Integrating Preventive Services Into Office-Based Practices

Physicians have long provided counseling on health promotion and disease prevention, often without reimbursement. Now, with the Affordable Care Act (ACA) and other recent value-based payment reforms, reimbursement is changing to reflect the importance of preventive care.

“ACA has opened up new incentives for preventive services with a strong evidence base,” explains David Meyers, MD, chief medical officer of the Agency for Healthcare Research and Quality (AHRQ). He points to the inclusion of annual well visits for Medicare patients and coverage (without co-pay) for prevention services recommended by the US Preventive Services Task Force (USPSTF) as well as by federal agencies like the Centers for Disease Control and Prevention. In addition, Medicare has proposed reimbursing for certain behavioral counseling programs, such as the Diabetes Prevention Program.

However, integrating health promotion and disease prevention counseling into patient care can present challenges. According to a survey by the Council of Accountable Physician Practices (CAPP), although 90% of responding physicians reported they often make recommendations to patients about diet, exercise, and screening examinations, only about 20% of patients reported hearing those recommendations.

In addition, the list of evidence-based recommendations grows each year. The USPSTF has issued recommendations on 95 different preventive services and is currently considering several more.

Keeping track of which patients should get what—and when—and then finding the time to remind patients and answer their questions can be tricky. “Thinking about how you’re going to deliver a new service is not as simple as prescribing a new medication. It involves changing workflow and sometimes hiring new people,” Meyers says. It may also involve learning new communication techniques.

Laura Fegraus, executive director of CAPP, says the key is to make “the right thing easy for everyone”—from the patient to office staff to the physicians themselves. The following suggestions can help providers effectively integrate preventive services.

Increasingly, information about applicable preventive services is built into electronic health records (EHRs), alerting the physician—or other staff—when a patient is due for a screening or other service.

AHRQ offers the free Electronic Preventive Services Selector as a mobile and desktop application and an online tool. The clinician enters the patient’s age, sex, and 1 or 2 other details and receives a list of recommended preventive services arranged by level of evidence and strength of recommendation.

Meyers says he often uses the tool during an office visit, showing the patient the list and discussing which ones he thinks are most important for him or her.

Fegraus also recommends opening up lines of communication between the practice and the patient with patient portals and mobile applications, for instance. This can make the health care relationship more interactive and continuous.

The physician shouldn’t be the only one responsible for ensuring patients receive preventive care, says John Meigs, a physician in Brent, AL, and president of the American Academy of Family Physicians. He urges his staff to talk to patients about screenings or procedures that might be due. “The entire team works together,” he says. “Then, I can focus on the patient’s next steps.”

Fegraus points out that a common EHR system in multispecialty groups can facilitate teamwork and allow any clinician to take a role in prevention counseling. For example, a cardiologist seeing a patient for a follow-up visit can point out that mammography is due. “It creates more opportunity to talk about prevention,” Fegraus says.

Staffing Changes
Many practices are adding staff or shifting roles to build more effective patient care teams. Practices that see a lot of patients with diabetes or prediabetes, for example, might consider hiring a diabetes educator or a nutritionist.

Reorganizing a practice like this is not easy, Meyers admits. Many clinicians “may not know about workforce structure and which professional is best for each task,” he says.

The Transforming Clinical Practices Initiative has created practice transformation networks that offer free technical support and quality improvement consulting for practices through specialty societies and medical associations. For example, American Academy of Family Physicians has an online directory of practice transformation networks by region.

Communication Techniques
Evidence-based communication techniques can boost the effectiveness of each encounter with patients. Ken Olson, MD, a faculty member for the American Academy on Communication in Healthcare, trains physicians and other clinicians in techniques such as agenda setting, teach-back methods, and motivational interviewing.

Often, the complaint that brings a patient into the office may not be his or her top concern, Olson says.

Without agenda setting, the physician may not discover that until the visit is almost done, at which point there may not be enough time to discuss prevention. “Look at the patient’s complaint, the need for preventive services, and come up with an agenda that addresses both,” Olson advises.

Motivational interviewing can be used when a patient refuses a recommended prevention activity. “The most powerful way to get people to change is to tie it to their own values,” Olson explains. Identify the patient’s concerns and address those first.

Finally, he suggests using the teach-back method to improve retention of information. For example, he recommends asking the patient the following at the end of the visit: “Tell me the 3 most important things you heard from me today.” He explains, “Remembering 3 things is better than not remembering any of the 6 things that you said.”