Applicable to PCPs and specialists. When patient is co-managed by PCP and specialist, roles must be clearly defined regarding who is responsible for ensuring patients receive needed preventive services. 

9.1

Primary prevention program is in place that focuses on identifying and educating patients about personal health behaviors to reduce their risk of disease and injury.

PCP and Specialist Guidelines:

1. Primary prevention is defined as inhibiting the development of disease before it occurs, and is typically performed on the general patient population. Secondary prevention, also called “screening,” refers to measures that detect disease before it is symptomatic. Tertiary prevention efforts focus on people already affected by disease and attempt to reduce resultant disability and restore functionality.
2. Patient questionnaire or other mechanism is used to elicit information about personal health behaviors that may be contributing to disease risk
   1. During well-visit exam and initial intake for new patients
   2. During other visits when behavior may be relevant to acute concern (e.g., tobacco use when patient presents with cough)
3. c. Patient assessment addresses personal health behaviors and disease risk factors, based on age, gender, health issues
   1. Behaviors and risks assessed should include a majority of the following (or other primary prevention procedures) as appropriate to the patient population: Alcohol and Drug Use, Breast Self-Examination, Awareness of Lead Exposure, Low Fat Diet and Exercise, Use of Sunscreen, Safe Sex, Testicular Self-Examination, Tobacco Avoidance, and Flu Vaccine

9.2

A systematic approach is in place to providing primary preventive services

PCP and Specialist Guidelines:

1. Preventive care guidelines are integrated into clinical practice (e.g., Michigan Quality Improvement Consortium – www.mqic.org). Examples of appropriate Guidelines include:
   1. Adult Preventive Services Guideline 18-49 Yrs
   2. Adult Preventive Services Guideline 50-65 Yrs
   3. Childhood Overweight Prevention Guideline
   4. Prevention of Unintended Pregnancy in Adults
   5. Preventive Service for Children & Adolescents Ages Birth – 24 Months
   6. Preventive Service for Children and Adolescents Ages 2-18 Yrs
   7. Tobacco Control Guideline
2. Systematic appointment tracking system (implemented as part of Individual Care Management Initiative) is in place
3. Applies to full range of primary preventive services (for example, an ob-gyn ensuring patients receive mammograms and pap tests, but not flu shots, would not meet the intent of this capability).

9.3

Strategies are in place to promote and conduct outreach regarding ongoing well care visits and screenings for all populations, consistent with guidelines for such age and gender appropriate services promulgated by credible national organizations

PCP and Specialist Guidelines:

1. Systematic reminder system is in place and incorporates the following elements:
   1. Age appropriate health reminders (e.g., annual physicals).
   2. Age appropriate immunization information consistent with most current evidence based guidelines
   3. If reminders are generated by PO, offices should have knowledge of the process
2. For children and adolescents from birth to 18 years of age examples of outreach strategies may include birthday reminders for well-visits, kindergarten round-up, flu vaccine reminders, health fairs, brochures, school physical fairs
3. For adults, examples of outreach strategies may include annual health maintenance examination reminders, and age and gender-appropriate reminders about recommended screenings (e.g., mammograms)
4. Outreach should be systematic and consistent with evidence-based guidelines

9.4

Practice has process in place to inquire about a patient’s outside health encounters and has capability to incorporate information in patient tracking system or medical record

PCP and Specialist Guidelines:

1. “Outside health encounter information” includes services such as immunizations provided at health fairs
2. Practice unit should include actual/estimated date of service in the medical record whenever possible
3. Information may be included in historical section of record

9.5

Practice has a systematic approach in place to ensure the provision/documentation of tobacco use assessment tools and advice regarding smoking cessation

PCP and Specialist Guidelines:

1. Examples may include yearly assessment sheet, tobacco use intervention programs

9.6

Written standing order protocols are in place allowing Practice Unit care team members to authorize and deliver preventive services according to physician-approved protocol without examination by a clinician

PCP and Specialist Guidelines:

1. Standing orders are orders for office personnel that are signed in advance by the physician authorizing the provision of specified services under certain clinical circumstances, and are reviewed/updated on a regular basis
2. Examples include vaccinations, fecal occult blood tests and mammogram orders, medication intensification algorithm for patients with lipid disorder or high blood pressure 

9.7

Secondary prevention program is in place to identify and treat asymptomatic persons who have already developed risk factors or pre-clinical disease, but in whom the disease itself has not become clinically apparent.

PCP and Specialist Guidelines:

1. System with guideline-based reminders for age-appropriate risk assessment and screening tests is in place.
   1. Practice Unit may choose to implement tools such as checklists attached to the patient chart, tagged notes, computer generated encounter forms and prompting stickers.
2. Mechanisms are established to identify asymptomatic at-risk patients and provide appropriate treatment
   Examples include accelerated regimen for colon and breast cancer screening in high risk patients

9.8

Staff receives regular training and/or communications and updates regarding health promotion and disease prevention and incorporates preventive-focused practices into ongoing administrative operations

PCP and Specialist Guidelines:

1. Applicable to either primary or secondary preventive services
2. Practice unit staff has received training or educational material regarding a full range of preventive services and health promotion issues
   1. New hires receive appropriate training
   2. Educational material is circulated or posted when guidelines change
   3. For example, PO or practice unit staff person may be assigned to update clinical personnel on standards and guidelines such as AHRQ newsletter updates, the immunization schedule & standards issued by the Advisory Committee on Immunization Practices, Alliance of Immunization in Michigan, or Centers for Disease Control and Prevention.
   4. For example, information may be provided to practice units educating them on appropriate billing and ICD-9 codes in order to ensure accurate reporting for preventive medicine services (including use of the correct ICD-9 code for a physical)
3. Staff is trained (as appropriate to patient population) regarding consistently using and entering information into the Michigan Care Improvement Registry (MCIR)

9.9

Planned visits are offered as a means of providing preventive services in the context of structured health maintenance exams for which the practice team and patient are prepared in advance of the date of service

PCP and Specialist Guidelines:

1. Reference 4.8 for requirements of planned visit