Implementing prevention within the patient-centered medical home (PCMH) in Veterans Health Administration primary care practice

Introduction: The Veterans Health Administration (VHA) has implemented components of the Patient Centered Medical Home over the last 2 years for 6 million patients; this includes a robust prevention program. The VHA's National Center for Health Promotion and Disease Prevention (NCP) has largely been responsible for oversight implemented at various levels within the VHA. Methods: Mixed methods descriptive approach using a multi-level systems perspective. In VHA, these levels include: National-VA Central Office; Regional-Several VHA facilities; and Local-individual primary care practice sites with respective staff. Results: National: Policy directives include a Handbook that delineates required roles and responsibilities of new positions. This includes a Health Behavioral Coordinator (HBC) and a Health Promotion Disease Prevention (HPDP) Program Manager at all 154 large facilities. Health Psychologists, Social Workers and Nurses have filled these positions. Regional: Each cluster of Medical Centers (21) has a designated prevention program administrative leader. A current project involves 5 regions and 2000 patients in a Telephone Lifestyle Coaching pilot that provides telephone-based health coaching in 6 areas of health behavior change (e.g., tobacco cessation, alcohol reduction). This effort is one of several to emphasize opportunities in non face to face prevention care. Local Facilities: HBCs and HPDP staff meet monthly on national calls and share best practices (e.g., shared medical appointments, tobacco cessation clinics and telehealth-delivered weight management interventions). Additionally, standardized, evidence-based training programs in health coaching (TEACH for Success) and Motivational Interviewing (MI) were developed for primary care staff. To date, TEACH Facilitators (517) have trained 10,000 primary care staff. MI Facilitators (175) will provide MI training to 3200 nurses. The goal is to enhance patient centered communication skills and optimize veteran engagement. “Healthy Living Reminders” are an Electronic Health Record tool to promote shared decision making and self-management goal setting conversations. The MOVE! Program for weight management includes screening, assessment, and lifestyle coaching to increase physical activity and improve diet. It is available for face-to-face, telephone based, group, or home-messaging devices participation. Patients who receive high intensity (> 8 encounters) and sustained MOVE! intervention (at least 4 months of participation) have improved outcomes (30% achieve 5% weight loss). Conclusions: The VHA's PCMH uses prevention and health behavior change experts within primary care settings to provide training, tools, and innovative clinical interventions. This assists primary care staff in delivery of patient-centered evidence-based preventive care. Lessons learned may assist community adoption of the PCMH model.