Good Clinical Health Promotion Practice
About the Authors
Director, WHO-CC, Clinical Health Promotion Centre, Bispebjerg & Frederiksberg Hospital, Copenhagen, Denmark
Professor, Clinical Health Promoting Centre, Lund University, Malmö, Sweden
Professor, University of Southern Denmark
CEO, International HPH Secretariat
President, Clinical Health Promotion Society
Clinical health promotion (ClinHP) is patient-centered health promotion activities performed by competent staff in collaboration with the individual patient; thus aiming at a better health gain for patients during their clinical pathway. Examples of highly effective ClinHP are smoking cessation intervention prior to surgery, intensive diet programmes for patients with diabetic, and rehabilitation in mental illness. ClinHP also includes the staff’s own health and development of specific ClinHP competences required for their patient groups. Furthermore, ClinHP reaches out for collaboration and continuity between the hospitals and the local communities (1).
Competences on ClinHP activities are not part of a classic medical, nursing, public health education program or the following specialist training. That is why the International HPH Network establishes HPH Summer Schools on this important theme. The HPH Summer Schools are held every year at the annual HPH Conference in collaboration between the local host and International HPH Secretariat. The two day school is held prior to the HPH Conference as a preconference activity, which provides participants with an opportunity to add additional education to their itinerary.
Need for ClinHP competences
Integration of ClinHP into a fast patient pathway requires specific competences in order to harvest the tremendous potential for effect and cost-effectiveness, and to get the benefits for the individual patients, the health care providers and society at large. An early example on the effect of further education in ClinHP showed that a nurse with special training had a recruitment rate on 97% when offering alcohol and smoking cessation programs to patients in an emergency room setting, compared to a recruitment rate on 47% for nurses without this specific training (2).
The competences required for ClinHP should cover knowledge, skills and performance; safety and quality; communication, partnerships and teamwork; as well as expertise on maintaining trust (3;4). However, these competences must be specified in order to establish excellent ClinHP services based on solid evidence instead of experience- or ideology-based health promoting practice. Inspiration for these specifications can be found from the recent development of competences described in Good Medical Practice and Good Surgical Practice amongst others (3;4). Since ClinHP is a relatively new field on the evidence-based platform, it is important to emphasize the need for evaluation in real life and for performance of high-quality research.
Evaluation for effect in real life
Tools for evaluation of ClinHP activities have been developed and validated by WHO and the International HPH Network, such as the HPH Standards and Indicators (1) as well as documentation models to the medical recording for identification of needs for ClinHP and delivery of ClinHP activities and services (5;6). As systematic data collection is crucial for evaluation. It is important to have access to the easy-to-use and low-time-consuming models in the daily routines. Some countries and regions have integrated the models in their electronic medical records with pop-up windows, while in other cases the individual hospitals and health services have built their own registration form based on the models.
Examples also exist on how to integrate the models into the clinical quality registries. One example is the hip prosthetic registry in Sweden, where the national program “smoke-free operation” was launched a few years ago (7). The Danish Smoking Cessation Database is a good example on how to follow-up directly on the effect on ClinHP activities (8). Since 2001 the database has registered more than 80,000 smokers undertaking face-to-face smoking cessation programs in Denmark. The database is run for about 160,000€ yearly and the costs includes quality assurance and development, which are delivered continuously to the consumers, clinical staff and the policy-makers (8).
The above mentioned models are also easy to integrate into the DRG-system and other re-imbursement systems. A joined task force under the WHO and the International HPH Network have concluded, that integration of ClinHP into the DRG reimbursement is feasible without technical barriers exist. However, the integration of the DRG reimbursement may meet political or administrative barriers (9).
ClinHP is a relatively new addition to the evidencebased platform, and the HPH member hospitals and health services are excellent arenas for multicenter studies as well as for local projects. Thus, many high quality research projects have been performed showing dramatic effects on adding ClinHP to the daily treatment routines of many diseases. Most studies have evaluated mono-factorial interventions, such as smoking cessation programs or physical activity programs; and they have showed that only the intensive programs running over 6-8 weeks have effect on the primary treatment outcomes like complication rates or functionality. Though the ClinHP results are very promising, the implementation process is the Achilles heel – as always. Therefore, an ongoing international research in a randomized design evaluates a fast-track 12 months model for implementation of ClinHP in the clinical departments (www.HPHnet.org). Other new studies focus on multi-factorial interventions, such as the VIP program (Very Integrated Program / Very Important Patient), because most hospital patients are suffering from multiple risk factors. The VIP program recruits participants among the patient groups with the highest ClinHP needs. The VIP program includes the most risky lifestyles (tobacco, alcohol, nutrition and physical inactivity) and comorbidity that are all predictors of a poor treatment outcome and at the same time potentially preventable or improvable.
Development of good clinical HP practice
Time has come to describe good ClinHP Practice in line with other clinical areas, such as medicine and surgery. The international “Clinical Health Promotion Society” (CHPS) starts a new initiative, where the aim is to describe the Clinical Health Promoters of the future. In line with this mission is the open CHPS Workshop at the 23rd International HPH Conference in Oslo, Norway. The HPH Conference takes place in June 10-12, 2015, and as the president of CHPS, I wish to invite you and all other interested to join the CHPS workshop on good clinical health promotion practice (www.clinhpsociety.org).
(1) Groene O. (Ed.). Implementing health promotion in hospitals: Manual and self-assessment forms. WHO Regional Office for Europe, Copenhagen 2006.
(2) Nelbom BM, Tønnesen H, Backer V. Motivational counselling. Possible in an emergency department?. Ugeskr Laeger. 2004; 166:2791-5
(3) Good Medical Practice. General Medical Council, Manchester, UK 2013. ISBN: 978-0-901458-60-5
(4) Good Surgical Practice. The Royal College of Surgeons of England, London, UK 2008.
(5) Tønnesen H, Christensen ME, Groene, et al. An evaluation of a model for the systematic documentation of hospital based health promotion activities: results from a multicentre study. BMC Health Serv Res. 2007; 7:145
(6) Tønnesen H, Svane JK, Lenzi Loprenza, et al. Handling Clinical Health Promotion in the HPH Data Model: Basic Documentation of Health Determinants in Medical Records of tobacco, malnutrition, overweight, physical inactivity & alcohol. Clin Health Promot. 2012; 2:5-11.
(7) Swedish Orthopaedic Association; www.enrokfrioperation.se.
(8) Danish Smoking Cessation Database; www.scdb.dk.
(9) Groene O, Tønnesen H. Reimbursing health promotion services in hospitals through diagnosis-related groups. [Technical paper]. WHO, Copenhagen, 2005.