Preventive Health Care
Preventive Services Delivery and Nursing
Empirical support of preventive health care and health promotion has grown considerably over the past decade, demonstrating that the short-term investment in preventive care could avert health problems and medical costs over time (US Preventive Services Task Force, 2000).
Many serious disorders can be prevented
or postponed by immunizations, chemoprophylaxis, and healthier lifestyles, or
detected with screening and treated effectively (US Public Health Service,
1994). However, many preventive care services are frequently not being
delivered by clinicians in practice.
Barriers to Preventive Services Delivery
Despite the benefits of preventive care services, such as cancer screening and immunizations, utilization of specific preventive care services in New Jersey remains below state and national goals. Documented barriers to the implementation of these services included:
(a) clinical uncertainty about what services to offer, to whom, and how often
(b) lack of reimbursement and associated time constraints
(c) clinical attitudes and lack of knowledge about preventive services
(d) patient attitudes, confusion, and lack of under-standing about clinical preventive services
(e) lack of organized
systems to facilitate the delivery of services (Griffith, Dickey, & Kamerow
, 1995).
Clinicians Role In Preventive Services Delivery
Clinicians are confronted with different recommendations regarding preventive care practices from the HPS they contract with. Multiple recommendations for preventive care sometimes conflict with each other, leaving clinicians confused about which services to provide.
Literature shows that lack of a standardized
approach to the delivery of clinical preventive services (CPS) is a barrier to
implementation (Griffith et al., 1995).
HP medical directors seek recommendations from government agencies and professional organizations in selecting CPS their HP should recommend. Some medical directors work with a committee of practicing member clinicians, obtaining feedback regarding recommendations they should provide.
However, some
medical directors decide what should be recommended on their own, reviewing
original empirical research to supplement the national guidelines, particularly
for newer or more controversial services (Fox & Cutie, 2001). In either
circumstance, HP medical directors work independently from other HPs.
Through a partnership between the New Jersey Association of Health Plans and Rutgers College of Nursing, nine NJ HP medical directors were brought together to form a coalition to identify a set of CPS guidelines that all plans could endorse as priorities for implementation.
In meeting this objective, these HP's will be
able to provide contracting clinicians with information on the value of
preventive services to their patients, compensating for uneven knowledge and
skill that many clinicians have in the area of prevention.
Sisk (1998) discussed that initiatives to improve consistency, both scientific evidence and clinical practice, are increasingly focusing on managed care plans and integrated delivery systems.
HP's should be able to implement guidelines,
particularly because plans are being held accountable for care provided. HP's
have leverage, if not control, over clinicians utilizing patterns.
The New Jersey Association of Health Plans and Rutgers College of Nursing collaborated in this concerted effort with nine HPs in NJ, HPs covering 4.8 million New Jerseyans that represent 98% of the state's HMO market.
Medical directors from competing HPs brought to the table expertise on CPS, discussed the current knowledge of evidence-based practice, and established a consistent ser of guidelines to which all of the nine HPs agreed. Agreed-upon guidelines of the coalition were based on the evidence-based US Preventive Services Task Force (USPSTF) guidelines.
The USPSTF, a body of preventive care experts convened by the US Public Health Services, conducted comprehensive evaluation of the scientific evidence for CPS, including counseling interventions, screening tests, immunizations, and chemoprophylaxis (Fox & Cuite , 2001).
Therefore, the coalition agreed on the value of these evidence-based guidelines
as the standard for which preventive care should be delivered to the general
population.
Areas of Preventive Services
Seventy areas identified by the USPSTF for preventive care were reviewed by each medical director, individually through questionnaires and collectively through coalition meetings. Two rounds of questionnaires were sent to the medical directors to assess their HP's level of agreement and/or disagreement with the USPSTF guidelines.
Positively stated recommendations that the medical directors
disagreed on were addressed at subsequent coalition meetings to promote
consensus. A third questionnaire was then sent to the medical directors,
requesting them to rank order these guidelines according to priority for
implementation.
Strategies In Preventive Services
Using consensus-building strategies including three Delphi rounds and four coalition meetings over the course of a year, medical directors were able to identify a subset of USPSTF guidelines that all HP's could endorse as priorities for implementation in clinician practice.
Medical directors discussed that these
guidelines serve as the minimum for which preventive care services should be
de-livered and do not replace the clinicians' judgment based on patient risk.
However, implementation of these guidelines will ensure that all patients receive
a consistent level of preventive care.
Decisions made at each level were based on scientific evidence and needs of their members at large. Their decision to include only those guidelines with good to fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination, a level of strength "A" or "B" recommendation as determined by the USPSTF, illustrates their commitment to sound and safe practice for their members.
They also identified
diabetes mellitus (DM) as a growing problem that warrants attention.Although
there is no evidence-based recommendation to screen for DM as a preventive
measure, the medical directors identified methods to screen for complications
of this disease.They unanimously agreed that clinicians should provide services
to prevent morbidity and/or mortality in this population.
Conflicting
and confusing guidelines are detrimental to the delivery of preventive care and
create a major barrier to CPS delivery. This project used a systematic approach
to reach consensus among medical directors from competing HPs regarding CPS. It
provides a template for other HPs nationwide to come to consensus on guidelines
that support clinicians in the delivery of CPS.
Give your opinion if have any.