Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Medical Home - Introduction to Preventive Health Tools
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Introduction to Preventive Health Tools

The future of healthcare and the foundation of PC-MH are going to be focused upon health and not simply upon excellent care of disease processes. Yet, the ideal of preserving and/or regaining a healthy state of being is not as easy as it sounds. Often, patients do not see any immediate benefit in making a change which may or may not make a difference in their sense of well being. Also, making a change in one's life style requires the hope that such change will make a difference. Many patients do not have hope. Many do not have the resources or mental or emotional capacity to make those changes. All of this complicates our realizing the promise of preventive care.

Typically, when we talk about "preventive health" we are talking about immunizations, screening and disease avoidance strategies. Another element of preventive health has to include risk stratification. Evidenced-based medicine not only helps us understand what treatment methodologies work but also who needs the most aggressive treatment either in prevention or therapeutics. "Preventive health" also must include life-style changes made by individuals.  The difficult thing is that the preventive health and life-style changes take place long before the benefits of those changes become apparent.

To sustain preventive care initiatives and life style changes, healthcare providers with healthcare recipients must be able to sustain change over a long period of time.  In order to do that, we need the ability to prove to patients that “if they make a change, that it will make a difference”.  If patients are going to participate in “shared decision making,” a key concept in PC-MH, we must be able to demonstrate that a change will make a difference.


    The most innovative use of the Framingham Risk Calculators were suggested by SETMA‘s associates at the Diabetes Center of Excellence in Boston (SETMA is the only multi-specialty Affiliate of the Joslin Diabetes Center). Drs. Richard Jackson and Ken Snow, while visiting SETMA, recommended the adding of a “What If Scenario” to our display of all twelve calculators.

    The concept is that we are asking patients to make changes which will not show up as benefits for decades. Of course, ignoring those changes will result in irrevocable deterioration in the patient‘s health over those decades. But how do you prove to a patient that if you make a change, it will make a difference? One way is with the Framingham Risk Calculators being presented to the patient with the inclusion of the changes which would result if the patient improved the elements of the risk calculator.

    Even though these risk calculators are not perfect, they are still the best we have. And, it is imperative that patients know and that their provider knows what their risk is, because it is with the knowledge of the patient‘s cardiovascular risk that a plan of care and a treatment plan can be designed to help preserve the patient‘s health.

    Remember, Risk is an attempt to determine what the future might be like which means it is imprecise. Some people with a high risk will not experience poor health and some who have low risk will. Overall, however, those with high risk will have more heart attacks and strokes than those with low risk.

    Dynamic ComplexityIndex

    The problem with biological systems is that change, even change which results in deterioration of your health, does not occur quickly and it often occurs without any signs or symptoms until the illness, or disease process has already caused significant damage. There is no explanation of this principle more apt to our use of risk calculators than Peter Senge‘s explanation of dynamic complexity in The Fifth Discipline.

    Senge defines dynamic complexity as a situation where cause and effect are subtle, and where the effects over time of interventions are not obvious. This perfectly describes the development of many disease states and the benefit of their treatment. We know that obesity causes, or contributes to most diseases including diabetes, hypertension, heart disease, cancer, etc. In these conditions, -obesity is the cause; cancer is the effect, but the change is slow and is not apparent. Also, the results of treatment are very slow. Consequently, it is hard to sustain the changes necessary to eliminate the cause, which is obesity, in order to avoid the - effect which is cancer.


    Increasingly pre-diabetes and cardiometabolic risk syndrome are key elements of the risk stratification of our patients, not only letting us know that a patient needs to change but giving us a tool with which to motivate that change.

    Quantifiable risk factors give a patient the ability to “see” the change which will make the difference.  This is where science, patient behavior and medical home join forces to improve the health of patients.

  • Annual Questionnaires:  Fall, Functional, Pain, Stress, Wellness

Preventive health initiatives can be measured and they should be. But, if those measurements are going to make a difference, the results must be transparently shared with provider, patient and the public. In a conversation with the staff of the American Medical Association's Physician Consortium for Performance Improvement (PCPI) Department, SETMA addressed the "missing element" in quality measures and in the three-part Performance Improvement Continuous Medical Education described by the AMA in 2004. That missing element is a systematic and consistent auditing of a practice's and/or of a provider's performance on those quality measures.

As a result, SETMA has added a major new tool to our preventive health initiatives which is our Business Intelligence COGNOS Project.  This will be described later in the Population Health Section of SEMTA’s medical home.  In summary, this is the ability for SETMA to report internally to our providers and staff and externality to our patients and community how we are performing on over 300 quality-of-care metrics. SETMA's BI Project involves the auditing of:

  1. What preventive measures a patient needs, before they are seen.
  2. What preventive measures a patient receives whey they are seen.
  3. What preventive measures remain to be fulfilled.
  • SETMA's LESS Initiative was begun in 2002 and was accepted by the Agency for Healthcare Research and Quality (AHRQ) in 2011.  This Initiative is the core of SETMA’s preventive health program.  Each patient seen at SETMA is confronted with these three needs.  The LESS is intended to globally improve the health of those who receive their care at our clinic. LESS stands for:

    L -- Lose weight
    E -- Exercise
    S -- Stop
    S -- Smoking

    While no one would argue that each of these is not valuable in the life or health of anyone, to our knowledge, there has never been a concentrated effort to confront an entire patient group with all three elements consistently every time they seek healthcare. Here is how the Initiative will work. Every time a patient is seen in the clinic, no matter what the occasion for the visit is, they will be alerted to the health risk of:

    Their current weight, as measured by their body mass index (BMI) and their body fat content. They will be given a Weight Management Assessment which tells them their BMI, their disease risk associated with their current BMI and waist measurement, their percent body fat and an explanation as to how a 5% change in their body fat will impact their health and future.

    The benefit which their heart and lungs are receiving from their current participation in exercise as indicated by the "aerobic points" which that exercise achieves for them and a recommend minimum exercise level which they need in order to achieve a "good" aerobic status for their age and sex. This exercise prescription will include information on how to increase the number of steps they take each day in order to have an "active" lifestyle which is defined by taking 10,000 or more steps a day. The average America takes fewer than 6,000.

    The imperative for stopping smoking . Even the tobacco companies' websites now state, "The only way to avoid the health hazards of tobacco smoke is to stop smoking completely." This is clever because with this warning, the tobacco companies which continue to encourage tobacco smoking have immunized themselves from future litigation because they have warned you that their product is harmful. Now, legally, the only one to blame for the harmful effects of smoking is the smoker. Also, the initiative includes the questioning of patients about exposure to "environmental tobacco smoke" either at home or at work.


    It is no longer enough to caution patient’s to avoid using all tobacco products, but they must also be counseled and encouraged to avoid environmental tobacco smoke (also referred to as secondary tobacco smoke or passive tobacco smoke).  It is now known that in addition to primary tobacco smoke (smoking), secondary tobacco smoke (being around smokers) that “tertiary” tobacco smoke is carcinogenic.  Tertiary smoke exposure is that which you smell on the clothing and body of others.  There is NO safe level of exposure to tobacco smoke.  As patients are “activated” in their medical home, i.e., they are informed and empowered to take charge of their own health, the first step is “stop smoking.”  When you smell tobacco on others, you are inhaling carcinogenic materials.


    A sedentary life style is either causative or contributory to all diseases including diabetes, cancer, heart and lung disease.  SETMA’s LESS Initiative includes a personalized exercise prescription with special formulations for patients with diabetes and congestive heart failure.  There are five complications of diabetes which impact the kind of exercise in which a patient should engage.  SETMA’s exercise diabetes prescription addresses appropriate modifications for each of those.  Patients with severe physical limitations should not avoid exercise.  SETMA’s CHF Exercise prescription describes how a poorly condition person should begin with two minutes of activity until they can work up to 15 minutes, then thirty, etc.