Clinical and Community Delivery Systems for Preventive Care

Abstract

Although clinical preventive services (CPS)—screening tests, immunizations, health behavior counseling, and preventive medications—can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success. Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical–community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical–community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time.

Adoption, Reach, Implementation, and Maintenance of a Behavioral and Mental Health Assessment in Primary Care

“…More effectively using co-located multidisciplinary teams and developing local community resources to refer patients for intensive counseling will be essential to help patients make difficult life changes. 49,50 This study has several limitations. We were not able to integrate MOHR fully into the practices' EHRs, despite initial plans to do so.…”

“…Future efforts will need to explore the roles of co-located health behavioral and mental health personnel and the integration of care between primary care practices and existing community resources. 49,51 Merely mandating that HRAs be added to an already packed wellness visit simply increases the chances that that practices will do this poorly or not at all.To read or post commentaries in response to this article, see it online at http://www.annfammed.org/content/12/6/525. …”

The impact of behavioral and mental health risk assessments on goal setting in primary care

“…While this is a substantial time investment for practices, patients will require greater support over an extended period of time to sustain improvements [9]. Future iterations of patient-centered HRAs, like MOHR, could serve to facilitate the integration of primary and community care providers to better leverage existing resources and better support patient needs [39]. Effective partnerships with health behavior and mental health counselors will be especially important.…”

A Taxonomy of Integration Interventions Between Health Care and Public Health

“…At this point, we do not propose subdomains; rather, we suggest the need for further efforts to elucidate these. Early work describes the "spanning infrastructures" 16,35 found in integration interventions to facilitate preventive services delivery, such as information systems for patient referral. Identifying and establishing the evidence for spanning infrastructures and other, organization-based resources and infrastructure that support the implementation and effectiveness of integration intervention are rich areas for future research.…”

“…Other authors have published models or frameworks for integration that focus on describing the facilitators and barriers to integration interventions rather than classifying the interventions themselves. 15,16 Thus, the heterogeneity of the integration activities and the need for a classification system have not been directly addressed since Lasker's work in the 1990s. 1 For researchers to evaluate and for federal agencies and other bodies to disseminate integration interventions, defining and classifying these interventions are necessary next steps.…”