Rethinking Prevention in Primary Care: Applying the Chronic Care Model to Address Health Risk Behaviors

Background/Objective: The Chronic Care Model (CCM) may serve as a template for prevention due to the many similarities between preventive care and management of chronic diseases. This study empirically examines the CCM as a framework for improving services to address risk behaviors that are leading causes of preventable death and disability in the U.S.

Methods: Cross-sectional survey data were obtained from 52 primary care practices participating in a national Robert Wood Johnson Foundation health promotion initiative. Practices were surveyed regarding their use of interventions to address risk behaviors as recommended by the U.S. Preventive Services Task Force. These included health risk assessments, individual counseling, group counseling, and referral to community programs for smoking, risky drinking, unhealthy dietary patterns, and physical inactivity. Based on prior conceptual and empirical work, various practice features were identified and measured as indicators of CCM elements. These indicators were included in multivariate regression analyses to estimate practices' use of preventive services to address health risk behaviors.

Results: Practices reported infrequent use of behavioral services and low implementation of the CCM. However, CCM elements explained 22-41% of the variance in use of USPSTF-recommended services to address patient risk behaviors. Practices owned by a hospital health system (b=0.60, p<0.01) and exhibiting a culture of quality improvement (b=0.03, p<0.001) were more likely to address health behaviors. Also, practices that had a multispecialty physician staff (b=0.50, p<0.05) and staff dieticians (b=2.05, p<0.05); decision support in the form of risk factor chart stickers (b=1.33, 0<0.001), checklists/flowcharts to manage care (b=1.01, p<0.01), patient chart review (b=1.03, p<0.01), and clinical staff meetings (b=0.55, p<0.05); and clinical information systems such as electronic medical records (b=0.44. p<0.05) were more likely to offer preventive services.

Conclusion: Despite a strong evidence base supporting behavioral interventions, we found that they are infrequently offered by a nationwide sample of primary care practices. However, CCM implementation in practice settings is generally associated with increased intervention. In particular, the “health system organization” component, as reflected by practices whose cultural beliefs and values support quality improvement, was most significantly and consistently associated with preventive services to address behavior change. Our findings suggest that primary care practices and their patients may benefit from more widespread implementation of the CCM. This framework adapted for prevention has the potential to not only better control existing chronic illnesses, but also reduce patients' risk of developing chronic diseases in the future.