The message is simple: deliver evidence-based clinical preventive services to help keep people healthy and save lives. Yet, research shows that even the most effective and accepted preventive services are not delivered regularly in the primary care setting. For example, although pneumococcal disease caused 10,000-14,000 deaths in 1997, only 43 percent of persons aged 65 and older received a pneumococcal vaccine (U.S. Department of Health and Human Services, 2000).
Barriers to making preventive services a routine part of patient care exist among clinicians, patients, and within the clinical setting. Clinicians report they do not have enough time to provide these services because most of their time is spent responding to patients' need for treatment (Frame, 1992; Kottke et al., 1993). Clinicians also cite competing demands, uncertainty about conflicting recommendations, and lack of training in prevention as barriers to providing clinical preventive services (Jaén et al., 1994).
Patients often do not ask their health care providers about preventive services because they are unaware of the benefits or availability of these services, are not motivated to seek them out, are deterred by what they perceive as the inconvenience and expense of preventive care (which their health plans may not routinely cover), and are worried about the discomfort they think preventive care may entail. In the clinical setting, barriers to providing preventive services include inadequate reimbursement for these services, patient mobility, and the lack of a system for integrating preventive services into regular patient care (Frame, 1992; Kottke et al., 1993; Stange, 1996; McPhee et al., 1989; Jaén et al., 1994; Solberg et al., 1997; Stange et al., 1998).
There is increasing evidence that many of these barriers can be overcome through a formal system for delivering clinical preventive services (Kottke et al. 1993). The Agency for Healthcare Research and Quality's (AHRQ's) Put Prevention Into Practice (PPIP) program presents such a system in this publication, A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach. The Guide describes easy-to-follow, logical steps to take you through the process. It is designed to be used by various audiences—physicians, nurses, health educators, and office staff—in public health clinics, community health centers, private practices, and other settings.1
1 Such settings will be referred to interchangeably as "clinics," "clinical settings," "practices," and "office settings" throughout this Guide.
A system is a process that integrates staff roles, responsibilities, and tools for the routine delivery of preventive care. In a system, individual responsibilities are defined, the flow of activities is specified, and performance is measured. A system must have an "owner" or champion: someone who will take responsibility for its implementation and monitoring (Frame, 2000).
Several studies provide evidence that implementing a formal system for delivering preventive services increases their delivery in the clinical setting.
The effect of implementing a system to deliver preventive services on the delivery rates of specific services was evaluated in two community health centers and three family practice residency programs at five Texas sites between September 1993 and February 1994 (Gottlieb et al., 2001). The new system included pre-auditing charts with reminder notices, using communication flow sheets, having patients use personal health guides for education and recordkeeping, and having clinicians use the Clinician's Handbook of Preventive Services (go to Chapter 6) to establish a preventive care protocol. With this system, 372 charts were selected for pre-auditing at baseline and 376 charts were selected for auditing 33-39 months after the new system was implemented.
Compared with baseline:
Documented tetanus-diphtheria vaccinations increased from 19 to 59 percent. For adults aged 66 and older, documentation of pneumococcal vaccination increased from 22 to 48 percent and influenza vaccination increased from 45 to 49 percent (not statistically significant).
Another study found statistically significant improvement in the documentation of patient education (assessment of risk plus appropriate counseling) delivered in five areas between 1994 and 1997 (Smith, unpublished data, 1994-97). Specifically, documented delivery of:
Kottke et al. (1992) tested a clinic-wide teamwork approach to delivering preventive services in 10 clinics at 29 sites in Minnesota. Responsibility was spread among staff for identifying smokers, assessing their smoking habits, advising them to quit, negotiating action, and providing follow-up counseling. Of the 466 patients reporting from these sites, 40.5 percent said that they had been counseled about smoking, compared with 26.4 percent of the 507 patients at the sites that did not deliver preventive care.
The Physician-Based Assessment and Counseling for Exercise (PACE) program was implemented to improve the rate and quality of counseling for physical activity in the primary care setting. In a controlled trial conducted in 17 physician practices, sedentary patients who received 3-5 minutes of counseling about physical activity plus a booster telephone call 2 weeks later demonstrated significantly higher rates of increased physical activity than those who were not counseled (Calfas et al., 1996). Investigators observed that in offices where this counseling was delivered consistently, forms were kept in convenient places, office staff had clear responsibilities for handing out PACE forms, and completed protocols were consistently found in charts.
Other studies have demonstrated that implementing a systems approach to delivering clinical preventive services is effective in increasing the rates of delivery of cancer screening (Carney et al., 1992; Kohatsu et al., 1994) and general disease prevention services (Dietrich et al., 1994a, 1994b) in the clinical setting.
The components of such a delivery system have been used and are documented in several studies (Frame, 2000; Carney et al., 1992; Dickey and Kamerow, 1994; Crabtree et al., 1998), the Texas adaptation of PPIP (Goodson et al., 1999; Goodson, in press; Smith, 1999; Gottlieb et al., 2001), and business literature (Mink et al., 1991, 1993; Senge, 1990; Wheatley, 1994; Argyris, 1990). There is scientific evidence to support the effectiveness of using certain tools in a system to deliver preventive services—such as preventive care flow sheets (Prislin et al., 1986) and reminder notes on patient charts (Chang et al., 1995; Cohen et al., 1989; Briss et al., 2000), standing orders (Briss et al., 2000), assessment and feedback to providers (Briss et al., 2000), and patient reminders, including telephone calls, letters, or postcards (Briss et al., 2000). The steps described in this Guide are based on empirical evidence.
PPIP can improve and enhance the system you already use in your clinic. It doesn't replace it, and can be easily incorporated into the normal processes of your daily clinic operation.
—Carol Mancinas
Health Educator, San Antonio, TX
This Guide explains how a system to effectively deliver clinical preventive services can be implemented in your setting. Although systems for delivering clinical preventive services vary among settings, the following steps will help you design a system appropriate for yours. These steps are described briefly below and are explained in detail in the chapters that follow:
Clinical practices use protocols for the delivery of preventive services as guides to adopting their own minimum acceptable standards of preventive care. Such evidence-based protocols are developed by the U.S. Preventive Services Task Force (USPSTF) and other organizations. Determining which preventive care protocols to adopt is complicated by the need for clinical settings to comply with the differing requirements and programs of each of the health plans with which they contract.
In an attempt to streamline the incorporation of preventive services into clinical practice, several groups have collaborated on a common set of guidelines and protocols. Much of this collaboration has been driven by the desire to meet the Health Plan Employer Data and Information Set (HEDIS) requirements. The Massachusetts Health Quality Partnership, the Atlanta Quality Council, the Colorado Clinical Guidelines Collaborative, and the Foundation for Healthy Communities are just a few of the groups that have developed and made available clinical preventive services guidelines and standards (go to Chapter 6, for more information about these groups).
It is important for the entire office staff to be involved in delivering preventive services so that the tasks are spread out among many staff members. Delivering preventive care requires a team approach. Counseling, a clinical preventive service in which all clinical staff can play key roles throughout a patient's office visit, should involve several staff members who take on different yet coordinated and complementary roles. Counseling to promote a healthy diet can be used as an example:
Specifying the people with whom the patient meets and interacts, and the nature of each interaction, is important. The flow of information and tools, such as flow sheets and health risk profiles, also needs to be determined. For example, determine when and where staff will administer the health risk profile to the patient (Chapter 6).
Monitoring performance helps determine how well a practice is delivering preventive services and what changes are needed to improve the delivery of preventive care.
Based on the results of your audits, you may decide that the clinician is having difficulty determining either (1) which preventive services are needed or (2) whether the preventive services being delivered are being documented routinely. You also may find that recommendations on providing certain screening tests have changed. The staff in your clinical setting will then need to determine how to readjust practices and adopt or develop new standards.
Predictors of Successful PPIP Initiation in Texas
A study of PPIP program initiation in nine Texas sites—including family practice residency programs, community health centers, and public health primary care sites participating in a demonstration project funded by the Texas Department of Health—identified several predictors of successful PPIP program initiation (Goodson et al., 1999; McVea et al., 1996; Dietrich et al., 1992).
One of the most frequently cited predictors is the use of outside facilitators to help establish and analyze the system for preventive services delivery, to facilitate the group process needed for implementation, and to help identify obstacles and ways to overcome them. Researchers also identified the involvement of internal facilitators who serve as program champions as predicting successful program initiation (Crabtree et al., 1998).
This Guide is for professionals with a wide range of experience in delivering clinical preventive services. It is an interactive tool that includes activities, exercises, and questionnaires to help you implement a system for delivering preventive care. It can be tailored to fit your needs. You may want to read some sections carefully, scan others, and use or adapt the forms as needed. You may not need to complete all of the exercises and chapters, but may prefer to select the information that would be most useful and use the corresponding worksheets.
The process described in this Guide is intended for clinical settings that use paper-based medical records; however, much of the information would also be useful for settings in which electronic medical records are used.2 The use of electronic medical records in clinical settings is increasing. They can improve preventive services delivery through features that provide practice-wide and unique patient protocols, track the provision of preventive services, provide physician reminders at patient visits, generate patient reminders, and provide relevant patient education resources (Ornstein et al., 1993).
This Guide is divided into six chapters and five appendixes. Chapters 1-5 describe the process of designing, implementing, and evaluating a system for delivering clinical preventive services. Figure 1 outlines the steps covered in each chapter (more detailed versions of this figure appear at the beginning of Chapters 1-5). These chapters include suggested activities and worksheets. Chapter 6 describes the purpose of PPIP materials and how to use them.
The appendixes contain the following materials:
Why Should You Use This Guide?
2 Contact the Medical Records Institute (http://www.medrecinst.com) for information about electronic medical records.
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