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CHS Research News
Vol 18, Issue 3, Summer 2006

Feature Article

Dr. David Grossman: New initiatives aim to transform preventive and chronic care throughout Group Health

By Katie Saunders

Making healthy behavior changes stick sometimes seems like health care’s Holy Grail. But CHS Senior Investigator David C. Grossman, MD, MPH, is hopeful. One reason he accepted the position of Director of Group Health’s Department of Preventive Care (DPC) in 2004 was the job’s potential to improve the health of Group Health’s half-million-plus members. Take Charge, a Group Health–wide initiative Grossman spearheads, is key to realizing this potential.

"This initiative brings essentially the whole organization together," says Grossman. Take Charge is an effort to improve preventive and chronic care services by increasing opportunities for long-term behavior changes, such as stopping smoking or losing weight. Such changes, called self-management, can prevent diseases and their complications, explains Grossman.

Formerly called the "Transforming Patient-Centered Care Initiative," Take Charge will facilitate these changes by giving patients access, 24/7, to customized online reports summarizing their most pressing needs for prevention, chronic disease management, or both. The reports may address cancer screening, immunizations, and risky behaviosrs, such as smoking and overeating, and will include relevant behavior-change programs available to members.

The customized feedback is based on combining data from patients’ electronic medical record (EpicCare) with information they enter themselves at least once a year through MyGroupHealth, members’ password-protected Web portal, at Group Health’s Web site, www.ghc.org. This 25-minute Health Profile asks about health risks (such as family history of colon cancer), health behaviors (positive and negative), relevant social factors (like living alone), and information needed to manage chronic disease.

Patients also indicate how ready they are to change risky behaviors: They choose responses ranging from "I have no plans to" increase my activity levels to "I’m already" increasing them. This approach is based on James Prochaska’s stages-of-change model: pre-contemplation, contemplation, preparation, action, and maintenance (and relapse). According to this model, encouragement to change one’s behavior is most effective when tailored to how ready a person is to change that behavior.

Grossman says the electronic Health Profile will provide a much more complete and accessible picture of a patient’s health risks and readiness to change than easily buried paper surveys filled out at a clinic visit. The online Health Profile might also help engage the substantial minority of members who never go to the doctor.

The idea of systematically gathering online patient health risk information has been "incubating for a while," according to Grossman. First, technology—in Group Health’s case, EpicCare and MyGroupHealth—had to catch up. With EpicCare now implemented throughout Group Health and over 100,000 members registered for MyGroupHealth, the time for the Health Profile has arrived. It will first be piloted among a subgroup of Group Health staff. Following this pilot, all Group Health employees and adult Group Health patients will have access to the Health Profile on MyGroupHealth. A paper based questionnaire will also be available to members who request one.

By itself, collecting electronic health risk information does not set Group Health apart. True, the readiness-to-change data are novel; but here’s the unique aspect of the Cooperative’s Health Profile experience: When patients enter data, it is permanently included in their electronic medical record—and shared with their care team. That makes the Health Profile a team tool with two-way connectivity with EpicCare, Grossman says, not a stand-alone self-management tool like those used by many employers and health care plans. After a Health Profile is completed, care teams as well as patients, receive electronic reports synthesizing self-reported health risks with customized recommendations for medical screening, self-management, and health promotion.

Grossman feels data from the Health Profile will help providers make the most of their limited "face time" with patients, raising the chances of catalyzing positive lifestyle changes and making them stick. Consider readiness to change: "This information will help us identify those areas where patients are interested and ready to change—and where they’re not," Grossman says. "That will help providers as they sort through what to spend their time on." (But he stresses, "we won’t give up on anyone," as people in the pre-contemplation phase need customized strategies distinct from those ready to change.)

As an illustration, Grossman describes a hypothetical 50-year-old woman who has scheduled a preventive care visit, one of several events triggering a reminder in MyGroupHealth for a Health Profile. Her responses to the Health Profile indicate her only apparent health problem, new in the last year, is a body mass index (BMI) of 27. This score is in the "overweight" range, halfway between 25, the upper edge for "normal" weight, and 30, the lower limit for "obesity," where the risk of adverse health consequences soars. She indicates she is ready to start working on her weight problem immediately. Noting her weight gain is relatively recent and her BMI below the "magic number of 30," Grossman says this is an ideal situation for the Health Profile. "With the Health Profile, we can capitalize on early intervention, which increases the odds of successful behavior change," he says.

The patient receives a customized online report that, in addition to making recommendations for screening and immunizations, highlights problematic behavioral areas—in her case, weight. Since she has indicated she is primed to make a change, the report also includes possible next steps Group Health endorses as effective for weight loss, such as Group Health’s weight management program and eventually any employer-sponsored programs that she is eligible for. The goal is to give her diverse options to maximize her chances of success. For example, the report would list both group- and telephone-format weight loss programs, which might appeal to different personalities. It encourages her to act on her weight problem immediately, not wait until her preventive care visit.

At the woman’s preventive care visit, her physician has more time to provide support and reinforcement, since the weight loss program has already addressed many weight control basics. Using the online provider report the Health Profile generates, the physician can focus on other important issues. In a future incarnation of the Take Charge initiative, the patient and provider would negotiate a Member Action Plan—MAP—specifying goals, barriers, strategies, and next steps surrounding an issue: in this case, weight. This action plan, like the Health Profile, would become part of the patient’s electronic medical record. MAP is scheduled to be implemented following rollout of the Health Profile.

While his hypothetical example concerns a "healthy" woman, Grossman stresses that the self-management underpinning of the Take Charge initiative applies to "sick" people too. "For healthy people, self-management is really about managing risks—managing your smoking, weight, activity levels—whereas for sick people it’s about managing not only risks but also conditions such as diabetes," Grossman explains. On this level, the Take Charge initiative is closely aligned with the MacColl Institute’s goals and its planned care model, a.k.a. chronic care model, which focuses on managing chronic disease.

This Health Profile for staff is only the first stage of Take Charge. "Our aim is to design, build, and implement a Health Profile for all Group Health patients—and most importantly, get everyone to use it," Grossman says. "We will promote its use widely by emphasizing its importance for high quality clinical care and even perhaps employer incentives," he continues.

MAP will be the second stage. And developing programs for long-term behavior change is an ongoing part of the Take Charge initiative and an overarching goal of DPC. Grossman calls the Free & Clear tobacco cessation program "an archetype" and envisions behavior change programs covering multiple behaviors, not just smoking or weight individually, for example.

Grossman characterizes Take Charge as a natural experiment implemented in a real-world setting—"living the trial." The initiative’s success will be measured by rates of risk factors—such as smoking and obesity—and shifts in readiness to change. A decline in disease rates is the ultimate goal, which Grossman says could take a long time.

Skeptics may consider it optimistic even to expect the Take Charge initiative to reduce rates of risky behaviors. Consider the sobering statistics on the United States’ "obesity epidemic," with two-thirds of adults overweight—and rising. "There’s a feeling that people can’t change their behaviors," Grossman says. But he’s not discouraged.

Tobacco and alcohol programs are considered effective, he points out, even though they do not report 90 percent success rates. He sees weight-management programs as similar. "When people try two or three times to succeed, they tend to see it as a failure," says Grossman. "But it’s probably just the natural course of things." He also wants to capitalize on early intervention. "With our Health Profile, the ideal would be to detect, for example, the new smoker. We won’t place our priority on people who have smoked for 30 years, because they will be a heck of a lot harder to change," he says.

While the Take Charge initiative is ambitious, it is not the only quality improvement effort with DPC involvement. The Group Health Wellness Inventory (WIN), currently underway, features a telephone survey of a random sample of 800 adult Group Health members. DPC Associate Director and CHS Assistant Investigator Robert J. Reid, MD, PhD, leads this effort, which the Group Health Community Foundation, the Group Health Quality and Informatics Division, and Group Health Permanente jointly fund. WIN’s purpose is to assess: patient health status; prevalence of risky behaviors; intervention preferences (for instance, telephone vs. group); and readiness to change. These data resemble information the Health Profile collects.

Grossman explains he expects the response rate to WIN to be higher than for the Health Profile, meaning WIN respondents will provide a more "representative" picture of Group Health members. "The motivation for WIN is a strong desire to have a better sense of the state of Group Health’s health," Grossman says. DPC plans to use the data to plan future health promotion efforts—and to compare health measures for Group Health patients with those of other Washington residents, since WIN is modeled on the Washington State Behavioral Risk Factor Survey.

Grossman emphasizes the importance of collaboration in these quality improvement efforts: "This is a crosscutting thing," he says. "We’re working with everyone—marketing and sales; Web services; communications—and not the least, of course, is the system for delivering care." Grossman points to the crucial role of research, and how the work of the Center for Health Studies and the MacColl Institute connects to Group Health–wide quality improvement efforts such as the Take Charge initiative.

"With the Center’s continued focus on solving problems in health care that Group Health can use, there is a really rich relationship between the delivery system and CHS," Grossman says. They share the common value of scientific discipline, the mission of transforming health care, and the strategy of achieving better health outcomes with lower costs.

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