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HealthPOWER! Prevention News - Spring 2010 (Health Promotion) HealthPOWER! Prevention News - Spring 2010 (Health Promotion)Training for Preventive Care: An Ambitious Plan Changing one’s health behavior is difficult. For example, smokers who are trying to quit often make numerous attempts before succeeding. People seeking to lose weight try different diets, programs, and perhaps pills during their repeated attempts. Once some weight is lost, studies indicate that most people regain a certain portion, if not all, of that weight. Maintaining weight loss is clearly a bigger challenge than losing it in the first place. That people begin an exercise program and then fail to continue is also a well known fact. From the point of view of medical providers and their associated health care teams, it is indeed challenging to get patients to change their health behaviors. However, many health behavior change strategies have been shown to be effective. These include motivational interviewing1 and health coaching, using the "5A’s"2,3 as well as behavioral techniques like setting very specific ("SMART")4 goals, self monitoring using behavior records, making stimulus control changes, changing thinking patterns, and arranging for support from others. Unfortunately, medical providers and their team members often lack skills and knowledge in these areas. This need has been recognized in medical education in recent years. Nearly all (124 out of 126) medical schools offer courses in communication skills. An equal number of medical schools offer courses in prevention and health maintenance, which include some of these topics.5 The lack of training in behavior change among health care staff has been repeatedly mentioned in the professional literature, and many books have been written and other efforts made to fill that gap.6,7,8 Training does change practice patterns, although the extent to which that is true may depend not only on trainee characteristics and institutional support for change, but also on course content.8,9 The "whole person" orientation of the Patient-Centered Medical Home (PCMH) provides renewed impetus to help patients improve their health behaviors. Certain clinical members of each PCMH "teamlet" (medical provider, RN Care Manager, Clinical Associate, and clerk) are expected to provide health and wellness consultation and coaching to Veterans working on health behavior changes, and the entire teamlet is to emphasize healthy living in addition to routine medical care. To be most effective, training in motivational communication, health coaching, health literacy, prevention, and related skills will be necessary for staff to provide these services. The National Center for Health Promotion and Disease Prevention (NCP) has drafted a plan to provide that training both at the PCMH Learning Centers and locally at each medical center. The NCP VHA Preventive Care Program training plan includes substantive training for many of the PCMH and other interested staff, as well as for Preventive Care Program staff members including the Health Promotion and Disease Prevention Program Manager and the Health Behavior Coordinator. A curriculum on motivational communication is being developed collaboratively with several VHA program offices including the Employee Education System (EES), Office of Mental Health Services, Public Health and Environmental Hazards, Office of Nursing Services, Spinal Cord Injury Service, and others. Other new curricula are being developed within NCP. The plan calls for each Health Behavior Coordinator to receive training to become a Facilitator for the "Patient Education: TEACH for Success" program (TEACH). The well-established 14-hour TEACH program includes components on communication and establishing rapport, health behavior change, coaching and partnering, and assessment of patient needs. Health Behavior Coordinators are also expected to receive training in motivational interviewing, prevention, and health literacy. In addition to many other activities, they will use their expertise to provide guidance to PCMH coaching staff members who are working with Veterans on health behavior change. The Health Promotion and Disease Prevention Program Managers will receive training in prevention science and practice and health literacy, as well as the staff-level version of TEACH. Their training will enable them to be content experts in prevention and related areas and to lead the Preventive Care Program effectively. They also will provide guidance to PCMH and other staff who are implementing and practicing preventive care. Veterans Health Education Coordinators who are not already certified TEACH Facilitators will have an opportunity to receive TEACH Facilitator training. Once that process is complete, each medical center will have both the Veterans Health Education Coordinator and the Health Behavior Coordinator available to present the TEACH curriculum. PCMH teamlets throughout VHA are to receive training at one of five regional Learning Centers to maximize their functioning in the PCMH model. As part of the planned training on team design and performance and care management and care coordination, the Preventive Care Program plan recommends that teams be offered courses on motivational interviewing, prevention, and, for some members, the "Clinician-Patient Communication to Enhance Health Outcomes" course from the Institute for Healthcare Communication.8 Back at each medical center, TEACH Facilitators will present the 14-hour course for as many PCMH and other staff members as time and scheduling permit. Skills learned through TEACH will be helpful in coaching patients on health behavior change and for facilitating other preventive care activities. Further, the Health Promotion and Disease Prevention Program Managers will be able to present a course on health promotion and disease prevention of variable length (1-8 hours), as time permits. In addition, three online health literacy courses are available. Those courses cover health literacy communication skills; creation of, and working with, health education print materials; and conducting a health literacy assessment of the facility environment. Additional training and coaching on motivational interviewing is also anticipated. Although providing training of this magnitude is an ambitious undertaking, it is clearly necessary if the PCMH is to facilitate positive health behavior changes effectively among patients. VHA is devoting substantial resources to the New Models of Care Transformation and the Patient-Centered Medical Home component. Training staff to facilitate patients’ health behavior change will be a major part of that effort. References
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