinics, PC-MHI as appropriate The visit sequence (Clinical Associate, RN Care Manager then Provider) depicted in these slides is arbitrary and may occur in a variety of sequences. Also, teamlet members will often initiate contact or respond to contact from the Veteran inbetween face-to-face visits , using telephone clinics, or secure messaging.

76 Wellness Clinic Led by Health Coach (RN or mid-level provider)
In-depth session on health-related behaviors (PA, healthy eating, weight management, stress, etc.) Uses MI techniques to address ambivalence and TEACH communication/health education skills and teaches problem-solving skills Reviews action plan, goals Describes other VA and community resources We anticipate that some sites will develop non-disease specific Wellness Clinics that focus on promoting healthy behaviors.

77 Impact on Karl and his Family
Well-informed about his conditions, risks Able to choose preferred format of care Participating in MOVE! and beginning to improve his diet, increase his physical activity, and lose weight Self-managing his diabetes better Depression, arthritis under better control Using problem-solving, less stress

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79 Behind the Scene HPDP Program HPDP Program Manager
Health Behavior Coordinator HPDP Program Committee Broad representation on committee/subcommittee HPDP PM and HBC positions filled as of 11/22/10

80 Behind the Scene Self-Study Orientation Program
Role-specific orientation checklists (HPDP PM, HBC and VISN HPDP Program Leaders) Orientation modules Phases I and II Phase III Overview and General Role Orientation Resources and Communication Core Prevention Messages Clinical Preventive Services Evaluation and Measurement MOVE! Weight Management Program Veterans Health Education and Information Primary Care- Mental Health Integration Employee Wellness Patient Aligned Care Teams (PACT) Systems Redesign My HealtheVet Phase III orientation expected to be available December 2010

81 Behind the Scene Mail groups Monthly national conference calls
VHA HPDP Program Managers VHA Health Behavior Coordinators VHA VISN HPDP Program Leaders Monthly national conference calls Monthly prevention education call Sample facility HPDP Program Committee Charter National Goals and proposed FY 11 facility HPDP Program Goals Internet, intranet and SharePoint resources

82 Behind the Scene Communication campaign for 9 Healthy Living Messages (in development ) Posters, brochures, other print materials Videos, audio resources Phone messages Social media Anticipate launch of communication campaign in 4th quarter FY 11

83 Behind the Scene Staff tools My Health Choices
Guide for Health Coaching Guide for Healthy Living Messages

84 Behind the Scene Tools/Resources in development
New Patient Orientation Toolkit Health Risk Assessment Veterans Health Library Telephone Lifestyle Coaching program TeleMOVE! service Web-based weight management program These are all complex projects in development. Implementation dates undetermined at this time.

85 Behind the Scene Measures/metrics EPRP measures about health behaviors
Smoking counseling/NRT Screening for obesity Participation in MOVE! Screen/counseling for problem alcohol use Assessment of healthy eating/PA Roll-out of new clinical reminder

86 Behind the Scene Measures/metrics CAHPS question
How often ways to prevent illness or injury were discussed (FY 11: 67% usually/always) FY 11 developmental measures ≥2 staff completed TEACH facilitator training; ≥1 completed MI facilitator training 20% PACT staff trained in TEACH by 4Q 25% RN Care Managers trained in MI by 4Q HPDP included in PACT certification

87 In Conclusion: HPDP and PACT have a synergistic approach to patient centered care. Motivational interviewing and health coaching facilitates trusting and goal directed relationships with the Veteran. Educating healthcare teams on the TEACH program and motivational interviewing techniques enables success with Veteran self management skills.

88 Acknowledgements and Contact Info Faculty: Kellee Bivens, PhD: Sheila Phillips, RN: Program Developers: John Baer, PhD: Cathy Cole, MSSW: Paula Wilbourne, PhD: Brian Kersh, PhD: Elizabeth Jenkins, PhD: NCP Supporting staff: Michael Goldstein, MD: Margaret Dundon, PhD:

89 References: Health Power! Prevention News – Winter 2010
Center of Disease Control (CDC) conservativedailynews.com – Uncle Sam Stop Smoking Ad sanfranciscosentinel.com – Health Care Ad


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