Reforming Disease Prevention & Health Promotion: Opportunities at the Boundaries

Slide Presentation from the AHRQ 2009 Annual Conference

On September 15, 2009, Kurt C. Stange made this presentation at the 2009 Annual Conference.

Select to access the PowerPoint® presentation (237 KB).

Slide 1

Reforming Disease Prevention & Health Promotion: Opportunities at the Boundaries

Kurt C. Stange, MD, PhD
American Cancer Society Clinical Research Professor
Professor of Family Medicine, Epidemiology & Biostatistics, Sociology and Oncology
Case Western Reserve University

Steven H. Woolf, MD, MPH
Professor of Family Medicine
Virginia Commonwealth University

Slide 2

Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care.

1000 persons

800 report symptoms

327 consider seeking medical care

217 visit a physician's office (113 visit a primary care physician's office)
65 visit a complementary or alternative medical care provider
21 visit a hospital outpatient clinic

14 receive home health care

13 visit an emergency dept

8 are hospitalized
<1 is hospitalized in an academic medical center
Fig. Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care. (Green LA et al., N Engl J Med 2001, 344:2021-2024)

Slide 3

It's About Health

Health as Function & Meaningful Relationships

Slide 4

It's About People & Families

Health as Function & Meaningful Relationships
Person & Family

Slide 5

It's About Accessible Health Care

Health as Function & Meaningful Relationships
Person & Family
Patient - Centered Medical Home

Slide 6

It's About Healthcare System

Health as Function & Meaningful Relationships
Person & Family
Patient - Centered Medical Home
Healthcare System

Slide 7

It's About Public Health & Community

Health as Function & Meaningful Relationships
Person & Family
Patient - Centered Medical Home
Healthcare System
Public Health System, Community Resources

Slide 8

It's About

Spanning Boundaries

Slide 9

Personalized, prioritized, integrated health caring

Health as Function & Meaningful Relationships
Person & Family
Patient - Centered Medical Home
Healthcare System
Public Health System, Community Resources
Abiding, Personalized Health Care

Slide 10

Healthcare environments that foster healing & integration

Health as Function & Meaningful Relationships
Person & Family
Patient - Centered Medical Home
Healthcare System
Public Health System, Community Resources
Abiding, Personalized Health Care
Healing Environments

Slide 11

Sustainable, grounded organizations

Slide 12

Healthy environments

Slide 13

Model of Agents and Relationships for Disease Prevention & Health Promotion

Aligned economic incentives

Patient & Family

Financial resources (insurance and costs)
Access to communication resources and health care
Social context (education, income)
Teachable moments
Support for behavior change

Primary Care Practice

Time
Training
Medical records/info/IT
Reminders and prompts
Staff
Skills/self-efficacy
Rewards/reimbursement (P4P)
Medical home & redesign

Health Care System

Specialists and lab/imaging referral and follow-up systems
Public health departments
Pharmacies
Worksite health clinics
School clinics
Group programs
IT support

Community

Work environment
School environment
Built environment/developers
Supermarkets
Parks and recreation authorities
Health clubs
Quit lines
Commercial weight loss firms
Retailers
Group initiatives
Individualized programs

Interrelationships

#1. Practice - Patient/family

Group visits
Outreach
Follow-up

#2. Care system - Patients

Patient-centered service redesign for preventive care
Information and engagement

#3. Community - Individual Family

Policy, supportive environments, & accessible, convenient programs that foster prevention where people live, work and go to school
Motivational programs

#4. Practice - System

IT, system redesign, and financing to coordinate primary and specialty care

#5. Practice - Community

Referral systems, liaison workers

#6. Health Care System? Community

Advisory boards, shared community benefit fund, and other programs that link medical community with public/private stakeholders

From: Policy Options in Support of High-Value Preventive Care
Stange & Woolf at: http://www.prevent.org/content/view/197

Slide 14

Policy Options

Slide 15

The Person and Family

Incentivize and foster healthy built environments
Disseminate a free personal health record that guides HP/DP and interfaces with an interoperable electronic health record platform
Financial incentives for healthier behaviors and recommended clinical preventive services.

Slide 16

Health Care Delivery System

Expand access to fundamental care and coverage for the uninsured and under-insured
Reorganize the delivery system to support HP/DP
Disseminate and promote the work of the National Commission on Prevention Priorities to target high-yield preventive services for individuals, medical practices, health care systems, and payers.
Require the Secretary of HHS to file annual reports on the state of primary care in the US, the integrity of the public health infrastructure, and the delivery of evidence-based clinical and community preventive services.

Slide 17

Health Care Delivery System

Invest in the National Center for Health Statistics to provide serial data on preventive service delivery rates and the prevalence of modifiable risk factors among all Americans and priority populations
Develop a national authority to oversee improvements in coordinating health-related data and IT
Engage medical software developers in a coordinated effort to standardize features

Slide 18

Primary Care Practice
Access for the Underserved

Expand support for community health centers
Expand funding for Title VII to reprise its success in the 1970s in training health professionals to provide primary and preventive care and a patient-centered medical home for the U.S. population
Triple the size of the National Health Services Corps and include health informatics experts as qualifying assignees
Universal health care coverage

Slide 19

Primary Care Practice
System Redesign to Improve the Delivery, Quality, and Intensity of Preventive Services

Implement the patient-centered medical home to make it easier for providers to offer the right services to the right people at the right time
Align financial incentives to reward primary care clinicians for delivering effective preventive services

Slide 20

Community

Invest in public health infrastructure to support evidence-based community preventive services
Support coordination of community and clinical preventive service delivery
Explore applying and expanding the Agricultural Extension Agent and Forestry Service models to help communities build collaborative linkages to foster prevention

Slide 21

Financing

Universal health insurance for the U.S. population
Define & annually update a core set of evidence-based preventive services for uniform coverage based on
- U.S. Preventive Services Task Force
- Advisory Committee on Immunization Practices
- Task Force on Community Preventive Services
- National Commission on Prevention Priorities
Expand coverage under federal and state programs (e.g., Medicare, Medicaid, Federal Employees Health Benefits Program) and private insurance to include the core set of evidence-based preventive services
Offer first-dollar coverage (e.g., no copayments) for the core set of evidence-based preventive services
Incentivize business consideration of the social determinants of health

Slide 22

Financing

Explore progressive approaches to reimbursement of preventive services for asymptomatic populations and for services delivered outside clinical settings
Reform health care payment to support the elements of the patient-centered medical home
Support the transitional costs for investment in IT, and reward those who already have made this investment and can document its benefits
Provide tax credits/deductions for participation in effective worksite and community behavior change programs
Shape pay-for-performance policies to provide incentives for evidence-based preventive services and for not delivering services that lack evidence

Slide 23

Infrastructure for Interface, Relationships & Coordination

Promote human systems and public and professional education programs that enable coordination of preventive services and the sharing of responsibility among individuals, families, primary and secondary care, health care systems, public health, & communities
Support research to better integrate health care and public health by expanding funding for the AHRQ and/or establishing a new NIH Institute for Integrated Health Care
Establish a CDC-based communication vehicle for supporting a culture of priority setting and shared responsibility
Establish a new CDC service equivalent to the Epidemiological Intelligence Service officer based on the U.S. Department of Agriculture's Extension Agent model, or expand the Extension Agent model to include promoting healthy behaviors. Charge this officer to serve as a "boundary spanner" between public health agencies, medical practice networks, and community groups and agencies

Slide 24

Opportunities for Reforming DP & HP

Health as function and meaningful relationships
Health care as relationships more than commodities
Health promotion as enabling environments and people
Boundaries between health an illness
Interfaces between people and systems
Recognizing commonality

Slide 25

Policy Options in Support of High-Value Preventive Care

Kurt C. Stange, MD, PhD
Steven H. Woolf, MD, MPH

http://www.prevent.org/content/view/197

Slide 26

Opportunities at the Interfaces

Current as of December 2009

Internet Citation: Reforming Disease Prevention & Health Promotion: Opportunities at the Boundaries: Slide Presentation from the AHRQ 2009 Annual Conference. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2009/stange/index.html