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Developing a Health Maintenance Schedule
John D. Prochaska, DrPH, MPH UTMB Department of Preventive Medicine & Community Health
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Learning Objectives To recognize stages of behavior change in clients / patients To understand how to tailor prevention based on the stage of the client/patient To outline the purpose of an organizational Health Maintenance Schedule To discuss the steps in developing a Health Maintenance Schedule
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What is Health Maintenance
Engaging in behaviors / activities / decisions to support health over the course of time rather than previously performed, less healthy behaviors How does a patient get to “maintenance”?
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Stages of Change Prochaska, et al.
Focused mostly on smoking cessation, but translates across multiple behaviors nicely Most follow 5 stages of change
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Pre-contemplation No intention for behavior change in next 6 months
May not be aware of the health harms of their behavior Intervene here by educating more about healthy behavior Encouraged to think about the pros of changing their behavior and cons of continuing less healthy behaviors Tend to overestimate the cons of change and underestimate the benefits
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Contemplation Intending to change in the next 6 months
More aware of the pros vs cons of behavior change Intervene by helping to reduce the impact of the cons (near the tipping point); remove barriers Balance between pros and cons can keep people here indefinitely
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Preparation Intending to take action in the very near future (next month or so) Usually have a plan, or are making a plan Assistance with developing or improving plan (including contingency management) can be helpful Management of expectations Will likely be amenable to enrollment into action oriented programs Smoking cessation program Medical weight loss Meeting with a physical therapist, physical activity professional, or dietician
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Action Overt action has been taken and sustained
Relapse is a primary concern here Inadequate planning Lack of commitment to plan Discouraged by lack or reality of results Starting with small wins can show early success which increases encouragement to maintain change
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Maintenance Maintenace begins when behavior change is maintained over 6 – 12 months Confident that change can be maintained Change is now the “new normal” Leading towards “Termination” Essentially risk of relapse is effectively 0 Relapse is still possible and a continuing threat during maintenance After 5 years, 7% of former smokers relapsed
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Examples of Maintenance of Frequent Behaviors
Exercising minutes, most days a week Nutritional program adherence Weight maintenance Smoking cessation Daily flossing
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What Maintenance Looks Like for Infrequent Behaviors
Conceptualized in 3 stages Initiation On-schedule Long-term maintenance / Completion Having ever engaged in maintenance behavior Adhering to guidelines at the most recent opportunity Long-term Maintenance / Completion Adherence across multiple previous opportunities Gierisch, et al. (2010). Am J Hlth Beh, 34 (6)
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What is a health maintenance schedule
A process for implementing prevention in patient care Defines goals of a given practice for delivering preventive services Should be in writing Removes ambiguity from what the practice is trying to achieve Practitioners can deviate from basic protocol based on preferences or patient circumstances
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Benefits of health maintenance schedule
Common statement of minimum standards of preventive care within the practice Ensures patients are consistently being provided with preventive health care Alignment among clinicians on the importance of prevention
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Developing a Health Maintenance Schedule
Consist of at least 6 components Plan for offering preventive services Clinician reminder plan Patient reminder plan Plan for engaging patients Incentive process Audit / evaluation process
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Common Barriers to Implementing Preventive Services
Lack of time Clinicians would need to spend over 7 hours each day to implement all USPSTF recommendations, 2 hours for just the strongest recommendations Uncertainty about the value of preventive services Conflict among recommendations
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Group Process Group processes help build consensus and buy-in among the practice group Goal is to set a minimum standard, rather than full consensus Remember: small diversions from the plan are acceptable The goal is to develop a minimum practice of prevention within the group
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Sources of Evidence-based Guidelines
Let’s look for some conflict Cervical cancer screening Prostate cancer screening Colorectal cancer screening Breast cancer screening Long URL for Sources:
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Evaluation Critical to any programmatic process Effectiveness
Efficiency Utility Desired outcomes Cost effectiveness Staff satisfaction Patient satisfaction Process improvements
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Elements to Consider Evaluating
Clinicians following schedule Why or why not Patients following schedule NOTE : THIS IS NOT FOR ASSIGNING BLAME IT IS THE PROCESS THAT IS BROKEN Develop changes to recommendations
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Choosing Interventions
Once the scope of and process for developing the schedule is established, need to start identifying and adopting recommendations U.S. Preventive Services Task Force National Guideline Clearinghouse Agency for Healthcare Research American Cancer Society Professional Organizations KEEP IT SIMPLE – Simple is what gets done
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Summary Patients are encountered at different stages of behavior change, and interventions should be tailored to their needs Health maintenance schedules align preventive services across a practice Provide minimum set of standards of practice Living document that should be continuously evaluated and updated
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