Healthy Living Messages

• Be Physically Active
• Eat Wisely
• Strive for a Healthy Weight
• Get Recommended Screening Tests & Immunizations
• Be Involved in Your Health Care
• Be Tobacco Free
• Limit Alcohol
• Manage Stress
• Be Safe
  

HealthPOWER! Prevention News - Spring 2010 (Prevention Practice)

Integration of the VHA Preventive Care Program into the Patient-Centered Medical Home
Kathleen S. Pittman, RN, MPH
Program Manager for Prevention Practice

The VHA Preventive Care Program is designed to work closely with the Patient-Centered Medical Home (PCMH) Initiative to provide financial resources, training, and support for Health Promotion and Disease Prevention activities within the PCMH. The goal of VHA Primary Care is to provide health care in a manner that is continuous, coordinated, comprehensive, and accessible. A carefully structured, efficient, and high functioning primary care team can provide a "medical home" for the Veteran, where he or she receives guidance and nurturing as health care needs change with time. Integrating preventive care services into the primary care of Veterans through a Patient-Centered Medical Home is a key feature of the VHA Preventive Care Program. In addition to providing care to patients in ways that are coordinated and comprehensive, the PCMH also strives to meet the Veteran’s needs, values, and preferences.

Each of the members of the PCMH plays an important role in ensuring that Veterans have the knowledge they need to make informed decisions to improve or maintain their health. The VHA Preventive Care Program provided funds to support the goal of integrating preventive care services into primary care. Nurses will take a population management approach to their team’s panel of patients for process improvements. For example, data can be used to identify preventive services that the panel as a whole has not received. The nurses will look for patterns and work with their teams to develop plans to ensure that Veterans are being offered and understand the services needed to make informed decisions about their health care. Nurses will take the lead role in working with individual Veterans to develop a health promotion plan of care and evaluate the progress toward meeting each Veteran’s health goals. All staff will use principles of health coaching and patient self management to assist Veterans in identifying individual health risks and setting goals to minimize those risks. Training curricula are being developed to help improve health coaching skills and ensure that all Veterans receive the same messages concerning preventive services and healthy lifestyle behaviors. As some of the principles of health coaching may be unfamiliar to staff, Health Behavior Coordinators will be available to assist staff in improving their skills in health coaching.

In the future, the Health Risk Assessment (see article in this newsletter on HRAs - page 10) will be a valuable tool for Veterans and will make it easier for staff and Veterans to track progress toward health goals. Clinical guidance statements are being developed to assist clinical staff in determining what preventive services should be offered to Veterans and promote discussion between staff and Veterans. Additional system-level performance and outcome measures will be developed for health promotion and disease prevention in the PCMH to help us monitor our progress and continue to deliver the "best care anywhere" to our Veterans.

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