Putting It Together: Finding Success in Behavior Change Through Integration of Services

Insights From Prescription for Health: Integration of Services to Achieve Comprehensive Care

Our review of the Prescription for Health projects found that pragmatic features were common among the interventions tested, an outcome reflective of the program’s design. The original call for proposals from the foundation specified that applicants test interventions that could be “easily adopted” and complete their projects within 16 months; project grants could not exceed $125,000. These constraints precluded the testing of complex or protracted interventions, and fostered innovation among grantees to fashion interventions that ordinary practices could implement.

Few Prescription for Health projects were able to evaluate a comprehensive system for promoting behavior change. The interventions instead addressed selected components of the 5 stages of counseling (Table 1⇑). Some interventions screened for unhealthy behavior, some changed the way advice was given, some focused on goal setting, and some provided more intensive assistance. In only 4 projects did the interventions address all of the 5 A’s.

Although no Prescription for Health project was totally comprehensive, when the projects’ interventions are examined as a whole, the design of a complete system to fully support behavior change takes form. A synthesis of the projects (Figure 1⇓) presents a vision for an integrated, multifaceted system with realistic potential for implementation in primary care settings. Practices that wish to support each of the 5 A’s can choose from the menu of options in the figure, tested by the grantees, to (1) identify unhealthy behaviors (eg, by health risk appraisals), (2) offer brief advice, (3) set collaborative goals and action plans (eg, behavior “prescriptions”), (4) provide more extensive information (eg, handouts, interactive Web sites), counseling (eg, in-office coaches or community health advisors, telephone counseling, group didactic sessions, and support groups, some using motivational interviewing), and self-help tools (eg, guidebooks, pedometers, activity logs, food diaries), and (5) arrange follow-up and reinforcement (eg, health buddies, e-mail or telephone follow-up).

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Figure 1.

Integrated model of interventions evaluated by Prescription for Health projects.

Other strategies not tested under Prescription for Health offer additional options for supporting behavior change. Examples include computer-generated physician and patient reminders and e-mails, chart reminder stickers and flow sheets, examination and waiting room posters, teamwork interventions, patient-held health diaries, and interactive technologies (eg, Web-based resources, clinic-based CD-ROMs, interactive voice-response telephone calls).^10,11

Integration Between the Practice and the Community: Reaching Out Beyond the Clinic

Intensive counseling can enhance behavior change but is often beyond the capacity of ordinary primary care practices, which lack the time and resources for such follow-up. As Cohen et al⁴ describe in this supplement, Prescription for Health grantees discovered that delivering high-quality counseling often taxed the capabilities of practices and their staff. Some interventions required clinicians to undergo extensive training or to depend on practice extenders and external support from research teams. The long-term sustainability of such self-contained interventions is unclear^4,12; furthermore, their generalizability to practices across the country is uncertain.

Real-world practices that lack the resources to replicate intensive approaches within their offices can still ensure that patients receive high-quality counseling by reaching out beyond the office—establishing integrated linkages with information and community resources. The few minutes that clinicians and staff have with patients can then be used for what clinicians do best: identifying the behaviors and conveying to patients the importance of change.^13,14 As Stange et al¹⁵ have advocated, these first steps can be leveraged into more effective interventions if they connect patients with professionals and programs—within or outside the office—that can provide more extensive follow-up. As with any consulting relationship, these resources should work in concert with primary care professionals in a team approach, reporting to and consulting with clinicians as counseling progresses, and integrating follow-up into ongoing health care.¹⁶

Certain smoking cessation models provide an example of the use and integration of resources beyond the office. In some states and health systems, clinicians can identify smokers (assess) and offer brief advice (advise) in the office and then refer patients to telephone quit line programs that can offer more intensive counseling (assist, arrange).¹⁷ The best models, as in Massachusetts’ quit line program,¹⁸ have a feedback component that enables counselors to share progress reports with the primary care clinician as part of a longitudinal team relationship. A research network in Virginia that was a grantee under Prescription for Health is now conducting a randomized trial, funded by the Agency for Healthcare Research and Quality, to test whether this integrated counseling model increases the quality of the assistance that smokers receive.¹⁹

A number of Prescription for Health projects pursued this approach, testing interventions that reached beyond the office to enable patients to access information at home (eg, through interactive Web sites), to use self-help methods (eg, guidebooks), to access intensive counseling after leaving the clinic (eg, intensive in-person or telephone sessions with trained counselors in the practice or through community health alliances),²⁰ and to obtain follow-up and reinforcement over time (eg, health buddies, telephone or e-mail follow-up).⁴ Almost every project provided patients with resources that they could use at home to act on the advice they received in the office (Table 2⇓). That so many grantees turned to this approach reflects not only the logic of leveraging, but also a recognition of the impracticality of the alternative: expecting practices to rely on their own staff and resources to deliver intensive counseling and follow-up, often with limited or no reimbursement.

Aside from its pragmatic value to practices, this outreach is potentially more useful to patients because the work of lifestyle change occurs outside the clinic. An approach to health promotion that is restricted to the clinical encounter ignores the basic principles of the socioecological model²¹ and compromises the effectiveness of health behavior counseling. Clinicians’ time with patients represents a tiny fraction of patients’ daily lives, and clinicians’ efforts have limited impact on patients’ health behaviors if conditions at home, at work, at school, and in the community are not supportive.^4,22 Clinicians’ influence on the lifestyle is possible through integrated and stable partnerships and linkages if an infrastructure is in place for these relationships to flourish.

Parallels in Chronic Disease Management

The same philosophy of integrated and comprehensive care is embedded in current thinking about how best to manage chronic disease. Good outcomes in chronic diseases cannot be expected without providing patients with the knowledge, tools, and support to incorporate self-care into their daily lives.²³ Systems of care are investing resources to expand the infrastructure required for coordination.²⁴ More than 500 health care organizations have participated in the Breakthrough Series, sponsored by the Institute for Healthcare Improvement, to pursue comprehensive systems change to improve chronic illness care.²⁵ They are establishing teams that streamline and integrate the work of health professionals and community services.²⁶ They are installing reminder systems for clinicians and patients, and adapting information technologies to better link clinicians and consumers with each other and with relevant knowledge information.^27,28

Similar support is needed to help patients achieve and sustain behavior change, suggesting the need to think more broadly about the aims of redesigning systems. Designing and investing in bridging systems that connect practices with implementation strategies outside the office can reap benefits simultaneously in the domains of disease prevention and chronic illness care.²⁹ To focus on only one domain is a lost opportunity to maximize public health impact and efficiency. The distinction is also alien to primary care, which provides both disease prevention and chronic illness care, often to the same patient and sometimes in the same visit. System changes made by practices for health promotion or chronic illness care accrue to the benefit of all patients: for example, the reminder system that prompts the clinician to perform a foot examination in a diabetic patient can also prompt questions about smoking status, and the telephone counseling program that supports physical activity can, with augmentation, support self-management in patients with heart failure.

The Bigger Picture: A Citizen-Centered Approach

The integration of primary care with the community and with information resources, as occurred in Prescription for Health projects, is a first step in fulfilling a much larger need—faced by communities—to provide a web of integrated services to help citizens sustain healthy behaviors. Ideally, a person who chooses to become physically active should find a community working together to support the effort. The individual’s physician might recommend exercise, but local media and advertising can reinforce the message,^30,31 employers can offer incentives,³² and the built environment (eg, neighborhood walkways) can be redesigned to foster outdoor activity.³³

A diverse collaboration is required to give citizens a seamless support system for healthy diet, physical activity, smoking cessation, and moderation in alcohol consumption. It includes not only local health systems but also school boards, park authorities, workplaces, churches, bars, restaurants, theaters, sports centers, grocers and other retail outlets, volunteer organizations, senior centers, news media, advertisers, urban planners, and the leaders who set direction for these sectors.

Community-level integration of this type is beginning to emerge in many communities, often through concerted efforts such as the Steps to a Healthier US Cooperative Agreement program.³⁴ In 2004, this US Department of Health and Human Services program issued $36 million in grants to 40 communities to develop integrated community action plans to reduce the burden of diabetes, overweight, obesity, and asthma, and to address risk factors such as physical inactivity, poor nutrition, and tobacco use.³⁵

One Steps grantee (Seattle and King County, Wash), for example, has undertaken a comprehensive approach that involves media, policy makers, schools, workplaces, health care, and the community in a 100-member consortium that includes clinicians, hospitals, health plans, universities, community organizations, faith groups, government agencies, and school districts.³⁶ Their work with clinicians establishes integration between patient care and the community by using chronic disease and wellness coordinators to facilitate systems change, linking patients with community resources, and using case management. Their citizen-centered approach takes integration to a much broader community level. Examples of their comprehensive efforts include promoting community and housing policies that support physical activity, discouraging sales of nonnutritious foods at schools, and working with faith communities to train lay educators in health promotion.

The Challenges of Integrating Clinical and Community Services

Integration makes sense but is hardly straightforward. Systems to help practices reach out beyond the office encounter logistical challenges, as Prescription for Health grantees discovered. Projects in Minnesota and Pennsylvania developed self-help materials but found that patients preferred telephone or face-to-face interpersonal contact. A Kentucky project found that only 500 of 15,000 patients who received postcard invitations to obtain telephone counseling called the program to arrange services. Projects in Virginia, Ohio, and Minnesota developed Web sites to facilitate behavior change but encountered technical challenges and low use rates.⁴ A New Hampshire project found that receiving e-mail messages was unpopular with adolescent patients. Projects using practice extenders required resources for training and efforts to maintain coordination with primary clinicians and to ensure privacy of data.⁴

Substantial resources are required to build an infrastructure within health care that integrates primary care practices and communities. The sources of funding to establish this infrastructure and their long-term sustainability are unclear. Tobacco quit lines, for example, have struggled as state budgets, a primary funding source, have tightened.³⁷ For integration to be truly viable, these and other counseling resources to which clinicians might refer patients require stable funding; in addition, clinicians and health systems will expect reimbursement for the added work entailed in establishing and maintaining ties with diverse community services.³⁸ Finally, the very definition of integration and the performance measures that evaluators would use to know when it exists require development.