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Community and Clinician Partnership for Prevention(C2P2)
Alex R. Kemper, MD, MPH, MS
Philip Sloane, MD, MPH
Rowena Dolor, MD, MHS
Tricia L. Trinite’, MSPH, ANP-BC
Funding: AHRQ; PBRN Task Order Request #1
Background
• Unhealthy behaviors are common and lead to significant morbidity and mortality– Tobacco use– Poor diet– Lack of physical activity
Background
• Rate of behavioral-based interventions to address unhealthy behaviors by primary care providers is low– Lack of knowledge– Poor self-efficacy– Challenge of delivering interventions in a busy
setting with limited capacity
Chronic Care Model
Objective
• To evaluate strategies to develop and foster linkages between primary care practices and community resources
Setting
www.learnnc.org
Orange County: Population: 120,000 Black: 13% Hispanic: 6%Durham County: Population 230,000 Black 37% Hispanic 11%Overall, 13% below FPL
In North Carolina Tobacco: 25% Overweight: 36% Obese: 27% ≥20 minutes physical activity ≥3 days per week: <25%
Ready to change: 44% who smoke, 60% with poor nutrition, 68% who lack exercise
Participants and Interventions
Control
Duration of the Intervention: 6 month, starting spring 2008
9 Practices
(IM and FP)
Passive
Intervention
Active
Intervention
R
Practices
• Control– 3 family practice clinics
• Passive Intervention– 1 family practice clinic– 2 internal medicine clinics
• Active Intervention– 2 family practice clinics (1 with trainees)– 1 internal medicine
Initial Selection of Community-Based Resources
• Behavioral-based interventions based on the 5 A’s
• Must be accessible
• Interested in new referrals
• Able to participate in bi-directional communication
Initial Community-Based Resources
• Tobacco Quitline
• Public Health Department Dietitians
• YMCA
• Duke Live-for-Life Program
Passive Intervention
• Brochure and referral material for selected community organizations:
• Practice kick-off meeting
• Brief help as requested
Practice Brochure
Practice Brochure
Active Intervention
• Passive Intervention Protocol plus:– Access to the “ACCTION Pack”– More regular contact with a “practice
champion”
ACCTION Pack
ACCTION Pack
Outcome Measures
• Main Quantitative Measure: – Referral from practices to a community
resource
• Description of the barriers to and facilitators of developing linkages between practices and community resources
Tobacco Assessment
Baseline Midpoint Final
Control 41% 56% 56%
Passive 46% 53% 54%
Active 80% 72% 72%
Tobacco Use
Baseline Midpoint Final
Control 9% 13% 9%
Passive 6% 9% 11%
Active 14% 12% 13%
Tobacco Referral
Baseline Midpoint Final
Control 3% (1) 0% 2% (1)
Passive 4% (1) 0% 7% (4)
Active 6% (3) 11% (6) 5% (3)
No intervention effect
Diet Assessment
Baseline Midpoint Final
Control 15% 22% 25%
Passive 10% 27% 28%
Active 36% 31% 38%
Diet Needs Modification
Baseline Midpoint Final
Control 8% 16% 19%
Passive 7% 21% 24%
Active 25% 22% 31%
Diet Needs Referral
Baseline Midpoint Final
Control 3% (1) 7% (5) 7% (7)
Passive 14% (4) 6% (7) 7% (9)
Active 14% (11) 6% (6) 6% (10)
No intervention effect
Physical Activity Assessment
Baseline Midpoint Final
Control 21% 27% 30%
Passive 17% 32% 29%
Active 41% 35% 37%
Physical Activity Needs Modification
Baseline Midpoint Final
Control 11% 15% 21%
Passive 9% 21% 23%
Active 21% 21% 30%
Physical Activity Referral
Baseline Midpoint Final
Control 1% (2) 3% (2) 2% (2)
Passive 2% (1) 1% (1) 1% (1)
Active 8% (6) 4% (4) 0% (0)
No intervention effect
What limited the impact of the interventions?
• Little understanding about how to build collaborations– Physicians were not motivated to form
collaborations, even when they were interested in engaging the community
– Organizations had significant staff turnover– No method for bi-directional communication
• Concerns about cost• Concerns about treatment• No information about outcomes
What limited the impact of the interventions?
• ACCTION Pack– Difficult to use to get to information quickly– Not populated with local resources– Practices wanted handouts– Practices overwhelmed with material
Conclusions and Next Steps
• Forming partnerships between clinicians and community-based organizations is difficult
• Successful partnerships cannot be developed by bringing materials to practices alone
Conclusions and Next Steps
• Future efforts should – work on bringing together potential partners
and allowing them to develop mutually beneficial collaborations
– focus on increasing consumer demand and the expectation that primary care providers will refer to such organizations
Thank You!