clinical prevention prerequisites a framework for health authorities ak’ingabe guyon msc md ccfp...
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Clinical prevention prerequisitesA framework for health authorities
Ak’ingabe Guyon MSc MD CCFP FRCPCPublic health and preventive medicine specialistMontreal Public Health Unit
Framework developped in collaboration withDavid Kaiser, Valérie Lemieux and Robert Perreault
Thursday, May 29th 2014CPHA conference, Toronto
Plan
1. Background and objectives
2. Clinical prevention prerequisites
3. Regional and provincial applications
Clinical prevention prerequisites A. Guyon, May 2014 2
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Prevention: an essential public health function
Public health
PreventionLast 2006, Starfield 2008, BC Clinical prevention policy review committee 2009,
It includes at least :• Immunisation• Counseling• Screening
and early detection• Preventive
treatments
Surveillance Protection Health
promotion
1. Background and objectives
Clinical prevention prerequisites A. Guyon, May 2014
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Initial project
• Montreal Public health unit within regional health authority• Strategic planning exercise • Clinical prevention services
1. Background and objectives
Clinical prevention prerequisites A. Guyon, May 2014
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Drifting project
• …define public health’s role (regional and provincial) in clinical prevention
1. Background and objectives
Clinical prevention prerequisites A. Guyon, May 2014
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Clinical preventive servicesUSTFPHS, CTFPHC,
Thivierge et al. 2014
Clinical prevention prerequisites
Walsh & McPhee 1992Barr et al. 2003
Groulx 2007, CSBE 2010BC Lifetime of prevention 2009, BCMA 2010
US National prevention strategy 2011UK Department of health 2014
1. Background and objectives
Clinical prevention prerequisites A. Guyon, May 2014
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Objectives
Propose a framework of clinical prevention prerequisites As a tool to rapidly identify who supports clinical prevention and how at a regional and provincial level
Apply the framework at a regional level (Montreal Public health unit) at a provincial level (clinical prevention services taskforce among Quebec’s
public health units)
Redefine public health’s clinical prevention mandatesAssist the regional clinical prevention team as it reassesses its responsabilities over clinical prevention
1. Background and objectives
8Clinical prevention prerequisites
A. Guyon, May 2014
Transversal functions necessary for clinical prevention
• Orchestration• Scientific leadership• Direct support to clinicians• Monitoring and surveillance• Patient empowerment
2. Clinical prevention prerequisites
Clinical prevention prerequisites A. Guyon, May 2014
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2. Clinical prevention prerequisites framework
Orchestration
Monitoring and surveillanceScientific
leadership
Patient empowerment
Direct support to clinicians
10Clinical prevention prerequisites
A. Guyon, May 2014
Orchestration Overall leadership and planning
• Responsibility for vision and planning• Balancing prevention with other public health functions• Ensuring a health equity focus
Stakeholders roles and engagement• Role and boundary negotiation among institutions, multiple clinicians, NGOs, industry • Workforce planning
Health care services that strenghten prevention• Access, comprehensiveness, continuity, coordination
Funding and incentives• Publicly funded coverage decisions on clinical preventive services• Incentives to clinicians for quality and access to preventive services
Logistics for clinical prevention• Patient recall and clinician reminder– Electronic health records
Populational prevention programs• For example: cancer screening, immunisation, smoking cessation, etc.
2. Examples of clinical prevention prerequisites
References on slide 6, Valaitis et al. 2009, Parks et al. 2012, Bodenheimer et al 2014.
11Clinical prevention prerequisites
A. Guyon, May 2014
Scientific leadership
Evidence based clinical prevention • Assess new trends, evidence• Priority setting of clinical preventive services and schedule• Evidence based practice guidelines
Training and knowledge transfer• Initial training of clinicians in clinical prevention• Continuing professional education
Research on clinical prevention• Clinical preventive services research• Public health and health services systems conducive to prevention
2. Examples of clinical prevention prerequisites
BC Lifetime of prevention 2009Maciosek et al. 2009
12Clinical prevention prerequisites
A. Guyon, May 2014
Direct support to clinicians
Practice support • Quality improvement teams• Facilitation• Communities of practice
Support of motivational interviewing techniques
Clinical decision support at point of care (web, apps, consultations to expert clinicians…)
2. Examples of clinical prevention prerequisites
AHRQ, Put prevention into practice, 2005Provost et al. 2007; Martel & Leaune, 2009; NICE 2014
13Clinical prevention prerequisites
A. Guyon, May 2014
Monitoring and surveillance
Monitoring • Clinical prevention services access, uptake• Quality improvement of clinical preventive services
Evaluation• Of clinicial prevention services effectiveness and efficacy• Of clinical prevention system’s implementation, relevance, efficacy, efficiency
Surveillance• Preventable disease and injury trends
2. Examples of clinical prevention prerequisites
References on slide 6 and Bodenheimer et al 2014
14Clinical prevention prerequisites
A. Guyon, May 2014
Patient empowerment
Vision of patients as partners
Supporting population demand for clinical prevention• Media campaigns
Literacy friendly patient education material • Unbiased and public prevention focused website(s)
Self management support• Web-based personal health plans • Self care guidelines for prevention
2. Examples of clinical prevention prerequisites
References on slide 6 and Bodenheimer et al 2014
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A. Guyon, May 2014
Usefulness of the clinical prerequisites framework
Montreal public health unit Identification and analysis of all clinical preventive mandates Shared understanding of clinical prevention prerequisites across the public
health unit’s divisions Strategic support for the upcoming regional public health plan
Provincial taskforce on clinical prevention among Qc public health units
(Groupe de travail de la Table nationale de concertation en prévention clinique) Identification of local, regional and provincial stakeholders Diagnosis of current stakeholders’ involvement Systematic identification of gaps and overlaps Strategic support for the upcoming provincial public health program
3. Regional and provincial applications
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Stakeholders weakly coordinated and
involved
Towards a clinical prevention system
Clinical prevention system•Clinical and public health expertise centres (INSPQ, INESS)•Ministry of health (public health, primary care, hospital services, RAMQ insurance plan, …)•Regional health authorities and local centres (ASSS, CSSS)•Public health (local, regional, provincial)•Health care services (CLSC, clinics, hospitals pharmacies, etc.)•Professional organisations (MD, nurses, pharmacists, etc.)•Patients, NGOs, etc.
3. Regional and provincial applications
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Questions ?Comments ?
Regional or provincial experiences in planning a comprehensive clinical prevention system?
Ak’ingabe Guyonaguyon@santepub-mtl.qc.ca
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References• Agency for healthcare research and quality (AHRQ). Put prevention into practice – website current as of
November 2005• Barr V et al. 2003. The expanded chronic care model: an integration of concepts and strategies from population
health promotion and the chronic care model. Healthcare Quaterly, 7(1) 73-82.• Bodenheimer T et al. 2014. The 10 building blocks of high-performing primary care. Annals of family medicine
12(2) 166-171.• British Columbia (BC) Clinical prevention policy review committee. 2009. A Lifetime of prevention. Ministry of
health, Governement of British Columbia, Vancouver. BC.• British Columbia Medical Association(BCMA). 2010. Partners in prevention. Implementing a lifetime of
prevention plan. BCMA, Vancouver.• Canadian task force on preventive health care (CTFPHC). Website consulted on may 19th 2014.
http://canadiantaskforce.ca/• Thiverge et al. 2014. Évaluation Médicale Périodique. Direction de santé publique - Agence de la santé et des
services sociaux de Montréal et Collège des médecins du Québec, Montréal, Québec. • Commissaire à la santé et au bien-être du Québec (CSBE). 2010. Rapport d’appréciation du système de santé et
de services sociaux. Adopte une approche intégrée de prévention et gestion des maladies chroniques: recommandations, enjeux et implications. Québec, Québec.
• Groulx S. 2007. L’intégration des pratiques cliniques préventives. Guide pour la promotion et le soutien des pratiques cliniques préventives. MSSS. Québec.
• Last J. 2006. A dictionary of epidemiology. New York: Oxford University press.• Maciosek, M. V., Coffield, A. B., Edwards, N. M., Flottemesch, T. J., & Solberg, L. I. (2009). Prioritizing clinical
preventive services: a review and framework with implications for community preventive services. Annu Rev Public Health, 30, 341-355.
Clinical prevention prerequisites A. Guyon, May 2014
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References• Martel D., Leaune V. 2009. L’amélioration des pratiques cliniques préventives à l’ égard des habitudes
de vie. Recension des écrits. Direction de santé publique, ASSS de Montréal.• National institute for health and care excellence (NICE). 2014. Behaviour change: individual approches.
NICE public health guidance 49, • National prevention council. National prevention strategy. America’s plan for better health and
wellness. US Dept of health and human services. Office of the surgeon general, Washington, DC. • Parks AV et al. 2012. Opporunity knocks for public health departments: increasing the use of clinical
preventive services by older adults. Policy note. UCLA center for health policy research. LA, California.• Provost, M.-H. (2007). Description, impact et conditions d'efficacité des stratégies visant l'intégration de
la prévention dans les pratiques cliniques : revue de la littérature. Québec, QC: Ministère de la Santé et des Services Sociaux.
• Starfield B, Hyde J, Gervas J, Heath I. 2008. The concept of prevention: a good idea gone astray? J Epidemiol Community health 2008 (62) 580-583.
• Walsh JME, McPhee SJ. 1992. A systems model of clinical preventive care: an analysis of facotrs influencing patient and physician. Health Education Quarterly 19, 157-75.
• United Kingdom’s Department of health. 2014. Living well for longer. National support for local actions to reduce premature avoidable mortality. April 2014. London, UK.
• U.S. Preventive services task force (USPST). Website consulted on may 19th 2014. http://www.uspreventiveservicestaskforce.org/
• Valaitis R et al. 2009. A scoping literature review of collaboration between primary care and public health. Report to the Canadian health services foundation.
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