Implementing Health Behavior Change in Primary Care: Lessons From Prescription for Health

Data Collection

The A-Team performed a multimethod assessment that included collecting survey data at the PBRN and practice levels, as well conducting interviews and a limited number of site visits with each investigative team (Figure 1⇓). Although these data provided cross-sectional PBRN-, practice-, and project-level information that allowed ongoing insight into the implementation process, interactive online project diary “rooms” were created on the AHRQ-sponsored PBRN secure extranet for each of the 17 investigative teams. Project diaries functioned as both a data collection tool, providing additional insight into the implementation process, and as a mechanism for facilitating ongoing 2-way communication between investigative teams and the A-team.

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Figure 1.

RWJF Prescription for Health evaluation plan.

The A-Team conducted a content analysis of all funded grant applications to determine the scope and focus of each project, and to identify potential diary keepers from each investigative team. In June 2003, the team sent a personalized letter to each principal investigator outlining the details of the evaluation and identifying research team members who were potential diary keepers. During a 30-minute telephone call with each investigative team, 3 to 5 people were selected to be diary keepers, at least 1 or 2 of whom would be in close contact with practices during the implementation process. Diary keepers were asked to make an entry twice a month. Questions to help spark the diary-writing process were provided via a help button in each diary room, but in general, diary keepers were asked to write about their project development, recruitment, and implementation experiences. The A-Team regularly posted responses to diary entries to elicit more information or elaboration from a diary keeper.

Two members of the A-Team received e-mail notification each time a new diary entry was posted. One team member read diary entries at the time of receipt, addressed immediate concerns, and copied the entry into a word-processing program to facilitate sharing with A-Team members.

Analyses

Theme 1: The Need for Health Behavior Change Interventions

Practices and patients enthusiastically respond to interventions that provide an additional health behavior change resource; practices eagerly refer patients to this resource, and patient recruitment is easy, with referrals often exceeding what research teams can offer. The data suggest that many patients want someone to talk with when undertaking a health behavior change, and when given options, patients choose intervention approaches that facilitate interaction with a counselor or coach rather than those that are self-guided. The following diary entries illustrate these observations.

Theme 2: Training and Supporting Practice Extenders

Several projects used practice members or practice extenders such as lay coaches or nonclinical peers to deliver health behavior counseling. One benefit of this approach was that moderate to intensive health behavior counseling could be offered while minimizing the impact on practice routines and resources. Our analysis highlights another benefit. In the context of practice extender–patient relationships, patients may share personal stories around behavior change, and for some doing so may be important to the change process. In one project, the intensity and depth of personal experiences patients shared was surprising to investigators and may have arisen from the nonthreatening and supportive relationship the practice extenders created. For example, a diary keeper noted the following:

My follow-up phone contact with the client on Friday was intense and lengthy (45 min). She began sobbing within one minute of my open-ended question, “How has your week been?” I also had a long telephone interview with a medical student who has struggled with obesity and suffered bulimia since age 12. She spoke eloquently about the internal workings of overweight folks in her experience. She spoke of a kind of numbness that feels both good and bad. That was new to me. She talked about shame and depression. (Project 9, diary entry, 9/19/03)

Although physician extenders relieve practices of work involved in facilitating and supporting health behavior change in patients, resources are needed to support physician extenders financially and provide extensive and continuous training. In addition, patients and extenders would benefit from access to a local care team (eg, clinicians, psychologists, social workers) for follow-up, consultation, and referral for treatment of issues that surface during counseling sessions, such as depression. One physician extender’s diary entries suggests that she felt inadequately trained and supported and, after several months of working with patients, began to experience burnout, reporting that she felt exhausted having “less compassion for the patients” and trying “to continue to be cordial and empathetic, but the energy demanded of contacts drained me” (Project 9, diary entry, 7/6/04).

Theme 3: Adapting Tools and Techniques to Primary Care Practice

Tools and techniques used in Prescription for Health interventions include Web-based resources, handheld computers or personal digital assistants (PDAs), e-mail follow-up, action plans and forms, lay coaches/community health associates, statewide and local telephone counseling, group visits, pedometers and walking groups, and prescription pads. Many of these approaches were not specifically developed for practice settings and, therefore, did not automatically fit well. For example, research teams modified action plan forms to fit with clinical practice (Project 17, field notes, 1/18/04), and another project tailored their patient coaching strategy to suit practice staffing patterns and work demands (Project 12, field notes, 3/31/04).

Although all projects managed to develop and integrate their behavior change tools, all seriously underestimated the time and effort needed to integrate and adapt these approaches to the primary care setting. For some, mobilization of other resources provided economic and intellectual support critical to this effort. Tool development was a labor-intensive process involving both special technical expertise (eg, software developers) and an understanding of the practice environment. For example, a Project 11 diary entry reported a list of information technology activities ranging from having meetings with computer programmers to discuss the big picture, as well as specifics on Internet service provider (ISP) algorithms, to registering domain names, obtaining permission from the Outreach Office to use an external domain to point to a university server, setting up Web space on a secure server, testing file transfer protocol (FTP) software and a beta version of the Web site, and so forth. Other projects noted similar activities:

Computer support feels using the Palm has its advantages as a collection device, but we’ve learned through experience that remote support of users is not easy. You have to deal with installation of Palm software on remote PCs, installation and support of the program on the Palm (and there’s little control of what else the practices put on the machine), network issues, and general end-user support. (Project 7, diary entry, 10/10/03)

Software issues were discussed and the final copy edits are being completed on the Palm version. The PC version is also getting closer to completion. Final testing will be performed prior to deployment. (Project 15, diary entry, 5/21/04—9 months into Round 1)

Developing tools that rely on computer-based technologies requires the early involvement of experts (eg, computer programmers, designers), not only to design, develop, and customize these tools, but also to work with the research team to develop realistic timelines that include time for pilot- and beta-testing. Integrating a new tool or approach into a primary care practice (computer-based or not) requires a good understanding of the practice’s systems. The collection of practice-level data aimed at identifying systems of organization and routine care processes in practices would help researchers tailor their tools to better fit the practice setting.

Theme 4: Using an Implementation Model to Guide Practice Change

Most Prescription for Health interventions asked practices to make substantial changes to their organization, including modifications to their work routines and systems of care (eg, referring to a new program, using a new tool or protocol, engaging in action planning). We examined grant applications, site visit notes, and diary data to look for references or allusions to characteristics identified in the literature as important for integrating innovations into primary care practices for sustainable change, such as stakeholder motivation, leadership, role of local champions, practice capacity and resources for change, external environment, and perceived benefit.^15,16 We found that few projects used a formal change model or proactively considered these characteristics.

Project diary entries highlight the potential consequences of this omission. For example, the need to consider stakeholder motivation and perceived benefit was apparent when an innovation (eg, PDAs, Web-based resources) was designed to replace an existing process that practices perceived as satisfactory. Project 13 diary entries (1/14/04 and 2/2/04) chronicle the many telephone calls and personal visits involved in recruiting practices. In more than 1 practice, the Web-based system the researchers offered seemed to be replacing a paper-based educational system, and clinicians did not appear eager to make this change. To encourage this transition, the research team attempted to tailor the new system to the practices by offering paper versions of educational materials posted on the Web:

Practices are selecting some materials that they would like to have on hand for their education files. Stacey is checking and requesting permission again from each source and being sure that the source is appropriately cited on each document. (Project 13, diary entry, 2/18/04)

Similar difficulties were observed for nontechnological interventions. As the following entry suggests, clinicians may be motivated to enhance preventive service delivery, but they may not see the value in changing aspects of their existing system:

Dr. stated he was quite confident he is addressing all behaviors and 5 A’s thoroughly and was satisfied to remain status quo. He stated he did use catch-all phrases like lifestyle modification as documented evidence and assurance that he is addressing all behaviors and believes that he would be “Covered in a court of law.” (Project 5, diary entry, 1/1/04)

Additionally, contact with research teams was required for problem-solving, and in many cases investigators needed to work with practice leaders and administrators to mobilize the resources necessary to implement an intervention. The following entries describe these interactions:

We are trying to work out a process that will allow the clinics to incorporate the action plan process into their regular routine after we are gone. (Project 17, diary entry, 9/24/03)

Biller receives request for chart identification. Spends several hours in one day trying to meet request and cannot. Doctor notes that this is too costly. Requests to be dropped from study. I follow up with doctor. “If we can get the PHO (Physician Health Organization) to do this part for you would that make it ok?” “Much better.” (Project 5, diary entry, 11/11/03)

All the clinicians that have been enrolled seem excited about the program, but I know from personal experience (since we at the University have had access to the program) that it is very easy to forget to actually make the referral. We are currently discussing ways to keep the P4H [Prescription for Health] program on the minds of the clinicians. (Project 1, diary entry, 1/7/04)

Although research teams were flexible when tailoring interventions to practices, this process was commonly problem-focused and reactive. There is little evidence to suggest use of a formal organizational change model to guide these efforts proactively.

Theme 5: PBRN Research Philosophy and Project Management Approach

Our data suggested that several participating PBRNs, particularly those with a long history of successful PBRN research, had well-developed strategies for generating enthusiasm for participation in studies and managing the research projects conducted in their PBRN. There was evidence that this extensive research experience, as well as a history of conducting projects with finite endpoints (eg, card studies and chart audit surveys), may have socialized research teams and member practices into a “project mentality,” leading them to regard interventions as finite research projects that have definable endpoints rather than improvements that may become a permanent part of the practice organizational design. Such experience and views are evident in the following entries:

This clinic will be upgrading their status in the PBRN from ruby to diamond as they participate in the P4H project. This is especially good news as it represents their willingness to assume more family practice based research projects in this clinic. (Project 2, diary entry, 11/17/03)

The doctor was interested in the project and expressed a bit of concern on the side of the physicians since they see 36 patients a day each physician. He mentions that the “demand for patient care is so high …Only 36 patients will need follow up calls (2 more) until the study ends. ...”At the end of the conversation, he supported the idea behind this project and agreed that he will supervise the progress of this project until the end of the study. (Project 12, diary entry, 5/24/04; A-Team emphasis added)

As usual, we have some “producers” and some “non-producers” in the clinics. Thanks goodness for the real time recruitment Web site. Because of it I have been able to identify and call all of the clinics who are behind schedule. (Project 2, diary entry, 4/26/04)

The idea that there are producers and nonproducers in terms of practice recruitment, and that practices just need to make it until the end of the study suggests that PBRN researchers and practice members view their implementation of interventions as a short-term obligation, not necessarily as a long-term practice improvement. Fostering this kind of project approach or project mentality may well be counterproductive if a study seeks to stimulate the practice to make sustained changes to its existing care processes. In fact, there are a number of diary entries, such as those above, that appear to set up an expectation among physicians that the goal of the research is to enroll a set number of patients and that this goal was all that was expected for participation. Bodenheimer et al¹⁷ further discuss the tensions between PBRN research and the realities of practice.