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Your Healthiest Self

Social Wellness Toolkit

From the time you’re born, your relationships help you learn to navigate the world. You learn how to interact with others, express yourself, conduct everyday health habits, and be a part of different communities from those around you. Positive social habits can help you build support systems and stay healthier mentally and physically. Flip each card below for checklists on how to improve your health in each area. Click on the images to read articles about each topic. You can also print the checklists separately or all together to share with others or as a reminder to yourself.

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6 strategies for improving your social health

Make connections.

Collage of four illustrations of people making social connections

Social connections might help protect health and lengthen life. Scientists are finding that our links to others can have powerful effects on our health. Whether with family, friends, neighbors, romantic partners, or others, social connections can influence our biology and well-being. Look for ways to get involved with others.

To find new social connections:

  • Join a group focused on a favorite hobby, such as reading, hiking, painting, or wood carving.
  • Learn something new. Take a cooking, writing, art, music, or computer class.
  • Take a class in yoga, tai chi, or another new physical activity.
  • Join a choral group, theater troupe, band, or orchestra.
  • Help with gardening at a community garden or park.
  • Volunteer at a school, library, hospital, or place of worship.
  • Participate in neighborhood events, like a park clean-up through your local recreation center or community association.
  • Get active in your community. Helping others can reduce feelings of loneliness .
  • Travel to different places and meet new people.

Take care of yourself while caring for others

Illustration of a man and woman talking on the sofa

Many of us will end up becoming a caregiver at some point in our lives. The stress and strain of caregiving can take a toll on your health. It’s important to find ways to care for your health while caring for others. Depending on your circumstances, some self-care strategies may be more difficult to carry out than others. Choose ones that work for you.

To take care of yourself while caring for others:

  • Get organized.  Make to-do lists, and set a daily routine.
  • Ask for help. Make a list of ways others can help. For instance, someone might sit with the person while you do errands.
  • Try to take breaks each day. Finding respite care can help you create time for yourself or to spend with friends.
  • Keep up with your hobbies and interests when you can.
  • Join a caregiver’s support group. Meeting other caregivers may give you a chance to exchange stories and ideas.
  • Eat healthy foods, and exercise as often as you can.
  • Build your skills. Some hospitals offer classes on how to care for someone with an injury or illness. To find these classes, ask your doctor or contact your local Area Agency on Aging .

Get active together

Illustration of a man, woman, and child walking with bags from a local grocery store

Where you live, work, or go to school can have a big impact on how much you move and even how much you weigh. Being active with others in your community can have a positive effect on your health habits and create opportunities to connect. You can help your community create ways to encourage more physical activity.

To help make a more active community:

  • Start a walking group with friends, neighbors, or co-workers.
  • Make the streets safer for walking by driving the speed limit and yielding to people who walk.
  • Consider joining a low- or no-cost exercise group or an office sports team such as softball or kickball, and enroll kids in community sports teams or lessons.
  • Participate in local planning efforts to develop walking paths, sidewalks, and bike paths.
  • Work with parents and schools to encourage kids to safely walk or ride bikes to school.
  • Join other parents to ask for more physical activity at school.
  • Try different activities to find the ones you really enjoy, and have fun while being active!

Shape your family’s health habits

Illustration of a dad and daughter jumping rope

Many things can influence a child, including friends, teachers, and the things they see when they sit in front of the TV or computer. If you’re a parent, know that your everyday behavior plays a big part in shaping your child’s behavior, too. With your help, kids can learn to develop healthy eating and physical activity habits that last throughout their lives.

To help kids form healthy habits:

  • Be a role model. Eat healthy family meals together. Walk or ride bikes instead of watching TV or surfing the Web.
  • Make healthy choices easy. Put nutritious food where it’s easy to see. Keep balls and other sports gear handy.
  • Focus on fun. Play in the park, or walk through the zoo or on a nature trail. Cook a healthy meal together.
  • Limit screen time. Don’t put a TV in your child’s bedroom. Avoid snacks and meals in front of the TV.
  • Check with caregivers or schools. Make sure they offer healthy foods, active playtime, and limited TV or video games.
  • Change a little at a time. If you drink whole milk, switch to 2% milk for a while, then try even lower fat milks. If you drive everywhere, try walking to a nearby friend’s house, then later try walking a little farther.

Bond with your kids

Illustration of family reading with child.

Parents have an important job. Raising kids is both rewarding and challenging. Being sensitive, responsive, consistent, and available to your kids can help you build positive, healthy relationships with them. The strong emotional bonds that result help children learn how to manage their own feelings and behaviors and develop self-confidence. Children with strong connections to their caregivers are more likely to be able to cope with life’s challenges.

To build strong relationships with your kids:

  • Catch kids showing good behavior and offer specific praise.
  • Give children meaningful jobs at home and positive recognition afterward. Help them improve their skills one step at a time.
  • Use kind words, tones, and gestures when giving instructions or making requests.
  • Spend some time every day in warm, positive, loving interaction with your kids. Look for opportunities to spend time as a family, like taking after-dinner walks or reading books together.
  • Brainstorm solutions to problems at home or school together. Be available for advice and support, especially for teens .
  • Set limits for yourself on mobile device use and other distractions. For instance, check your phone after your child goes to bed.
  • Ask about your child’s concerns, worries, goals, and ideas.
  • Participate in activities that your child enjoys. Help out with and attend their events, games, activities, and performances.

Build healthy relationships

Two men at a table engaged in conversation over a cup of coffee

Strong, healthy relationships are important throughout your life. They can impact your mental and physical well-being. As a child you learn the social skills you need to form and maintain relationships with others. But at any age you can learn ways to improve your relationships. It's important to know what a healthy relationship looks like and how to keep your connections supportive.

To build healthy relationships:

  • Recognize how other people influence you .
  • Share your feelings honestly.
  • Ask for what you need from others.
  • Listen to others without judgement or blame. Be caring and empathetic.
  • Disagree with others respectfully. Conflicts should not turn into personal attacks.
  • Avoid being overly critical, angry outbursts, and violent behavior.
  • Expect others to treat you with respect and honesty in return.
  • Compromise. Try to come to agreements that work for everyone.
  • Protect yourself from violent and abusive people. Set boundaries with others. Decide what you are and aren't willing to do. It's okay to say no.
  • Learn the differences between healthy, unhealthy, and abusive ways of relating to others. Visit www.thehotline.org/healthy-relationships/relationship-spectrum .

Want to learn more?

NIH scientists study how your family, relationships, and communities impact your health and well-being. Read more resources from the NIH institutes advancing research in these areas.

More resources about social wellness »

This page last reviewed on August 26, 2021

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Quality Improvement in Primary Care

External supports for practices.

By Erin Fries Taylor, Deborah Peikes, Kristin Geonnotti, Robert McNellis, Janice Genevro, and David Meyers

Why is quality improvement important for primary care practices?

Engaging primary care practices in quality improvement (QI) activities is essential to achieving the triple aim of improving the health of the population, enhancing patient experiences and outcomes, and reducing the per capita cost of care, and to improving provider experience. In an effort to create a high-value health care system in the United States, many providers, insurers, delivery systems, and quality improvement organizations are focused on improving the performance and safety of primary care. One prominent approach to redesigning primary care, the patient-centered medical home (PCMH), requires primary care practices to have a systematic focus on QI and safety. (Please access the Agency for Healthcare Research and Quality's definition of the PCMH ).

Primary care practices with a strong QI orientation continually seek to improve their own performance and the outcomes of their patients. This QI orientation guides practices to set priorities for areas to improve and the work needed to achieve these goals. The specific areas that practices choose to address through ongoing QI efforts, and the methods they use to address them, are likely to vary based on the practice's concerns, circumstances, and resources. Some examples of specific areas that might be priorities for practices include improving the identification, monitoring, and followup of patients with diabetes, or improving the delivery of recommended preventive services for all of their patients.

Engaging in ongoing QI is likely to be a new activity for many primary care practices, and even the most determined practice is likely to need new skills to meet its improvement goals. These skills include identifying areas for improvement, understanding and using data, planning and making changes, and tracking performance over time. External supports—defined here as the various forms of technical assistance, learning activities, and tools and resources provided by organizations outside the practice—can assist practices in undertaking QI.

What external supports can help practices with quality improvement?

Four categories of external supports, which can be used alone or in combination, can assist practices with QI:

  • Data feedback and benchmarking provide practices with information on their performance, as compared to external benchmarks (such as regional or national averages), and help target areas for improvement.
  • Practice facilitation (or coaching) by external organizations helps practices develop skills and organize their approach to QI, provides QI tools and expertise, and helps them troubleshoot challenges or barriers.
  • Expert consultation (also called peer-to-peer mentoring) provides practices with specific evidence-based knowledge from clinicians and staff outside the practice.
  • Shared learning or learning collaboratives provide a community in which practices can share challenges, lessons learned, and best practices and draw motivation and inspiration.

Table 1 at the end of this brief provides more information on these supports and links to resources.

What types of organizations provide QI support to primary care practices?

Although there is currently no nationwide system to support QI by practices, area health education centers (AHECs), health information technology regional extension centers (RECs), quality improvement organizations (QIOs/QINs), practice-based research networks (PBRNs), public and private insurers, primary care professional organizations, and others provide these types of supports to some primary care practices in some geographic areas. These supports are currently typically financed by Federal grants and contracts, State programs, multipayer and single payer initiatives, and foundations.

Example: AHRQ IMPaCT Grantees' Work to Support Quality Improvement in Primary Care

In 2011, AHRQ launched the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative, awarding four cooperative grants to support State-level QI efforts. Grants were awarded to projects in New Mexico, North Carolina, Oklahoma, and Pennsylvania. These programs used primary care extension agents to assist small and medium-sized primary care practices with primary care redesign, and also provided technical assistance to 13 other States to support their transformation efforts. Select for more information about the projects .

Selected examples of IMPaCT's work to support practices with QI activities:

  • New Mexico deployed practice coaches to add new practice improvement strategies targeted toward small and medium-sized primary care practices. This approach complemented its existing IT component of primary care practice transformation, which the State-designated REC provides. In addition to practice transformation, the program also promoted collaborations to improve community health, with a focus on addressing social determinants of health. Select for more information .
  • North Carolina launched two learning collaboratives, among other activities, to enhance its infrastructure to support primary care practices. The regional leadership collaborative helped regional teams develop skills to: (1) lead successful QI initiatives, and (2) increase coordination and collaboration among local medical home care networks and AHEC's working toward shared objectives. Select for more information ( PDF , 80 KB) on North Carolina's range of activities.
  • Oklahoma created the infrastructure for a statewide primary care extension system, intended to support local primary care needs. With counties and local partners as the foundation, the infrastructure now supports continuous QI, connects practices and communities to resources, and encourages innovative primary care delivery models. Select for more information .
  • Pennsylvania conducted a survey of primary care providers across the State about what support they most needed. Top-ranked needs included identifying and coordinating behavioral health services, improving office efficiency, and implementing evidence-based guidelines, among others. Pennsylvania also convened a large cadre of partner organizations to collaborate on practice transformation, focusing on how to reach more practices in the State. Select for more information .

Table 1. External Supports for Helping Practices with Quality Improvement Work

Publication: 14-0048-ef.

PDF (PDF, 260 KB)

Internet Citation: Quality Improvement in Primary Care. Content last reviewed November 2020. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html

Click to copy citation

National Academies Press: OpenBook

Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health (2019)

Chapter: 2 five health care sector activities to better integrate social care, 2 five health care sector activities to better integrate social care.

Health care sector leaders often make decisions about improving-social care through care integration and investment in the absence of information about different strategies ( Alderwick et al., 2018 ; Bickerdike et al., 2017 ; De Milto and Nakashian, 2016 ; Gottlieb et al., 2017b ; Institute for Alternative Futures, 2012 ). An evidence-informed taxonomy of health care–based strategies that can be used to support and strengthen integration may help guide activities in this area.

Based on the existing literature and other sources, as described in Chapter 1 , the committee identified five mutually complementary categories of activities that health systems can adopt to strengthen integration (see Figure 2-1 ). While all of the categories will ultimately benefit patients, two of these ( adjustment and assistance ) focus on improving care delivery provided specifically to individual patients based on information about their social risks and protective factors (conditions or attributes that may mitigate or eliminate risk). Two others ( alignment and advocacy ) relate to roles that the health care sector can play in influencing and investing in social care resources at the community level. All of these delivery and community-level activities are informed by efforts that increase awareness (the fifth category) of individual or community-level socioeconomic risks and assets relevant to a health system’s geographic region or served population. Health care stakeholders—including providers, care delivery organizations, health plans, and government payers—that are exploring opportunities to launch or strengthen integration should understand the challenges of and interplay among these different strategies as well as the range of activities possible within each category. Each of


the five categories (awareness, adjustment, assistance, alignment, and advocacy) depends on systems-level changes to implement and sustain integration—including a defined and well-trained workforce, data and digital tool innovations, and new financing models. These systems-level elements are the focus of subsequent chapters of this report.


The five complementary types of integration activities correspond to different roles that health systems can play to strengthen the delivery of social care in health care settings. These activities build on the community-informed and patient-centered care 1 recommendations from a previous National Academies of Sciences, Engineering, and Medicine (the National Academies) report, Systems Practices for the Care of Socially At-Risk Populations ( NASEM, 2016 ) (see Figure 2-2 ), by illustrating how these two approaches can most efficiently interact to enable high-quality care, whether to keep people healthy or reduce the burden of disease.

In developing its overall strategy to social care integration, the committee drew on this report’s overarching theme—moving upstream to


1 Patient-centered care is defined as providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions ( IOM, 2001 ).


improve the nation’s health—and recognized that there are both “near” and “far” upstream activities for strengthening integration. Near-upstream activities are targeted toward interactions that individuals have with health care clinical providers or clinical systems, whether for primary prevention or treatment of acute and chronic illness. They include ensuring that health care providers adjust traditional medical care decision making based on social risk and assets data and that patients with social risk factors then receive assistance connecting with and securing available government and community resources related to identified social needs. Far-upstream activities are more community-oriented. They involve aligning health care resources and investments to facilitate

collaborations with community and government sectors as well as bringing health care assets into broader advocacy activities that augment and strengthen social care resources. As an example of how this could work in practice, Table 2-1 describes ways in which individuals’ access to transportation might be improved using the five categories of activities.

The five broad categories are not part of a sequential process; they instead complement one another, and health care stakeholders might engage in multiple strategies simultaneously. These categories provide multiple pathways to achieving integration based on the evidence considered by the committee. Therefore, it would be a disservice to the field to suggest rules, guidelines, or a one-size-fits-all approach because one size does not fit all. Any of these categories is an umbrella for many specific activities that may take different forms, including similar activities that involve different levels of intensity. For example, assistance programs can range from light touch (e.g., providing patient handouts with basic information about social resources) to high touch (offering intensive case management to patients who need more help obtaining resources). These activities are described in more detail below, accompanied by relevant examples.

Awareness: Strategies to Increase the Health Care Sector’s Awareness of Social Risks

Both national and local health sector activities seeking to increase social and health care integration frequently begin with elevating and sustaining awareness about the influence of social risk and protective factors

TABLE 2-1 Transportation-Related Examples Highlighting Different Categories of Social and Health Care Integration Activities

on health outcomes. Across both social and health sectors, the general awareness of the relevance of social factors on health is increasing rapidly. The committee documented an exponential increase in medical literature published over the past 18 years that (1) refers to the social determinants of health (SDOH); and (2) links those determinants with health care delivery (see Figure 2-3 ).

The committee defined awareness as those activities that identify the social risks and assets of defined patients and populations. Awareness strategies are not limited to sector-level awareness of the intersection of social risks and health outcomes. Instead, the committee recognized that building stakeholders’ investments in social care also involves a more active, immediate awareness of a specific population’s social risks and assets. Though the committee acknowledged that awareness is an important component of both individual- and community-level activities aimed at improving care integration, no consensus exists regarding the most effective or efficient strategies to increase awareness in ways that can facilitate subsequent actions. The strategies that health care systems already invest in to increase awareness vary across settings. The Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET) has highlighted five different pathways through which information about social risks and assets can be brought to the attention of health care systems (see


Figure 2-4 ): clinical care, screening large populations, screening high-risk groups, hotspotting, and identifying vulnerable communities.

On the clinical side, patients visiting health care organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality ( MassHealth, 2018a , b ). Similar initiatives are under way in North Carolina and Rhode Island. Clinic-based screening can be universal (everyone in a health care setting is asked about social risks, such as housing or food, either at each visit or at defined intervals; see Pathway 1 in Figure 2-4 ), or it can be more directed at specific age groups (e.g., children and seniors) or high-risk groups (e.g., people with certain diseases or who are on government insurance) (see Pathways 2 and 3 in Figure 2-4 ). As an example, Geisinger Health directs food security screening and interventions specifically at patients with diabetes ( Feinberg et al., 2017 ). It is important to note that efforts to raise awareness by collecting data (both on patient clinical history and overall community health) may be affected by unconscious or implicit biases held by program leaders and practitioners, which can create new implementation barriers and workforce training demands (detailed further in Chapters 3 and 6 ) ( Garg et al., 2005 ; Gottlieb and Alderwick, 2019 ).

A wide array of social risk screening tools has emerged to meet the demand for clinic-based social risk awareness activities ( UCSF, 2019 ). Existing screening tools vary in the social domains covered, length, language accessibility, and other characteristics ( UCSF, 2019 ) (see Table A-1 for adult screening tools; pediatric screening tools also are available).


Often these tools use different measures to assess social risks even under a single domain.

Though some screening tools use items from domain-specific validated instruments (e.g., hunger vital signs) ( Hager et al., 2010 ), scant research is available on the psychometric validity of grouped items (Lewis et al., 2019). Existing studies generally indicate that a strong majority of patients find clinic-based social risk screening acceptable ( Fleegler et al., 2007 ), though the unintended consequences ( Garg et al., 2016 ) and possible opportunity costs of clinic-based screening have not been clearly articulated ( NASDOH, 2019 ).

Some health systems use neighborhood- or community-level data to help select patients for more targeted social risk screening or to help identify high-risk communities (see Pathway 5 in Figure 2-4 ). For example, Cincinnati Children’s Hospital conducts particularly intensive outreach with patients from two high-poverty zip codes to identify children with social needs ( Auger et al., 2017 ). To facilitate such targeted outreach activities, the American Board of Family Medicine and the University of Missouri’s Center for Applied Research and Engagement Systems have together developed the Population Health Assessment Engine (PHATE), which is provided to clinical providers enrolled in the American Board of Family Medicine’s PRIME registry ( American Board of Family Medicine, 2019 ). PHATE uses patient address data to incorporate “community vital signs” into patient charts based on publicly available census-tract-level characteristics. These and other uses of PHATE are summarized in Box 2-1 . Some nonprofit hospitals, federally qualified health centers, and local public health departments also use the community-level social risk data in community health needs assessments, which are required by the Internal Revenue Service and are intended to influence community-level investments ( Alberti et al., 2014 ).

The committee searched for indicators of the prevalence of awareness activities (e.g., social risk assessments or data linkages across social and medical sectors). Though multiple surveys targeting different health care stakeholders (e.g., payers, health systems executives, providers, and consumers) have asked about the prevalence of social screening in health care settings, there are limited data that can be synthesized across these surveys (findings from 23 surveys are summarized by SIREN) ( Cartier et al., 2019 ). The majority of the existing surveys ask whether the health care system conducts some form of social risk assessment broadly without asking further questions about the specific strategies undertaken to obtain information. For example, survey items typically fail to distinguish among universal, clinic-based social screening, targeted screening for high-risk patients, and community data integration; they do not ask respondents to report the numbers of patients who complete social risk

assessments; and they do not ask about the capacity of the workforce or activities undertaken in general or by discipline to respond to any identified risks. Some research has explored the adequacy of using electronic health record (EHR) documentation (e.g., LOINC, SNOMED, International Statistical Classification of Diseases and Related Health Problems, 10th Revision [ICD-10], Current Procedural Terminology [CPT] codes) to gauge the prevalence of individual-level social risk screening, though this would fail to capture other related activities that facilitate social needs and asset awareness. At this time, the lack of both coding standards and capacity in medical coding systems and documentation incentives makes EHRs an unreliable source of information ( Arons et al., 2018 ; DeSilvey et al., 2018 ; Lewis et al., 2016 ; Navathe et al., 2018 ; Torres et al., 2017 ). These and other technology-based opportunities to strengthen care integration are the focus of Chapter 4 .

In reviewing different strategies to increase the health care sector’s awareness of patient and population social risk and protective factors, the committee went on to ask whether increasing the health care sector’s recognition of social risks alone could contribute to changes in health outcomes in the absence of dedicated social care interventions. Specifically, does asking equate to an intervention? This question could be especially relevant to the awareness strategies in which individual patients are asked about their social risks in the context of a health care delivery encounter. Does asking about social risks without coupling screening activities with a related social care intervention, such as, at a minimum, making a referral for a patient to follow up at his or her discretion, affect the

provider–patient relationship in some way? Could asking have negative consequences, such as triggering or creating trauma ( Garg et al., 2016 )? The committee did not find a strong body of evidence to support either positive or negative consequences of implementing awareness strategies in isolation. This is likely because there are few clinical systems implementing clinic-based screening without some form of intervention.

Even in settings when relevant interventions are offered, patients do not consistently desire assistance, making it important to consider shared decision-making principles as part of patient-centered care planning that results from identifying social risk factors and social needs ( Swavely et al., 2018 ; Tong et al., 2018 ). Some research suggests that patients do not believe that social screening needs to be accompanied by interventions and may have salutary effects in isolation, although the evidence is mixed ( Byhoff et al., in press ; Palakshappa et al., 2017 ). As an example, patients’ perceptions that they are receiving equity-oriented care—including care that is trauma-, culture-, and context-informed—are linked with comfort and confidence in care, which itself is associated with improved confidence in managing health problems ( Ford-Gilboe et al., 2018 ). Lower rates of patient–provider discussions about social demographic circumstances were found to be associated with six times higher odds of poor medication adherence ( Schoenthaler et al., 2017 ). More research is needed on how screening activities themselves affect patient–provider relationships.

Adjustment: Activities Where Social Risk Information Is Used to Inform Clinical Care Decision Making

There are many different ways in which an awareness of social risks (collected through any of the awareness strategies described above) can subsequently influence health care sector activities, leading to such things as providing social care coordination and services and augmenting the availability of social care resources (see assistance, alignment, and advocacy sections below). Social risk data also could be used to inform adjustments to care that focus not on resolving social risks directly but instead on altering clinical care to accommodate identified social barriers. Thus, social and economic barriers to high-quality care may be mitigated by changes to how the health care services are delivered in addition to any attempts to resolve the social risk itself.

Many examples of adjustment strategies were identified in the literature, including the delivery of language and literacy-concordant services; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs [VA] health system have panel sizes smaller than the

size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas ( Felland et al., 2003 ; VA, 2019 ). Other examples of ways that providers can adjust care based on known social risks involve changing insulin dosages at the end of the month when food benefits are more likely to run out ( Seligman et al., 2014 ) and shifting to indoor or supervised physical activity recommendations for patients who live in unsafe neighborhoods ( Waite, 2018 ). These adjustments can have a significant impact; for instance, providing last-shift or overnight dialysis beds, offering longer acting anti-hypertensive medications, or changing visit schedules may improve outcomes in homeless patients with end-stage renal disease ( Holley et al., 2006 ; Podymow and Turnbull, 2013 ). These examples highlight adaptations to traditional care designed to accommodate patients’ social contexts but are not interventions focused on changing the underlying social risk.

The amount of evidence suggesting that adjustment interventions affect health varies depending on the type of intervention because there are many different activities in this general category. For example, a strong body of evidence supports providing interpreter services, which can be considered a form of adjusted care delivery since care modifications (as opposed to English classes) are provided based on an understanding of patient social and cultural characteristics that can be gained through better communication ( Ku and Flores, 2005 ; Wasserman et al., 2014 ). As described in the awareness section above, some evidence suggests that context-informed care can influence patients’ experience of care, health behaviors, and health outcomes. Health services researchers have described clinical care that incorporates an understanding of social context as “contextualized care” ( Weiner et al., 2010 ). And while there is a relevant, intersecting body of evidence on shared decision making and patient-centered care approaches, research in those areas has not consistently and explicitly focused on care modifications or interventions that mitigate the impacts of social and economic adversity ( Sambare et al., 2017 ).

Social risk–adjusted payments also could be considered adjustment strategies if they are not linked explicitly to requirements like social care coordination or housing supports. Massachusetts is currently experimenting with Medicaid capitation rates that change based on patients’ social risks (e.g., neighborhood deprivation and housing status) ( Breslin et al., 2017 ; Commonwealth of Massachusetts, 2017 ; Crumley and Marlise, 2018 ). Chapter 5 provides more details about risk-adjusted payments.

The increased focus on the intersection of social risk and health outcomes at a national level provides an opportunity to recognize, evaluate,

and potentially incentivize contextualized care so that it can be implemented more systematically throughout the U.S. health care sector. The adjustment approach to social care integration is potentially the least controversial of health care strategies to strengthen social care since the focus of care remains within the traditional wheelhouse of medical care. Nonetheless, substantial gaps in knowledge exist about how adjustment strategies should affect disease-specific care decisions. For example, though many expert care guidelines on diabetes, hypertension, and obesity recognize the influence of social context, sparse information is provided in those social guidelines about how providers should alter their care based on specific social risks ( American Diabetes Association, 2017 ; Armstrong and Joint National Committee, 2014 ; Eckel et al., 2014 ; Jensen et al., 2014 ; Stone et al., 2014 ). Thus, it is not surprising that some research shows that clinical care is not systematically context-informed in U.S. health care settings. When social risk data are provided via verbal cues, for instance, providers inconsistently incorporate the information into care decisions ( Levinson et al., 2000 ; Tong et al., 2018 ; Weiner et al., 2010 ). In one study, providers given verbal cues about patients’ complex contextual circumstances subsequently provided contextually appropriate care in less than 23 percent of cases ( Weiner et al., 2010 ). Health care workers may resist universal screening given the limited evidence on how to screen most effectively, insufficient support for referrals and follow up, and changes in procedures and workflow that may be necessitated by screening.

There are many outstanding questions about whether there should be more explicit adjustments to care recommended for patients with specific social risks (e.g., food or housing insecurity) in order to maximize the uptake of guideline-concordant care. For instance, the potential for such adjustments to widen rather than lessen health inequities must be considered. Concerns have arisen from concrete examples in the health care system where social risk factors have been wielded to deny evidence-based care to select populations. For instance, history suggests African Americans have been systematically denied adequate pain management due to both conscious and unconscious biases about pain perception and racialized depictions of addiction, substance abuse, social support, and a perceived inability to comply with pain management practices ( Primm et al., 2004 ). To avoid such discrimination caused by the presence of social risks, new care management guidelines must be thoughtfully designed both to incorporate social risks into personalized care and to provide guardrails against discrimination. As these guidelines emerge, appropriately applying them will require relevant training curricula and incentives ( Weiner and Schwartz, 2016 ). Training of the social care workforce is discussed in Chapter 3 , and payment and financing reform that can support this work is the focus of Chapter 5 .

Assistance: Strategies to Link Patients with Social Needs to Government and Community Resources

Beyond increasing awareness of patients’ social risks and adjusting care to accommodate endorsed risks, there is a new focus on health care–based interventions on reducing social risk by providing assistance in connecting patients with relevant social care resources. The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activities vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more comprehensively ( Bickerdike et al., 2017 ; Gottlieb et al., 2017b ; Hannigan and Coffey, 2011 ).

Lighter-touch assistance activities can include providing information or vouchers for patients to obtain resources in the community (e.g., through curated resource lists) or referring patients to specific programs (e.g., to medical–legal partnerships to address legal barriers to housing or benefits, to eligibility counselors to enroll in Medicaid, or to social workers to obtain help with heating bills or short-term rental assistance). These lighter-touch interventions can include direct assistance (e.g., sending patients home with food if they report being hungry, providing rides directly to and from appointments, or offering respite care activities to support caregivers) ( Berkowitz et al., 2018 ; Chaiyachati et al., 2018 ; Lindau et al., 2016 ; Martin et al., 2015 ).

More intensive assistance activities are often directed to medically and socially complex patients, and they typically include processes such as relationship building, comprehensive biopsychosocial needs assessments, care planning, interventions (e.g., resource connections, ongoing case management, and behavioral activation interventions, such as motivational interviewing), and long-term community-based supports ( Burns and Essing, 2018 ; Lukens and McFarlane, 2004 ; Miller and Rollnick, 2012 ; NEJM Catalyst, 2017 ; Rizzo and Rowe, 2016 ). These more intensive assistance activities can enable the identification of co-occurring mental health concerns (such as low self-esteem, loneliness, and a history of trauma) and physical health barriers. As a result, intensive assistance activities can contribute to care adjustments at the same time as they are supporting the different processes. This has made the impacts of social care assistance activities difficult to disentangle from other intervention activities targeted at high-complexity patients ( Gottlieb et al., 2017b ). The AIMS care coordination model and the IMPaCT model are two examples of a higher-intensity assistance approach (see Box 2-2 ).

Assistance is sometimes provided directly by clinical care team members, such as primary care providers or registered nurses. Other times,

these activities are assigned to individuals whose roles are more focused on social care, such as social workers ( Altfeld et al., 2012 ; Boutwell et al., 2016 ; Fabbre et al., 2011 ; Fraser et al., 2018 ; Gehlert et al., 2015 ; Rizzo and Rowe, 2016 ; Stanhope and Straussner, 2017 ), patient navigators, community health workers, or care coordinators ( Berkowitz et al., 2018 ; Chinman et al., 2015 ; Dale et al., 2008 ; Gunderson et al., 2018 ; Kangovi et al., 2015 ; Repper and Carter, 2011 ; Salzer et al., 2010 ). These staff may be employed by health systems or by partner community-based organizations ( Schrage, 2018 ). Systematically integrating assistance activities into health care organizations may necessitate changes in workflow, team dynamics, and organizational culture, and it may demand strategies to engage patients that depart from usual care. Together these requirements can present substantial barriers to implementation ( Helfrich et al., 2016 ; also see Chapter 6 ).

Despite substantial evidence concerning the connection between social risks and health outcomes and use, there are few rigorously designed studies on the impact of assistance interventions on outcomes or use among participants ( Gottlieb et al., 2017a ). Rather, most evaluations of interventions have focused on process outcomes, such as patient satisfaction and self-reported health-related measures, and have not differentiated between specific intervention components ( Gottlieb et al., 2017a ). Moreover, many assistance interventions have evolved over time under principles of continuous quality improvement and learning health systems, using techniques such as pre–post analyses rather than more rigorous randomized control trials ( McGinnis et al., 2014 ). Further research is needed in this area on the wide range of interventions that are and could be used to reduce patients’ social risk. This research will need to more clearly articulate the added value of providing assistance services, particularly for specific populations who may report the same social need but have differing complexities and benefit eligibility that should inform assistance activities. The health care sector’s approach of providing assistance with basic material needs, for instance, to patients who are medically complex is likely to differ from providing assistance to healthier populations.

Alignment and Advocacy: Activities Where Health Care Organizations Partner and Collaborate with Other Sectors

Increasingly, health care delivery organizations, health plans, and other health care stakeholders play roles in aligning health care assets with existing social care assets in communities and advocating for more social resources to improve community health and well-being. The committee defined alignment activities to include those undertaken by health care systems to understand existing social care assets in the community,

organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes. The committee defined advocacy activities as those in which health care organizations work with partner social care organizations to promote policies that facilitate the creation and redeployment of assets or resources in order to improve health outcomes and prevent emergence of unmet social needs. While providers, patients, and caregivers also can advocate to improve social resources for individual patients, the committee defined health care sector advocacy as activities that are aimed more broadly at increasing the availability of community resources for groups of patients. The net effect of both of these types of activities (alignment and advocacy) is to achieve what the Centers for Medicare & Medicaid Services defined as the objective of the alignment track of the Accountable Health Communities Model, which is to “optimize community capacity to address health-related social needs” ( CMS, 2019 ).

In both the alignment and advocacy categories, health care organizations leverage their political, social, and economic capital within a community or local environment to encourage and enable health care and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the health care and social care services available in the community. Since 2009, reports from the Agency for Healthcare Research and Quality; the National Academies of Sciences, Engineering, and Medicine; 2 the U.S. Preventive Services Task Force; and other organizations have recommended improving the integration of clinical, public health, and community-based services and focusing on increasing the uptake of clinical preventive services ( AHRQ, 2016 ; ASTHO, 2015 ; Dzau et al., 2017 ; IOM, 2012 ; Long et al., 2017 ; Ockene et al., 2007 ). Cross-sector collaboration is also a foundational strategy in the Robert Wood Johnson Foundation’s Action Framework to build a Culture of Health and has been described in multiple reports on how partnership-driven work can integrate health care and social care services to improve population health ( Plough, 2015 ; Towe et al., 2016 ). An important limitation of these collaborations is that they often occur in the context of uneven power dynamics and historical fragmentation between sectors due to differing funding sources and workforces.

Though such partnerships are not new, health care organizations are engaging in collaborative work in increasingly varied ways. However,

2 As of March 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to publications issued prior to July 2015.

despite national recommendations and increasing activity concerning the use of intersectoral work to strengthen community resources, the literature on the effectiveness of the health care sector’s alignment and advocacy work in large part remains limited to case studies. Some evidence suggests that alignment and advocacy activities can improve a variety of health outcomes, from infection control to asthma and cardiovascular outcomes ( Boex et al., 1998 ). One study demonstrating effectiveness found significantly lower death rates from potentially preventable conditions among communities with multi-sector networks supporting population health activities with alignment and advocacy strategies extending well beyond the boundaries of the traditional health care system to include policy changes supporting improved health outcomes (e.g., smoking bans and increasing access to healthy food) ( Mays et al., 2016 ). Reporting bias may skew the literature toward positive outcomes narratives, including impacts on health care use, expenditures, and overall population-level health outcomes.

With the above caveats, a handful of illustrative examples are available to demonstrate three strategies that health care stakeholders have taken to increase alignment and advocacy in their communities.

  • Partner with social care agencies to fill known gaps in services for beneficiaries. One approach used by health care organizations to improve alignment and advocacy is to strengthen collaborations with social care organizations to directly provide needed services. For instance, the network Area Agencies on Aging coordinates with community-based organizations to provide community case management, home-delivered meals, and caregiver respite to aging populations ( Brewster et al., 2018 ). This partnership formalized the referral infrastructure and established a compensation mechanism for these services that supports the assistance activities of the clinics while also aligning and investing in local resources and helping sustain and strengthen local, trusted institutions. In another example, the Henry Ford Health System partnered with Uber, Lyft, and Ford Motor Company to provide transportation to its patient population, with a particular focus on those in underserved communities ( Knowles, 2018 ; Martinez, 2018 ). At the same time they are campaigning to modify existing transportation infrastructure in the city of Detroit in order to facilitate access in vulnerable communities. An increasing number of health care organizations are also investing in low-income housing. For example, UnitedHealth Group invested $50 million in low-income housing tax credit funds managed by the Greater Minnesota Housing Fund and Enterprise Community Investment,

resulting in the development of multi-family rental units for very low-income and special needs households ( UnitedHealth Group, 2013 ).

  • Develop anchor institution strategies. A growing number of health care initiatives explore roles that the health care sector can play in improving the social, economic, and political landscape of local economies. In these cases, health care organizations adopt place-based, health-equity-focused strategies that recognize that social and economic determinants are largely responsible for health outcomes. These organizations often describe an “anchor mission” that helps them realign institutional assets to broadly combat social and economic disparities by investing in communities. Hospitals and health systems spend $782 billion annually, employ more than 5.6 million people, and hold investment portfolios of more than $400 billion ( Ubhayakar et al., 2017 ). Investments made through anchor institution strategies sometimes rely on community development financial institutions, which provide access to capital often unavailable from traditional lenders, or on social impact bonds, in which case private funds are used to catalyze initiatives to address community needs. In 2019, more than 40 health care delivery organizations were participating in an anchor institution collaborative activity ( Healthcare Anchor Network, 2019 ). For example, Rush University Medical Center’s (RUMC’s) anchor strategy involves hiring individuals from underserved communities to provide them with economic opportunity, establishing local and minority-owned business preferences for vendor and supply chain contracts, and creating a local financial investment strategy ( Harkavy, 2016 ; Ubhayakar et al., 2017 ). As part of this approach, since 2017 RUMC has provided $6 million in loans to community development financial institutions, such as one supporting the city of Chicago’s Neighborhood Rebuild Training pilot program. In programs like these the funding can be used in various aspects of the community, including renovations to homes in high crime areas and providing on-the-job training and credentialing opportunities to youth and ex-offenders ( Chicago Community Loan Fund, 2018 ; Community Development Financial Institutions, 2019 ; RUMC, 2017 ). While it is difficult to gauge the impact of such long-term investments and collaborations, more outcome data will become available as more health care stakeholders undertake and report on their anchor activities. Another example is Stephen and Sandra Sheller 11th Street Family Health Services, a federally qualified health center in Philadelphia, Pennsylvania ( Waite, 2018 ). 11th Street

works with neighborhood residents in cooperation with schools, churches, and community groups and agencies to provide for the biological, psychological, and social needs of its patients by offering a wide range of services, including creative arts therapies, fitness training, and nutrition classes.

  • Organize and engage in cross-sector coalitions. Other alignment and advocacy activity involves more actively organizing and engaging in multi-sector coalitions generally aimed at place-based community improvement. Johns Hopkins University, located in Baltimore, Maryland, is a member of the East Baltimore Development Initiative, a multi-stakeholder coalition seeking to revitalize the East Baltimore neighborhood ( East Baltimore Development Inc., 2010 ). The university has engaged with the community through the Homewood Community Partners Initiative (HCPI) in 10 neighborhoods located around its main campus ( JHU, 2019 ). HCPI has worked with the Central Baltimore Partnership, various community and neighborhood organizations, and other stakeholders, such as foundations and anchor institutions, to develop an implementation plan for the area. This plan contains 29 priority recommendations for action, including blight removal, housing and commercial development, and fundraising. From 2013 to 2016 Maryland established health enterprise zones in five communities to stimulate alignment and advocacy activities among local health departments, health care delivery organizations, and social care and community-based organizations; the effort resulted in a net cost savings of $93.39 million (across all zip codes that participated) due to reduced inpatient hospital visits ( Gaskin et al., 2018 ). Hennepin Health, a Minnesota-based managed care program, reported similar notable gains coordinating assets at the county level, including across social care agencies, county-based health departments, multiple health systems, and a nonprofit health plan ( Vickery et al., 2018 ). Together these agencies reported reductions in emergency department use and increased primary and preventative care use for Medicaid beneficiaries.

These strategies alone or in combination may be funded by health care organizations via community benefit programs—the required contributions that nonprofit health care delivery systems must make to earn their tax-exempt status.

The committee recognizes that health care organizations can bring funds, data, and political and other forms of capital to catalyze community activities—including through the various strategies described in this chapter. But the health care sector has not consistently wielded this capital

in the interest of primary prevention of clinical conditions or prevention of the complicating social conditions. Effective strategies to strengthen social and health care integration are likely to require more attention to the experience and expertise of community stakeholders. This will demand organizational humility from the health care sector, particularly as it moves from health care delivery to community-focused activities. Alignment and advocacy initiatives should incorporate patients, families, and community members in program planning and execution to help avoid historical missteps.

As effective strategies emerge, attention will need to be given to implementation feasibility and program sustainability, including the workforce, technology, and payment models that will support the strategies and enable long-term interventions and corresponding reductions in health disparities.

  • Five complementary types of activities can facilitate the integration of social and health care. They are awareness, adjustment, assistance, alignment, and advocacy.
  • These types of activities should not be considered mutually exclusive, and one does not necessarily build on another. The exception involves awareness activities, which typically are foundational to the others.
  • Some health care systems have had success with using these strategies to strengthen social care services and, subsequently, to link social care activities with improved health outcomes.
  • Robust outcome evaluations have not been conducted on social care integration activities, which limits the committee’s ability to draw conclusions and make recommendations about specific evidence-based practices.
  • A one-size-fits-all approach is neither feasible nor advisable, since context should influence the adoption of specific social and health care integration activities.

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Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health was released in September 2019, before the World Health Organization declared COVID-19 a global pandemic in March 2020. Improving social conditions remains critical to improving health outcomes, and integrating social care into health care delivery is more relevant than ever in the context of the pandemic and increased strains placed on the U.S. health care system. The report and its related products ultimately aim to help improve health and health equity, during COVID-19 and beyond.

The consistent and compelling evidence on how social determinants shape health has led to a growing recognition throughout the health care sector that improving health and health equity is likely to depend – at least in part – on mitigating adverse social determinants. This recognition has been bolstered by a shift in the health care sector towards value-based payment, which incentivizes improved health outcomes for persons and populations rather than service delivery alone. The combined result of these changes has been a growing emphasis on health care systems addressing patients' social risk factors and social needs with the aim of improving health outcomes. This may involve health care systems linking individual patients with government and community social services, but important questions need to be answered about when and how health care systems should integrate social care into their practices and what kinds of infrastructure are required to facilitate such activities.

Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health examines the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes. This report assesses approaches to social care integration currently being taken by health care providers and systems, and new or emerging approaches and opportunities; current roles in such integration by different disciplines and organizations, and new or emerging roles and types of providers; and current and emerging efforts to design health care systems to improve the nation's health and reduce health inequities.

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Peckham S, Falconer J, Gillam S, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.29.)

Cover of The organisation and delivery of health improvement in general practice and primary care: a scoping study

The organisation and delivery of health improvement in general practice and primary care: a scoping study.

Chapter 5 health improvement activities undertaken in general practice and primary care.

  • Introduction

The aim of this chapter is to describe the types of health improvement activities undertaken in general practice or by practice staff in other locations. This includes activities undertaken in community pharmacies and in schools by primary health-care staff. The information in this chapter is drawn from all papers selected for the review including those that were marked only as ‘of interest’.

Variation in practice and activity was evident in the literature. As discussed earlier in this report, we identified a substantial number of papers that described specific activities or interventions undertaken in general practice. However, closer examination of papers provided less information about how activities were organised. The data presented here provide a general overview of health improvement approaches and are grouped broadly into specific topic areas. The selected papers included a wide range of prevention activities and intervention types. As discussed earlier in this report, it was difficult to distinguish between levels of prevention, with many papers not distinguishing between interventions with asymptomatic and symptomatic individuals. In addition, examining the papers for details of the organisation of the delivery of these interventions was not straightforward but primarily related to who delivered the service, where it was delivered or some other aspect of its organisation. For ease of presentation the findings have been summarised around key areas of activity:

  • child health
  • exercise promotion and weight reduction (including interventions aimed at the prevention of specific diseases)
  • smoking cessation
  • community activities
  • welfare benefits advice.
  • Types of screening activities undertaken in general practice

We identified 148 papers that examined the delivery and organisation of screening services. Most of these papers addressed specific screening programmes undertaken in general practice or examined the involvement of practice and primary care staff in national screening programmes. Others focused on screening as part of child health programmes, cardiovascular prevention or treatment, or addressed health checks for people with learning disabilities or the new NHS Health Check programme.

  • Systematic screening

Several activities aimed at identifying health conditions, or risk factors which predict ill health, are delivered systematically to a target population. The role of general practice in systematic screening programmes includes performing cervical smears, child health surveillance and providing health checks as part of the NHS Health Check programme.

Cervical screening

The national cervical screening programme is delivered by primary care in conjunction with regional screening centres, which manage the call and recall system for inviting eligible women who are due for screening. General practice is the major location of sample taking for cytology, the first stage in cervical screening. Around 90% of all samples that were examined by pathology laboratories in 2010/11 and 2011/12 originated from general practices. 125 Although both GPs and practice nurses are involved in sample taking, it has been reported that practice nurses take the majority of smears, and when GPs perform smears it is often on an opportunistic basis. 126 General practices also have an important role in checking the lists of women registered with them who are due to be invited for screening, in order to identify cases where invitations for screening should be postponed or ceased. 127

The national cervical screening programme has been operational for over two decades and has been credited with considerable reductions in cervical cancer mortality. 128 The literature identified by our review tended to focus on screening coverage and women’s experiences of the process, including the extent to which informed consent was promoted. A few studies explored patient views on non-attendance for cervical screening, including qualitative research conducted in deprived areas and the Somali community. 129 – 131 One study examined women’s views on communication of cytology results, highlighting the importance of co-ordination between general practice teams and screening centres to ensure the provision of consistent messages. 132

Health checks and cardiovascular risk assessment

The NHS Health Check programme was introduced in England in 2009 and aims to screen people aged 40–74 years old for risk of heart disease, stroke, diabetes and kidney disease. Papers reporting on this specific programme described screening occurring in a variety of settings including general practice, community pharmacy, workplaces and even a mobile screening bus. 133 – 136 The NHS Health Check can be delivered in different ways in general practice. For example, three broad approaches have been employed simultaneously at two general practices in the West Midlands region of England, and reported in a descriptive study. 137 These were invitations to people to make booked appointments, a drop-in clinic and an opportunistic approach utilising electronic flags in patient notes. The authors considered a combination of the approaches to be beneficial.

Prior to the introduction of the NHS Health Check, similar initiatives geared to identifying cardiovascular risk and related risk factors, such as diabetes, were also delivered in a range of locations. These were general practice, 138 community pharmacy, 139 , 140 general practice and community pharmacy, 141 and community settings including workplaces, pubs, leisure centres and religious buildings. 142 – 145 Three cardiovascular screening and health promotion studies in the early 1990s, including the Oxford and Collaborators Health CHECK (OXCHECK) and British Family Heart Study RCTs, were general practice based. 146 – 148 In these three studies, practice nurses were tasked with screening and provision of health promotion advice.

Where health-check screening occurred in general practice, it was carried out by nurses in the majority of cases, although health-care assistants and PCT employed staff were also mentioned. 133 , 134 , 138 , 148 – 150 However, in one programme in inner-city Birmingham, some of the participating GPs were paid to provide health checks, which included taking blood samples. 141

With regard to health-check projects delivered in community locations, screening was conducted by a wide range of personnel including practice nurses, 145 health visitors, 142 staff from an independent sector organisation 144 and district nurses working in conjunction with lay health workers. 143 Onward referral of screening participants to smoking cessation clinics or to general practice, for example in cases of raised blood sugar level, was noted in two papers. 142 , 143

Screening specifically for diabetes

Although the objectives of many health-check programmes have included identifying undetected diabetes or risk of developing diabetes, studies have also been conducted to examine systematic screening focused specifically on diabetes. The 2003–5 national pilot diabetes-screening programme and the Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care (ADDITION)-Cambridge cluster RCT occurred in 24 general practices in relatively deprived areas of England and 49 general practices in the east of England, respectively. 151 , 152 The ADDITION-Cambridge study formed part of a larger multinational study with sites in Denmark and the Netherlands, termed ADDITION-Europe. It is noteworthy that recently published results from ADDITION-Cambridge have shown that screening for type 2 diabetes was not associated with reductions in mortality over a 10-year period. 153 ADDITION-Europe found that screening followed by intensive management of patients diagnosed with type 2 diabetes was associated with a small, but non-statistically significant, reduction in cardiovascular events and death. 154

Notwithstanding the generally negative results of the ADDITION research with respect to the UK context, publications arising from ADDITION-Cambridge and the national pilot diabetes-screening programme have provided some useful information for this review with respect to how the screening was delivered. This has relevance in light of the inclusion of diabetes risk assessment in the more recently introduced NHS Health Check programme. A study examining the implementation of screening activities at six general practice sites in ADDITION-Cambridge highlighted the involvement of a range of practice staff in screening, including practice nurses, health-care assistants, GPs, practice managers/administrators and reception managers. 155 Practice nurses seemed to have significant involvement in delivering the screening, the involvement of GPs seemed to be limited and information on the specific contributions of health-care assistants, practice managers/administrators and reception managers was patchy. One paper reporting on the delivery of the national pilot diabetes screening programme at five of the 24 general practice sites described the employment of health-care assistants to perform screening at four practices, with the remaining practice employing a practice nurse. 156 In the same paper the screening was described as generally being led by practice managers and practice nurses, with one practice manager stating that ‘the GP doesn’t get involved because GPs are busy seeing patients’ (p. 80). 156 Interestingly, several practice nurses had taken it upon themselves to conduct the screening at the start of the programme, but had subsequently delegated an increasing amount of the work to health-care assistants because of time constraints. The consensus that emerged over time was that the most appropriate staff member to carry out the screening was a health-care assistant, and care was taken to ensure that health-care assistants would refer patients to practice nurses when uncertain of their needs. 156

In both the national pilot diabetes-screening programme and the ADDITION-Cambridge study, inconsistency between participating practices in how screening activities were delivered was encountered, despite attempts by programme designers to standardise it. 151 , 155 Practice teams ‘adapted the work according to the size of the practice, the numbers to be screened, the way that they made decisions in the team and their particular interests’ (p. 391). 155 Recent research on the implementation of the NHS Health Check suggests that there is considerable diversity in general practices’ implementation of the NHS Health Check. 157

Health checks for people with learning disabilities

Several research studies on health checks for people with learning disabilities were found among our selected papers. There seemed to be wide variation in service delivery. For example, checks were carried out in different locations including GP surgeries and people’s homes, 158 , 159 and different practitioners carried out the checks, including GPs, practice nurses and community nurses. 159 – 161 Despite the inconsistency in service delivery, a systematic review of the impact of health checks for people with intellectual disabilities found that they had consistently led to the detection of unmet health needs, and actions to address those needs. 159

Assessment of the health needs of older people

Policies such as the inclusion of health checks for people over 75 years in the 1990 GP contract and the 2001 National Service Framework for Older People have emphasised preventing ill health and promoting health among those in older age. Examples of different strategies for targeting the older population for health needs assessment were found. Some approaches involved offering a health check to all people on general practice lists aged over 75, to be carried out either at their home 162 , 163 or in the general practice with the offer of home visits for those unable to attend. 164

Alternatively, people ‘at risk’ were identified by asking them to complete posted questionnaires. 165 , 166 Of these, ‘Health Risk Appraisal for Older people’ was notable in its use of a computer expert system to analyse questionnaire responses and provide tailored information for both patients and their GPs. 166 A project also examined the feasibility of a team made up of community nurses and social welfare officers from a voluntary sector organisation in assessing the health and social care needs of people over 75 years deemed to be potentially ‘at risk’, through not having contacted their GP in the last year or not responding to a call for a routine health check. 167 The team referred people defined as having unmet needs to a wide variety of services including those concerned with health care, social care, housing, leisure and transport. The highest percentage of referrals was to GPs.

  • Opportunistic screening

Opportunistic screening can be said to occur when people attend a service provider for a matter related or unrelated to the condition being screened for. The distinction between systematic and opportunistic screening is not absolute, as opportunistic approaches may be used in general practices to increase the screening uptake of systematic programmes. 126 , 137 While identifying smoking status is a key role for practices and has been included in the QOF, a discussion of smoking is included later in this chapter alongside interventions on smoking.

Screening activities driven by the Quality and Outcomes Framework

A general survey on screening sent to GPs in Essex and north-east London in 1996 asked, among numerous other questions, whether they offered screening for hypertension, cholesterol and diabetes to all adults, on an opportunistic basis or for other reasons. 168 A major limitation to this section of the survey was a lack of clarity in terms of how and when screening was offered and what was meant specifically by offering screening ‘to all adults’. However, the results are perhaps of note in that variation in reported practice was found, and a high proportion of GPs reported offering some form of ‘screening’ for each of hypertension, cholesterol and diabetes. With regard to hypertension, 51% of GPs offered screening ‘opportunistically or for a combination of reasons’, 42% of GPs offered screening ‘to all adults’, 2% of GPs did not offer screening, 2% of GPs offered a test for medical reasons only, 1% of GPs offered a test on patient request only and 2% of GPs did not specify whether or how they offered it. A relevant question to current research into service delivery is how the QOF, introduced into the GP contract in 2004, has affected screening activity in general practice. The QOF adjusts target payments of specified conditions, including CHD, hypertension and diabetes, for the prevalence of the condition in the practice population, and thus in theory provides a financial incentive to find and register cases.

Although several studies have examined the impact of the QOF on the quality of care delivered in general practice, few have specifically examined its effect on the identification of new cases of disease. Two studies that have touched on this issue suggest that the effect of the QOF on uncovering undiagnosed disease has been modest and geographically variable. 65 , 169 The epidemiological analysis conducted by Soljak et al. 169 suggested that a large proportion of undiagnosed CHD and hypertension remained in many areas of England in 2007, 3 years after the introduction of the QOF. Through qualitative research with GPs in deprived areas, Dixon et al. 65 found that ‘for the most part, practices were engaged in opportunistic case finding, screening patients with family members with particular conditions, or patients who looked overweight; but the exact causal relationship between the QOF and case finding was difficult to discern in most cases, as most practices that did extensive screening said they did it pre-QOF’ (p. 106). The method employed to adjust QOF payments for achievement of targets for particular diseases, which involved using the square root of the prevalence of the disease, potentially dampened the incentive to identify new cases of disease. 65 In 2009 the square-rooting arrangement in the calculation of QOF payments was discontinued and now actual prevalence rates are used to calculate QOF payments.

The QOF may have had a greater impact on screening rates for complications of existing disease. 65 , 170 Taking diabetes as an example, a study using QOF data in Northern Ireland reported that the increase in the prevalence of diabetic nephropathy recorded on general practice registers from 2004/5 to 2006/7 was proportionally greater than the increase in the prevalence of diabetes recorded on practice registers in the same period. 170 However, this study also found considerable variation among general practices with regard to the proportion of diabetic patients recorded on their registers as having diabetic nephropathy.

Chlamydia screening

In 2008–9, the two locations in which the highest proportion of chlamydia screening in England occurred were community contraception/sexual health services and general practice, with 25.0% and 16.1% of chlamydia screening activity, respectively. 171 Both GPs and practice nurses offer chlamydia tests in general practice. 172 – 174 Furthermore, three papers identified in this review reported the involvement of receptionists in distributing leaflets or discussing screening with patients. 175 – 177 Treatment of chlamydia infection and partner notification can be provided by programme area screening team offices. 176 Alternatively, a study conducted in one practice described patients with a positive result being invited to discuss their results and receive treatment, and being offered referral to a local genitourinary medicine clinic for contact tracing. 178

Screening and brief intervention for alcohol misuse

Patients are often asked in general practice about their alcohol consumption, although it is not routine for all patients on practice lists to be asked on a regular basis. 179 , 180 GPs may be unaware of potentially problematic drinking behaviour in many of their patients whose alcohol consumption is only moderately above recommended levels. 179 Between 1999 and 2009 there was a trend towards patients being asked more about drinking, with 40% of GPs reporting in a closed survey question in 2009 that they asked about alcohol ‘all of the time’ or ‘most of the time’, in situations where the patient does not ask them first. 180

Several types of professionals have been involved in delivering screening and brief intervention for alcohol misuse in primary care including GPs, practice nurses, psychologists, counsellors and community pharmacists. 124 , 181 , 182 However, nurse involvement in alcohol intervention was reported as being low in a paper published in 2003, 183 and community pharmacists in Scotland were found to provide little advice on alcohol use in a paper published in 2011. 182

Within general practice, asking about alcohol consumption tends to occur when patients are not specifically seeking help for alcohol problems, usually in the context of new patient registration forms, during health checks or during consultations. 179 , 181 Within consultations, GPs report asking patients in a wide range of scenarios including those presenting with psychological conditions such as depression and anxiety, social problems, as well as physical conditions. 180 GPs have described some awkwardness in enquiring about drinking and seem to have responded with strategies such as either embedding the question about alcohol consumption within a list of questions about lifestyle or reassuring the patient that they ‘ask everyone’. 179

The term ‘brief intervention’ has been used broadly with respect to alcohol to refer to interventions which last between 5 and 60 minutes, usually consisting of no more than a few sessions, and focusing on providing counselling and education. 184 Because of a complex combination of factors, having ascertained a patient’s drinking status as risky does not necessarily mean that GPs will follow this with a brief intervention aimed at changing their behaviour. 185 A paper reporting on the ‘real world’ implementation of screening and brief alcohol intervention in a primary care setting in three countries described the development of two levels of brief intervention as part of an action research approach taken in England. 124 This allowed a simple brief intervention (structured advice needing only a few minutes to deliver) or an extended brief intervention (behavioural counselling taking 20–30 minutes, plus repeat consultations where thought to be beneficial) to be employed by practitioners depending on the patient’s level of drinking and level of interest in discussing alcohol consumption. The research in England involved GPs and practice nurses, and to a lesser extent practice managers, receptionists and voluntary sector counsellors. However, it did not delineate the roles of these staff members in delivering the simple and extended brief interventions.

  • Screening for other conditions

Our literature review also identified papers on a wide range of other screening activities that can be conducted in general practice. These included antenatal screening for haemoglobin disorders, 91 , 186 , 187 screening for dementia, 188 , 189 falls, 190 – 192 osteoporosis, 193 , 194 atrial fibrillation, 195 depression, 196 domestic violence, 197 adult hearing, 198 hepatitis C, 199 human immunodeficiency virus, 200 oral cancer, 201 syphilis 202 and tuberculosis. 203

  • Support of screening programmes delivered outside general practice

Aside from performing screening activities, general practice also has an information provision and advocacy role with respect to screening programmes delivered outside practice sites. This applied to breast screening, which is usually provided at units run by hospital staff, and bowel screening using home testing kits, which is organised centrally and conducted by post. General practice involvement included GPs verbally recommending screening, 204 – 207 practices sending GP-endorsed screening invitation letters or information leaflets, 208 – 212 and interventions to promote opportunistic reminders for people to attend screening. 210 , 211 One RCT investigated the effectiveness of nurse visits to women who had not attended breast screening. 213

  • Child health

There were a large number of papers (50) addressing issues in primary prevention among the child population. These spanned a range of topics relating to breastfeeding, accident prevention, weight management and exercise. Many of the studies focused on the activities of community nurses, school nurses and health visitors with activities taking place outside the practice: in the home, community or schools. The majority of the studies were rated as of good methodological quality, although some were qualitative and descriptive rather than studies of effectiveness. There are gaps in both knowledge of activities actually undertaken and evidence to support interventions. For example, a review on the effectiveness of school nurse interventions 89 found little research of acceptable quality and little could be said about its effectiveness.

Most research papers examined changes in patient behaviour as a result of the intervention but few examined clinical outcomes. Studies fell into three broad categories. The first group examined interventions within practices or by primary health-care team staff to identify children at risk of health problems, accidents, etc. In this area of activity, interventions were often targeted at specific groups of children. The second group were interventions aimed at intermediary organisations such as changing school policies or practices. This included training and educational interventions for teachers. 214 , 215 The third group examined interventions or activities in the community or in schools. 216 – 219 With respect to childhood and adolescent obesity, some studies suggest that GPs are less inclined to blame their young obese patients for their condition and to hold less negative and stigmatised views towards them, but, as with their obese adult patients, there is a sense of futility and lack of confidence evident in GPs’ approaches to treatment. 220 Generally, however, GPs are less involved in addressing obesity in childhood than other primary health-care staff and teachers. There is some potential for GPs to adopt a more population approach to childhood obesity and play a more active role.

Breastfeeding promotion is largely conducted by health visitors and community-based midwives. One of the few papers that addressed the context of a breastfeeding intervention policy 221 discusses the variance in outcomes of a RCT of a community based breastfeeding support group. Through ethnographic enquiry of the complex intervention, they found there was variation in the way that services were organised, which could be explained through a Hierarchy of Service Attributes Model. In the study sites where breastfeeding rates increased, the model was underpinned by good personnel resources and organisational stability, and demonstrated reflective action cycles at its apex. In localities where breastfeeding declined, the authors found that managers focused on solving the problems within the model, such as staff shortages, rather than ways to deliver the policy. The model provides a useful approach to understanding and explaining delivery of public health interventions in primary care and could be usefully applied to other scenarios.

Provision of childhood vaccinations is a key component of public health for children and adolescents. Proactive campaigns by general practices do seem to increase uptake of vaccinations. 222 – 226 GP recommendation appears to improve uptake compared with non-primary care and other primary care staff. 223

  • Exercise, weight reduction and diet

Most of the papers on exercise targeted the general patient population although one referred to people with mental health problems and another three to older people. The majority of papers on weight loss were focused on people who already had risk factors or a health issue, primarily CVD. There were few very good-quality studies; most were of medium quality with some mainly minor concerns about sampling, analysis and outcome assessment. Previous reviews 227 , 228 have also found few good-quality studies and described research as suboptimal. Interventions ranged from lifestyle advice to specific interventions such as exercise or weight loss classes. There was a mixture of interventions delivered by practice and community nurses, GPs, specialists (e.g. nutritionists, dieticians), community workers and health promotion specialists.

In 2009, the QOF included physical activity for the first time under a ‘cardiovascular risk assessment and management’ indicator. 229 The indicator set a target that between 40% and 70% of newly diagnosed hypertensive patients should be ‘given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet’. The QOF has been a major driver in the development of more systematic approaches to public health interventions. 65 , 230 While this appears to have stimulated such advice, with practices introducing clinics and ‘lifestyle reviews’, the evidence on its effectiveness is limited. This area of activity is also being driven by the introduction of the NHS Health Check.

The prevalence of overweight and obesity is rapidly increasing in both the developed and the developing worlds, while tobacco use is largely declining or has levelled off in the developed world. A 2007 study of 168,000 patients in 63 countries showed that 64% of men and 57% of women were overweight or obese. 231 In England in 2007, 24% of all adults were classified as obese, an increase of 37.5% since 1993, along with 16.5% of children aged 2–15 years, an increase of 11.5% since 1995. 232 We found 16 papers that examined primary care interventions that addressed weight loss and obesity. Much of the research is of poor quality, with only one study rated as high quality.

Overweight people rarely turn first to their GP or the formal health-care system for help in losing weight. They try various self-help approaches first, despite consistently citing their GP as the most trusted source of advice on matters regarding diet and nutrition. 233 GPs regard obesity, both its treatment and its genesis, as largely the responsibility of the patient, and believe that their capacity to effect positive change in their obese patients’ weight status is seriously limited, 234 – 238 despite having higher than average frequency of contact with their obese patients. 239 Clearly this attitude stands in stark contrast with the move by public health and obesity experts to treat obesity as a chronic disease. The biggest obstacle is health professionals’ inability to recruit patients. This may relate to their limited knowledge of potential benefits. 240 There is also likely to be a resulting underutilisation of pharmacotherapy and weight loss services, as fewer than 40% of GPs view these options as effective, despite their evidence-based inclusion in practice guidelines for both adults and young people. 234 GPs (and practice nurses) make relatively few referrals in a rather haphazard way owing to lack of time, lack of feedback, medicolegal concerns or their view that patients are unlikely to go/respond, and because exercise is not a priority during consultations. They are uncertain about their own influence. 241 As with offering a smoking cessation intervention, and for similar reasons relating to lack of faith in efficacy, GPs are hesitant to raise the issue of weight loss with obese patients if they feel it will negatively impact on their relationship with the patient. 235 Many GPs believe that obesity does not belong within the medical domain. 234

  • Smoking cessation

There is a vast body of literature on issues related to smoking cessation, ranging from the effectiveness of various pharmacotherapy and behavioural interventions to the role of public policy and government. This review focuses on what GPs are currently known to do when promoting smoking cessation and what the literature says about the effectiveness of various smoking cessation approaches. It was not always possible to distinguish between stopping-smoking services that targeted all smokers and those focusing on smokers with an existing health problem. Services were often provided generically.

General practitioners in England have access to much smoking cessation guidance and numerous best practice documents, including those produced by NICE and the Health Education Authority. 242 , 243 There is also an emphasis on GPs and other primary care professionals raising smoking in consultations and visits, with brief interventions highlighted as particularly important. 244 Brief interventions are generally defined as lasting between 5 and 10 minutes and include one or more of the following: asking the patient to stop smoking; assessing the patient’s willingness to stop; offering pharmacotherapy and/or other behavioural support; providing self-help materials; and referring the patient to specialist counselling.

There is good evidence that services for helping people quit smoking are cost-effective and the evidence suggests that a belief in clinical effectiveness and cost-effectiveness is an important influence over whether or not GPs offer smoking cessation advice or interventions. 245 – 247 Smoking is a major contributor to health inequalities, and cessation services do help reduce these. 248 – 250 However, few studies examined specific population groups although one study suggests a lack of services for ethnic minority groups despite some evidence of the benefit of community outreach services. 251 , 252 Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance. 253 This systematic review identified 48 papers. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on GP registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified, and providing cessation services in different settings appeared to improve access. Overall, the evidence on the effectiveness of some interventions in increasing quitting behaviour and access in disadvantaged groups is limited. While many studies collected socioeconomic data, very few analysed their contribution to the results. 253

Many studies demonstrated that there was poor recording of smoking status in practice patient records and more can be done to identify patients who smoke. 254 , 255 While recording improved following the introduction of the new GMS contract in 2004 (for patients with various comorbid factors: CHD, stroke or transient ischaemic attack, hypertension, diabetes, COPD or asthma 254 , 256 ), a 2008 study showed that levels of recording were still low in some practices. This study of practices in Nottingham found a range of recorded smoking status between 39% and 100%. 255 However, of key importance was the fact that, while in many practices the ascertainment of smoking status was incomplete and/or inaccurate, it was the failure to intervene appropriately on known status that remained the biggest challenge. 255

A GP’s query regarding a patient’s smoking status and subsequent recording of this status are the first steps in an effective smoking cessation intervention, as indicated by NICE, the Health Education Authority/Thorax and the US Department of Health and Human Services guidelines. 242 Virtually all English GPs (98%) report following these steps. 257 It is clear that in the UK the universal uptake by GPs of the QOF process 258 and its reimbursement for recording smoking status and providing smoking cessation advice have had an impact on levels of recording smoking status, although rates of recording do vary. 254 – 256 Smoking cessation is a good example of the QOF changing the way in which practices work, by providing prompts and reminders which have helped to ensure practices try and reach people. In group discussions GPs also referred to systems and prompts, but there was some disagreement among GPs about whether these were helpful or not.

However, knowing a patient smokes does not routinely trigger a smoking cessation intervention by the GP. Fewer than half of all GPs consistently advise patients to stop smoking. 257 , 259 – 261 The reasons for this are complex. In addition to not believing that the patient is motivated enough to quit smoking, many GPs report concern about harming the doctor–patient relationship by broaching the topic of smoking cessation with a potentially unreceptive patient, deciding, on balance, that protecting this relationship is more important than providing a smoking cessation intervention with questionable odds of succeeding. 262 – 267 Pilnick and Coleman 267 argue that smoking cessation is complex and that offering help on how to quit is difficult. They also suggest that the benefits of nicotine replacement therapy may be due not simply to the clinical effects but also to the legitimisation of the view that stopping smoking is an appropriate problem for medical intervention.

A randomised controlled study of 74 GPs in England has shown some success in overcoming GPs’ concerns about harming the doctor–patient relationship by providing GPs with a simple desktop resource which triggers a smoking cessation intervention. 263 Furthermore, English GPs are more likely to initiate discussion regarding smoking when the patient presents in the surgery with a smoking-related problem. 268 , 269 Training GPs and nurses in effective delivery of stop-smoking interventions results in better outcomes. 94 Other research supports or encourages such action, including evidence from a Cochrane review. 259 , 270 – 272 A lack of knowledge among GPs about how to affect behaviour change when working with addiction, even among GPs who regularly initiate smoking cessation interventions, presents evidence of the need for further specialised training for GPs. 273

Overall, few papers examined the delivery and organisation of smoking cessation services and only two compared different service approaches. There is a mix of activity in general practice and communities more widely but there appears to be little evidence on how best to organise services despite an increase in the recording of smoking status and incentives to promote smoking cessation. 255 , 256 , 274 – 277 In practices, GPs and nurses provide smoking cessation interventions and, while more nurses may be involved, they have restricted prescribing rights. 278 Lack of time in consultations remains a key barrier to services, as do concerns about how to raise smoking issues within the consultation. 279 However, increasing awareness of smoking status, targeting smokers and provision of training to health-care professionals increase cessation interventions in primary care. 261 , 280 – 283 There is some evidence to suggest that patients prefer specialist smoking cessation services but that not all GPs make appropriate referrals for these services. 284

  • Cardiovascular disease

Papers discussing prevention activities related to CVD were one of the most common groups found in our initial literature search and were the largest group of papers included in the evidence synthesis. Within these, by far the most common activity taking place in primary care with regard to the prevention of CVD is the attempt to modify lifestyle risk factors in symptomatic and asymptomatic patients who are deemed to be in the ‘at risk’ category. The risk factors that are commonly targeted are obesity, poor diet, lack of exercise, alcohol use and smoking. Other key areas were the monitoring of, and strategies to control, blood pressure in symptomatic patients, especially those patients with peripheral arterial disease, patient compliance with medications (especially statins), strategies to improve patient outcomes for people with angina and the cost-effectiveness of nurse-led clinics for those with existing CVD. In addition there were a number of studies looking at GP and practice nurse knowledge and behaviour with regard to guidelines for CVD.

Ten papers directly addressed lifestyle risk factor improvement in asymptomatic patients. 285 – 294 Five papers 285 – 289 looked specifically at trying to alter patients’ behaviour regarding the amount of exercise they took, their diet and other risk factors (e.g. smoking). This was delivered through short interventions which employed a wide range of activities, such as tai chi, exercise classes, guided walks, counselling sessions and, in one case, a home exercise kit. Two papers looked specifically at the effect of risk factor awareness on asymptomatic patients’ behaviour. 290 , 291 The first of these studies looked specifically at the level of awareness of risk factors for cancer and CVD. 290 It found that there was a good level of understanding for the lifestyle risk factors for CVD but that risk factors for cancer were less well understood. One study focused on lifestyle risk factors with particular reference to patients with high blood pressure where patients were given information and advice about diet and weight loss to help lower blood pressure. 292

Some of the papers provided details about who delivered the interventions. The role of the GP in giving advice concerning lifestyle risks was considered specifically in two papers. 293 , 294 The first of these examined the use of ‘pop-up’ reminders on practice computers to improve GPs’ awareness of patients with CVD risk factors. The ‘nudge’ screen would prompt the GP to offer advice and give information about lifestyle risk factors for the patient. The second study examined tailored practice care plans which included ‘motivational interviewing’ and target setting for lifestyle change delivered in a primary care setting.

There were five studies on the effectiveness of nurse-led clinics for secondary CVD prevention in a primary care setting. 295 – 299 All of the studies looked at clinics where practice nurses monitored lipid levels, blood pressure, medication use and other risk factors such as diet, exercise and smoking. Three studies 300 – 302 looked at the effect of nurse-led interventions in primary care on patient compliance with drug regimens for high blood pressure.

Three studies looked specifically at the management of patients with peripheral arterial disease. One study 303 looked specifically at the patterns of management of patients with CVD and peripheral arterial disease. It found that, while most patients were given advice concerning smoking cessation and blood pressure, fewer than half were given advice about weight loss or exercise. The second study 304 looked specifically at the treatment received by patients who presented with either peripheral arterial disease alone or peripheral arterial disease and CVD. It found that those patients who had peripheral arterial disease alone were given suboptimal care. The third was a simple description of prescribing practices for peripheral arterial disease patients in Ireland. It found that prescribing patterns varied widely and that patient compliance was less likely when they were required to take a number of different medications. It was also found that prescribing patterns for this group of patients was influenced strongly by budgetary concerns, as some of the medications were expensive.

Two papers looked specifically at ethnicity and CVD. 305 , 306 Murray et al. 305 looked at a strategy to reduce health inequalities between the white ethnic majority and ethnic minorities in Wandsworth, London. It was a 10-year study using blood pressure and cholesterol measurements as proxy markers for CVD. It was difficult to assess whether or not a significant narrowing of inequalities between ethnic groups had been achieved and there were also insufficient data in the paper to assess the approach. An additional problem was that small numbers of some ethnic minorities and South Asians from different countries were pooled. Previous studies have found that CVD risk is not necessarily uniform among the South Asians population, and there are important differences between Indians, Pakistanis and Bangladeshis. The second study 306 looked at the feasibility of using screening services to reach ethic minority groups in Sandwell. It was a series of community-based screening events for CVD and diabetes. The screening events were very popular with the ethnic minorities who attended them, but it unclear if the strategy actually resulted in any lifestyle risk factor change, as this does not appear to have been assessed.

Two papers looked at sex and CVD. 307 , 308 One study used computerised data from primary care practices to investigate how CVD is treated. 308 The results showed that considerable variation existed between practices, though women were consistently given suboptimal care with regard to prescribing and diagnostic tests. Also, doctors did not always follow the guidelines and procedures. The second study 307 looked at the clinical management of patients with stable chronic angina pectoris. Women received a lower level of risk factor assessment, secondary prevention therapy, cardiac investigation and coronary revascularisation.

There was just one paper that looked specifically at deafness and screening for cardiovascular risk. 309 The study was carried out in Sandwell and was part of a community-based programme to provide health promotion advice in a deaf community. The approach in the study did not reduce estimates of CVD risk after 6 months among deaf people determined to be at ‘high risk’, despite the high-risk group of deaf people being given advice and being referred to their GP. A speculative link with language barriers was identified (e.g. a lower reading ability preventing access to information on health promotion, and the discovery that there was no sign for cholesterol in British Sign Language).

  • Community participation

Community participation in general practice and the role of primary health-care teams in tackling population health beyond the surgery door have long been championed. However, the research literature betrays a focus in favour of a biomedical and technical approach to public health. Most papers concern what might be called ‘preventative medicine’ rather than more complex community-based interventions. Regarding this subset, three immediate observations can be made.

Firstly, there was a paucity of papers – only 18 papers in this category – reflecting the focused nature of our original search strategy. Secondly, few studies focus on outcomes: most papers described case studies and used interviews with key stakeholders to illustrate the potential benefit of participatory approaches. Few studies attempted to measure health processes or outcomes. Thirdly, methodological quality was poor. The evaluation of complex community interventions is a study in itself. Unfortunately, beyond rather woolly references to ‘action research’ and the complexity involved, few studies were of the quality required to ground firm conclusions. In many instances, the initiative had apparently progressed without the necessary resources to undertake detailed evaluation.

Six papers examined health promotion initiatives from the vantage of different groups involved. 310 – 315 For example, Daykin and Naidoo 310 explored the views of health professionals on promoting health in areas of poverty with low-income clients. They questioned the assumption that primary health care is the best setting for health promotion; several constraints are identified as limiting its effectiveness. Firstly, the emphasis on individual lifestyle change that often informs government strategy for health promotion causes frustration among health professionals. Characteristics of primary health care limited its scope in addressing socioeconomic inequalities and engaging in multiagency initiatives. Their interviews indicate that, despite these constraints, workers in primary care demonstrate high levels of awareness and commitment to a social model of health promotion. On the other hand, Abbott and Riga 311 exposed limited understanding of the links between deprivation and ill health among health-care professionals in east London. Better professional education on equality, diversity and public health approaches, and improved patient education to overcome knowledge barriers were proposed solutions but their views seemed to be anecdotal rather than evidence-based. Both studies suggested a need for resources and training.

Conceptual uncertainties are mirrored in the views of deprived residents. Parry et al. 312 found that they conceptualised health in both physical and non-physical (e.g. being happy, peace of mind) terms. Sense of place affected health through three key levers: physical structures (e.g. quality of housing), social structures (e.g. friendliness of neighbours) and provision of services (e.g. transport). The interplay between these factors was complex and fear was a common node in many of the pathways residents described linking place with health.

A survey of faith groups in Dundee 313 found they were already involved to different degrees in health promotion and ready to engage in more. They constitute an untapped resource whose potential has been evidenced in the USA. Kennedy and colleagues 314 , 315 have explored the benefits arising from lay involvement in community-based nutrition programmes in poor neighbourhoods. These include increased service coverage and the ability to reach populations, personal development and enhanced social support.

A similar gulf in expectations characterised health professional views on health visiting in an orthodox Jewish community. 316 The community only partially understood or valued the health visitors’ role, while health visitors’ awareness of aspects of Jewish culture was limited. Closer partnership is required to develop a service that the community finds valuable.

Participatory approaches to health-needs assessment have gained credence as an effective substitute for traditional, epidemiological approaches. A comprehensive literature review found that research on African and Afro-Caribbean populations was limited and uneven, focusing on specific particular diseases. Okereke et al. 317 used a triangulation approach to identify the community’s perspectives on local priorities.

A narrative review of published research on community capacity to manage hypertension among black groups identified 27 relevant studies. 318 However, collaborative methods yielded insufficient evidence of effectiveness in terms of quantifiable outcomes. Intrinsic assumptions about the homogeneity of communities and how they are represented were challenged.

The Community Health Educator is a model developed through a series of participatory action research projects in UK cancer screening during the 1990s. However, little is known about its effectiveness, or how researchers/practitioners engage with communities. 319 Researchers and practitioners need to be flexible in accommodating the ambiguity implicit in the concepts of ‘community’ and ‘ethnicity’. The efficacy of social networks has similarly been questioned. 320 The prevailing assumption that the community health educators’ personal networks are ethnically and neighbourhood-bounded has influenced intervention design but may not reflect the complexity of urban communities. Concepts such as ‘social capital’ and ‘embeddedness’ are notoriously difficult to operationalise.

  • Welfare advice services

We evaluated eight papers that described or reported research findings on welfare advice services in general practice. These papers constituted a focused assessment of the organisation, role and impact of advice services for practice populations. The general conclusion of these papers was that welfare advice services are an excellent strategy by which primary care organisations address the social, economic and environmental influences on the health of their population. 321 , 322 In addition, studies show that services are valued by patients and practice staff 323 , 324 and lead to positive social and health outcomes for patients. 325 – 328

While a number of the studies were small, the quality of the research was mainly rated as A or B (see Chapter 3 for definitions) and the cumulative findings suggest that there are measurable health benefits for those patients who achieve additional income and high levels of patient satisfaction. There were no cost-effectiveness studies of these services. However, most services were delivered by existing welfare services, with practices merely providing premises.

  • Organisational issues

The focus of most studies we examined in the review was on general practice, although a number of papers described or evaluated activities linked to the primary health care team but delivered in community settings, people’s homes or schools. Generally those activities outside the practice seldom involved GPs and were predominantly delivered by community nurses or other professionals (e.g. health promotion specialists, pharmacists). The papers reviewed identified a number of important issues related to the location of health improvement activities. For example, there is evidence to support the use of community and school-based locations for health improvement activities with people from ethnic minorities. Evidence shows that schools are more likely to be the most appropriate setting for family-based interventions for ethnic minority groups because of easier access and availability, and the relationship between healthy lifestyle and curriculum. Places of worship are more likely to engage in a dialogue around traditional food practices. Places of worship also provide access to the wider family, including grandparents, and offer opportunity for culturally and family-specific support. 329

In group discussions with GPs, the variation in approach and how services were organised and delivered was very evident. Some practices had invested in training and developing their practice nurses and employing health-care assistants to undertake routine screening and monitoring. In some cases this activity was undertaken by running clinic sessions or group sessions while in others it was based on individual patient recall systems. Younger GPs tended to focus more on the impact of the QOF on these sorts of activities. There was much debate about the impact of the QOF not only on preventative interventions but on the way the practices organised activities and patient care. There are some new issues that have been forged by the QOF such as a more embedded emphasis on systematised models of care through the use of disease registers, computerised working methods and greater use of clinical templates. 93 The literature on the impact of the QOF also suggests that it has focused on individual interventions with patients and more depersonalised care. 93 , 330

While there has been a particular focus on GPs, it is clear that primary care approaches to public health involve all workers in the practice, as well as the wider primary health-care team. There has been an increasing involvement of practice nurses in patient care, particularly for routine screening and review activities, although the majority of consultations are still with the GP. The introduction of the QOF has been important in opening up new opportunities for practice nurses, although these are a continuation of pre-QOF trends (increasing employment of health-care assistants, delegation of clinical work from GPs to nursing staff). 331 These approaches are also reflected in general practice approaches to prevention and health promotion. 65

While this review describes a wide range of activity, there does not appear to be any consistency in how services are organised between practices. From the papers examined in this review it does seem that many of the interventions have been successful in improving record keeping in practice. In areas such as CVD, diabetes, etc., there is an emphasis on identifying risk factors and on education, most of which seems to have limited benefit. Interventions aimed at changing lifestyle (e.g. for weight management, exercise and CVD) of patients who are asymptomatic seems to be limited in terms of any long-lasting impact. Studies tend to be short in duration and rely on self-reported behaviour change. Studies suggest that there are huge variations in prescribing practices, and the amount of information and advice given by GPs. A number of papers report that GPs feel ill-equipped to give that sort of advice. Practice nurses are used more often to provide information and monitoring of patients, both those ‘at risk’ and symptomatic patients. Generally speaking, patients seem to like this, but with disappointing outcomes with regard to patient benefit. However, it is also not clear how far lifestyle advice is either delivered or remembered by patients. In a study of patient views on health promotion and lifestyle advice in general practice, only 6% of patients recalled receiving advice on diet, 4% on exercise and smoking and only 2% on alcohol. 332 Few papers examined services for specific groups of people or reducing health inequalities between groups.

More attention needs to be paid to skill mix in general practice, although the nature of general practice varies. In this sense, although the systematisation of activity provided by QOF has been seen as restrictive for many practices, it has also been helpful. 65 , 93 , 331 , 333

General practitioners also referred to other financial support for public health activity in practices. Some GPs recognised that the principle of capitation funding should provide some incentive to explore prevention activities but felt that limited time in consultations and the demands of clinical practice made this difficult. Some PCTs have been using other elements of the GMS contract such as LES to support health promotion activity based on financial incentives. However, some respondents questioned if such activity being incentivised was already covered either within the core contract or through the QOF. 63 In a more recent study on the early development of CCGs, the researchers identify a number of uncertainties in this area and report mixed views among CCGs and public health staff about the relationships between GP practices and public health. 334 Data from this study also suggest that there is considerable uncertainty and concern about how public health will work in the new system.

The focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The focus is on medical conditions related to prevention of specific diseases such as diabetes or CHD. GP activity appears to be driven by specific contractual incentives and conditions. However, the wider literature also suggests that general practice is also affected by other factors such as peer pressure, relationships with public health departments, education and training. While direct incentives such as contracted standards or the QOF do influence practice, there is some debate about whether or not GPs simply react to maximise their income and do not prioritise activities towards those most in need. The use of thresholds can provide perverse incentives and there is some evidence that GPs use exception reporting to maximise their points score and income. However, there is some evidence that the wider primary care team, such as health visitors, are engaged in health improvement interventions such as breastfeeding support where variance in outcomes have been explained from a service delivery perspective. 221

There appears to have been little shifting from the position described by Lawlor et al. , 79 who argued that GPs do not adopt a population approach as they focus on high-risk patients and adopt a predominantly medical approach. They also argued that GPs felt that giving lifestyle advice interfered with the doctor–patient relationship. However, it is clear that many GPs see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice approach to improving the health of their patients.

There is little evidence to show that GPs undertake wider public health roles in terms of population surveillance beyond contractually defined screening and monitoring. These do not target major areas of health concern (such as mental health, eye problems and oral health), which receive less attention despite the potential of general practice to play a leading preventative role. While there is good evidence, for example, that GPs address eye health for people with diabetes, less is known about their wider role in screening for eye problems. It is important that GPs link mental and physical health issues, as people with mental health problems, particularly severe mental illness, are at increased risk of a number of physical health problems. 335

Included under terms of UK Non-commercial Government License .

  • Cite this Page Peckham S, Falconer J, Gillam S, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.29.) Chapter 5, Health improvement activities undertaken in general practice and primary care.
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Activity-Based Costing: Healthcare’s Secret to Doing More with Less

Health Catalyst Editors

Article Summary

Delivering high-quality, cost-efficient care to specific patient populations within a service line is nearly impossible without a sophisticated costing methodology. Activity-based costing (ABC) provides a nuanced, comprehensive view of cost throughout a patient’s journey and reveals the “true cost” of care—the real cost for each product and service based on its actual consumption—which traditional costing systems don’t provide.

With the true cost of care at their fingertips, healthcare leaders can identify at-risk populations earlier—such as pregnant women diagnosed with gestational diabetes mellitus—and more quickly implement effective interventions (e.g., more scrupulous monitoring and earlier screenings). Health systems that leverage the actionable insight from ABC further benefit by implementing the same, or similar, process/clinical improvement measures across other service lines.

Health Catalyst® Introduces Closed-Loop Analytics™ Services

Tarah Neujahr Bryan

This report is based on a 2018 Healthcare Analytics Summit presentation given by Paula Lounder, Director, UPMC Corporate Finance, Women’s Health Service Line Finance Lead; Hyagriv Simhan, MD, MS, Executive Vice Chair, Obstetrical Services, UPMC; and Beth Quinn, MSN, RNC-MNN, Program Director, Women’s Health Services, UPMC: “Integrating Clinical Improvement and Activity-Based Costing Identifies Pathway to Healthier Moms and Babies.”

With gestational diabetes mellitus (GDM) affecting up to  10 percent  of pregnancies in the U.S. every year, health systems have a vested interest in identifying women at risk for the condition as early as possible. GDM—hyperglycemia, or high blood sugar, during pregnancy—not only affects a large population but also increases cost for organizations and compromises care for not one but two patients, the mother and the baby. Furthermore, the mother’s high blood sugar affects the baby’s, exposing newborns to risks including overgrowth, trauma due to large size at delivery, metabolic consequences, hypoglycemia, jaundice, and increased chance of cesarean section delivery.

For healthcare organizations today—whether for-profit or not-for-profit, in an urban or rural area—the biggest challenges in delivering quality healthcare are sustainability and cost. Because GDM affects two patients, doubling health risks and cost, GDM is potentially a significant opportunity area for improvement. And, with mounting pressure to deliver better care with fewer resources, health systems face a larger threat that is often overlooked in the journey to meet these new standards of care: inaccurate, siloed data. Comprehensive, actionable data—derived through an activity-based costing (ABC) system—improves healthcare delivery by laying the foundation for long-lasting clinical and administrative improvement.

Activity-Based Costing in Healthcare Unleashes Actionable Data to Improves Outcomes

Rather than rely on traditional, outdated costing systems, healthcare organizations can leverage data to improve healthcare delivery with ABC solutions, a costing methodology that assigns a cost to each product and service based on its actual consumption. With ABC applied to a specific service line (e.g., maternal-fetal medicine [MFM], more commonly known as care for high-risk pregnancy), service line leaders and providers can identify a patient’s risk for certain conditions earlier, improve patient outcomes, and decrease cost overtime.

Although improving clinical care processes might seem like an obvious focus for improving GDM, insight from ABC spurs the real change. This sophisticated costing approach allows service lines, such as MFM, to understand the nuances of cost across every activity within a high-risk pregnancy and effectively manage these costs at a granular level, versus the limited traditional cost accounting approach that provides only siloed data at a high level.

A Collaborative Approach Lays the Groundwork for Activity-Based Costing Success

Proper implementation and process changes are critical for success in an advanced ABC landscape; however, the importance of collaboration cannot be overstated. In a collaborative approach, multidisciplinary leadership works with stakeholders from not only the clinical arena but also operations, finance, and information technology; each team brings a different perspective from their unique discipline. In some cases, organizations may need to restructure teams or create new ones to foster an environment for successful ABC (particularly if current team structure is based on antiquated costing systems).

For example, when the  University of Pittsburgh Medical Center  (UPMC) decided to leverage ABC in its GDM improvement efforts, the health system built a new team around ABC. The organization’s MFM leadership created a multidisciplinary team that leveraged the actionable analytics from the new costing system to create a reliable process map (Figure 1), including sustainable solutions.

Data-derived improvements included how to engage frontline staff earlier, identify institutional champions, and communicate process changes to avoid duplicate work. The diversity of thinking and collaborative efforts, based on accurate data, also empowered UPMC to achieve standardization and consistency in its MFM department and across its system of 30-plus academic, community, and specialty hospitals.

Activity-Based Costing—the Bedrock for Effective Service-Line Management

A service-line management approach combined with an ABC system give organizations easy access to integrated clinical and financial information for specific patient populations, allowing clinicians to immediately and more easily identify populations at risk (e.g., expectant mothers with GDM) and define appropriate interventions.

Ideally, OBGYNs would identify risks for and signs of GDM early and immediately refer patients to MFM providers for diagnosis and management. Effective management would include reliable postpartum follow-up with a six-week checkup and a diabetes screening to prevent Type 2 diabetes.

However, early identification and intervention is only possible when health systems understand the complete picture of cost across the continuum of care for a patient. The ABC approach combines data from disparate sources, fostering better communication between the clinical, financial, quality, and IT teams and giving all sides an accurate, comprehensive view of cost for specific services and episodes of care within the service line. With ABC methodology, health systems see the “true cost” of care at the patient level—insight traditional costing systems can’t provide.

ABC generates the true cost, or actual cost, of GDM by allowing for every contact the patient has at the healthcare organization throughout her pregnancy and after delivery. This true cost includes primary costs (e.g., administrative costs and provider costs) and the cost of secondary support systems that are often unaccounted for.

In the case study at UMPC, ABC allowed the health system to capture each aspect of a woman’s nine-month prenatal care experience, including regular OBGYN visits, ultrasounds, lab work, delivery, post-delivery inpatient stay, care for the new patient (the newborn), any testing during the inpatient stay, and postpartum care.

By revealing quality data at the patient level, ABC helps organizations generate patient lists by physician, facility, procedure, or diagnosis. ABC also allows all teams across the system to easily sift through large amounts of actionable data and present findings much faster than with traditional costing. Improvement teams can write queries to automatically identify at-risk populations, eliminate waste and costly inefficient processes, and immediately intervene for at-risk women.

Aligning Cost and Quality Means Specialized Care Reaches Patient Subgroups

Aligning cost and quality through ABC allows health systems to target specific patient populations and thoroughly review subpopulations of larger groups to create more targeted preventive interventions.

The new cost data empowered UPMC to tailor care to the subpopulations within the MFM group, rather than delivering the same care to all women experiencing a high-risk pregnancy. For example, the data revealed that women within the MFM group who experienced two or more conditions—aside from being high risk—incurred nearly a quarter of all GDM expenses. With that data, UPMC implemented a different set of care standards that addressed the other health conditions earlier and watched them more closely throughout the pregnancy. UPMC also implemented other interventions in its diagnostic and screening processes, based on this new insight, that clearly defined best practices when caring for a high-risk pregnancy.

By merging cost and quality data, ABC revealed the following areas UPMC had not previously targeted because the old costing system didn’t identify them as opportunities:

  • Out of all the babies born to mothers with GDM, 48 percent had neonatal outcomes and incurred 54 percent of episode expenses.
  • On average, GDM pregnancy episodes at UPMC were more costly by approximately $4,000 per patient and a cesarean section more costly by $12,000 more per patient.

Executive Leadership Support Proves Crucial for Activity-Based Costing Impact

Gaining executive sponsorship and clinician engagement is also imperative in creating a new pathway to ABC success. When leaders, both clinical and non-clinical, understand the benefits of the sophisticated ABC approach—as it reveals supply and labor costs, assigns cost to multiple activities within a department, and uses a fluid cost mechanism—they can mold the cost strategy and its features to fit the health system’s unique needs.

Once the ABC foundation is laid, the team leading the change must collaborate and create an environment in which a flexible, iterative approach—based on reliable, actionable data from the new ABC model—can be successful. With buy-in at the executive level and clinical champions on the forefront, team leads are empowered to deviate from the standard course and roll out practices to support the new strategy. Leadership must also ensure the continued merging of finance, quality, and operations data and fight the urge to fall into old patterns that might feel easy and more familiar.

At UPMC, the support and positivity of its leadership team led to more effective results. As the team fine-tuned their approach to treat women with GDM, they were careful to make sure the new processes were sustainable and scalable across other service lines throughout the system.

ABC Approach Scales Other Service Lines—Leads to High-Quality, Cost-Efficient Care

As organizations implement the ABC approach and see reduced costs and improved clinical outcomes, they have tremendous opportunity to spread the wealth. Relying on ABC to understand data across an entire service line, such as MFM, allows leadership to take advantage of economies-of-scale cost savings by implementing similar changes for other service lines.

For example, leaders can roll out the same, or a similar, standardized education plan they used within one service to all providers and hospital administration serving the OB population. Leadership can also scale new interventions, based on the ABC data, across other service lines, including best-practice alerts within the EHR, standardized education plans across other hospitals and clinics, and  process improvements  to ensure consistency and a seamless experience for patients and their families.

ABC Improves Neonatal Outcomes, Decreases Cost

UPMC’s improved neonatal outcomes and better practices for high-risk pregnant patients were due to many factors (leadership support, collaborative environment, etc.), but, by offering cost insight at a detailed level, the ABC approach, combined with leadership support, was the perfect recipe for success within the high-risk pregnancy population, and now other service lines. The GDM initiative illustrated the value of tying detailed cost data closely to a clinical improvement project, engaging stakeholders early for assistance with multiple levels of intervention, and identifying other areas in which to repurpose these new principles.

Clinical solutions can seem straightforward and even easy to apply, but the reality of delivering better care while utilizing fewer resources is nuanced and complex, requiring a range of experts throughout the brainstorming and problem-solving phase—but only after ABC methodology is in place. With the power that comes from easy-to-access, reliable data at a granular level, healthcare organizations can leverage data through ABC to prioritize problem areas, eliminate waste, and make a plan that tackles all touchpoints of the pregnancy journey, leading to decreased costs and improved outcomes for mothers and their newborns.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

  • Activity-Based Costing and Clinical Service Lines Team Up to Improve Financial and Clinical Outcomes
  • UPMC and Health Catalyst Honored as Recipients of the 2018 Microsoft Health Innovation Award
  • Value-Based Purchasing: Four Need-to-Know Domains for 2018

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Health Care

What’s Your Role?

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As a person working in health care, you can help your patients, employees, and community access the immediate and long-term benefits of physical activity.

Most US adults report visiting a health care professional at least once during the year. These encounters give health care organizations and professionals a unique opportunity to promote physical activity with their patients.

Health care professionals can assess and advise patients on the many benefits of physical activity, how much physical activity they need to receive health benefits, and how to do it safely. They can also help connect their patients to community-based physical activity programs and resources.

As employers, health care systems can provide their employees with individual and social supports for physical activity.

Health care systems may also be anchor institutions: governmental or nonprofit entities with a significant and stable presence. Their influence in the community can facilitate partnerships with other anchor institutions (e.g., universities, financial institutions, faith-based organizations, and arts and culture organizations) and with other sectors (e.g., public health, transportation , land use and community design , and parks, recreation, and greenspaces ). These partnerships can improve community design by creating safe and equitable access to places for walking, biking, and other forms of physical activity for their patients, employees, and other community residents.

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Tax-exempt hospitals can fulfill their Internal Revenue Service obligation to provide community benefit through activities such as coalition building, leadership development, and neighborhood revitalization. They can also meet the requirement by supporting policies and programs related to public health, housing, and transportation to increase physical activity. In addition to delivering community benefit, these investments can improve the health, quality of life, and overall prosperity of communities.

You can use the following strategies to encourage physical activity with your patients and in your community:

Educate people about the benefits of physical activity and implement or refer your patients to resources that can help them increase their activity levels:

  • Establish physical activity as a key health indicator tracked by health systems and electronic health records.
  • Offer physical activity counseling to patients who need it (e.g., those at risk for cardiovascular disease).
  • National Diabetes Prevention Program .
  • Walk with Ease and other lifestyle management programs  for arthritis.
  • Park prescriptions .

Active People, Healthy Nation SM has many strategies that work . Visit the website to find options that fit your needs. Look for ways to collaborate with other sectors.

Promote the design of community spaces that support safe and easy access for everyone to be physically active , regardless of age, income, ability, or race and ethnicity.

  • Create or join cross-sectoral partnerships to help improve community designs and ensure that development decisions benefit residents equitably.
  • Support safe, efficient, and easy-to-use public transit systems and equitable transit-oriented development.
  • Support transportation policies and plans to create safe streets, sidewalks, and crosswalks that encourage physical activity.
  • Support community planning, land use, development, and zoning policies and plans that encourage walking and other forms of physical activity. One example is building affordable housing close other essential destinations such as jobs and health care.

Educate health professionals on how to promote walking, walkability, and other forms of physical activity.

  • Include information on physical activity and behavioral counseling in training, continuing education, and accreditation processes for health care professionals.
  • Tell health professionals about community social support programs for physical activity, such as Walk with a Doc.

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These health care organizations and professionals are using effective strategies to increase physical activity in their communities.

Healthy by Design Coalition in Montana The Healthy by Design Coalition, a group sponsored by three health care providers in Yellowstone County, is working across sectors to improve physical activity, nutrition, and healthy weight. They were strong supporters of a Complete Street policy for the city of Billings, which was passed by the City Council in 2011. The group continues to focus on ways to promote active transportation in their community, such as supporting their clinics to become bicycle-friendly.

Trail Prescriptions in Pennsylvania Hospitals in the Philadelphia region encourage physical activity through organized trail walks. Physicians can prescribe a trail to patients and lead walks on trails in the area. During the walk, physicians and other health educators offer brief presentations and answer questions about health topics such as nutrition and sleep. Participants also get social support from fellow walkers.

Walkable Health and Wellness District Development in Connecticut [PDF-4.63MB] A partnership between Stamford Hospital and the Stamford Housing Authority led to the development of a wellness district. What started as a land swap to help expand the hospital and create new housing turned into a lasting collaboration. After a community health needs assessment found the greatest needs in areas right next to the hospital campus, Stamford formed a coalition with 12 local youth, health, education, and human services organizations. Their collaboration has helped increase walkability, community safety, and access to health care and healthy food.

  • Creating Effective Hospital-Community Partnerships to Build a Culture of Health [PDF-1.58MB] This guide describes how hospitals and health care systems can create effective community partnerships, align efforts with other organizations, and optimize financial resources to help increase community health and well-being.
  • Health Care Providers’ Action Guide [PDF-781KB] This is a guide for doctors and other health care providers on how to best “prescribe” physical activity to patients to help them prevent, treat, and manage chronic health conditions. Screening guides and patient handouts are included.
  • National Physical Activity Plan: Healthcare Sector [PDF-9.39MB] The  National Physical Activity Plan  provides policy and programmatic recommendations to increase physical activity. It includes strategies and tactics that communities, organizations, and individuals in the healthcare sector can use to support physically active lifestyles.
  • Park Prescription Program Toolkit This interactive, step-by-step guide is for agencies, health professionals, or communities interested in starting their own Park Prescription program. Sample meeting agendas, worksheets, training videos, case examples, and promotional resources are included.
  • The Challenge of Reimbursement-Coding and Billing Tips [PDF-64KB] This resource includes tips and lists of ICD10 and CPT codes for health care professionals to use when assessing, prescribing, and counseling patients about physical activity during office visits.
  • Walk with a Doc Tools This website has a portal with tools and resources for doctors to start their own Walk with a Doc program and for community members to find or start a program. During a typical walk, doctors give a brief presentation on a health topic and then lead participants on a walk at their own pace to facilitate discussion. The website includes information on marketing, health topics, and resources provided by “headquarters,” including a starter kit and liability insurance.

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50 self-care ideas for when you need a mood boost

Feeling anxious? Overwhelmed? Tired? Wired? You’re not alone. In fact, federal data analyzed by the Kaiser Family Foundation showed that 32.3% of all adults reported symptoms of anxiety and/or depressive disorder as of February 2023.

The last few years have been an uphill climb for many of us, and this new level of stress doesn’t show signs of stopping. If you’re feeling a lot more stressed these days and burning the candle at both ends is the new normal, it’s time to make some changes.

Enter: self-care. It’s a buzzword term you’ve likely heard in recent years, but what is it exactly? And does it really help in the grand scheme of things?

“Self-care is the different ways we take care of ourselves that lead to increased well-being, and health — physically, emotionally and spiritually,” Hope Weiss, LCSW , tells TODAY.com. And keep in mind that while self-care is incredibly important for those who have been diagnosed with anxiety and depression , it’s something that can benefit everyone, whether you’re struggling with a specific condition or not.

Dr. Shaakira Haywood Stewart, PhD, CEO of Dr. Shaakira Haywood Stewart Psychology, P.C. , stresses that self-care is an active practice. “There’s no ‘self-care goal’ to be reached,” she says of the opportunity to elevate your emotional, spiritual, physical and mental wellbeing. “It’s a constant journey that accompanies you throughout life and allows you to handle the stress that life is bound to give you,” adds Dr. Haywood Stewart.

Practicing self-care regularly helps us be more resilient. “It provides a strong foundation so that we are not knocked down as easily by the stresses, challenges and experiences that we have in life,” Weiss says.

That’s why it’s key to establish a daily routine that emphasizes self-care so that when challenges inevitably pop up, you’ll feel even more capable to take them on. Self-care is “something that we build into our lives so that it becomes a routine — just like brushing our teeth,” Weiss says.

If you’re looking for some inspiration to be kinder to yourself and embrace TLC for your wonderful, glorious self, here are 50 self-care ideas that can lift your mood and make you feel better — mind, body and soul.

Care for houseplants

If you find yourself in a cheery mood when you're surrounded by houseplants and all-things-green, it’s not just in your head. For example, in one study that focused on participants staying at home at the start of the pandemic, those with indoor plants reported considerably fewer symptoms of anxiety and depression. You know what that means: Outfit your home with plants to bring the outdoors in. As a bonus, you’ll feel good every time you care for each plant.

Read a book from your childhood 

Perhaps a warm and fuzzy dose of nostalgia will make you feel better. Think of a few of your favorite books from when you were little, and head to the library or your local bookstore to pick them up. Curl up in a chair with a snack of your choice and read your worries away.

Do some journaling

“Journaling restructures our self-talk, and increases our emotional intelligence, self-awareness, and communication skills,” says Dr. Haywood Stewart. You don’t even need to make a massive time commitment to the practice; simply set a five- or 10-minute timer and write until the alarm goes off.

Listen to a podcast while going on a walk

“We all know that walking is good exercise, but it also can be a moment of stress-reducing ‘me’ time, especially when coupled with a favorite audiobook, or podcast on a topic that interests you,” says Mario Palacios, MA, LMFT , a licensed marriage and family therapist. Palacios recommends the following happy podcasts to give you a self-care boost: “ The Happiness Lab with Dr. Laurie Santos ;” “‎ Happier with Gretchen Rubin ;” and “ Feeling Good ” from psychiatrist Dr. David D. Burns.

Try a eucalyptus shower mist

Frank Thewes, LCSW, of PathForwardTherapy.com says that this quick hack can get you started on the right foot every morning. The scent wakes you up and helps you start the day feeling refreshed and ready, he says. These products are readily available online; simply search for “eucalyptus spray” or “aromatherapy spray.”  

Handwrite someone a letter, just because

“This activity requires time and focus, and involves physical, tactile labor that many of us in the world of 2024 may not be used to,” says Dr. Kerry McBroome, PsyD, of Full Focus Therapy .” Expensive stationery or fountain pens may add to the experience but are not necessary; the point is to focus on letting words and sentences flow onto the page, getting them out of your head.” Bonus: You’ll brighten someone’s day on the receiving end when they receive an unexpected piece of mail.

Cook a new recipe

Dr. Caroline Fenkel, LCSW, DSW, chief clinical officer and co-founder at Charlie Health says cooking a new recipe is a wonderful form of self-care that involves mindfulness, creativity, and a tangible sense of achievement. “The act of selecting ingredients, following a step-by-step process, and savoring the final dish engages your senses, and promotes relaxation and mental well-being,” she says. “Additionally, making a delicious homemade meal and nourishing your body makes cooking a holistic and rewarding self-care practice.”

Make an after-care plan

This one from Katherine Morgan Schafler, LMHC, psychotherapist and author of The Perfectionist’s Guide to Losing Control was a new concept to us, but an excellent idea:

“When you know a future event is going to be a big deal to you, after-care plans are a way to make sure that after that event is done, you connect to something salutary,” she says. “To make an after-care plan, consider what ‘future you’ will most likely need to restore after a stressful event, even if it’s the good kind of stress (like a wedding, for example),” she elaborates, adding that big deal events can include job interviews, first dates, elections, birthday parties or a presentation. It could also be something you arrange post-travel or after the end of a particularly stressful work week.

Whatever situation calls for an after-care plan, “you might tell a friend about the event and ask them to be ‘on call’ in case you want to talk. Or you might set out an empty mug with a tea bag, comfy clothes, and a pre-selected show to watch so that when you get home, your self-care is automated,” suggests Morgan Schafler. Or, have a favorite online yoga video ready to stream upon arrival to your digs with a bubble bath on deck. 

Spend 15 minutes decluttering

Rome wasn’t built in a day; you don’t need to declutter your home in an afternoon. How about spending just 15 minutes tidying up when you need a mood lift? “When our environment is clean, free of clutter and unnecessary objects, and has the things that we enjoy or need in place, we feel better,” says Dr. Hannah Yang, PsyD, founder and licensed psychologist at Balanced Awakening . “Anything that we can do to tend to our immediate environment is a form of self-care.”

Volunteer for a meaningful cause

“Keeping perspective on our lives is essential to self-care,” says Thewes. “Take stock of your blessings and take the focus off of your own issues by devoting time to make someone else’s life a little better. A selfless task allows us to step out of our self-focused routine and come back with a fresh set of eyes.” Whether you decide to volunteer at a soup kitchen or offer to teach a sport or crafts class at a local youth center, there are countless ways to get involved with those in need throughout your community. 

Increase self-compassion

“Self-compassion is an internal way to practice self-care,” Weiss says. Start by talking with kindness, understanding and warmth, just like you would a good friend.

Over time, you'll become more in tune with your own thoughts and feelings. "You can then put a hand on your heart and say to yourself things like, ‘This is really hard for me right now,’ ‘I am dealing with a lot,’ ‘May I be happy’ or ‘May I be free from pain,’” Weiss says.

Have an at-home spa day

One classic way to practice self-care is by pampering yourself, and for good reason. If you haven’t had a free minute to yourself lately, an avocado mask, bubble bath and pedicure can feel amazing right in the comfort of your home. Not to mention you can do it all on a budget if heading to an actual spa isn’t in the cards for you right now.

Don't have enough time for a full spa day? Take a hot shower with a lavender or peppermint-scented shower steamer instead for a quick pick-me-up.

Spend time by water 

“If you are in a body of water, your internal state just becomes calm,” Dr. Natalie Azar, NBC News medical contributor, said on the 3rd Hour of TODAY.

Simply being near water can drastically improve mental health , whether it’s a walk next to a lake, looking at a creek in your backyard or even watching YouTube videos full of seaside views. Make some time in your day for an H2O boost, even if it’s just watching a two-minute video of the ocean during your lunch break.

Eat something whole and fresh 

Feeling stressed and eating every processed food in sight? No judgement from us, but your body and mind might feel a bit better if you reach for something whole and nutritious. Even if it’s an apple that you eat in between bites of cookie dough, it’s a step toward practicing good self-care.

Do this quick shoulder exercise

Dr. McBroome walks us through this simple movement: “Lift up your shoulders to your ears, tense them as tight as you can, and then release and let them drop,” she says, adding that you should repeat this motion several times. “This is an example of paired muscle relaxation, which comes from DBT [dialectical behavior therapy], a type of behavioral therapy. It is designed to be paired with your breathing, such that you inhale as your shoulders rise and exhale as they release,” adds Dr. McBroome.  

Attend to basic needs

Sometimes, it's best just to back to the basics.

“Are you taking care of your basic needs?” Weiss asks. “I see this so often get neglected when people are dealing with stress. Are you taking time to eat? If this is a challenge, perhaps set an alarm to remind yourself to get something to eat. Are you getting enough sleep? Are you drinking enough water? Are you moving your body during the day? These are all things that provide us with fuel to move through our days.”

Cuddle a pet

According to a 2020 study from the Human Animal Bond Research Institute , 74 percent of all participating pet owners said that they’ve experienced mental health improvements from having a pet. If you’re in need of a little self-care, cuddle with your cat or dog and feel the stress lift with each pat — which, by the way, is beneficial for you and your furry friend. If you don’t have a pet, volunteer at an animal shelter or pet sit for a friend.

Implement good sleep hygiene

“Make quality sleep a priority, and focus on creating good sleep hygiene, including going to bed at the same time each night, especially during the work week,” says Palacios. To obtain quality sleep, you’ll want to make some regular routines, which can be as simple as brushing your teeth and changing into pajamas, he continues, noting that “these routines signal to your brain that it’s time to wind down,” importantly.  Palacios also advises you keep electronics out of the bedroom, and make the space nice and dark.

Move your body 

Get those endorphins going with a workout, even if you don’t feel like it at first. You’ll feel better as soon as your blood starts pumping, whether you’re going for an all-out run or lifting some light weights. If you’re having a tough mental health day, know that even five minutes of marching in place can have an uplifting effect.

Take a mindful walk

Indeed, you don’t need to do a full-fledged workout to reap the benefits of mindful movement. As Dr. Haywood Stewart explains, simply walking reduces cortisol, increases endorphins, strengthens neurological connections and reduces the risk of cognitive declines and neurodegenerative diseases. “Adding a mindful aspect to the walk grounds you and brings you to the present moment, allowing your stress to decrease,” she says.

Snuggle up in a “nest”

When in doubt, put yourself in your very own “nest.” Pile on tons of blankets, wear a hooded sweatshirt and cozy up on the couch.

Throw on a weighted blanket to mimic the feeling of being hugged. "Many people like the feeling of pressure against their body and do find this pressure to be quite relaxing,” behavioral sleep psychologist Lynelle Schneeberg tells TODAY.com.

Go on a solo vacation

Even if you’re overwhelmed at the thought of traveling solo, it can be good for your spirit to get some grounding and perspective on your own. Book a “self-care vacation” to a place you’ve always wanted to go. While there, spend some time in nature, make a couple spa appointments and bring a journal along to get your thoughts down on paper.

Take time off from social media 

Social media can, at times, be a real drain on one’s mental health, especially when you’re comparing your life to others, reading negative comments or getting involved in less-than-nice political debates. Commit to one week or month off from social media when you really need a break. Or practice social media self-care by controlling the types of posts you see, muting certain people or stepping away from scrolling for prolonged periods of time.

Have a movie marathon 

Thank goodness for Netflix and Hulu, right? Hunker down for an evening of self-care with a couple of your favorite movies, ones that make you feel good right down to your toes. Don’t forget the weighted blankets and comfort snacks, too.

Listen to records 

While music is certainly therapeutic in general, there’s something about listening to records that can make you lose all sense of time in the best way possible. Take yourself back to another era (or imagine what it was like to live during that time) by playing some old-school albums, with the sounds of pops and crackles for extra ambiance.

Sip a hot beverage as slowly as you can

“This self-care skill is rooted in mindfulness, in that it requires intentional focus on the taste of the beverage or the warm feel of the mug,” says Dr. McBroome. “If you feel yourself getting pulled into distracting thoughts, forgive your tired brain and try to come back to the taste and the feel.” Extra brownie points if you savor a cup of tea, which has many health benefits . 

Book time with a therapist

Therapy is absolutely a form of self-care, whether you’ve already been diagnosed with a mental health condition or simply need some extra support these days. Ask for recommendations from friends, receive a referral from your primary care doctor, or turn to virtual therapy if staying at home rather than going out is your form of self-care. 

Set boundaries

Setting boundaries, even with those you love most, is an underrated form of self-care. Saying “yes” to too many things might make you feel like a superhero who’s come to save the day, but you’ll be stretched thin before you know it. Practice saying “no” in a way that feels kind and right to you to make sure you have plenty of time for self-care in your schedule.

Luxuriate in a “Sunday bumday”

“Ever heard of ‘Sunday funday?’ Try having a ‘Sunday bumday’ where you plan to do nothing,” says Dr. Courtney Conley, Ed.D, NCC, LCPC-S (Licensed Clinical Professional Counselor- Supervisor), founder and therapist for Expanding Horizons Counseling and Wellness . On days that you designate as such, Conley says to try things like watching as much TV as you want, eating quick and easy foods and taking the pressure off yourself as much as possible. “If Sunday doesn’t work for your schedule, then choose another day or evening,” she says.

Put on your warmest socks and stretch your hamstrings

Because why not take a break for your hammies? “Sitting bent over a desk or hunched over a phone can make these muscles in our legs tighten over time. Stretching them out again is self-care in the most direct, physical sense,” says Dr. McBroome. “Bend at the waist and reach towards your toes. Feel the floor underneath your feet, feel the comfortable fabric of your clothing, and focus on the sensation of these muscles as you move.”

Call in the troops

Sometimes, we’re tempted to keep our emotions and needs bottled up to ourselves, even when we could use a listening ear or assistance from others. “It’s OK and beneficial to ask for help and support. Take a look at the tasks and daily things that need to be completed. How can these be divided up? Who can help you? We often feel bad asking for help,” states Conley. “We don’t want to inconvenience those around us. However, I think it’s a beautiful gift if I can step in and support a friend or family member so they can get a restorative moment for themselves.” You can also think beyond people in your circle, says Conley, and see what you can outsource, such as laundry or cleaning services or meal kits.  

Learn something new

“As humans, we all enjoy learning and growing, as long as it’s an area of interest. One of the biggest things that nourishes us is growth,” offers Dr. Yang. “So spend some time on an adult learning platform like Mindvalley . Or read a few pages of a book on a topic you’re interested in that helps to expand your mind.” You could also search a skill you’re curious to pick up on YouTube and watch a tutorial or two. 

Turn on some music and dance

You don’t need to be a talented dancer, you just have to be open to having fun and being a little silly. “Dancing can quickly shift us into a more joyful state,” says Dr. Yang. “You can even use headphones for the music if you don’t want to disturb anyone,” she continues, noting that five minutes of moving and grooving can drastically shift your mood.

Book a massage

This doesn’t need to be a once-a-year on vacation thing; if your budget allows, massages are something you can incorporate into your regular routine every few weeks. “Take 60–90 minutes and get the tension and stress worked out of your body,” with a therapeutic massage, suggests Thewes. “Many of us store emotional tension in our bodies, and massage can be a great way to reset that,” he elaborates, noting that it’s a good idea to consider making a professional massage a monthly ritual.

Phone a friend 

Even if you’re not a chatty person, you might be surprised by the boost you get from catching up with a loved one for 20 minutes or so on the phone. “Connecting with friends and family is a wonderful way to prioritize self-care and enhance your well-being,” she says. Better yet, pair that phone call with a walk outside so you can get some fresh air and movement into your day.  

Take your shoes off and step on the grass or sand

“This is called earthing,” explains Dr. Yang, sharing that our bodies can benefit from having that direct connection with the earth. “If you live in a warm climate where this is possible, give it a try,” she says. Plus, it gets you outside, which is always a good thing for your state of mind.

Play in the snow

Too cold in your area to go earthing? If you’ve got snow near you, try this similar exercise and head outdoors to frolic in the snow. “Build a snowman. Play with childlike wonder,” Dr. Yang says. “See if you can identify individual snowflakes. Make a snowball and throw it against a building,” says Dr.Yang of engaging with nature in this playful way.

Lose track of time

“Have you ever had an experience where you don’t know where the time went?” Weiss says. “A wonderful way to provide self-care is to participate in an activity where you get so focused that you lose track of the time."

Of course, this differs from person to person, but Weiss recommends "being out in nature or doing some kind of creative pursuit, such as art, baking or writing."

"These activities often feel bigger than ourselves. They fuel us and can help us feel both peaceful and inspired," she adds.

Wear your coziest outfit

Even if you’re going out, devise a way to put together the coziest outfit possible so you can feel good from top to bottom. Wear jeans that feel like velvety leggings, rock your softest oversized sweater and put on flats, preferably ones with cushioned lining. Or if you’re staying at home, spend the day in your favorite sweats and don’t feel bad about it — even if you're expecting guests.

Study after study shows that meditation has been proven to do wonders for mental health . The good news: You don’t have to be the Dalai Lama to harness its benefits.

Have a meditative self-care session with a meditation app, practice some yoga, or simply sit quietly in a room and take in everything around you, noting the sights, sounds and smells to help you live in the moment.

Practice 4-5-4 breathing

Meditation is wonderful, but even a quick breathing exercise can work wonders for how you feel. Palacios recommends this 4-5-4 breathing technique: “Breathe in through your nose to a count of four; hold for a count of five; breathe out for four counts through your mouth,” he says. “It’s a proven stress-reducer and a relaxing break you can do anywhere, anytime.”

If all else fails? Close the curtains and take a nap. Whether it’s 15 minutes or a couple hours, don’t feel guilty for attending to your needs when your body is telling you to rest. In fact, never feel guilty for any type of self-care activity. The world can wait, but your well-being can’t.

Take a mental health day

From time to time, you deserve a break from it all — and it’s okay to give yourself one. “So many people don’t hesitate to take a sick day off from work when they are physically ill, but it’s often more difficult to take a mental health day when you aren’t feeling well mentally,” says Tatiana Garcia, LPC, a licensed professional counselor and coach behind Be Calm With Tati . “Even if it’s only a half-day or an hour, taking time for yourself when you are feeling down, anxious, or overwhelmed, can help you recharge and de-stress, so you will feel better able to tackle the work on your plate when you return.”

Create a vision board 

“Craft a visual representation of your goals, dreams, or even your perfect relaxation plan,” says Jennifer Gray, LPC, Jennifer Gray Counseling , founder of Therapy for Entrepreneurs. “It’s a motivating and inspiring way to focus on yourself.” Here’s how to make a vision board and help bring your dreams to life .

Go stargazing

“Spend time gazing at the stars for a peaceful, awe-inspiring experience. It’s a simple way to connect with the universe, nature, and the world around you,” says Gray. “Use a stargazing app to identify constellations and planets,” adds Gray, and you can also check out astrophysicist Neil deGrasse Tyson’s tips on how to stargaze for more ideas .

Indulge in a solo “photowalk”

What’s this, you ask? Exactly what it sounds like: “Take a walk with the intent to capture interesting sights and moments that stimulate your joy. It’s a creative exercise in mindfulness, observation, and learning more about what strikes your heart,” says Gray, who advises choosing a different theme for each walk, like capturing emotions or nature, to keep it engaging.

Play an instrument

Thewes advises grabbing that guitar, piano, or any instrument you prefer out of storage and getting to playing. “Take a lesson online or in person, because playing a musical instrument can get us into a mindful space and help to reduce stress and channel out negative emotions,” he says. 

Do something crafty

It’s time to get crafting, ladies and gents. Fenkel says that crafting is a great way to get in touch with your inner child, and we agree. “Whether it be drawing, painting or collaging, getting creative is a wonderful way to treat your mind well,” she says. Fenkel emphasizes the importance of crafting for the process, not the product — “it doesn’t matter if your final product isn’t beautiful, as long as you have fun creating it,” she says. 

Explore your city like a tourist

“Rediscover your city by visiting new places, eating at lesser-known restaurants, or viewing familiar spots with fresh eyes,” offers Gray of having “an adventure close to home.” Whatever you decide to do, Gray says to act like a true tourist by taking photos, visiting major landmarks, and asking for recommendations from the “locals.”

Treat yourself like royalty

“Prepare something special for yourself,” says Conley. “Create a dessert or charcuterie board and use your best dinner and stemware. These small, simple acts of kindness towards yourself signify just how special and worthy you are.” To make it a routine, pick a time every week when you do one tiny, thoughtful act for yourself, whether it’s buying yourself fresh flowers or drawing a hot bath.

Put yourself first, always

  • How to love yourself to the core, according to experts
  • Stressed? This 7-step plan will help you respond better
  • How to manage work stress and burnout

Shelby Deering is a freelance lifestyle writer living in Madison, Wisconsin. She specializes in writing about home design and decor, wellness and mental health, and other lifestyle topics, contributing to national publications like Good Housekeeping, AARP The Magazine, USA Today, and more. When she’s not writing, you can find her shopping flea markets and exploring local trails with her husband and corgi, Dolly.

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Perri is a New York City-born-and-based writer. She holds a B.A. in psychology from Columbia University and is also a culinary school graduate of the Natural Gourmet Institute. She's probably seen Dave Matthews Band in your hometown, and she'll never turn down a bloody mary. Follow her on Twitter  @66PerriStreet  or learn more at  VeganWhenSober.com

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Healthcare in Moscow – Personal and Family Medicine

Emergency : 112 or 103

Obstetric & gynecologic : +7 495 620-41-70

About medical services in Moscow

Moscow polyclinic

Moscow polyclinic

Emergency medical care is provided free to all foreign nationals in case of life-threatening conditions that require immediate medical treatment. You will be given first aid and emergency surgery when necessary in all public health care facilities. Any further treatment will be free only to people with a Compulsory Medical Insurance, or you will need to pay for medical services. Public health care is provided in federal and local care facilities. These include 1. Urban polyclinics with specialists in different areas that offer general medical care. 2. Ambulatory and hospitals that provide a full range of services, including emergency care. 3. Emergency stations opened 24 hours a day, can be visited in a case of a non-life-threatening injury. It is often hard to find English-speaking staff in state facilities, except the largest city hospitals, so you will need a Russian-speaking interpreter to accompany your visit to a free doctor or hospital. If medical assistance is required, the insurance company should be contacted before visiting a medical facility for treatment, except emergency cases. Make sure that you have enough money to pay any necessary fees that may be charged.

Insurance in Russia


Travelers need to arrange private travel insurance before the journey. You would need the insurance when applying for the Russian visa. If you arrange the insurance outside Russia, it is important to make sure the insurer is licensed in Russia. Only licensed companies may be accepted under Russian law. Holders of a temporary residence permit or permanent residence permit (valid for three and five years respectively) should apply for «Compulsory Medical Policy». It covers state healthcare only. An employer usually deals with this. The issued health card is shown whenever medical attention is required. Compulsory Medical Policyholders can get basic health care, such as emergencies, consultations with doctors, necessary scans and tests free. For more complex healthcare every person (both Russian and foreign nationals) must pay extra, or take out additional medical insurance. Clearly, you will have to be prepared to wait in a queue to see a specialist in a public health care facility (Compulsory Medical Policyholders can set an appointment using EMIAS site or ATM). In case you are a UK citizen, free, limited medical treatment in state hospitals will be provided as a part of a reciprocal agreement between Russia and UK.

Some of the major Russian insurance companies are:

Ingosstrakh , Allianz , Reso , Sogaz , AlfaStrakhovanie . We recommend to avoid  Rosgosstrakh company due to high volume of denials.

Moscow pharmacies

A.v.e pharmacy in Moscow

A.v.e pharmacy in Moscow

Pharmacies can be found in many places around the city, many of them work 24 hours a day. Pharmaceutical kiosks operate in almost every big supermarket. However, only few have English-speaking staff, so it is advised that you know the generic (chemical) name of the medicines you think you are going to need. Many medications can be purchased here over the counter that would only be available by prescription in your home country.

Dental care in Moscow

Dentamix clinic in Moscow

Dentamix clinic in Moscow

Dental care is usually paid separately by both Russian and expatriate patients, and fees are often quite high. Dentists are well trained and educated. In most places, dental care is available 24 hours a day.

Moscow clinics

«OAO Medicina» clinic

«OAO Medicina» clinic

It is standard practice for expats to visit private clinics and hospitals for check-ups, routine health care, and dental care, and only use public services in case of an emergency. Insurance companies can usually provide details of clinics and hospitals in the area speak English (or the language required) and would be the best to use. Investigate whether there are any emergency services or numbers, or any requirements to register with them. Providing copies of medical records is also advised.

Moscow hosts some Western medical clinics that can look after all of your family’s health needs. While most Russian state hospitals are not up to Western standards, Russian doctors are very good.

Some of the main Moscow private medical clinics are:

American Medical Center, European Medical Center , Intermed Center American Clinic ,  Medsi , Atlas Medical Center , OAO Medicina .

Several Russian hospitals in Moscow have special arrangements with GlavUPDK (foreign diplomatic corps administration in Moscow) and accept foreigners for checkups and treatments at more moderate prices that the Western medical clinics.

Medical emergency in Moscow

Moscow ambulance vehicle

Moscow ambulance vehicle

In a case of a medical emergency, dial 112 and ask for the ambulance service (skoraya pomoshch). Staff on these lines most certainly will speak English, still it is always better to ask a Russian speaker to explain the problem and the exact location.

Ambulances come with a doctor and, depending on the case, immediate first aid treatment may be provided. If necessary, the patient is taken to the nearest emergency room or hospital, or to a private hospital if the holder’s insurance policy requires it.

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Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery

Clinical data science.

Researchers in the Mayo Clinic Kern Center for the Science of Health Care Delivery's Clinical Data Science Program have expertise in a wide range of mathematical, statistical and machine learning methodologies. They lead the development and integration of solutions based in artificial intelligence (AI) and machine learning. Such solutions are a hallmark of the center's unique, practice-transforming work. The Clinical Data Science Program develops and guides the infrastructure needed for fast, efficient integration of data and information technology-based tools.

Focus areas

The center's Clinical Data Science Program is focused on:

  • Developing, implementing, and evaluating AI and machine-learning models for clinical applications.
  • Implementing AI algorithms into practice workflows.
  • Bayesian modeling for complex problems.
  • Designing evaluations for testing the effect of AI -based tools in practice.

These are some examples of research projects carried out by the Clinical Data Science Program.

COVID-19 and influenza-like illness modeling

From the earliest days of the coronavirus disease 2019 (COVID-19) pandemic, the center's clinical data scientists focused on identifying the best data sources while advising Mayo Clinic's internal data collection processes. They built new models and updated them daily. These models considered the rapidly evolving knowledge surrounding the SARS-CoV-2 virus' behavior as well as clinical observations describing COVID-19 infections.

In support of local, regional and state pandemic responses, the team developed a Bayesian Susceptible-Exposed-Infected-Recovered (SEIR) model. This model can predict COVID-19 cases and hospitalizations across the country. The program team worked with and made the model available to internal and external collaborators.

Related work led to a hospital census prediction model. The team later expanded this model to encompass numerous patient services across Mayo Clinic's hospitals and clinics in Arizona, Florida, Minnesota and Wisconsin. The expanded model can adapt to constantly changing infectious disease dynamics and uncertainties in human behavior. Furthermore, it can predict the effects of emergent therapies or vaccines based on possible levels of adoption or observed uptake.

In 2023, the focus of this work shifted to a more general influenza-like illness model. This allows researchers to account for other respiratory illnesses, such as influenza and respiratory syncytial virus (RSV). Program researchers translated many of the lessons learned and solutions developed from 2020 to 2022 into a robust framework for a wider reaching predictive model. This new model can predict infection activity level, patient census and staff absences due to any influenza-like infections.

Related publications:

  • A panel evaluation of the changes in the general public's social-media-following of United States' public health departments during COVID-19 pandemic.
  • Analytics and prediction modeling during the COVID-19 pandemic.
  • Deployment of an interdisciplinary predictive analytics task force to inform hospital operational decision-making during the COVID-19 pandemic.
  • Practical development and operationalization of a 12-hour hospital census prediction algorithm.
  • Quantifying the importance of COVID-19 vaccination to our future outlook.

Remote patient monitoring

Mayo Clinic studies new and unique ways to reliably deliver high-quality care and medical knowledge to people wherever they are. The Clinical Data Science Program leads in working AI into solutions that help clinicians personalize that care.

One example of this work is a pragmatic clinical trial evaluating clinical decision aids that use AI . The trial tests the decision aids' usability, clinical usefulness and effectiveness to help enroll patients in real-world remote monitoring programs after they leave the hospital.

The study team's findings will guide final improvements to the function and delivery of these models. This work will provide the critical groundwork necessary to introduce the aids across Mayo Clinic. The team's findings also will benefit people everywhere through peer-reviewed publication and knowledge dissemination.

Complex patient identification algorithm

Program researchers, with collaborators at and outside Mayo Clinic, are developing an algorithm based on health insurance administrative claim data. This algorithm will identify patients with complex disease who may need to see a specialized healthcare team at a tertiary medical center. The team plans to use the tool primarily to support the care of patients with complex and serious conditions.

Sometimes these patients "churn," or move around the healthcare system, in care patterns that are less than ideal. Ideally, the algorithm will improve continuity of care, reduce the time to develop correct diagnoses and treatment plans, and improve both experiences and outcomes for patients.

Control Tower: Innovation framework for patient care support

The Control Tower project provides a support tool for healthcare professionals in the inpatient setting. It is a framework that is built on Mayo Clinic's unified data platform and combines engineering, design, knowledge management and analytics abilities. This framework provides the elements needed to build both a physical interface and the AI to power proposed solutions.

The first proof-of-concept case for the innovation framework was developed and tested by researchers from the Mayo Clinic Kern Center for the Science of Health Care Delivery and Mayo's Center for Palliative Medicine. Researchers used machine learning techniques to develop a new and unique risk score, a real-time dashboard and alerts.

This tool predicts the potential need for a patient to receive palliative care support, allowing palliative care specialists to proactively offer recommendations. The tool has decreased the time for specialists to provide patients with palliative care consultations by more than 40%. Using the tool has reduced 60-day readmissions by more than 25%.

  • Effect of an artificial intelligence decision support tool on palliative care referral in hospitalized patients: A randomized clinical trial.
  • Impact of a machine learning algorithm on time to palliative care in a primary care population: Protocol for a stepped-wedge pragmatic randomized trial.
  • Randomized trial of a novel artificial intelligence/machine learning model to predict the need for specialty palliative care.
  • Targeted therapy: Improving the delivery of palliative care through artificial intelligence/machine learning models.
  • Use of machine learning algorithm to identify patients in need of palliative care in a primary care population: A pilot study (RP502).

Curt B. Storlie, Ph.D.

  • Robert D. and Patricia E. Kern Scientific Director for Clinical Data Science
  • Email: [email protected]

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Activities for Caregivers of Older Adults

Brooke Phillips, CWCMS

While routines and schedules are beneficial for both caregivers and seniors, fresh activities can bring new life to your time spent together. There are plenty of crafts, food activities, and games that can be modified to accomodate people of all abilities. Activities such as game play stimulate the mind in beneficial ways. Game play brings a wide range of benefits, including boosting memory and concentration, improving mental health, nurturing creativity, and relieving stress. Most games can easily be modified to suit the physical and cognitive abilities of the people playing.

Many older adults lose the ability to engage in activities they once loved. If you aren’t already familiar, take some time to explore what the seniors in your life loved to do when they were younger. While some experiences may be difficult to recreate, with imagination and creativity you can bring back the enjoyment of many forgotten activities.

The art of crafting is enjoyed by everyone from toddlers to seniors. Before planning out your activities, ask your senior what kinds of outings they enjoyed when they were younger. If you learn that they enjoyed the beach, for example, explore inexpensive crafts with shells, colored glass, sand, and other beach-associated items. Making ornaments, painting picture frames, accessorizing everyday household items, or crafting wreaths are easy ways to start. A craft store or dollar store will often carry inexpensive crafting materials. You can also carry a bag with you to collect craft materials on outdoor walks, such as pinecones, leaves, or interesting sticks or rocks. Some other craft ideas include:

  • Painting clay pots. Painting terra cotta pots requires only paint, pots, and imagination. If for any reason you are not able to use a breakable pot, plastic or metal pots are reasonably-priced alternatives.
  • Creating a bookmark. This can be a fun activity for anyone who enjoys reading and is a simple starter project.
  • Making centerpieces. From a few flowers in a vase to a more complicated art piece, centerpieces can be immensely enjoyed by everyone in the family.
  • Arranging flowers. This activity is ideal for seniors who already have and/or enjoy a flower garden. If they are willing to take fresh cuts from the garden, you can avoid the cost of purchasing flowers from a store.

Food Activities

Some seniors have difficulties cooking, but there are a variety of food-related that activities caregivers and seniors of all abilities can enjoy together. These activities include:

  • Making a cookbook together. Ask your senior if they had any recipes they would like to keep in writing. Help them create a cookbook online for their family and friends.
  • Creating artful fruit (fruit carving). This activity involves cutting fresh fruit into artful shapes. Strawberry flowers, for example, are easy to make and enjoyable to eat. Here is a video tutorial on how to create a strawberry rose .
  • Baking mini pizzas. This activity is flexible enough to fit almost any budget. From fresh dough to a storebought english muffin or bagel, choose the base that best fits your situation. Toppings can be shopped for together at a farmers market, picked from the garden, frozen, canned or fresh. If your senior no longer uses a full-sized oven, a simple toaster oven can easily cook a mini-pizza.
  • Baking together. Breads, cakes and other sweets have several steps in the cooking process that allow for an unsteady hand (stirring batter or kneading dough for example.) The scents of baking are ideal for bringing back memories, and decorating cakes and cookies with icing or other toppings can be an artful – and delicious – conclusion to the activity.

No matter how old we are, we never really lose our childlike love of games. Games can stimulate the brain, produce new brain cells, boost memory and concentration, nurture the imagination, relieve stress, and encourage socializing and bonding. Most games can be easily modified to suit the abilities of the players. In addition to the games listed below, other game-style activities include:

  • Identifying leaves. This activity involves going on a walk either through the neighborhood or at a local park. Bring a book to identify plants and trees, and take turns identifying foliage and sharing interesting facts about the plant or tree. If local laws allow it, you can also collect leaves as you go for craft activities.
  • Name that Tune. If your loved one loves music, this game can also trigger long-term memories. Play a tune, and have them guess the song title and musician/band name. If they get the song right, ask them if they have any memories that involve this particular song.
  • When was it invented? Pick some common household items and take turns guessing when it was invented. Create a points scale for the most accurate guesses, and then research when, where, how and why these items were originally invented (try whenwasitinvented.org for quick answers). Learn interesting tips and facts along the way!

Puzzle Games

  • Jigsaw puzzles stimulate the mind, reduce blood pressure, and boost visual-spatial skills, memory and logic. Choose from a wide range of difficulty levels and designs to match your ability. Some puzzles are designed specifically for people living with dementia.
  • Ubongo is an abstract, competitive puzzle game that involves using tetris-style interlocking shapes to cover a player’s board. It can be played by two to four players and adjusted to meet the abilities of the players.
  • Tic-tac-toe is a simple but challenging paper-and-pencil game that has been around for 3,000 years. In a three-by-three empty grid, two players take turns marking the spaces with their chosen symbol: X or O. The first person to create a row of three matching symbols wins.

Classic Board Games

  • Chess and Checkers use logic and strategy as you work to beat your opponent. Both games have been shown to improve focus, concentration, and memory.
  • Scrabble is a great game for word-lovers and can be expanded to include multiple languages. Play with two to four people and boost your vocabulary at the same time.

Card or Dice Games

  • Gin Rummy is classic card game familiar to many seniors. In gin rummy each player uses their hand to form combinations of three or more cards, with the goal of organizing your hand first. Players take turns drawing new cards and discarding those that don’t fit. Points are awarded for the winning hand and for every uncombined card in your opponent’s hand.
  • Old Maid requires a good poker face. In old maid, you take turns discarding cards in pairs as quickly as you can until one person is left holding the unwanted ‘Old Maid’ card.
  • UNO is a colourful card game where players work to get rid of their cards by matching them to the upturned card on top of the deck. When players are down to one card, they must declare ‘UNO’ or face a penalty.
  • Yahtzee is a dice rolling game where players take turns to put five dice in a cup and roll them. You win this game by rolling the highest-scoring combinations possible.
  • Crosswords challenge the brain and can be easily enjoyed as a shared group activity. Call out clues and describe the number of spaces, then brainstorm possible answers. Free daily crossword puzzles are available in many newspapers and downloadable online. You can also find inexpensive books of crosswords at the dollar store, grocery store, or bookstore.2.
  • Hangman is a simple pen-and-paper game played with a partner. One player thinks of a word, phrase, or sentence and the other(s) tries to guess it by suggesting letters or numbers within a certain number of guesses. Each wrong guess brings your little stick figure closer to danger, so guess carefully!
  • Word Searches  hide words and phrases within a block of letters. Similar to crosswords, the hidden words are often categorized by different themes. Work together to find and mark words written backwards and forwards in horizontal, vertical, or diagonal patterns.

Number and Memory Games

  • Sudoku puzzles are little number puzzles where players must complete a grid of numbers so that each row, column and sub-grid contains a number from one to nine – but that number appears only once in that row, column or sub-grid. Difficulty ranges from beginner to “diabolical”, and number clues are given at the start.
  • Card Matching  is a great memory-building activity for everyone from children to seniors. Place a deck of cards or special picture cards face-down on a table. Players each take a turn turning over first one, and then a second card – looking at the pictures – and then returning the cards to their original face-down position. The goal is to remove the most matching pairs from the table. If a player uncovers a matched pair during their turn, that pair is removed from the table and added to the player’s pile. Players can watch their opponents turn over their cards and use their memory to find a match during their own turn.
  • Flags of the World Quiz. If your loved one or patient is a geography whizz, challenge yourself to identify all the different flags of the world with this online or mobile app game
  • The Tray Game.  Similar to the card matching game, the tray game enhances and builds memory skills. To play, put a variety of different objects on a tray and give participants a limited period of time to look at everything. Then, cover the items with a cloth and see who can list and/or remember the location of most items in a set time limit.

Stimulating activities can be critical to a senior’s physical, mental, and emotional well-being. As human beings – regardless of  age or ability – staying active and participating in things we enjoy brings satisfaction and a sense of accomplishment. Shared activities allow us to laugh deeply, participate in the moment, build trust in our support circle, and take a break from feeling frail or in pain. If you are unsure whether a senior is able to engage in an activity, talk to their doctor or healthcare team.

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Why Self-Care Can Help With Depression — Plus, 7 Science-Backed Activities to Try

Alongside professional treatment, consistent self-care can help relieve depressive symptoms.

Julie Lynn Marks

Along with treatments like psychotherapy and medication , lifestyle management strategies — including a solid self-care regimen — can help people with depression feel better.

Understandably, consistent self-care can be challenging for some people with depression, especially those with symptoms like low energy, fatigue , or lack of motivation.

“The most important thing to realize is that self-care may be hard if you’re depressed,” says Debra Kissen, PhD , a psychologist and the CEO and clinical director of Light on Anxiety CBT Treatment Centers throughout Illinois. “It’s going to be the very opposite of what your brain wants to do. So it’s going to be helpful, but it’s not going to be easy.”

How Can Self-Care Help if You Have Depression?

“Life requires a lot of energy, so we need to maintain our energy supply to function well,” Kissen says. The trouble is that many people with depression experience lack of energy as a symptom.

Although self-care can help just about anyone with depression feel better, Kissen warns that if you have severe depression, self-care likely isn’t sufficient on its own, and you should prioritize professional treatment above all else. “The only harm would be if somebody thinks that self-care is enough when they are really stuck in depression,” she says.

Evidence-based treatments for depression like psychotherapy or medication will provide the most rapid and long-lasting relief for severe depression, she notes. Self-care often works best alongside standard treatments for depression.

7 Top Self-Care Strategies for Depression

“There isn’t a one-size-fits-all approach here to specific methods,” says Ash Shah, LCSW , the clinical counseling director at Empower Your Mind Therapy in New York City and on Long Island, New York. “It’s important to try various strategies out to see which ones work for you and help you feel better afterward.”

Research shows that these seven common self-care strategies can help people with depression feel better.

1. Set a Sleep Routine and Stick to It

Practicing good sleep hygiene — meaning you have healthy sleep habits and surroundings — is a good goal for anyone, and it’s especially important if you have depression.

If changes like these don’t help, tell your doctor. They can recommend professional treatments to improve your sleep.

RELATED: Sleep 101: The Ultimate Guide to a Better Night’s Sleep

2. Exercise Regularly

Exercise doesn’t always have to be long or intense to help you feel better. Just 30 minutes of walking every day can boost your mood and your overall health.

RELATED: 7 Great Exercises to Ease Depression

3. Spend Time in Nature

Getting outdoors, especially on sunny days, can help you feel better if you have depression.

RELATED: Why Nature Is So Helpful for Depression — Plus, How to Spend More Time Outdoors

4. Try Mindfulness, Yoga, or Other Activities You Find Relaxing

  • Deep breathing
  • Guided imagery (a relaxation exercise that helps people visualize a calming environment during times of stress)
  • Progressive muscle relaxation (a technique that involves tensing and releasing muscles in your body, with a focus on the releasing phase)

5. Try Journaling

6. eat a nutritious diet.

RELATED: Depression: 6 Tips for Eating Well When Cooking Feels Impossible

7. Stay Connected With Others

Although it may be challenging, especially if you struggle with fatigue or lack of energy, Kissen suggests trying to stay connected with others, even if it’s for brief periods of time. “Being around people helps give you that lift in mood. Going to the supermarket and seeing others counts,” she says.

RELATED: 4 Ways to Cope With Loneliness if You Have Depression

How to Get Started With Self-Care for Depression

If you’re not sure where to start, these tips could help you begin a self-care routine that you can stick to in the long run:

  • Talk to your therapist. If you see a therapist or another mental health provider, work with them to plan how you’ll fit self-care into your routine, Shah suggests.
  • Start small. “There are so many strategies out there, it is easy to get overwhelmed and feel unsure of what to do for yourself,” says Shah. “Start with short, easy tasks.”
  • Break bigger tasks into smaller chunks. For instance, as mentioned earlier, you could break up 30 minutes of exercise into three smaller, 10-minute increments throughout the day. Or if you want to eat more nutritiously, start by eating one additional piece of fruit or a vegetable per day and gradually add more.
  • Try your best to stay consistent. There may be days when self-care will feel difficult to accomplish. If you’re struggling with symptoms like fatigue or low motivation, try your best to get self-care done, says Kissen. “You kind of have to do the behaviors first and then the feelings catch up. Don’t do it because you want to; do it because it’s good for you,” she says. If you’re consistent with self-care, the benefits will follow.

RELATED: 76 Top Self-Care Tips for Taking Care of You

Editorial Sources and Fact-Checking

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

  • Caring for Your Mental Health. National Institute of Mental Health . February 2024.
  • What Is Self-Care?. Global Self-Care Federation .
  • Pilkington K et al. Self-Care for Anxiety and Depression: A Comparison of Evidence From Cochrane Reviews and Practice to Inform Decision-Making and Priority-Setting. BMC Complementary Medicine and Therapies . August 2020.
  • Depression and Sleep: Understanding the Connection. Johns Hopkins Medicine .
  • Exercise Is an All-Natural Treatment to Fight Depression. Harvard Health Publishing . February 2, 2021.
  • Balanzá-Martínez V et al. Lifestyle Prescription for Depression With a Focus on Nature Exposure and Screen Time: A Narrative Review. International Journal of Environmental Research and Public Health . May 2022.
  • Mayo Clinic Minute: How Change in Sunlight Can Affect Your Mood. Mayo Clinic . November 1, 2023.
  • Radiation: The Known Health Effects of Ultraviolet Radiation. World Health Organization . October 16, 2017.
  • Seasonal Affective Disorder Treatment: Choosing a Light Box. Mayo Clinic . March 30, 2022.
  • Mindfulness. American Psychological Association .
  • Parmentier FBR et al. Mindfulness and Symptoms of Depression and Anxiety in the General Population: The Mediating Roles of Worry, Rumination, Reappraisal and Suppression. Frontiers in Psychology . March 2019.
  • Norelli SK et al. Relaxation Techniques. StatPearls . August 2023.
  • Bridges L et al. The Efficacy of Yoga as a Form of Treatment for Depression. Journal of Evidence-Based Integrative Medicine . June 2017.
  • Sani NA et al. Tai Chi Exercise for Mental and Physical Well-Being in Patients With Depressive Symptoms: A Systematic Review and Meta-Analysis. Journal of Evidence-Based Integrative Medicine . February 2023.
  • Sohal M et al. Efficacy of Journaling in the Management of Mental Illness: A Systematic Review and Meta-Analysis. Family Medicine and Community Health . March 2022.
  • Selvaraj R et al. Association Between Dietary Habits and Depression: A Systematic Review. Cureus . December 2022.
  • Ge L et al. Social Isolation, Loneliness and Their Relationships With Depressive Symptoms: A Population-Based Study. PLoS One . August 2017.
  • Social Support: Getting and Staying Connected. Mental Health America .

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Wellness and rewards programs

Staying on top of your health is no small task. It takes dedication to keep your health in check. Eating well, moving your body, reaching health goals and getting your annual checkup are just some of the ways you can invest in your health.

With UnitedHealthcare rewards programs, you can earn rewards for reaching activity and health goals. UnitedHealthcare also offers programs, like Renew Active, to give you support and motivation to help keep your mind and body active and healthy.

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Rewards programs for insurance through work

If you have an employer-sponsored health plan, you may have access to the following rewards programs.

UnitedHealthcare Rewards

UHC Rewards is a digital experience where you can earn rewards for reaching goals and completing one-time activities. It's included in your health plan through work, at no additional cost. You choose the activities you go after— and then enjoy spending your earnings the way you want. Get in on an experience that’s designed to inspire — and reward — healthier habits.

Rally is a website and mobile app that helps you learn simple ways to take care of yourself — from being more active to eating better. Making small changes and adding healthy habits to your everyday life can move you closer to better health management, so you may live a full, active life. Plus, you earn Rally coins for rewards at the same time.


SimplyEngaged is a wellness incentive program to help you get and stay healthier. You’re rewarded when you participate in a biometric screening and complete health activities using a personalized dashboard with recommendations designed to help keep you on track. You can expect things like:

  • Incentives to make positive health changes
  • Tips on ways to live healthier
  • Support to build better health through lifestyle habits

UnitedHealthcare Motion®

With UnitedHealthcare Motion, you’ll use an activity device to track your activity, set goals and earn financial rewards when you reach them. You may earn $3 to $4 a day toward your health savings account. And that adds up! The more goals you reach, the more rewards you get — it’s that simple.

UnitedHealth Personal Rewards®

UnitedHealth Personal Rewards combines incentives and tools to help you make more informed health and lifestyle decisions, like getting recommended preventive care or reaching health goals. You get tailored solutions and communications designed to help improve your health and earn rewards, like gift cards, health savings account deposits or reimbursements, or Rally® Coins.

Fitness and rewards programs for Medicare members

Medicare members may have access to the following fitness and rewards programs.

Renew Active®

Renew Active is a fitness program that helps you reach fitness goals and stimulates your brain. This program helps you move your body at the gym or at home, stay sharp with brain exercises, and take care of your social well-being by keeping you connected to your communities.

UnitedHealthcare® Medicare Advantage members have many ways to earn rewards 1  and lots of ways to spend them, too. You may be eligible to earn rewards for completing certain activities, like your annual physical or wellness visit.

Rewards programs for Medicaid members

If you have a Medicaid plan, you may be eligible to earn the following rewards. 

Want to earn rewards for being healthy? Members with some UnitedHealthcare Medicaid plans 2 may be eligible for just that with Member Rewards. It’s simple. If it’s part of your plan, you may earn rewards for completing healthy activities. These may include going to see your provider or completing health screenings. While these activities may not be at the top of your to-do list, they are important. And may be rewarding too.

Senior Living

What is Memory Care?

A s a caregiver, watching your loved one struggle with memory loss is heartbreaking. When it’s time to explore care options, it’s essential to fully understand memory care , the costs involved, and how to choose the right facility. With the proper memory care, your family member can thrive. In this guide, we’ll cover everything you need to know about memory care as you start your research.

Table of Contents

What is memory care, memory care services and activities, what is the average stay in memory care, questions to ask when choosing a memory care facility, alzheimer’s and other dementias in the united states, how much does memory care cost, is memory care covered by medicare, memory care vs. skilled nursing: what’s the difference, what is the difference between assisted living and memory care, when to move from assisted living to memory care, finding a memory care facility near me.

Memory care is a specialized form of care for seniors struggling with memory loss due to Alzheimer’s disease or another form of dementia , or other cognitive impairments. Specially trained staff deliver personalized care focused on keeping your loved one comfortable, engaged, and safe.

Services and activities focused on stimulating your loved one cognitively and physically are an essential part of memory care. Keep in mind, each senior has a different level of capability. These activities should provide stimulation, not stress:

  • Art therapy to increase self-expression
  • Exercises such as chair yoga or tai chi to improve balance and muscle strength
  • Music therapy to boost mood and emotions
  • Crafting such as knitting, coloring, collages, and ceramics for sensory stimulation
  • Mental health therapy for depression or anxiety
  • Group walks for social interaction
  • Games such as bingo, dominos, or checkers to encourage fine motor skills

While the average stay in memory care is two to three years, memory loss is a progressive disorder that affects each patient at a different pace. This means the length of stay in memory care can be as short as a few months or as long as a decade. The severity of symptoms, the senior’s overall health, and the caregiver’s ability to provide proper care to their loved one affect a senior’s need for memory care.

As you interview local memory care facilities, be mindful of these questions and considerations:

  • What is the staff-to-resident ratio during the day and night?
  • Is there a medical professional, such as a doctor or nurse, on staff 24/7?
  • What type of memory care training has your staff received?
  • Do the residents have dedicated staff daily? Or will the personnel rotate?
  • What medical services are offered on-site?
  • What is your pricing structure, and what does it cover?
  • What types of daily activities are offered?
  • How is your facility secured?
  • Do you group residents by cognitive level?
  • How do you respond when a patient becomes confused or combative?
  • What does your meal plan offer?
  • How often do you provide updates on the resident’s health and well-being?
  • Do you perform background checks on all employees?

Memory care red flags you should never ignore:

  • The facility is not clean, brightly lit, or easy to navigate.
  • The residents appear unhappy.
  • The staff does not appear compassionate.
  • The residents are not properly groomed and dressed.
  • The staff does not actively engage with the residents.
  • The facility has violations or complaints.
  • The admissions policy and facility pricing are not clear.
  • There are not proper safety protocols in place, such as window locks, smoke alarms, exit signs, and handrails or nonslip material on flooring for fall safety .
  • There appears to be excessive use of the television to keep the residents occupied.
  • The staff are unwilling to answer your questions.

Alzheimer’s and other forms of dementia are a lot more common than you might think. Know that if you’re seeking memory care for a loved one, you’re not alone. Below is a breakdown of the prevalence of dementia in the U.S. based on a 2020 report from the Alzheimer’s Association. 1

Dementia in the U.S. based on Alzheimer’s Association data

According to Genworth’s 2024 Cost of Care Survey, the estimated monthly median memory care cost for a semiprivate room is $8,641 and a private room is $9,872. Memory care costs vary depending on the level of care required, the setting, and the geographical location. For more detailed information on the cost of memory care, visit our state-by-state memory care cost guide .

Did You Know? The need for memory and long-term care is staggering. According to the U.S. Department of Health and Human Services, someone turning 65 today has almost a 70 percent chance of needing some type of long-term care service and support in their remaining years. 2

Over 50 million seniors aged 65 and over are enrolled in Medicare. Unfortunately, Medicare does not cover all memory care costs , and the costs can be significant. Individuals can pay for memory care through private insurance, Veterans Affairs health care, or out-of-pocket.

Memory Care Services Covered by Medicare

  • Care planning services for people recently diagnosed with cognitive impairment, including Alzheimer’s and other dementias 3
  • Annual wellness visits
  • Up to 100 days of skilled nursing home care under specific conditions
  • Prescription medications (under Medicare Part D)
  • Inpatient hospitalization to treat an illness or injury 4
  • Hospice care costs directly related to pain relief and symptoms associated with end-stage dementia 5

Memory Care Services Not Covered by Medicare

  • Long-term care (also known as custodial care)
  • The “room and board” portion of memory care

Did You Know? If your loved one is enrolled in Medigap or a Medicare Advantage plan , additional long-term care benefits may be covered.

While both skilled nursing and memory care facilities offer 24-hour medical care and assistance with activities of daily living (ADLs), such as personal care and medication management, skilled nursing focuses on short-term care and rehabilitation.

Many times, once a senior is released from the hospital, they require additional care before returning home. Skilled nursing facilities provide in-patient medical care, along with physical, speech, or occupational therapy. Patients in need of post-surgery wound care, physical therapy after a hip replacement, intravenous medications, or speech therapy post-stroke will benefit from skilled nursing.

Memory care is specialized long-term care focusing on patients with memory loss.

The major difference between assisted living and memory care is the overall need of the resident. As the name suggests, assisted living is designed to “assist” your loved one. Within assisted living communities, you’ll find seniors who remain largely independent. While residents may need help with specific ADLs, they do not require 24-hour medical attention.

Memory care is for seniors living with memory-related challenges such as dementia or Alzheimer’s disease. Memory care facilities provide round-the-clock care for seniors experiencing memory loss.

Did You Know? In addition to stand-alone memory care facilities, you can find special care units (SCUs) for memory care in assisted living facilities and skilled nursing homes. 6

Many older adults make the move from assisted living to a memory care facility as they enter new stages of life and their needs change. But when exactly is the right time to move from assisted living to memory care? It may be time to move your loved one to memory care if they:

  • Show increased signs of confusion within their daily life
  • Pose a safety risk to themselves by wandering
  • Show signs of agitation, aggression, or violence
  • Neglect their personal care and hygiene
  • Require care over and above what assisted living care can provide

Family members and caregivers can experience immense emotional stress when finding the right memory care facility for their loved one. While this is a challenging time, you are not alone. There are many resources to help during this journey. The U.S. Administration on Aging offers an Eldercare Locator tool to find memory care facilities in your area. You can check with your state Department of Social Services. We’d also suggest asking your loved one’s doctor to see if they have any local recommendations. You can also use our senior housing directory to find options near you.




  • 1 Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department, 115088, Moscow, Russia.
  • 2 Directorate for the coordination of the activities of medical organizations of the Moscow Department of Health, 115280, Moscow, Russia.
  • 3 Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department, 115088, Moscow, Russia, [email protected].
  • 4 Diagnostic Center No. 5 with an outpatient department of the Moscow Department of Health, 127572, Moscow, Russia.
  • 5 Children's City Polyclinic No. 110 of the Moscow City Health Department, 127490, Moscow, Russia.
  • 6 Moscow City Health Department, 127006, Moscow, Russia.
  • 7 Consultative and Diagnostic Polyclinic No. 121 of the Department of Healthcare of the City of Moscow, 117042, Moscow, Russia.
  • 8 Sechenov First Moscow State Medical University (Sechenov University), 119991, Moscow, Russia.
  • 9 City Polyclinic No. 2 of the Moscow City Health Department, 117556, Moscow, Russia.
  • PMID: 34792886
  • DOI: 10.32687/0869-866X-2021-29-s2-1331-1337

Scientific research and their inclusion in the health care system is an important part of modern medical science. To study the readiness of primary care physicians as well as administration staff to introduce a research component into the national health care system, "The Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department" conducted an online survey of two groups of respondents - physicians of primary care settings (n = 593) and heads of outpatient clinics in Moscow (n = 168) in 2021. The results of the study show the insufficient involvement of primary care doctors in research activities in their working places: more than half do not consider scientific activities as a priority, motivating it by the lack of conditions, practical skills, age and health status as well as high level of employment, although they do not reject it in the future. Heads of Moscow primary health care settings demonstrate similar answers. According to their opinion, research activities are poorly represented in organizations of this type, and most likely the situation will not be changed in the near future; about half do not have sufficient information about the number of employees engaged in scientific work and are rarely familiar with their topics (often extensive, represented by various fields of medicine); about one third of managers reported participating in research projects of Moscow City Department of Health. The study made it possible to identify barriers that prevent the introduction of research components into the activities of Moscow primary health care organizations, which should be taken into account when making managerial decisions.

Keywords: health care; outpatient clinic; research activities.

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ESL Speaking

Games + Activities to Try Out Today!

in Activities for Adults · Activities for Kids

ESL Health Activities: Games, Activities, Worksheets, Vocabulary

Are you looking for some fun, engaging ESL health activities to make your health lessons even better? Then you’re most definitely in the right place. Keep on reading for my favourite ESL health games and activities to add to your classes.

ESL Health Activities and Games


ESL health games and activities

Let’s get into the best ESL health games for the classroom to consider trying out with your students.

#1: Just One Question

This is a survey kind of activity with a bit of a twist. Each pair of students will only ask one question to their classmates. Then, they’ll tabulate the results and report them back to the class. In this case, you’d want to focus on health-related questions. The sky is actually the limit in terms of what students could ask each other!

If you want to learn more, you can find out more details here: Just One Question ESL Survey Activity .

#2 ESL Health Game: Taboo

You’ve probably played taboo at a party before. It’s where you have to describe a word without using other certain words. I’ve adapted it for ESL by omitting the second part.

In this case, you’d want to write down a bunch of health-related vocabulary words on cue cards. Then, a student has to select one from the pile and describe it to their teammates. You can turn this into a whole game by having a number of timed rounds with different people describing words each round.

Check it out here: Taboo ESL Game .

#3: Do you Like to _____?

This is a simple warm-up activity for beginners that can be used for a variety of topics, including health. The way it works is that students write down a few facts about themselves related to health. They could be either healthy or unhealthy things. For example:

  • I rarely drink water
  • I love to eat salads for lunch
  • I’m a junk food junkie

Once the students are done, they cut up each statement into a strip of paper and you distribute them randomly throughout the class to the other students. Then, they have to find matches for their papers by asking correct questions.

You can learn more about this ESL health activity here: Do you like to? ESL Warmer.

English Teaching Emergency: No Textbook, No-Prep, No Materials ESL/EFL Activities and Games for Busy...

  • Amazon Kindle Edition
  • Bolen, Jackie (Author)
  • English (Publication Language)
  • 68 Pages - 11/12/2019 (Publication Date)

#4 ESL Health Game: Vocabulary Auction

Although this health game takes a while to set up, the results are so good that it’s totally worth it. I love to do this activity at least once per semester, but I’ll generally only do it in classes where I can prepare once, but use it multiple times with different sets of students.

In this case, the vocabulary you choose would all be related to health. You can learn how to do it here: ESL Vocabulary Auction .

#5 ESL Health Activity: Partner Conversation Starters

If you tell your students to, “Talk about health” for 5 minutes with their partner, you may have a lot of silence going on in your classroom. Of course, it depends on the country that you’re teaching in if this will happen or not.

The better way is to give your students a small list of conversation starters related to health that they can use if they’d like to. Encourage free discussion, but then tell students to refer to the conversation prompts if they need another thing to talk about.

Check it out here: English Conversation Starters .

#6: Picture Prompt

This is a quick warm-up ESL activity that makes a nice lead-in to your health lesson. It’s an ideal way to help students activate their prior knowledge about this topic. Put up a picture on the screen, either of very healthy, or very unhealthy.

Then, depending on the level of the students, you could do a few different things. For beginners, they could simply state vocabulary words they know from the picture. Higher-level students could discuss with a partner about what they see, or compare that person to themselves.

Check out this ESL health activity here: Picture Prompt ESL Warm-Up .

#7 ESL Health Activities: Dictogloss

This is a classic ESL activity that’s perfect for helping students improve their listening skills. It challenges them to try and understand as much as possible from something that is slightly too difficult for them. Then, the response can either be with writing or speaking.

In this case, the reading passage you choose to use should be related to health. Even better if there are lot of vocabulary from it that are new words that the students have just learned. Bonus points for you!

Do you want to try it out in your classes? More details here: Dictogloss ESL Listening Activity .

#8: Agony Aunt

Have you ever noticed that the health topics in ESL textbooks is often paired with problem/advice? They just fit so nicely together that it’s natural to do this. One of the ways to spice up problems and advice is with this Agony Aunt ESL activity.

Find out what you need to do here: Agony Aunt Problem/Advice Activity.

#9: Just a Minute

Just a Minute is a fun activity for your more advanced students. Students have to speak for a minute without stopping on a certain topic. In this case, you could use something like, “Are you healthy or unhealthy? Why?”

The best thing about this activity is that you can turn it into a fun conversation activity by requiring the students who are listening to ask some follow-up questions.

#10: English Central Videos

I’m ALL about using videos in my classes for a variety of reasons, but the most common one is that I’ll use them as a quick warm-up. There are lots of options on YouTube, or you may also consider English Central which is geared specifically to English learners.

Either way, the key is to design a variety of activities related to the video so your students get the most out of it. Find out more details here:

Using English Central Videos in the ESL Classroom .

#11: Word Association

This is a super-quick ESL warmer that helps students to activate prior knowledge they have about health vocabulary. Basically, students shout out some vocab words related to the topic and help you categorize them into a mind map.

Learn more about it here: Word Association ESL Vocabulary Activity .

#12 ESL Health Games: Charades

You can use this game for just about the topic, but it does work quite well with health. Think about things like drinking too much, smoking, jogging, eating a salad. Students acting this stuff out will likely be hilarious and you’ll have a great class.

Learn more about using charades with ESL students here: ESL Charades .

#13: Find Someone Who Bingo Game

This is an ESL icebreaker that can be very, very easily adapted into a health Bingo Game. Instead of getting to know you questions, choose ones related to health. More details here:

Find Someone Who ESL Bingo Game

#14: ESL Health Surveys

I love using ESL surveys in my classes. They’re super easy to design and are a true 4-skills ESL activity. They’re also ideal for sleepy classes because students have to get out of their seats and mingle with their classmates.

In this case, you’d want to focus yours on health. There is certainly a wide variety of questions you could consider adding.

Find out more about using them here: ESL Surveys.

Or, check out some other frequency expression activities as well.

#15 ESL Health Game: Running Dictation

This classic ESL game is a favourite with most of my students. It’s ideal because it gets students up out of their seats and moving around the classroom. Try it out on Monday morning or Friday afternoon and you’ll probably love the results.

The way it works is that you choose a short dialogue or conversation related to health. Then, divide it up into sentences and put the strips of paper around the classroom. The students have to work together to recreate the conversation or dialogue.

Learn more about it here: Running Dictation ESL Game .

#16: Telephone Game

If you want to review some key health vocab, then consider playing this fun game for kids: telephone. The way it works is that you give the first student in line a sentence with some health words in it. Then, they have to pass that along until it reaches the end. At the point, compare with the original.

If you’ve ever played this before you’ll know that the results are usually hilarious! Find out all the details you need to know here:

Telephone Game for TEFL .

#17: Modal Verbs and Health Activities

Modals (may, might, should, can, etc.) are a natural fit to go along with a unit on healthy or unhealthy habits. Have a look here for some of the best ideas for teaching them:

#18: Hot Potato ESL Health Game

One of the best ESL health games is Hot Potato if you want to create some fun and excitement in your classes. You may have played this as a kid but this version has a twist.

The person holding the potato when the music stops has to answer (or ask) a question of some kind related to health. Some examples could be:

  • What are your healthy (unhealthy) habits?
  • How often do you _____?
  • When was the last time you _____?

#19: Task-Based Health Activities

There are a number of in-depth activities that are perfect for ESL health lessons. In particular, a presentation about a topic like smoking, drinking, diet, etc. can be an ideal way to go deeper with this vocabulary. I also like it because students can learn some things that may benefit them in their “real life.”

There are lots of other task-based activities to consider as well that will work well. Here are some of the best options:

Task-Based Teaching .

#20: Plan your Own Health Lesson Plan

It’s easier than you might think to plan your own lesson plan about almost anything, including this topic. Check out this video for the simple steps to follow:

#21: Health Role-Plays

A nice activity for an ESL health lesson is to do some role-plays. For example, situations like going to the doctor for a small ailment work particularly well for this. Learn how to use them in your classes here:

ESL Role Plays .


Fun health games for the classroom

#22: Fruit and Vegetable ESL Activities

Of course, eating fruits and veggies is closely linked with better health! That’s why these vocabulary words can be a natural fit for this unit. If you want to see some of the best ideas for this topic, have a look here:

ESL Fruit and Vegetable Games .

#23: Body Parts ESL Games and Activities

Health and body parts are a natural fit for each other and I always like to slip in a bit of body part review into this unit. Things like eyelashes, lips, toes, nails, etc. are easy to forget because students don’t use these words that often. Here are some of my favourite ways to do this:

ESL Body Parts Games .

#24: TEFL Fruits and Vegetables Quiz

Try out this simple online quiz with your students:

#25: What Am I?

This is a quick warm-up activity that I often use for famous people. However, it can be easily adapted into a fun health class activity.

On a PowerPoint slide, put pictures of various healthy and unhealthy things. For example, someone smoking, jogging, fruits and veggies, taking a shower, etc. Then, put students into pairs and they have to take turns describing one of the activities to their partner who has to guess what it is. Try it out:

What Am I? 

#26: Small Group Discussion about Health

I personally find health one of the most interesting topics in ESL/EFL textbooks. Almost everyone has an opinion about healthy or unhealthy activities and it’s one of those things that basically everyone is interested in!

When I’m teaching intermediate or advanced level students, I love to have some small group discussion time related to health. It’s usually a hit and students always have lots to talk about! Here are some tips for setting up this time to make it as awesome as possible:

Small-Group ESL Discussions .

#27: Health Board Games

I love to play board games in real life and I also enjoy getting my students to play them in class. It’s easy enough to design a game in just a few minutes. Have a look here to find out how I do it:

#28: Use Realia 

Why show flashcards or describe objects if you can bring the real thing? Use a bunch of healthy/unhealthy things:

  • fruits and veggies
  • junk food wrappers
  • cigarette box
  • various kinds of drinks
  • sports equipment

Then, have students name the objects and decide if they’re healthy or unhealthy. Learn more here:

Realia meaning .

#29: Kinds of Doctors

Help students remember the names of the various medical specialties with this handy guide:

Doctor Names in English .

Health Vocabulary for English Learners

If you’re looking for some common ESL health vocabulary that you could include in these activities or games, or teach your students, then here are a few ideas:

  • Emergency room (ER)
  • Temperature

ESL Health Lesson Plans

Are you looking for some ready-made ESL health lessons? Then these activities and games probably aren’t what you need. Check out our go-to source for lesson plans that are ideal for beginners to advanced, kids or adults.

ESL Library

Breaking News English

Do you have any go-to sources for health lesson plans for ESL/EFL students? Leave a comment below and let us know your favourite resources. We’ll add them to this list.

ESL Health Worksheets

Do you want some health worksheets that you can use with your students or assign them for homework? Here are some of the best resources from around the web for ESL health and fitness worksheets:

ISL Collective

Busy Teacher


What about a printable fitness quiz? If you want to design a quick quiz to give your students related to health and fitness, here’s our go-to source.

Fitness Quiz Printable

What are some Conversation Questions for Health and Fitness?

If you want to get the discussion ball rolling, then you’ll want to check out this list of health and fitness questions for ESL/EFL students.

  • Do you regularly exercise?
  • Are you healthy or unhealthy? Give some examples of your good and bad habits.
  • How are your eating habits?
  • Do you have a weakness for a certain kind of junk food?
  • How often do you get sick?
  • How much do you drink?
  • Do you eat lots of fruits and veggies?
  • What’s your normal daily diet like?
  • Do you ever eat fast food?
  • Are you interested in health and fitness?
  • How often do you go to the dentist?
  • Do you have any allergies?
  • Have you ever stayed overnight in the hospital?
  • How much stress do you have?
  • Do you smoke?
  • What do you do when catching a cold or the flu?
  • Is it unhealthy to have pets in your home?
  • How long do you think you’ll live?
  • Do you wake up to your alarm or just naturally?
  • How much sleep do you get? Is it enough?
  • What do you know about “wellness?”

Do you have any questions about health and fitness that you like to talk with your students about? Let us know by leaving a comment below and we’ll add them to this list.

Did you like these ideas for an ESL Health Lesson?

101 ESL Activities: Games, Activities, Practical ideas, & Teaching Tips For English Teachers of...

  • 148 Pages - 03/09/2016 (Publication Date)

Yes? Thought so. Then you’re going to love this book: 101 ESL Activities for Teenagers and Adults that you can find on Amazon. It’s filled with dozens of fun, engaging ESL games and activities that will make your classes even better. There’s enough material for you to get through the semester in style.

The best part is that the book is well-organized into various sections to make it easy to find what you’re looking for in under a minute. Listening, speaking, reading, writing, grammar, review, icebreakers, 4-skills, etc.

The book is available in both digital and print formats. Keep a copy on the bookshelf in your office and use it as a handy reference guide. Or, take it with you to your favourite coffee shop for lesson planning on the go. Yes, it really is that easy to have better ESL classes.

Check it out on Amazon, but only if you want to get yourself a dose of ESL awesome in your life:


Have your Say about ESL Health and Wellness Activities

What are your thoughts about these ideas for an ESL health lesson? Do you have a go-to game or activity for the wellness unit? Leave a comment below and we’d love to hear from you.

Also be sure to give this article a share on Pinterest, Facebook, or Twitter. It’ll help other busy teachers, like yourself, find this useful teaching resource.

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About Jackie

Jackie Bolen has been teaching English for more than 15 years to students in South Korea and Canada. She's taught all ages, levels and kinds of TEFL classes. She holds an MA degree, along with the Celta and Delta English teaching certifications.

Jackie is the author of more than 100 books for English teachers and English learners, including 101 ESL Activities for Teenagers and Adults and 1001 English Expressions and Phrases . She loves to share her ESL games, activities, teaching tips, and more with other teachers throughout the world.

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Scope of registration: Introduction


Who has to register?

  • General exceptions and exemptions from registration
  • The regulated activities
  • Glossary of terms

You may need to register with CQC if you provide, or intend to provide, health or adult social care activities in England. This is a legal requirement under the Health and Social Care Act 2008.

You must apply to be registered even if you do not intend to provide those services on a regular or permanent basis.

This guidance will help you decide whether you need to register with us. It explains:

  • what we mean by regulated activities
  • who and what needs to be registered – we call this the scope of registration
  • which regulated activities you are most likely to need to register for.

It is an offence to carry on a regulated activity without being registered.

To make sure you have all the information to register correctly, you need to read this guidance and refer to the Health and Social Care Act 2008 and associated regulations and our guidance on meeting the regulations . Make sure you always refer to the latest version of the regulations. This is a guide to the regulations but is not a substitute for them.

You can also see our guidance on how to register as a new provider or how to make changes to your registration .

This guidance on the scope of registration replaces the previous version published in March 2015. We have added information to clarify some sections and reflect changes in the way health and social care is now delivered.

To decide whether and how you need to register with CQC you may find it useful to ask yourself the following questions:

  • Will I be carrying on a regulated activity? If so, which will apply to me?
  • Who will be responsible for directing and controlling the regulated activity? (called ‘carrying on’ the activity)
  • Will any exceptions apply?
  • Where will the regulated activity be carried on at or from? (called location(s)) 
  • Is a registered manager required at any or all locations?
  • If I am intending to provide services to children, do these activities need to be registered with CQC, Ofsted or both?

This guidance will help you answer some of these questions. 

It is important to focus on the activities that will trigger the need for registration. This depends on what regulated activity you provide within your 'service type'. See Information on service types .

If you are already registered and want to change the type of activities or services you provide, refer to the regulations and use this guidance to determine whether you need to apply for any changes to your regulated activities.

If you support people with a learning disability and/or autistic people, also refer to our guidance Right support, right care, right culture . 

Download and print

You can download and print a PDF version of the Scope of Registration.


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