IMPLEMENTING PREVENTIVE
SERVICES Perry
Pong, MD
AMBULATORY CARE BLOCK
ROTATION SPRING
2004
LEARNER’s GOALS
At the end of the session, the learner will
be able to recognize his/her own attitudes towards preventive services and how they
impact on performance. The learner will begin to recognize barriers to
preventive services that exist for the patient, provider and society. The
learner will be able to select a preventive service and draft a plan to improve
the delivery of that service, utilizing either the barriers to care model or
the continuous quality improvement model.
ORGANIZATION OF THE
SESSION:
1 Questionnaire
2 Examining Barriers
3 Continuous Quality Improvement
4 Interventions
REVIEW QUESTIONS:
1. According to reviews of studies by The
Community Guide for Vaccine Preventable Diseases:
a.
Standing Orders for influenza or pneumococcal vaccine can increase vaccination
rates by 28%.
b.
Giving Assessment and Feedback to Providers can increase vaccination rates by
61%.
c. Reminding
Clients alone can increase vaccination rates by 33%.
d.
All of the above are true
2. According to the Put Prevention into Practice Program,
the essential elements for delivering preventive services are:
a.
Establish preventive care protocols
b. Define
staff roles for delivering and monitoring preventive care
c.
Determine patient and material flow
d.
Audit your delivery of preventive care continually
e.
Readjust and refine your delivery system and standards
f.
All of the above
SUGGESTED READING:
Web Sites
US Preventive Services Task Force:
http://www.ahrq.gov/clinic/uspstfix.htm
Put Prevention into Practice: http://
www.ahrq.gov/ppip/manual/
Guide to Community Preventive Services: http://www.thecommunityguide.org/
General References
Agency for Healthcare Research and Quality Pub No
APPIP01-001, May 2002 A step-by-step guide to delivering clinical preventive
services: a systems approach.
US Preventive Services Task Force. Guide to clinical preventive services, 2nd
ed. Baltimore: Williams & Wilkins, 1996.
Woolf S, Jonas S, Lawrence R eds. Health Promotion and Disease Prevention in
Clinical Practice. Baltimore: Williams & Wilkins, 1996.
IMPLEMENTING PREVENTIVE SERVICES
Ambulatory Care Block Rotation Spring 2004 Perry Pong,
MD
PART I ATTITUDES
1. I recommend the influenza vaccine to
patients.
Strongly disagree Neutral Strongly agree
1 2 3 4 5 6 7
2. I received the influenza vaccine this
past winter.
1 Yes 2 No
3. Studies show that the most effective
influenza prevention strategy in a nursing home is to:
1 Vaccinate all residents 2 Vaccinate all staff 3. Vaccinate all staff and residents
PART II THE PATIENT ENCOUNTER
1. Your first patient today is a 54-year-old
nurse’s aide with hypertension, obesity and low back pain. She is your regular
patient and says nothing is new, her back pain is the same. She takes hydrochlorothiazide, calcium
carbonate and an occasional ibuprofen. You glance at her chart, BP 135/85 P 72;
no Pap smear or mammogram in years, no advance directive, no immunizations
since childhood, no colonoscopy and menopausal since 2002.
CHECK THE THINGS YOU
CHOOSE TO DISCUSS TODAY:
|
Issue |
|
Issue |
|
|
Advance |
|
Low |
|
|
Cholesterol |
|
Mammogram |
|
|
Colonoscopy |
|
Obesity |
|
|
Depression |
|
Osteoporosis |
|
|
Diabetes |
|
Pneumococcal |
|
|
Domestic |
|
PAP |
|
|
Hepatitis |
|
Stool |
|
|
Hypertension |
|
Tetanus |
|
|
Influenza |
|
|
|
What is your strategy to accomplish the prevention issues
selected?
2. Your next
patient is a new patient: 23 year old
female needing a physical exam for graduate school.
CHECK THE PREVENTION
AREAS YOU CHOOSE TO DISCUSS TODAY:
|
Issue |
|
Issue |
|
|
AIDS |
|
GC/Chlamydia/RPR |
|
|
Alcohol |
|
Guns/Firearms |
|
|
Cholesterol |
|
Immunizations |
|
|
Contraception |
|
Nutrition |
|
|
Depression |
|
PAP |
|
|
Domestic |
|
PPD |
|
|
Drugs |
|
Seat |
|
|
Exercise |
|
Sexual |
|
|
Folate |
|
Smoking |
|
How did you make your choices?
How do you remember to do all that you checked?
PART III: THE PRACTICE
After graduation, you find a job in a group of 10 physicians
and nurse practitioners in Brooklyn. Your patients are diverse: young, old, with
many immigrants from the Caribbean and Latin America, and some older Italian
American and African American patients. Most have Medicare or Medicaid, some
have commercial insurance and about 10% are self-pay.
Because you are the newest hire, the medical director
assigns you to improve mammogram performance. The current percentage of
patients over age 50 having a yearly mammogram is 34%. Your target is 50%. The
radiology office is in the same building.
Outline your strategy (include resources needed, personnel
involved, timeline for implementation, and how you will get the staff and
doctors to “comply” with your recommendations):
POINTS TO MAKE:
Major:
1. Physician
factors
Pt factors
Organizational
Factors
2. What can the
physician do?
What does
the physician want to do?
3. Look at
processes, more than individuals
FACTS TO BRING UP
1. Time not
really the determining factor
Mayo clinic study- time not related
to prevention performance
2. Patient
factors are complex
3. Organization
is the key
Make it routine!
4. You will be audited by insurance
companies, outside agencies,
Boards! on how well you do. Might
as well excel at it.
WHAT TO DO?
Example: Vaccines
1. Standing
orders: example Flu vaccine
2. Reminders to
Providers
Assessment
and Feedback to Providers on Performance
3. Reminder
notices to Patients
Educational brochure was more
useful than just reminder letter
4. Flow Charts
Critical to have flow chart to keep
track of patient’s
5. Enhance
Access: Financial incentives, reducing out of pocket costs
Others:
1. Community
Involvement: Involve the patients in
planning
2. Flow Charts
3. Get all the
staff involved
4. Continuous
Quality Improvement
5. Audit
yourself
6. Disease
Management Trend
Community Control: Smoking Cessation
Ban, Increasing price of tobacco, media campaigns, quitter
telephone support with interventions
