1. Developing a Health Maintenance Schedule
John D. Prochaska, DrPH, MPH
UTMB Department of Preventive Medicine
& Community Health

2. 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

3. 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”?

4. Stages of Change Prochaska, et al.
Focused mostly on smoking cessation, but translates across multiple behaviors nicely
Most follow 5 stages of change

5. 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

6. 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

7. 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

8. 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

9. 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

12. Examples of Maintenance of Frequent Behaviors
Exercising minutes, most days a week
Nutritional program adherence
Weight maintenance
Smoking cessation
Daily flossing

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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:

20. Evaluation Critical to any programmatic process Effectiveness
Efficiency
Utility
Desired outcomes
Cost effectiveness
Staff satisfaction
Patient satisfaction
Process improvements

21. 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

22. 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

23. 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