Presenters: Kellee R. Bivens, PhD Sheila Phillips, RN, BSN

Health Promotion and Disease Prevention Program

VA Gulf Coast Health Care Systems

Implementing a Behavioral Approach to Health Promotion and Disease Prevention

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Objectives:

1. Describe the TEACH patient education model and discuss its value to primary care staff and patients

2. Describe how a behavioral approach facilitates patient centered care

3. Describe the 9 Healthy Living Messages and how they are integrated into the Patient Centered Medical Home model

VHA Preventive Care Program

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Core Elements:• Infrastructure• Integration with PACT• Tools and Resources

Vision of VHA Preventive Care Program

The Veteran will experience health promotion and disease

prevention (HPDP) clinical interventions that are seamlessly

integrated across the continuum of their health care and are

delivered in a variety of modalities matched to the Veteran’s

needs and preferences. VHA clinicians and clinical support

staff will value and participate in the delivery of HPDP

interventions for patients as appropriate to each Veteran’s

priorities and overall plan of care.

Prepared,Proactive

Practice Team

Informed,Activated

Patient

Productive Interactions

Functional and Clinical Outcomes*E. Wagner, MD, W.A.MacColl Institute, Group Health Cooperative of Puget Sound

Health SystemOrganization of Health CareSelf-

Management Support

DecisionSupport

DeliverySystemDesign

ClinicalInformation

Systems

CommunityResources and Policies

A Model for Planned Care*

PACTTeamlet

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Assumes knowledge drives change

Clinician sets agenda

Goal is compliance

Decisions made by caregiver

Assumes knowledge + confidence drives change

Patient sets agenda

Goal is enhanced confidence

Decisions made collaboratively

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PACT TransformationA Fundamental Shift in the Process of Care

Traditional Care Collaborative Care

(Bodenheimer et al, CA Health Care Foundation, 2005)

Principles of PACT

• Patient-centered• Ongoing relationship with a primary care

team• Patient is full partner with team• Comprehensive: whole person orientation • Easier communication

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Implementing PACT Principles• Staff training in patient-centered

communication– TEACH for Success course (health

coaching)• Facilitators: Health Behavior

Coordinators and Veterans Health Education Coordinators

– Motivational Interviewing training• Facilitators: Health Behavior

Coordinators

– Follow-up mentoring and coaching

TEACH Philosophy

• Evidence-based best practice• Holistic approach to patient care• Patient-centered• Patient self-management• Partnerships with patients

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TEACH Philosophy

• Shared decision making• Interdisciplinary process• Practical, specific techniques• Meets The Joint Commission standards• Goal: improve competencies

TEACH Target Audience

Clinical staff involved in educating patients:– PACT teamlets & expanded teams– Nurses & advanced practice nurses– Physicians & physician assistants– Dietitians– Pharmacists– Psychologists– Social workers– Therapists—physical, occupational, speech, hearing

Premises of Course

1.Health education makes a difference–health outcomes–patient & clinician satisfaction

2.Health education skills can be learned and mastered with practice

TEACH Goals

• Skills development—patient-centered health education, health coaching, partnering– Mastery requires practice & feedback– Follow-up: reinforcement & boosters

• Participants use strategies & techniques with Veterans

TEACH Course UnitsT Tune in to the Patient

E Explore the Patient’s Concerns, Preferences, and Needs

A Assist the Patient withBehavior Changes

C Communicate Effectively

H Honor the Patient as a Partner

Introduction

• Assess own patient education skills• Course overview

Tune in to the Patient• Most effective approaches to build

rapport with patients

• How to quickly establish & maintain effective relationships with patients

• Clinician behaviors that help or hinder effective clinician-patient relationships

• Effective listening & questioning skills

Explore the Patient’s Concerns, Preferences and Needs

• Components of a learning assessment

• How to assess a patient’s level of importance & confidence for a health behavior

• Quick needs assessment method

• How to detect limitations to learning

Assist the Patient with Behavior Change

• Health coaching framework– Elements– Benefits

• Process

• Health coaching practice

Communicate Effectively

• How to incorporate tailoring into communications with patients

• How to help patients deal with strong emotions such as fear

• How to deal with patient ambivalence

• How to deal with patient resistance

Honor the Patient as a Partner

• Characteristics of effective clinician-patient partnerships

• How to assess clinician & patient preferences for partnering

• How to incorporate both clinician and patient perspectives in goal setting, decision making, treatment & learning activities

Definition of Health Coaching

Health coaching is the practice of health education and health promotion within a coaching context to enhance the well-being of individuals and to facilitate the achievement of their health-related goals.

Palmer S, Tubbs I, and Whybrow A. (2003) Health coaching to facilitate the promotion of healthy behaviors and achievement of health-related goals. International Journal of Health Promotion & Evaluation, 41(3), pp. 91-93

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Health Coaching Characteristics

• Collaborative, not directive• Patient-centered• Supports patient autonomy• Empowers patient for self-management

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Goals of Health Coaching

• Help patients– Clarify personal health goals– Implement and sustain healthy behaviors– Reduce negative impact of chronic disease

• Guide patients in self-management– Skill development– Problem solving

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Importance for VHA

• Many Veterans have chronic diseases and the number is increasing.

• Poor health behaviors lead to and complicate chronic diseases.

• Improving poor health behaviors is key to improving health.

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Benefits of Health Coaching

• Consistent with PACT and Preventive Care Program

• Framework for making PACT principles and goals operational in practice

• Strategies are easy to learn and use• Positive effects for both staff and patients– Health outcomes– Satisfaction

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Who are the health coaches?

• All PACT team members can coach patients

• Degree of involvement in health coaching may differ among team members

• Trained patients can coach other patients

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Delivery Models

• Face to face during a clinic visit• During group visits• In classes, especially self-management

programs• Over the telephone• Via the Internet

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Process of Health Coaching

1. Establish a positive relationship with the patient• Develop a partnership with the patient• Explain your role as a coach

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Process of Health Coaching

2. Elicit the patient’s concerns and issues• Use active listening skills• Express empathy

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Process of Health Coaching

3. Set an agenda with the patient for this session

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Process of Health Coaching

4. Connect the coaching topic to the patient’s life goals and values• Focus on the whole person, not just a specific

diagnosis or behavior

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Process of Health Coaching

5. Acknowledge the patient’s likes, dislikes and preferences• Empower the patient by reminding him/her that

the choices are his/hers to make• Offer to help the patient find the answers that

will work best for him/her

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Process of Health Coaching

6. Ask before telling• Ask what the patient already knows and what

the patient wants to know• Provide new information and clarify

misperceptions as needed• Invite the patient to consider a different

perspective• Confirm the patient’s understanding

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Process of Health Coaching

7. Ask the patient how important he/she thinks it is to change

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Process of Health Coaching

8. Help the patient set a goal• Ask the patient to identify something he/she

can do to improve his/her health

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Process of Health Coaching

9. Help the patient create an action plan• Ask the patient how confident he/she is to

reach the goal• Help the patient modify the action plan as

needed

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Process of Health Coaching

10. Develop a follow-up plan with the patient

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Health Coaching Applications

Video Example

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Motivational Interviewing

Intensive facilitator training with follow-up mentoring for:• Health Behavior Coordinators• Veterans Health Education Coordinators• Health Promotion/Disease Prevention Program Managers

Training/coaching by Health Behavior Coordinators for:• PACT staff• Other clinicians

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Presenter: Sheila Phillips, RN, BSN

Health Promotion and Disease Prevention Program

VA Gulf Coast Health Care Systems

How the 9 Healthy Living Messages are integrated into the Primary Care Medical Home Model.

VA Mission Honor America’s Veterans by providing exceptional health care

that improves their health and well being.

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Health Promotion and Disease Prevention

Ultimate Goal

To create the best primary care delivery model in the world and thereby create one of the healthiest populations in the

country!

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Health Promotion and Disease Prevention (HPDP) Initiative

• National 2010 Health Care Reform– HPDP initiative provides two parts to the new bill.

• National Directive

• Joint Commission– National Patient Safety Goals are integrated into HPDP.

• Evidence-based care – a systematic review capable of improving quality and consistency in healthcare.

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- Healthy Living Messages for Veterans - Are actions taken to protect oneself or those you love from disease!

• Top five chronic diseases: Cardiovascular, Stroke, Cancer, Chronic Obstructive Pulmonary Disease & Diabetes.

• These account for 95 cents out of every dollar spent on health care and two out of three deaths.

• The World Health Organization estimates that 80% of heart disease, stroke and type 2 diabetes and > 40% cancers are preventable if you stop smoking, eat healthier and get physically active.

• The evidence has lead to the development of the 9 Healthy Living Messages and to encourage our Veterans to chose healthier lifestyles.

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1. Get Involved with Your Health Care• Getting involved in your health care. There are many

ways to take an active role. Work with your Patient Aligned Care Team (PACT) to improve your health.

• WWW.MyHealtheVet.com is now available for veterans to access their health record. Please take advantage of this opportunity.

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• Meaningful Use means providers need to show they are using certified Electronic Health Record technology in ways that can be measured in quality and in quantity. According to Centers for and Medicare Services (CMS), the five broad goals of Meaningful Use are to:– Improve quality, safety, efficiency, and reduce health disparities – Engage patients and families – Improve care coordination – Improve population and public health – Ensure adequate privacy and security for personal health information

• The American Recovery and Reinvestment Act of 2009 describes Meaningful Use.

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2. Be Tobacco Free• Don’t use tobacco in any form. If you are using

tobacco, the VA can help you quit. Avoid second hand smoke. If you are pregnant both you and your baby will benefit when you quit using tobacco.

• Tobacco use and exposure to secondhand smoke kill approximately 443,000 people in the United States each year.

• VA offers Tobacco Cessation groups, one on one appointments, follow up

and medications to help stop tobacco use. www.tobaccofree.org

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3. Eat Wisely

• Maximize your health by eating wisely. Eat a variety of foods including vegetables, fruits and whole grains. It is important to include fat-free or low-fat mild and milk products in your diet, and limit total salt, fat, sugar and alcohol.

• VHA offers nutrition counseling through it’s dietitians. It is easy to get a consult submitted by the RN Care Nurse assigned to your PACT teamlet.

• The VHA’s website www.MOVE.org is available to assist you with your nutritional, physical activity & healthy weight.

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www.MyPyramid.gov, Steps to a Healthier You.

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4. Be Physically Active• Avoid inactivity. Some activity is better than none. Aim

for at least 2 ½ hours of moderate-intensity aerobic activity each week. Every 10 minute sessions counts. Do strengthening activities at least 2 days each week.

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Physical activity will add:

YEARS TO YOUR LIFE

and

LIFE TO YOUR YEARS

5. Strive to Maintain a Healthy Weight• Losing even a little weight helps, if you need to lose weight. If you are at

a normal weight, maintain it. Staying in control of your weight helps you be healthy now and in the future.

• A simple way to know if you are at a healthy weight is to know your body mass index (BMI). – BMI Guidelines:

• Underweight = BMI less than 18.5 • Normal weight = BMI of 18.5—24.9 • Overweight = BMI of 25—29.9 • Obesity = BMI of 30 or greater

• A reasonable and safe weight loss is 1-2 lbs per week. It might take 6 months to reach your ultimate goal, but making gradual lifestyle changes can help you maintain a healthier weight for life.

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6. Limit Alcohol• If you choose to drink alcohol, drink in moderation (women no more

than 1 drink a day; men no more than 2 drinks a day). Avoid “binge drinking.” If you are concerned about your drinking, talk to your VA health care team about getting help.

• Binge drinking is having more than 3 drinks on one occasion for women and adults over age 65. More than 4 drinks on one occasion for men.

Alcohol MisuseGoal: Improve Detection and Management of Alcohol Misuse in Primary

CareClinical Implementation

Improved efficiency and standardization of alcohol screeningCPRS clinical reminder for brief alcohol counseling

Participation in national efforts to integrate mental health care in primary care

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7. Get Recommended Screening Tests and immunizations -

• Get the right preventive services including vaccines, screening tests, and preventive medications. The pros and cons of receiving each service depend on your age, gender and health status. Find out which vaccines, screening tests and preventive medications are right for you!

• NCP website: www.prevention.va.gov

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8. Manage Stress

• Pay attention to stress. Tools are available to help you manage and reduce your stress.

• If you or someone you know is in an emotional crisis call The Veterans’ Hotline at 1-800-273-TALK and press 1 for Veterans.

• There are several strategies you can use to cope with or manage stress.

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9. Be Safe • Protect yourself and those you love from harm.

• Common Safety issues –

• Prevent sexually transmitted infections

• Prevent Falls

• Prevent Motor Vehicle Crashes and Injury

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Integrating the 9 Healthy Living Messages into the Patient Aligned Care Teams

• Clinical Staff Guide for Healthy Living Messages

Promotes an effective patient-centered interaction through evidence based in information about the HLM to initiate discussions or response to Veterans’ questions about healthy behaviors.

• My Health Choices (goal setting tool) - used to help Veterans choose an area of interest and for

health behavior goal-setting and action planning.

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Integrating Interventions in Patient Aligned Care Teams & Health Promotion/Disease Prevention

• Program charter developed to create a purpose and designate committee members who implement the mission and vision of the program.

• HPDP Program goals were developed and initiated through a team effort .

• An internal resource scan is being developed, which lists available VA services.

• The HPDP Program is introduced in New Employee Orientation.

• HPDP team effort to ensure clinical reminders (screenings/immunizations, etc.) are aligned with VHA preventive clinical guidance statements.

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HPDP Interventions in the planning phase:

• Prevention visits by RN Care Coordinator

• Care Coordination/Home TeleHealth collaboration

• New Patient Orientation

• Action Plan - Management of Diabetes Mellitus in Primary Care

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Health Promotion and Disease Prevention Benefits

Everyone

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Case Study of Health Coaching in the

PACT Model

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Karl

59 y/o Vietnam Veteran with high BP poorly-controlled diabetes poor diet, physical inactivity depression arthritis stress

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First VHA Contact

Attends a Vietnam Veterans of America (VVA) meeting and hears a talk about health and well-being presented by VHA staff member. Picks up a brochure and information about services.

VA Medical Facility Contact

• Calls for appointment– While on hold briefly, hears a message promoting

physical activity.– Gets appointment for a New Patient Orientation

group visit

New Patient Orientation group visit

• Gets information about healthcare services offered by VA medical facility

• Learns about programs and educational resources to help him improve and maintain his health.

• Registers for My HealtheVet and gets “in-person authenticated”

My HealtheVet

• Goes to My HealtheVet website to:– Complete the online Health Risk

Assessment and get feedback report

– Search for more health information in online Veterans Health Library

– Sign up for Secure Messaging

HRA hosted by My HealtheVet

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Demo only

Next…

• Veterans Health Benefits Handbook

• Appointment letter for visit with primary care team

• Brochure about healthy lifestyle

First Primary Care PACT Visit

• At the medical center, he notices:– Posters on walls with health

promotion messages– Video on CCTV in waiting room

about healthy living– Signs encouraging taking the

stairs

In Primary Care PACT Clinic

• Greeted by clerk– Asks him how he’d like to be

addressed– Encourages him to write down

any questions for the provider and other PACT team members

In Primary Care PACT Clinic

• Clinical Associate– Explains concept of PACT care– Begins completing clinical reminders, including

depression, PTSD screening– Asks about current meds and any changes – Takes vitals– Wears an “Ask Me about MOVE! button”

In Primary Care PACT Clinic

• RN Care Manager– Addresses needed clinical preventive services– Notes (+) screen for depression, follows up– Utilizes MI to address obesity– Offers options for self-management support:• Group face-to-face sessions• TeleMOVE support• Telephone Lifestyle Coaching program• Web-based weight management program

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In Primary Care PACT Clinic

• RN Care Manager– Uses MI to address physical activity and healthy

eating – Uses My Health Choices tool to help Karl set goals

and develop an action plan– Uses clinical reminder to document– Follows up as requested

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In Primary Care PACT Clinic• Provider– Reviews current problems, medical history, meds, does

exam– Reviews HRA responses, feedback– Addresses any complex issues related to clinical

preventive services– Discusses goals, action plan, supports behavior change– Writes scripts– Refer to individual/group wellness or disease

management clinics, PC-MHI as appropriate

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Wellness Clinic

• Led by Health Coach (RN or mid-level provider)– In-depth session on health-related behaviors (PA,

healthy eating, weight management, stress, etc.)– Uses MI techniques to address ambivalence and

TEACH communication/health education skills and teaches problem-solving skills

– Reviews action plan, goals– Describes other VA and community resources

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Impact on Karl and his Family

• Well-informed about his conditions, risks• Able to choose preferred format of care• Participating in MOVE! and beginning to

improve his diet, increase his physical activity, and lose weight

• Self-managing his diabetes better• Depression, arthritis under better control• Using problem-solving, less stress

Behind the Scene

• HPDP Program– HPDP Program Manager– Health Behavior Coordinator– HPDP Program Committee • Broad representation on

committee/subcommittee

Behind the SceneSelf-Study Orientation Program • Role-specific orientation checklists (HPDP PM, HBC and VISN

HPDP Program Leaders)

• Orientation modulesPhases I and II Phase III • Overview and General Role Orientation• Resources and Communication• Core Prevention Messages• Clinical Preventive Services• Evaluation and Measurement• MOVE! Weight Management Program• Veterans Health Education and Information• Primary Care- Mental Health Integration• Employee Wellness

• Patient Aligned Care Teams (PACT)• Systems Redesign• My HealtheVet

Behind the Scene• Mail groups

– VHA HPDP Program Managers– VHA Health Behavior Coordinators– VHA VISN HPDP Program Leaders

• Monthly national conference calls• Monthly prevention education call• Sample facility HPDP Program Committee Charter• National Goals and proposed FY 11 facility HPDP

Program Goals• Internet, intranet and SharePoint resources

Behind the Scene

• Communication campaign for 9 Healthy Living Messages (in development )– Posters, brochures, other print materials– Videos, audio resources– Phone messages– Social media

Behind the Scene

• Staff tools– My Health Choices– Guide for Health Coaching– Guide for Healthy Living Messages

Behind the Scene

• Tools/Resources in development– New Patient Orientation Toolkit

– Health Risk Assessment

– Veterans Health Library

– Telephone Lifestyle Coaching program

– TeleMOVE! service

– Web-based weight management program

Behind the Scene• Measures/metrics– EPRP measures about health

behaviors• Smoking counseling/NRT• Screening for obesity• Participation in MOVE!• Screen/counseling for problem alcohol

use• Assessment of healthy eating/PA

– Roll-out of new clinical reminder

Behind the Scene• Measures/metrics– CAHPS question • How often ways to prevent illness or injury were

discussed (FY 11: 67% usually/always)

– FY 11 developmental measures• ≥2 staff completed TEACH facilitator training; ≥1

completed MI facilitator training• 20% PACT staff trained in TEACH by 4Q• 25% RN Care Managers trained in MI by 4Q

– HPDP included in PACT certification

In Conclusion:• HPDP and PACT have a synergistic approach to

patient centered care.

• Motivational interviewing and health coaching facilitates trusting and goal directed relationships with the Veteran.

• Educating healthcare teams on the TEACH program and motivational interviewing techniques enables success with Veteran self management skills.

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Acknowledgements and Contact Info

Faculty: Kellee Bivens, PhD: Kellee.Bivens2@va.gov

Sheila Phillips, RN: Sheila.Phillips@va.gov

Program Developers: John Baer, PhD: john.baer@va.gov

Cathy Cole, MSSW: cathy.cole@va.gov

Paula Wilbourne, PhD: paula.wilbourne@va.gov

Brian Kersh, PhD: brian.kersh@va.gov

Elizabeth Jenkins, PhD: elizabeth.jenkins@va.gov

NCP Supporting staff: Michael Goldstein, MD: michael.goldstein2@va.gov

Margaret Dundon, PhD: margaret.dundon@va.gov

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References:• Health Power! Prevention News – Winter

2010• Center of Disease Control (CDC)• conservativedailynews.com – Uncle Sam

Stop Smoking Ad• sanfranciscosentinel.com – Health Care Ad