Clinical prevention prerequisites A framework for health authorities

Clinical prevention prerequisitesA framework for health authorities

Ak’ingabe Guyon MSc MD CCFP FRCPCPublic health and preventive medicine specialistMontreal Public Health Unit

Framework developped in collaboration withDavid Kaiser, Valérie Lemieux and Robert Perreault

Thursday, May 29th 2014CPHA conference, Toronto

Plan

1. Background and objectives

2. Clinical prevention prerequisites

3. Regional and provincial applications

Clinical prevention prerequisites A. Guyon, May 2014 2

Clinical prevention prerequisites A. Guyon, May 2014

3

Prevention: an essential public health function

Public health

PreventionLast 2006, Starfield 2008, BC Clinical prevention policy review committee 2009,

It includes at least :• Immunisation• Counseling• Screening

and early detection• Preventive

treatments

Surveillance Protection Health

promotion



4

Initial project

• Montreal Public health unit within regional health authority• Strategic planning exercise • Clinical prevention services



5

Drifting project

• …define public health’s role (regional and provincial) in clinical prevention



6

Clinical preventive servicesUSTFPHS, CTFPHC,

Thivierge et al. 2014

Clinical prevention prerequisites

Walsh & McPhee 1992Barr et al. 2003

Groulx 2007, CSBE 2010BC Lifetime of prevention 2009, BCMA 2010

US National prevention strategy 2011UK Department of health 2014



7

Objectives

Propose a framework of clinical prevention prerequisites As a tool to rapidly identify who supports clinical prevention and how at a regional and provincial level

Apply the framework at a regional level (Montreal Public health unit) at a provincial level (clinical prevention services taskforce among Quebec’s

public health units)

Redefine public health’s clinical prevention mandatesAssist the regional clinical prevention team as it reassesses its responsabilities over clinical prevention


8Clinical prevention prerequisites

A. Guyon, May 2014

Transversal functions necessary for clinical prevention

• Orchestration• Scientific leadership• Direct support to clinicians• Monitoring and surveillance• Patient empowerment

2. Clinical prevention prerequisites


9

2. Clinical prevention prerequisites framework

Orchestration

Monitoring and surveillanceScientific

leadership

Patient empowerment

Direct support to clinicians


A. Guyon, May 2014

Orchestration Overall leadership and planning

• Responsibility for vision and planning• Balancing prevention with other public health functions• Ensuring a health equity focus

Stakeholders roles and engagement• Role and boundary negotiation among institutions, multiple clinicians, NGOs, industry • Workforce planning

Health care services that strenghten prevention• Access, comprehensiveness, continuity, coordination

Funding and incentives• Publicly funded coverage decisions on clinical preventive services• Incentives to clinicians for quality and access to preventive services

Logistics for clinical prevention• Patient recall and clinician reminder– Electronic health records

Populational prevention programs• For example: cancer screening, immunisation, smoking cessation, etc.

2. Examples of clinical prevention prerequisites

References on slide 6, Valaitis et al. 2009, Parks et al. 2012, Bodenheimer et al 2014.


A. Guyon, May 2014

Scientific leadership

Evidence based clinical prevention • Assess new trends, evidence• Priority setting of clinical preventive services and schedule• Evidence based practice guidelines

Training and knowledge transfer• Initial training of clinicians in clinical prevention• Continuing professional education

Research on clinical prevention• Clinical preventive services research• Public health and health services systems conducive to prevention


BC Lifetime of prevention 2009Maciosek et al. 2009


A. Guyon, May 2014

Direct support to clinicians

Practice support • Quality improvement teams• Facilitation• Communities of practice

Support of motivational interviewing techniques

Clinical decision support at point of care (web, apps, consultations to expert clinicians…)


AHRQ, Put prevention into practice, 2005Provost et al. 2007; Martel & Leaune, 2009; NICE 2014


A. Guyon, May 2014

Monitoring and surveillance

Monitoring • Clinical prevention services access, uptake• Quality improvement of clinical preventive services

Evaluation• Of clinicial prevention services effectiveness and efficacy• Of clinical prevention system’s implementation, relevance, efficacy, efficiency

Surveillance• Preventable disease and injury trends


References on slide 6 and Bodenheimer et al 2014


A. Guyon, May 2014

Patient empowerment Vision of patients as partners

Supporting population demand for clinical prevention• Media campaigns

Literacy friendly patient education material • Unbiased and public prevention focused website(s)

Self management support• Web-based personal health plans • Self care guidelines for prevention


References on slide 6 and Bodenheimer et al 2014


A. Guyon, May 2014

Usefulness of the clinical prerequisites framework

Montreal public health unit Identification and analysis of all clinical preventive mandates Shared understanding of clinical prevention prerequisites across the public

health unit’s divisions Strategic support for the upcoming regional public health plan

Provincial taskforce on clinical prevention among Qc public health units (Groupe de travail de la Table nationale de concertation en prévention clinique)

Identification of local, regional and provincial stakeholders Diagnosis of current stakeholders’ involvement Systematic identification of gaps and overlaps Strategic support for the upcoming provincial public health program



16

Stakeholders weakly coordinated and

involved

Towards a clinical prevention system

Clinical prevention system•Clinical and public health expertise centres (INSPQ, INESS)•Ministry of health (public health, primary care, hospital services, RAMQ insurance plan, …)•Regional health authorities and local centres (ASSS, CSSS)•Public health (local, regional, provincial)•Health care services (CLSC, clinics, hospitals pharmacies, etc.)•Professional organisations (MD, nurses, pharmacists, etc.)•Patients, NGOs, etc.



17

Questions ?Comments ?

Regional or provincial experiences in planning a comprehensive clinical prevention system?

Ak’ingabe [email protected]


18

References• Agency for healthcare research and quality (AHRQ). Put prevention into practice – website current as of November

2005• Barr V et al. 2003. The expanded chronic care model: an integration of concepts and strategies from population

health promotion and the chronic care model. Healthcare Quaterly, 7(1) 73-82.• Bodenheimer T et al. 2014. The 10 building blocks of high-performing primary care. Annals of family medicine

12(2) 166-171.• British Columbia (BC) Clinical prevention policy review committee. 2009. A Lifetime of prevention. Ministry of

health, Governement of British Columbia, Vancouver. BC.• British Columbia Medical Association(BCMA). 2010. Partners in prevention. Implementing a lifetime of prevention

plan. BCMA, Vancouver.• Canadian task force on preventive health care (CTFPHC). Website consulted on may 19th 2014.

http://canadiantaskforce.ca/• Thiverge et al. 2014. Évaluation Médicale Périodique. Direction de santé publique - Agence de la santé et des

services sociaux de Montréal et Collège des médecins du Québec, Montréal, Québec. • Commissaire à la santé et au bien-être du Québec (CSBE). 2010. Rapport d’appréciation du système de santé et de

services sociaux. Adopte une approche intégrée de prévention et gestion des maladies chroniques: recommandations, enjeux et implications. Québec, Québec.

• Groulx S. 2007. L’intégration des pratiques cliniques préventives. Guide pour la promotion et le soutien des pratiques cliniques préventives. MSSS. Québec.

• Last J. 2006. A dictionary of epidemiology. New York: Oxford University press.• Maciosek, M. V., Coffield, A. B., Edwards, N. M., Flottemesch, T. J., & Solberg, L. I. (2009). Prioritizing clinical

preventive services: a review and framework with implications for community preventive services. Annu Rev Public Health, 30, 341-355.


19

References• Martel D., Leaune V. 2009. L’amélioration des pratiques cliniques préventives à l’ égard des habitudes de

vie. Recension des écrits. Direction de santé publique, ASSS de Montréal.• National institute for health and care excellence (NICE). 2014. Behaviour change: individual approches.

NICE public health guidance 49, • National prevention council. National prevention strategy. America’s plan for better health and wellness.

US Dept of health and human services. Office of the surgeon general, Washington, DC. • Parks AV et al. 2012. Opporunity knocks for public health departments: increasing the use of clinical

preventive services by older adults. Policy note. UCLA center for health policy research. LA, California.• Provost, M.-H. (2007). Description, impact et conditions d'efficacité des stratégies visant l'intégration de la

prévention dans les pratiques cliniques : revue de la littérature. Québec, QC: Ministère de la Santé et des Services Sociaux.

• Starfield B, Hyde J, Gervas J, Heath I. 2008. The concept of prevention: a good idea gone astray? J Epidemiol Community health 2008 (62) 580-583.

• Walsh JME, McPhee SJ. 1992. A systems model of clinical preventive care: an analysis of facotrs influencing patient and physician. Health Education Quarterly 19, 157-75.

• United Kingdom’s Department of health. 2014. Living well for longer. National support for local actions to reduce premature avoidable mortality. April 2014. London, UK.

• U.S. Preventive services task force (USPST). Website consulted on may 19th 2014. http://www.uspreventiveservicestaskforce.org/

• Valaitis R et al. 2009. A scoping literature review of collaboration between primary care and public health. Report to the Canadian health services foundation.

http://www.uspreventiveservicestaskforce.org/

http://www.uspreventiveservicestaskforce.org/

Documents

Clinical prevention prerequisites A framework for health authorities