Background

Physical inactivity, unhealthy diet, tobacco use and risky use of alcohol are leading causes of disease, disability and premature death, and impose a significant yet preventable burden on our healthcare system. The U.S. Preventive Services Task Force concluded that “the most effective interventions available to clinicians for reducing the incidence and severity of the leading causes of disease and disability in the U.S. are those that address patients’ personal health practices.”

In 2002, people in the United States made more than 480-million visits to the offices of family physicians, general internists and general pediatricians (Cherry et al, 2003). At least 100 million people identify these primary care clinicians as their usual source of care (Medical Expenditure Panel Survey, 2001), value their advice, and are motivated to act on that advice (Integration of Health Behavior Counseling in Routine Medical Care Report, 2001). Many proven approaches to health behavior counseling require several minutes of clinician time in any single visit. These approaches often make strategic use of full office practice teams that do not involve face-to-face patient-clinician intervention, such as telephone counseling, Web sites, follow-up through e-mail, expanded roles for office staff, or referral to community-based clinics or services. Despite serious time constraints, many primary care clinicians spend two or three minutes on health promotion and/or health education during office visits (Stange et al, 2002). However, few clinicians are able to go beyond a basic approach of counseling patients to more complicated and effective brief behavior-change counseling. Practical strategies are needed to tailor more complex and multilevel interventions to the realities of primary care practice.

Insights emerging from the first round of funding suggest that the Chronic Care Model (CCM) and the RE-AIM framework are helpful in understanding the extent to which different interventions are effective in improving patients’ health behaviors and quality of life, and in achieving practice changes. Round 2 projects considered the domains and relationships in the CCM and RE-AIM when designing and evaluating interventions aimed at changing patient and practice behavior.

The CCM provides a functional framework and set of organizational principles for basic changes to support care that is evidence-based, population-based and patient-centered. The model defines six broad dimensions that must be considered when redesigning systems of care:

1. Organization of Care
2. Clinical Information Systems
3. Delivery-System Design
4. Decision Support
5. Self-Management Support
6. Community Resources

The model does not provide a specific set of interventions; rather, it acts as a framework within which improvement strategies can be tailored to local conditions. The same framework can be used to support improvement efforts in health behavior counseling and chronic illness care, possibly leading to practice efficiencies that will help to achieve both prevention and chronic care goals.

The RE-AIM framework offers a comprehensive way to evaluate health behavior interventions. It can be used to estimate their potential impact on five elements or dimensions that relate to health behavior interventions:

1. Reach the target population.
2. Efficacy or effectiveness.
3. Adoption by target settings or institution.
4. Implementation—consistency of delivery of intervention.
5. Maintenance of intervention effects in individuals and populations over time.