prevent disease now! -...
TRANSCRIPT
PREVENT Disease NOW!
Agenda
• Connection: Poverty and Chronic Disease
• PREVENT Disease Now! - Ten Best Practices to Prevent Chronic Disease
• Successful Implementation in Clinic
• Outcomes and Costs
PREVENT Disease NOW!
Connection: Poverty and Chronic Disease
• 50% of US deaths from disease are preventable.
• Top two diseases that cause death: heart disease and cancer. (CDC, 2018)
• Fastest growing chronic disease is diabetes. (American Diabetes Assocation, 2014)
• Leading cause of disability for people 15-44 is depression.(NIMH, WHO)
• Obesity will surpass tobacco as the number one risk factor for cancer by 2030.(American Society of Clinical Oncology, 2015)
National Research Council (NRC) and Institute of Medicine, Measuring the Risks and Causes of Premature Death: Summary of Workshops, H.G. Rhodes, rapporteur, Committee on Population, Division of Behavioral and Social Sciences and Education and Board on Health Care Services, Institute of Medicine (Washington, DC: The National Academies Press, 2015). J. Michael McGinnis, "Actual Causes of Death, 1990-2010," Workshop on Determinants of Premature Mortality, Sept. 18, 2013, National Research Council, Washington, DC.U.S. Burden of Disease Collaborators, "The State of U.S. Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors," Journal of the American Medical Association 310 n. 6 (2013): 591-608.
PREVENT Disease NOW!
Connection: Poverty and Chronic Disease
Shaw KM, Theis KA, Self-Brown S, Roblin DW, Barker L. Chronic Disease Disparities by County Economic Status and Metropolitan Classification,
Behavioral Risk Factor Surveillance System, 2013. Prev Chronic Dis 2016;13:160088. DOI: http://dx.doi.org/10.5888/pcd13.160088.
PREVENT Disease NOW!
Connection: Poverty and Chronic Disease
Source: J. S., Schiller, J. W. Lucas, and J. A. Peregoy, “Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2011.”Vital and
Health Statistics 10, no. 256 (2012): 1–207, tables 1, 4, 8, and 12. http://www.cdc.gov/nchs/data/series/sr_10/sr10_256.pdf.
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Goal
• Goal – To reduce modifiable risk factors and prevent or delay the onset of chronic disease as well as maintain sustained recovery.
• Program Based On Best Practices:– American Cancer Society– American Diabetes Association– American Heart Association– Centers’ For Disease Control– UT Southwestern Medical Center (UTSW)
PREVENT Disease NOW!
Ten Best Practices
1. Have a Disease Risk Assessment2. Obtain Recommended Screenings3. Keep immunizations up-to-date4. Take medications consistently, if required5. Maintain healthy body weight6. Eat heathy and nutritious Food7. Get moderate physical activity8. Get adequate good sleep9. Reduce and manage stress10.Stop smoking – tobacco cessation
PREVENT Disease NOW!
Step 1: Patient self administers My Own Health Report (MOHR) via Ipad.
Step 2: Patient identifies risk factors for Action Plan. Meets with medical provider who discusses risks
and recommends next steps.
Step 3: Patient meets with Clinic Nurse, RDN and/or Behavior Specialist per Treatment Plan.
My Own Health Report (MOHR)
Benefits: Tool:
- Scores and identifies health risks
- Proven effective tool in medical research
studies by UCLA and Virginia Commonwealth
University
- Makes patients aware of lifestyle connections
with health risks
- Educational tool for healthcare provider(s) to
initiate conversation
- Patients prioritize risk factors for an Action Plan
- Electronic Assessment with 16 lifestyle
questions
- Available in English or Spanish
- Creates a print out for provider and
patient
- Is scanned and attached to EHR Medical
Record
- Is used by Care Team Members
1. Have a Disease Risk Assessment
Critical starting point for disease prevention plan.
PREVENT Disease NOW!
Lab Tests• Thyroid Panel Lipid Panel
Complete Blood Count
• Complete Metabolic Panel
• Hemoglobin A1c Vitamin D
• Urine Test
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
Patient compliance key challenge. Cost is a key barrier.
1. Have a Disease Risk Assessment
Screenings• Depression• Mammography• Pap smear and HPV • Cholesterol Screening• Colorectal Screening• Diabetes Screening• Hypertension Screening• Prostate Cancer Screening• Sexually Transmitted
Diseases
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2. Obtain Recommended ScreeningsDepression – PHQ9Anxiety – GAD7
Patients self administer via Ipad
What Did STAR*D Teach Us? Results From a Large-Scale, Practical, Clinical Trial for Patients With DepressionBradley N. Gaynes, M.D., M.P.H., Diane Warden, Ph.D., M.B.A., Madhukar H. Trivedi, M.D., Stephen R. Wisniewski, Ph.D., Maurizio Fava, M.D., and A. John Rush, M.D.Psychiatric Services 2009 60:11, 1439-1445
VitalSign6: Making Screening for Depression the Sixth Vital Sign is an easy-to-use, comprehensive program for the identification and treatment of depression in primary care, pediatric and specialty clinics.
PREVENT Disease NOW!
3. Keep Immunizations Up-To-Date
CDC announced the availability of the 2018 adult immunization schedule in the Morbidity and Mortality Weekly Report (MMWR). 1 The schedule is published in its entirety in the Annals of Internal Medicinehttps://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
Offer onsite as much as resources allow.
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4. Take Medications Consistently if required- Patient Education on Medical Compliance - Why It is important- Medical Reconciliation, Questioning, and Side Effects - Pharmacy Assist- GoodRX coupon- Samples- Generics
PREVENT Disease NOW!
5. Maintain a Healthy Body Weight• Evaluation of overall eating habits are assess by RDN using
My Own Health Report (MOHR).• Providers and Registered Dietetic Nutritionist (RDN) explains
connection between body weight and disease.• RDN starts with emphasis on healthy nutrition:
– Eat 5 serving of fruits and veggies a day– Do not skip meal– Meal prep.– Exercise 30 minutes per day– Watch out for correct food portions– Choose foods that are lower in fat and more nutrient dense
foods– Make better choices when eating out.
• RDN and Patient create a “My Wellness Plan”: setting goals for the next few weeks.
• Encourage follow up visits with RDN if any questions
Onsite RDN and Behavioral Specialist are key to patient success.
Institute of Medicine, 2012 report, Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.
Fact sheet: Obesity and cancer risk, 2017 National Cancer Institute
NC http://www.cancer.gov/cancertopics/factsheet/risk/obesity
PREVENT Disease NOW!
6. Eat Healthy and Nutritious Food
Step 1: Patient completes My Own Health report and identifies risk factor for an Action Plan.
Step 2: Patient meets with medical provider who discusses risks and recommends Nutrition
Therapy.
Step 3: Patient meets with RDN for Nutrition consultation – “walk down” at primary care visit or
appointment.
Nutrition ConsultationTopics address: Materials
- lab results and impact of diet
- Diagnosis and impact of diet
- 24 hour dietary recall
- “Create My Plate”, food groups,
portion size
- how to read food labels
- creates a My Wellness Plan, SMART
goals
- schedules a follow up visit in person
or telephone
- Handout, Create Your Own Plate, ADA
- Portion Control Plate – ADA
- Food Models – Nasco
- Sugar Shockers Food – Learning Zone
Express
- The DASH Diet Cookbook – AHA
- Sample Meals – Woven Health
- Menu Plan For Week – Woven Health
- Heart Healthy Guide – Woven Health
- Insulated Lunch Bage
- Food Log – Woven Health
- My Wellness Plan
Onsite RDN and Behavioral Specialist are key to patient success.
PREVENT Disease NOW!
7. Get moderate physical activity
Department of Health and Human Services recommends to have at least:• 150 minutes of moderate aerobic activity• Or 75 minutes of vigorous aerobic activity a week• Or a combination of moderate and vigorous activity.What are we doing to motivate our patient to exercise?• Provider writes a prescription for exercise• Physician, FNP, RDN, BHE recommend: start with walking
about 10 minutes per day for the first month. Then increase it by a few minutes every week until it reach 30 minutes per day.
• Walk with a Doc – once or twice in a month• Write prescriptions for Exercise – Exercise is Medicine• Zumba class at National Nutrition Month®• Stretching class National Nutrition Month®• Patient to set goals and fill out the action plan.
PREVENT Disease NOW!
8. Get adequate good sleep
Step 1:Screen patient’s sleep habits- screening tools: PHQ9 and My Own Health report
(MOHR).
Step 2: Patient meets with medical provider- start with Sleep Hygiene and OTC.
Step 3: Patient meets with Behavior Specialist for a Sleep Hygiene consultation.
Sleep Hygiene consultation:
Topics address: Materials
–Assessment: current sleep habits
– Sleep diary
– Sleep hygiene education
– Create an action plan to improve sleep
- UTSW Sleep better handout
- Tips to sleep better infographic
- Sleep diary handout
- Sleep Hygiene based on UTSW
recommendations
PREVENT Disease NOW!
9. Reduce and manage stress
Step 1: Screen patient’s stress level- screening tools: Oral report, PHQ, GAD7 and My own Health report
(MOHR).
Step 2: Medical Provider referrals patient to the Behavior Specialist for a Stress Management
Consultation.
Step 3: Patient meets with Behavior Specialist for a Stress Management Consultation.
Stress Management ConsultationTopics address: Materials:
–Assessment: identify stressors, how stress affects you.
– Stress management education: Provide patient ideas to address stressors (example: solution focused, acceptance, referrals to social services, relaxation techniques, etc.)
– Create an Action Plan to manage identified stressors.
- UTSW Stress Management
handout
- Stress management pamphlet
- Stress management action
plan based on the Harvard
Medical School
recommendations
PREVENT Disease NOW!
10. Stop Smoking - Tobacco Cessation
Step 1: Patient is screened for tobacco use in the intake- screening tool: My Own Health
report.
Step 2: Patient meets with medical provider- discusses options with patient.
Step 3: Patient meets with Behavior Specialist for a tobacco cessation consultation.
Tobacco Cessation Consultation
Topics address: Materials
The “5-A” framework provides a useful
counseling strategy:
1. Ask about tobacco use.2. Advise to quit through clear
personalized messages.3. Assess willingness to quit.4. Assist to quit.5. Arrange follow-up and support.6. Create Action Plan to quit.
- “Quit smoking for good”, Brochure by
the American Heart Association.
- “How you can stop smoking for good”,
pamphlet by the American Heart
Association.
- “Stop smoking: control your weight” by
the American Heart Association.
- How to quit smoking- pamphlet or
brochures.
- Stages of change infographic
- My Tobacco Cessation Action Plan.
PREVENT Disease NOW!
Clinic Implementation
PREVENT Disease NOW!Implementation in Clinic Environment
Success Factors• Health care provider(s) and all staff must be on board.• Majority of the best practices are based on life style change.• Critical Resources available in the Clinic vs Referral Outside
– LMSW or LCSW– Nutritionist or Registered Dietician
• Team Based Care – Quick Huddle and Team Communications• Leverage technology – Electronic assessments, Tele-therapy, Tele-
medicine, Text Message, Ipads, Videos, Apps, email, EHR• Multiple points for Patient Education at each visit• Don’t under estimate the “power” of the Provider• Build relationships with patients
PREVENT Disease NOW!Implementation in Clinic Environment
Challenges• Changing your clinical workflow• Team Based Care takes time to work effectively.• Patient Outreach and Communications requires new tools and
skills.• Preventative Care both Physical and Mental/Behavioral take
more time at each visit.• Tools, Time and Knowledge to tracking outcomes and results
Majority of Patients love the resources and results.Health Care Team loves the outcomes and results.
PREVENT Disease NOW!
Factor Outcome
Weight Loss >=5% 19%
Hemoglobin A1C >9% 12%
(down 3 percent in 18 months)Blood Pressure <140/90 83%
Tot Cholesterol, LDL, HDL <200 mg/dL; <100 mg/dL; >40 mg/dL
36% showing improvement
PHQ9 >=5 60%
Lifestyle changes (exercise, diet, stress mgmt,
sleep, and tobacco cessation)TBD
Outcomes and Costs
Program Participation – 2,200 Patients (2017)• 1,650 Mental Health Screenings• 2,000 Patient Education/Chronic Disease Mgmt.• 1,760 Nutrition Counseling Sessions• 602 Cancer or Disease Screening• 1,100 Immunizations (Influenza)• 150 Patient Attending Stretching/Exercise/Mindfullness
PREVENT Disease NOW!
Outcomes and Costs
PREVENT Disease NOW! cost an average of $600 per patient annually for average of 3.4 visits.
PREVENT Disease NOW!
Additional Citations
The impact of behavioral and mental health risk assessments on goal setting in primary care, 2016, Department of Family Medicine and Population Health, Virginia Commonwealth University, Alex H. Krist,1 Russell E. Glasgow,2 Suzanne Heurtin-Roberts,3 Roy T. Sabo,4,5 Dylan H. Roby,16 Sherri N. Sheinfeld Gorin,6 Bijal A. Balasubramanian,7 Paul A. Estabrooks,8,9 Marcia G. Ory,10 Beth A. Glenn,11 Siobhan M. Phillips,12 Rodger Kessler,13 Sallie Beth Johnson,8,9 Catherine L. Rohweder,14 Maria E. Fernandez15 For The MOHR Study Group.
Centers for Disease Control and Prevention. National diabetes statistics report, 2017. Centers for Disease Control and Prevention website. www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdfExternal Link Disclaimer (PDF, 1.3 MB)
Diabetes Prevention Program, U.S. Department of Health and Human Services, National Institutes of Health NIH Publication No. 09–5099 October 2008
JAMA. Published online October 5, 2015, Association Between Hospitalization With Community-Acquired Laboratory-Confirmed Influenza Pneumonia and Prior Receipt of Influenza Vaccination, JAMA. 2015;314(14):1488-1497. doi:10.1001/jama.2015.12160
Grijalva CG, Zhu Y, Williams DJ, Self WH, Ampofo K, Pavia AT, Stockmann CR, McCullers J, Arnold SR, Wunderink RG, Anderson EJ, Lindstrom S, Fry AM, Foppa IM, Finelli L, Bramley AM, Jain S, Griffin MR, Edwards KM. Association Between Hospitalization With Community-Acquired Laboratory-Confirmed Influenza Pneumonia and Prior Receipt of Influenza
Vaccination. JAMA. 2015;314(14):1488–1497. doi:10.1001/jama.2015.12160
Suterwala, A. M., Rethorst, C. D., Carmody, T. J., Greer, T. L., Grannemann, B. D., Jha, M., & Trivedi, M. H. (2016). Affect Following First Exercise Session as a Predictor of Treatment Response in Depression. The Journal of Clinical Psychiatry, 77(8), 1036–1042.http://doi.org/10.4088/JCP.15m10104
Alan S.Go MD, Mary Ann Bauman MD, Sallyann M.Coleman King MD, MScGregg C.Fonarow MD, FAHA, FACC Willie Lawrence MD, FAHA, FACC Kim A.Williams MD, FAHA, FACC Eduardo Sanchez MD, MPH (2013). An Effective Approach to High Blood Pressure Control: A Science Advisory From the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Journal of the American College of Cardiology, Volume 63, Issue 12, 1 April 2014,1230-1238 https://doi.org/10.1016/j.jacc.2013.11.007
