Effective interventions that address personal health practices are likely to lead to substantial reductions in the incidence and severity of the leading causes of diseases and disability in the U.S. Primary prevention as it relates to such risk factors as smoking, physical inactivity, poor nutrition, alcohol and other drug abuse, and inadequate attention to safety precautions holds greater promise for improving overall health than many secondary preventive measures such as routine screening for early disease. Therefore, clinician counseling that leads to improved personal health practices may be more valuable to patients than conventional clinical activities, such as diagnostic testing.
— Office of Disease Prevention and Health Promotion,
1996, pp. xxix-xxx.
Clinicians, office settings, and patients use prevention materials in different ways. Clinicians use them as the evidence-based foundation for delivering preventive care. Office settings use them to develop a system for improving the delivery of preventive services. Patients use them to understand and keep track of the preventive care they receive. This chapter describes U.S. Preventive Services Task Force (USPSTF) and Put Prevention Into Practice (PPIP) resources and related materials and suggests how to use them in your setting.
The materials described in this chapter—particularly the health risk profiles, preventive care flow sheets, posters, and patient education materials—have been designed to be used in counseling patients. Descriptions of the materials that follow explain how they may be used for this purpose.
Patient Materials
1 To order these publications, E-mail your request to AHRQPubs@ahrq.hhs.gov or call the AHRQ Publications Clearinghouse: 1-800-358-9295.
2 Publications in the PPIP series.
The USPSTF is an independent panel of experts in primary health care and prevention that systematically reviews the evidence of effectiveness of a wide range of preventive services—including screening tests, counseling, and chemoprevention—and then recommends the services that clinicians should routinely provide as part of primary health care.
Recommendations and Evidence Reviews. Release of the recommendations of the current USPSTF, and the evidence on which they are based, began in the Spring of 2001. AHRQ will release new and updated USPSTF recommendations, evidence summaries, and Systematic Evidence Reviews individually on AHRQ's Web site and in print as they are completed.
Select for a description of USPSTF products. To order, please E-mail your request to AHRQPubs@ahrq.hhs.gov, or call the AHRQ Publications Clearinghouse: 1-800-358-9295.
Guide to Clinical Preventive Services, Second Edition. The USPSTF Guide to Clinical Preventive Services, second edition, contains recommendations from the previous USPSTF, based on data available through 1995, on delivering more than 200 preventive services in the primary care setting. This Guide helps clinicians determine which preventive services to provide their patients.
Principal Findings of the Second U.S. Preventive Services Task Force
Clinician's Handbook of Preventive Services, Second Edition. The Clinician's Handbook of Preventive Services, second edition, is a reference for clinicians and office staff. The Handbook includes evidence-based recommendations of the previous USPSTF and 51 other major medical authorities, provides detailed instructions for performing each preventive service recommended, and refers readers to hundreds of patient and provider resources.
The Handbook can be used by clinicians and office staff to create a protocol for preventive care, to teach or remind them how to deliver preventive services, to serve as a resource for clinical preventive care guidelines, and to locate patient and provider resources.
The Handbook is divided into four main sections:
Guide to Community Preventive Services. While the USPSTF Guide to Clinical Preventive Services provides evidence-based recommendations for delivering preventive care in the clinical setting, the Centers for Disease Control and Prevention (CDC) Guide to Community Preventive Services provides evidence-based recommendations for delivering preventive services in the community. Systematic reviews are conducted for interventions in each health topic and organized as "chapters." Chapters will address:
The Guide to Community Preventive Services will help public health practitioners and others make informed decisions for selecting and implementing community preventive services.
For more information and to view individual chapters as they become available, search the Web site for this Guide (www.thecommunityguide.org) or call 1-770-488-8189.
Health risk profiles (HRPs) are tools to help office staff and clinicians identify whether age, gender, or health-related behaviors put the patient at risk for cardiovascular disease, diabetes, certain types of cancer, certain infectious diseases, and other conditions. The identification of risk factors guides the clinician in deciding which screenings, immunizations, patient education, and follow-up to provide each patient. (The HRP is not a patient health history.
You may need to adapt the HRP to fit the minimum standards for preventive care that your setting creates.
Patients will walk out of the clinic and say, "Wow, nobody's ever asked me these questions before. I didn't know that I had this particular risk factor."
— Teresa Ruiz, MD,
Pediatrician, San Antonio, TX
Office staff should complete the HRP annually as part of a comprehensive health assessment for all adult patients and more frequently for children. Clinicians can use the HRP to:
After completing the HRP, the preventive care flow sheet should be initiated to document patient education, counseling and referrals, the results of screening tests or examinations, and immunizations given.
HRPs are tools to aid in risk assessment and do not cover all possible risk factors. You can either use the HRPs "as is" or modify them to fit your patient population's needs.
Preventive care flow sheets help office staff and clinicians monitor and document physical examinations and test results, counseling provided, and immunizations administered to patients. These flow sheets can also serve as reminders of which preventive services your setting recommends. The preventive services listed on the flow sheets should be based on the risks identified on the HRP and the preventive care standards adopted by your setting.
There is evidence that using preventive care flow sheets can increase the documentation of clinical preventive services. In a study conducted with patients from the Oregon Health Sciences University Family Practice Center, researchers concluded that inserting flow sheets into patient charts increased the documentation of two preventive services studied-fecal occult blood testing and breast examinations (Prislin et al., 1986).
The flow sheets correspond to the HRPs. If an HRP is changed, then the appropriate flow sheet must be modified to reflect these changes.
The Adult Preventive Care Flow Sheet lists recommended preventive services, including immunizations, as well as space for recording the services. The Child and Adolescent Preventive Care Flow Sheet also lists recommended preventive services, with the exception of immunizations. Instead, the Child Immunization Flow Sheet lists the recommended immunizations for children and adolescents and includes space for recording the immunizations administered. The reverse side of this flow sheet contains more detailed information about each recommended immunization.
Purpose of Preventive Care Flow Sheets
Preventive care flow sheets will allow you to identify:
Along with improving the quality of life, having a system for documenting preventive care is important, since managed care organizations and other accrediting organizations are looking for documentation in patients' medical records.
— Carol Mancinas,
Health Educator, San Antonio, TX
Using Preventive Care Flow Sheets. Office staff should start a flow sheet when the patient receives an annual risk assessment, recording dates of previous screenings, exams/tests, counseling, and immunizations. Staff should update the flow sheet during the year as a test or exam is completed, results are received, or counseling is provided. The flow sheet is designed to work in conjunction with the HRP. Any risks found on the HRP must be addressed in the appropriate area of the flow sheet.
One of the things that helped people get over their fear of using PPIP was the fact that you do not have to address every issue—that one or two items can be approached and discussed and documented. It didn't have to be the whole program.
— Mia Latham, RNC
Lubbock, TX
Chart reminders can be used to alert the nurse or clinician to needed preventive services, such as screening tests, immunizations, and/or counseling and education. These reminders can be stickers or pieces of paper—often brightly colored—attached to the front of patient charts. Although these are not PPIP tools, you may decide to create your own and use them as part of your new system for delivering preventive care.
Research shows that chart reminders can increase rates of the delivery of preventive services. Chart reminders have been particularly effective in increasing the rate of smoking cessation counseling by physicians (Chang et al., 1995; Cohen et al., 1989).
Using Chart Reminders. The day before a patient's visit, a staff member should review the patient's chart, including the completed HRP and preventive care flow sheet from the previous visit, and record on a "reminder note" the screening tests, immunizations, and counseling needed. The note should then be placed in a conspicuous place on the chart.
Office staff can send postcards to remind patients to return to the clinical setting for specific screening tests, immunizations, followup, or the annual assessment.
Ideally, a staff member (or even the patient) will complete a reminder postcard while the patient is in the office and mail the postcard to the patient a month before the patient is to return for a visit. To ensure the patient's privacy, fold and staple or tape the card before mailing.
The PPIP adult and child preventive care timeline posters depict USPSTF-recommended preventive care in a timeline format. Displayed in the examining room, they are quick references for clinicians and educational tools for patients.
You can discuss the materials described below with your patients. You can encourage them to take these materials home, read them, and bring them back at their next office visit.
Prevention prescriptions are tools designed to educate patients, motivate and remind them to change behaviors that put their health at risk, and reinforce clinician-patient discussions about prevention. Prevention prescriptions are given to the patient by the clinician at the end of the office visit. The clinician should deliver these along with brief advice about changing behaviors that put the patient at risk for disease, such as smoking and physical inactivity. The prescriptions can be printed with carbonless duplicate sheets so that a copy of the instructions given to the patient can be placed in the patient's record. Sample adult prevention prescription forms are included in Appendix D. These forms were adapted from those created by the TDH.
The Personal Health Guide, the Child Health Guide, and Staying Healthy at 50+ (available in English and Spanish) are pocket-sized booklets that provide patients with information about preventive care and guide them in changing behaviors that put their health at risk:
These booklets also help patients and providers assess patient risk for health problems and plan individualized schedules for delivering preventive services. These guides include simple charts to track personal health information, questions to ask health care providers, and other resources. Clinicians and office staff should encourage patients to note in their booklets when preventive services are due and to request these services as needed.
Using the Health Guides. Office staff can use the health guides as aids when counseling patients about the patient's role in preventive care. If this is the patient's first PPIP assessment, staff should issue the appropriate guide and instruct the patient briefly about how and when to use it. (This task may best be performed by the front office staff, but may be performed by others during the patient's visit.) Include the date the counseling is provided, and by whom, beside the corresponding topic on the appropriate prevention care flow sheet.
Helpful Hint
Encourage your patients to write test results and appointment/exam dates in their personal health guides. Reinforce positive behavior changes at every patient encounter. Offer assistance in taking notes, if needed, or identify family members who can help with notetaking.
Be creative in using additional materials, and remember that patients' education begins when they enter your clinical setting. Explore the possibility of attaching prevention messages to bare walls, doors, and restrooms.
Use colorful posters and lively messages as effective ways of reinforcing information that patients receive when interacting with office staff. Remember to change your messages frequently so they do not become part of the scenery.
Have educational materials about prevention available in the waiting room. Such material can include pamphlets that are eye-catching and easy to read and videotapes that tell stories and depict role models for preventive behaviors.
Helpful Hint
Some clinical settings use the patient's birthday for scheduling the annual assessment.This may help patients and staff remember to schedule a yearly appointment.
We encourage you to send us your comments and let us know about your experiences in delivering clinical preventive services using the PPIP program and materials. We plan to update this publication as needed to include new ideas, new research findings, and new information. To contact us, send an E-mail to info@ahrq.gov.
Agency for Healthcare Research and Quality. Child Health Guide (AHRQ Publication No. APPIP 98-0026). Rockville, MD: Department of Health and Human Services, Agency for Healthcare Research and Quality, 2000.
Agency for Healthcare Research and Quality. Staying Healthy at 50+ (AHRQ Publication No. AHRQ00-0002). Rockville, MD: Department of Health and Human Services, Agency for Healthcare Research and Quality, 2000.
Chang HC, Zimmerman LH, Beck JM. Impact of chart reminders on smoking cessation practices of pulmonary physicians. Am J Respir Crit Care Med 152:984-987, 1995.
Cohen SJ, Stookey GK, Katz BP, et al. Encouraging primary care physicians to help smokers quit. Ann Intern Med 110:648-652, 1989.
Office of Disease Prevention and Health Promotion. Guide to Clinical Preventive Services, 2nd ed. (AHRQ Publication No. OM97-0001). Washington, DC: U.S. Government Printing Office, 1996.
Office of Disease Prevention and Health Promotion. Personal Health Guide. (AHRQ Publication No. APPIP98-0027) Rockville, MD: Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1997.
Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services, 2nd ed. (AHRQ Publication No. APPIP98-0025) Rockville, MD: Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1998.
Prislin MD, Vandenbark MS, Clarkson QD. The impact of a health screening flow sheet on the performance and documentation of health screening procedures. Fam Med 18:290-292, 1986.
Brody DS, Miller SM, Lerman CE, et al. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care 27(11):1027-1035, 1989.
Cogswell B, Eggert MS. People want doctors to give more preventive care: A qualitative study of health care consumers. Arch Fam Med 2:611-619, 1993.
Green LW. Health Education Planning: A Diagnostic Approach. Mountain View, CA: Mayfield, 1980.
Griffiths W. Health education definitions, problems, and philosophies. Health Education Monographs 31:12-14, 1972.
Mink O, Esterhuysen PW, Mink BP, et al. Change at Work: A Comprehensive Management Process for Transforming Organizations. San Francisco: Jossey-Bass, 1993.
National Task Force on the Preparation and Practice of Health Educators, Inc. A Framework for the Development of Competency-Based Curricula for Entry Level Health Educators. New York: National Task Force on the Preparation and Practice of Health Educators, 1983.
Redding JC, Catalanello RF. Strategic Readiness: The Making of the Learning Organization. San Francisco: Jossey-Bass, 1994.
Schauffler HH, Rodriquez T, Milstein A. Health education and patient satisfaction. J Fam Pract 42(1):62-68, 1996.
Senge PM. The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday, 1990.
Weston DM. Organizational Learning as Strategy: Promoting Long-term Success Through Learning. (Report No. 827). Menlo Park, CA: SRI International, Business Intelligence Program, 1994.
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