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 PreventionPresenters: Kellee R. Bivens, PhDSheila Phillips, RN, BSN
2 Objectives:Describe the TEACH patient education model and discuss its value to primary care staff and patientsDescribe how a behavioral approach facilitates patient centered careDescribe the 9 Healthy Living Messages and how they are integrated into the Patient Centered Medical Home model
3 VHA Preventive Care Program Core Elements:InfrastructureIntegration with PACTTools and ResourcesAnnotations:a. Facility Level Activities• Program Development• Management• Evaluation• Reportingb. Support Clinical Care Activities• Promote HPDP Clinical Resources (e.g., Health Risk Assessment, VHA Clinical PreventiveServices Guidance Statements)• Provide Staff Training and Mentoring for Healthy Lifestyle Coaching• Identify Community Resources/Partnershipsc. Provide Clinical Care• Tobacco Cessation Counseling and Treatment• Weight Management• Other HPDP Servicesd. 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 SystemOrganization of Health CareSelf-ManagementSupportDecisionDeliverySystemDesignClinicalInformationSystemsCommunityResources and PoliciesPACTTeamletBriefly 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 shortlyDecision 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 careHealth system organization – this includes leadership and supportAnd finally links to Community ResourcesPrepared,ProactivePractice TeamInformed,ActivatedPatientProductiveInteractionsFunctional 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 TransformationA Fundamental Shift in the Process of CareTraditional CareCollaborative CareAssumes knowledge + confidence drives change Patient sets agenda Goal is enhanced confidence Decisions made collaborativelyAssumes knowledge drives change Clinician sets agenda Goal is compliance Decisions made by caregiverTom 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 teamPatient is full partner with teamComprehensive: whole person orientationEasier communication
8 Implementing PACT Principles Staff training in patient-centered communicationTEACH for Success course (health coaching)Facilitators: Health Behavior Coordinators and Veterans Health Education CoordinatorsMotivational Interviewing trainingFacilitators: Health Behavior CoordinatorsFollow-up mentoring and coaching
9 TEACH Philosophy Evidence-based best practice .TEACH PhilosophyEvidence-based best practiceHolistic approach to patient carePatient-centeredPatient self-managementPartnerships with patients
10 TEACH Philosophy Shared decision making Interdisciplinary process Practical, specific techniquesMeets The Joint Commission standardsGoal: improve competencies
12 Premises of Course Health education makes a difference health outcomes patient & clinician satisfactionHealth education skills can be learned and mastered with practice
13 TEACH GoalsSkills development—patient-centered health education, health coaching, partneringMastery requires practice & feedbackFollow-up: reinforcement & boostersParticipants 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 NeedsA Assist the Patient withBehavior ChangesC Communicate EffectivelyH Honor the Patient as a Partner
15 IntroductionAssess own patient education skillsCourse overview
16 Tune in to the PatientMost effective approaches to build rapport with patientsHow to quickly establish & maintain effective relationships with patientsClinician behaviors that help or hinder effective clinician-patient relationshipsEffective listening & questioning skills
17 Explore the Patient’s Concerns, Preferences and Needs Components of a learning assessmentHow to assess a patient’s level of importance & confidence for a health behaviorQuick needs assessment methodHow to detect limitations to learning
18 Assist the Patient with Behavior Change Health coaching frameworkElementsBenefitsProcessHealth coaching practice
19 Communicate Effectively How to incorporate tailoring into communications with patientsHow to help patients deal with strong emotions such as fearHow to deal with patient ambivalenceHow to deal with patient resistance
20 Honor the Patient as a Partner Characteristics of effective clinician-patient partnershipsHow to assess clinician & patient preferences for partneringHow 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 directivePatient-centeredSupports patient autonomyEmpowers patient for self-management
23 Goals of Health Coaching Help patientsClarify personal health goalsImplement and sustain healthy behaviorsReduce negative impact of chronic diseaseGuide patients in self-managementSkill developmentProblem solving
24 Importance for VHAMany 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 ProgramFramework for making PACT principles and goals operational in practiceStrategies are easy to learn and usePositive effects for both staff and patientsHealth outcomesSatisfaction
26 Who are the health coaches? All PACT team members can coach patientsDegree of involvement in health coaching may differ among team membersTrained patients can coach other patients
27 Delivery Models Face to face during a clinic visit During group visits In classes, especially self-management programsOver the telephoneVia the Internet
28 Process of Health Coaching Establish a positive relationship with the patientDevelop a partnership with the patientExplain your role as a coach
29 Process of Health Coaching Elicit the patient’s concerns and issuesUse active listening skillsExpress 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 valuesFocus on the whole person, not just a specific diagnosis or behavior
32 Process of Health Coaching Acknowledge the patient’s likes, dislikes and preferencesEmpower the patient by reminding him/her that the choices are his/hers to makeOffer to help the patient find the answers that will work best for him/her
33 Process of Health Coaching Ask before tellingAsk what the patient already knows and what the patient wants to knowProvide new information and clarify misperceptions as neededInvite the patient to consider a different perspectiveConfirm 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 goalAsk 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 planAsk the patient how confident he/she is to reach the goalHelp the patient modify the action plan as needed
37 Process of Health Coaching Develop a follow-up plan with thepatient
39 Motivational Interviewing Intensive facilitator training with follow-up mentoring for:Health Behavior CoordinatorsVeterans Health Education CoordinatorsHealth Promotion/Disease Prevention Program ManagersTraining/coaching by Health Behavior Coordinators for:PACT staffOther 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 MissionHonor 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 ReformHPDP initiative provides two parts to the new bill.National DirectiveJoint CommissionNational 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.
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 disparitiesEngage patients and familiesImprove care coordinationImprove population and public healthEnsure adequate privacy and security for personal health informationThe American Recovery and Reinvestment Act of 2009 describes Meaningful Use.
48 2. Be Tobacco FreeDon’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 upand medications to help stoptobacco use.
49 3. Eat WiselyMaximize 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.
51 Physical activity will add: 4. Be Physically ActiveAvoid 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 LIFEandLIFE 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 18.5Normal weight = BMI of 18.5—24.9Overweight = BMI of 25—29.9Obesity = BMI of 30 or greaterA 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.
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 MisuseGoal: Improve Detection and Management of Alcohol Misuse in Primary CareClinical ImplementationImproved efficiency and standardization of alcohol screeningCPRS clinical reminder for brief alcohol counselingParticipation 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 StressPay 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 infectionsPrevent FallsPrevent Motor Vehicle Crashes and Injury
58 Integrating the 9 Healthy Living Messages into the Patient Aligned Care Teams Clinical Staff Guide for Healthy Living MessagesPromotes 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 tohelp Veterans choose an area of interest and forhealth 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 CoordinatorCare Coordination/Home TeleHealth collaborationNew Patient OrientationAction 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 stressHere is a case presentation to show how the Prevention Program can help address the care needs of a prototypical Veteran.
64 First VHA ContactAttends 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 appointmentWhile 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 facilityLearns 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 reportSearch for more health information in online Veterans Health LibrarySign up for Secure MessagingMy 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 onlyThis 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 teamBrochure about healthy lifestyle
70 First Primary Care PACT Visit At the medical center, he notices:Posters on walls with health promotion messagesVideo on CCTV in waiting room about healthy livingSigns encouraging taking the stairs
71 In Primary Care PACT Clinic Greeted by clerkAsks him how he’d like to be addressedEncourages him to write down any questions for the provider and other PACT team membersOnce 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 AssociateExplains concept of PACT careBegins completing clinical reminders, including depression, PTSD screeningAsks about current meds and any changesTakes vitalsWears 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 ManagerAddresses needed clinical preventive servicesNotes (+) screen for depression, follows upUtilizes MI to address obesityOffers options for self-management support:Group face-to-face sessionsTeleMOVE supportTelephone Lifestyle Coaching programWeb-based weight management programNote 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 ManagerUses MI to address physical activity and healthy eatingUses My Health Choices tool to help Karl set goals and develop an action planUses clinical reminder to documentFollows up as requested
75 In Primary Care PACT Clinic ProviderReviews current problems, medical history, meds, does examReviews HRA responses, feedbackAddresses any complex issues related to clinical preventive servicesDiscusses goals, action plan, supports behavior changeWrites scriptsRefer to individual/group wellness or disease management clinics, PC-MHI as appropriateThe 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 skillsReviews action plan, goalsDescribes other VA and community resourcesWe 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, risksAble to choose preferred format of careParticipating in MOVE! and beginning to improve his diet, increase his physical activity, and lose weightSelf-managing his diabetes betterDepression, arthritis under better controlUsing problem-solving, less stress
79 Behind the Scene HPDP Program HPDP Program Manager Health Behavior CoordinatorHPDP Program CommitteeBroad representation on committee/subcommitteeHPDP 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 modulesPhases I and IIPhase IIIOverview and General Role OrientationResources and CommunicationCore Prevention MessagesClinical Preventive ServicesEvaluation and MeasurementMOVE! Weight Management ProgramVeterans Health Education and InformationPrimary Care- Mental Health IntegrationEmployee WellnessPatient Aligned Care Teams (PACT)Systems RedesignMy HealtheVetPhase III orientation expected to be available December 2010
81 Behind the Scene Mail groups Monthly national conference calls VHA HPDP Program ManagersVHA Health Behavior CoordinatorsVHA VISN HPDP Program LeadersMonthly national conference callsMonthly prevention education callSample facility HPDP Program Committee CharterNational Goals and proposed FY 11 facility HPDP Program GoalsInternet, intranet and SharePoint resources
82 Behind the SceneCommunication campaign for 9 Healthy Living Messages (in development )Posters, brochures, other print materialsVideos, audio resourcesPhone messagesSocial mediaAnticipate launch of communication campaign in 4th quarter FY 11
83 Behind the Scene Staff tools My Health Choices Guide for Health CoachingGuide for Healthy Living Messages
84 Behind the Scene Tools/Resources in development New Patient Orientation ToolkitHealth Risk AssessmentVeterans Health LibraryTelephone Lifestyle Coaching programTeleMOVE! serviceWeb-based weight management programThese 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/NRTScreening for obesityParticipation in MOVE!Screen/counseling for problem alcohol useAssessment of healthy eating/PARoll-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 training20% PACT staff trained in TEACH by 4Q25% RN Care Managers trained in MI by 4QHPDP 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 InfoFaculty: 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 Adsanfranciscosentinel.com – Health Care Ad