An Electronic Linkage System for Health Behavior Counseling: Effect on Delivery of the 5A's

doi:10.1016/j.amepre.2008.08.010

American Journal of Preventive Medicine

Volume 35, Issue 5, Supplement, November 2008, Pages S350-S358

https://doi.org/10.1016/j.amepre.2008.08.010 Get rights and content

Background

A variety of factors limit the ability of clinicians to offer intensive counseling to patients with unhealthy behaviors, and few patients (2%–5%) are referred to the community counseling resources that do offer such assistance. A system that could increase referrals through an efficient collaborative partnership between community programs and clinicians could have major public health implications; such was the subject of this feasibility evaluation.

Methods

At nine primary care practices, an electronic linkage system (eLinkS) was instituted to promote health behavior counseling and to automate patient referrals to community counseling services. Patients were offered 9 months of free counseling for weight loss, smoking cessation, and problem drinking at a choice of venues: group counseling, telephone counseling, computer care, and usual care. The delivery of behavioral counseling, measured by the 5A's (ask, address, advise, assess, agree, arrange) and patients' reported experiences with eLinkS, was examined.

Results

For 5 weeks eLinkS was used, until high referral volumes depleted counseling funds. Of the 5679 patients visiting the practices, 71% had an unhealthy behavior. Of these patients, 10% were referred for intensive counseling from a community program, most often for weight loss. Counseling and referrals occurred regardless of visit type—wellness, acute, or chronic care. eLinkS was used more often for middle-aged adults and women and by more-experienced clinicians.

Conclusions

The intervention increased the rate at which patients were referred for intensive behavioral counseling compared to current practice norms. Given the evidence that intensive counseling is more effective in promoting behavior change, implementing eLinkS could have substantial public health benefits.

Section snippets

Background

Four unhealthy behaviors—tobacco use, unhealthy diet, physical inactivity, and risky alcohol use—account for approximately 37% of deaths in the U.S.¹ Addressing these behaviors could help stem the rising prevalence and cost of chronic diseases,2, 3, 4 and clinicians can play a pivotal role. Americans have regular contact with clinicians and value their advice. A clinician's recommendation to change behavior is widely cited as a motivating factor.5, 6 Guidelines recommend that clinicians use the

Setting

Nine primary care practices in the Tidewater region of Virginia were recruited.²⁵ The practices, members of a single medical group and of the Virginia Ambulatory Care Outcomes Research Network (ACORN), share a common type of EMR (GE Centricity Physician Office^©) that is managed by a central informatics staff. The practices have used the EMR for 3 to 10 years. Practice size ranged from 1 to 30 clinicians (median=3), and 48 (87%) clinicians participated in the study. Two sites were solo

Study Population

A total of 5679 adult patients visited the practices during the 5-week exposure period. Their ages (median=53 years); gender (64% female); and frequency of prevention visits (14%) were typical of adult primary care populations (Table 2).³³ The frequency of chronic-care visits at other places was lower than published norms (9% vs 44%)³³ because only visits for selected reasons met this study's definition of relevant chronic illnesses. The prevalence of circulatory diseases was similar to the

Discussion

This study was designed to observe whether clinicians would use eLinkS, what options the patients would self-select, and what effect the intervention would have on counseling practices and patients' behaviors. The results are encouraging. The prompts appeared at more than one third of the encounters (due to the prevalence of overweight/obesity). The use of eLinks was steady throughout its 5 weeks of availability, and occurred at all manner of office visits, not just those devoted to prevention.

Conclusion

Collaboration between clinicians and community resources, as occurred here, presents a win–win scenario for patients, clinicians, and community programs. Patients obtain more-intensive assistance. Clinicians, who frequently cannot provide intensive counseling themselves,⁶³ welcome an easy means to connect patients with the help they need. Community programs, which often struggle to attract clients through media and advertising, appreciate the influx of referrals from the medical community.

This

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People with a mental illness have higher prevalence of behavioral risks for chronic disease than the general population. Despite recommendations regarding the provision of preventive care by mental health services, limited research has examined the extent to which such care is provided.
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A cross-sectional survey was undertaken of 151 community mental health clinicians in New South Wales, Australia regarding the provision of three elements of preventive care (i.e., assessment, brief advice, and referral/follow-up) for four health risk behaviors (i.e., tobacco smoking, inadequate fruit and vegetable consumption, harmful alcohol consumption, and inadequate physical activity). Clinicians reported the availability of 16 strategies to support such care delivery. Data were collected in 2010 and analyzed in 2012−2013.
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Effective weight management and physical activity counseling should be incentivized as important quality measures for a PCMH. Third, findings suggest that community-clinic linkages have not been created consistently in CHCs; public health efforts should focus on working with communities and clinics to create easy access (both for patients and for clinicians) to evidence-based referral resources [16], and on identifying appropriate incentives to motivate patients to use identified resources. Finally, electronic health records could also be leveraged to provide clinicians with decision support prompts, facilitating more evidence-based interactions in the clinic.
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ArticleAn Electronic Linkage System for Health Behavior Counseling: Effect on Delivery of the 5A's

Background

Methods

Results

Conclusions

Section snippets

Background

Setting

Study Population

Discussion

Conclusion

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Jt Comm J Qual Improv

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Actual causes of death in the U.S., 2000

JAMA

Counseling to prevent tobacco use and tobacco-caused disease: recommendation statementU.S. Preventive Services Task Force. AHRQ Pub. No. 04-0526

Does counseling by clinicians improve physical activity?A summary of the evidence for the U.S. Preventive Services Task Force

Ann Intern Med

Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force

Ann Intern Med

Contribution of primary care to health systems and health

Milbank Q

Tobacco use: prevention, cessation, and control

Evidence Report/Technology Assessment No. 140

Treating tobacco use and dependenceClinical practice guideline

Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work?

Arch Intern Med

Models for provider-patient interaction: applications to health behavior change

Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study

Ann Fam Med

Tobacco cessation quitlines in North America: a descriptive study

Tob Control

Weight loss with self-help compared with a structured commercial program: a randomized trial

JAMA

Randomised controlled trial of four commercial weight loss programmes in the UK: initial findings from the BBC “diet trials”

BMJ

Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial

JAMA

Frequency of physician-directed assistance for smoking cessation in patients receiving cessation medications

Arch Intern Med

Improving primary care for patients with chronic illness

JAMA

Primary care practice organization and preventive services delivery: a qualitative analysis

J Fam Pract

Putting it together: finding success in behavior change through integration of services

Ann Fam Med

Riverside online: Riverside medical group

Riverside online: Riverside wellness and fitness centers

Article
An Electronic Linkage System for Health Behavior Counseling: Effect on Delivery of the 5A's