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

Transforming Your Practice - Preventive Health Tools
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The future of healthcare is going to be focused upon health and not simply upon excellent care of disease processes. Yet, the ideal of preserving and/or regaining of 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 by individuals.

Preventive health initiatives can be measured and they should be. But, if those measurements are going to make a difference, the results must be disclosed. In a recent 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. That missing element is a systematic and consistent auditing of a practice's and/or of a provider's performance on those quality measures.

The foundation of effective preventive care is “hope.”  The following link gives a more detailed explanation of this last statement:  Value, Virtue, Trust and Hope - The Foundation of Health Improvement.   Without a sense of person value and personal virtue from which comes the capacity to trust, the result of the coexistence of these three, hope, will not exist.  And without “hope” individuals will not take the steps and make the changes for the power and potential of preventive medicine to improve health.

    SETMA’s Weight Management Program is built on the AMA’s Adult Weight Management Program which was published in February, 2004.  It is premised on the proposition that excess weight and/or frank obesity is not simply coincidental with virtually every disease which we treat but is either contributory and/or directly causative of those conditions including hypertension, congestive heart failure, diabetes, metabolic syndrome, hyperlipidemia, coronary artery disease, and a number of types of cancer, among many others.  SETMA’s weight management program is designed to make it simple for health care providers to determine and to document whether or not patients are qualified for treatment with medication or surgery, based on sound scientific evidence.  This tutorial will help all providers learn to utilize this suite of templates either for intensive weight management of a patient, or for giving the patient a weight-management assessment, and/or to help a patient understand why they do, or do not qualify for pharmaceutical and/or surgical treatment of their weight.  The weight management assessment is a part of SETMA’s LESS Initiative which is utilized with every patient we see.

    The premiere primary preventive health initiative of SETMA is the LESS Initiative. LESS is an acronym for: lose weight, exercise, and stop smoking. Included in the LESS Initiative are diabetes prevention, hypertension prevention and insulin resistance risk analyses. The following procedure is the proper way to complete the LESS Initiative.  The LESS Initiative is explained in the TCPI section of this website under its own drop down.

    The best way to treat diabetes is “don’t get it”.  It is in diabetes and in hypertension where “screening” and “prevention” are best seen as two parts of the same process.  SETMA’s Diabetes Prevention Tool enables SETMA providers to systematical screen patients for diabetes, activate the patient with the knowledge of the process of developing diabetes and engage the patient in a program which will prevent or delay the onset of diabetes in patients who are at high risk and to work with the patient in a “shared-decision” making process.  If patient has “pre-diabetes” their record is note so that efforts can be sustain to prevent the disease.

    If a person is 55 years of age and does not have hypertension, their life-time risk of developing hypertension is 90%.  That is not a misprint.  Without taking affirmative steps to avoid hypertension almost everyone will develop it.  SETMA’s prevention program teaches the patient how to avoid the development of hypertension.

    Health and Human Services through CMS is becoming increasingly more  involved with preventive care and more payments are being made for screening and preventive care which will ultimately make a difference in the care, the health and the cost of care for Medicare beneficiaries.  Two new services are:  Intensive Behavioral Therapy (IBT) for Obesity (G0477) and Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (G0446).

    CMS is getting serious about Preventive Health Services which have the potential for moving us toward the fulfillment of the Triple Aim:  improved care (processes), improve health (outcomes) and decreased costs (sustainability).  The new Intensive Behavioral Therapy codes for obesity and cardiovascular disease along with the Initial Preventive Physical Exam (IPPE), the Annual Wellness Visit Initial and Annual Wellness Visit Subsequent are significant advances in recognizing the value of preventive care and in recognizing the expertise of those who have the tools to provide those services.   Along with the Transitions of Care Management Codes which have been published this year, these preventive codes encourage the “right stuff” in primary healthcare delivery.   SETMA is determined to support and to promote these efforts by utilizing them in our practice.   The following is a link to our published deployment on our website of the Transitions of Care Management Codes which we are currently using in our almost 5,000 hospital discharges a year. The following references provide content information for Preventive Services authorized by Centers for Medicare and Medicaid (CMS). SETMA’s Clinical Decision Support (CDS) tools for these Preventive Services were developed on the basis of these and other official AMA and CMS publications.

The last four preventive tools are elements of the LESS Initiative; they are:

    Exercise Assessment

    The foundation to health is physical activity regardless of age and/or state of one's health. Research has shown that when a healthcare provider discusses physical activity with a patient at every visit, that there is a significantly increased level of physical activity in the patient's life style. SETMA's Exercise Prescription, along with the disease specific exercise prescriptions for CHF and Diabetes, aid healthcare providers in the fulfillment of this element of quality healthcare.

    Current Exercise Activity

    This allows for the documentation of the patient's current structured activity in:

    • Running/Walking/Jogging,
    • Outdoor Cycling,
    • Swimming,
    • Tennis (Singles and Doubles),
    • Rowing, and
    • Golf

    This is not to imply that these are the only valuable forms of exercise or that activities such as golf give effective aerobic benefit.  In fact, it is possible to achieve health with the level of activity in one's routine work, gardening, house work, or other activities. However, the above six categories are the most common forms of activities which are done with health in mind.  When completing the exercise prescription, once the distance, when it applies, the duration of exercise and frequency are documented, the Calculate button displays the Aerobic Units per Session and the Aggregate Units per week. These aerobic units are based on the Cooper Clinic data which is published elsewhere...

    This is an exercise prescription specifically for patients with CHF or other exercise limiting conditions.  Congestive heart failure (CHF) has been steadily increasing over the past 10 years. Lack of physical activity is considered an independent risk factor for the development of CHF. In addition, other primary risk factors include: obesity, hypertension, and diabetes.  Patients diagnosed with CHF benefit greatly from participating in exercise-training programs. For example, exercise training of patients with moderate to severe CHF:   lowered all-cause mortality by 63% and reduced hospital readmission for heart failure by 71%.   The Agency for Health Care Policy and Research Guidelines on Cardiac Rehabilitation recommended exercise training for patients with chronic stable HF.

    There are three groups of cautions for exercise with patients who have diabetes. None of these are absolute contraindications but represent cautionary guides to help patients with diabetes improve their glycemic levels with safe physical training or activities. The cautions are indicated by:  Risk Factors for CVD, Age >35 and Type 2 Diabetes >10 years or Type 1 Diabetes >15 years.  Patients with longstanding diabetes are at higher risk for cardiovascular disease, as the very presence of diabetes is a cardiovascular risk equivalent, which means that a patient with diabetes is at the same risk for a future cardiac event as a person who has already had a heart attack or other cardiac event. Therefore, exercise programs in patients with diabetes ought to be started but they ought to be started with caution.

    Only about half of smokers are ever advised to quit smoking by their physicians. The Agency for Health Care and Policy and Research recommends that physicians should discuss the dangers of smoking with their patients and should continue to encourage them to quit at every office visit. Physicians are in an ideal position to advise against smoking because 70 % of smokers see their primary care physician about three to four times a year. Research indicates that success rates for unaided smoking cessation doubles from 5% to 10% of attempts when instigated by simple advise to quit from the clinician. Yet, the literature continues to document the failure of physicians and other healthcare professionals to intervene with all of their patients who smoke, with only half of current smokers reporting having been encouraged to quit and even fewer receiving specific counseling.  Healthcare settings provide an important teachable moment for smoking cessation intervention. Seventy-five percent of the adult population visits a physician at least once a year, with the average adult making five visits per year. In the physician's office, patients are often conscious of their health and most receptive to risk factor intervention, providing an important opportunity for change.