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Presentation to the Presentation to the California Prevention California Prevention Collaborative SummitCollaborative Summit

The IOM Model and its Implications The IOM Model and its Implications for Prevention Planningfor Prevention Planning

Presented byPresented by

Joël L. PhillipsJoël L. PhillipsCenter for Applied Research Solutions (CARS) & Center for Applied Research Solutions (CARS) &

Community Prevention Institute (CPI)Community Prevention Institute (CPI)

April 25, 2006April 25, 2006

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Purpose of the WorkshopPurpose of the Workshop

1.1. Introduce a historical perspective on the Introduce a historical perspective on the development of the IOM model.development of the IOM model.

2.2. Understand the components of the IOM Understand the components of the IOM model dealing with prevention model dealing with prevention (Universal, Selected, Indicated)(Universal, Selected, Indicated)

3.3. Examine each of the three IOM Examine each of the three IOM prevention components and how they prevention components and how they can be used in planning prevention in can be used in planning prevention in your community.your community.

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Prevent: Prevent: “Keep “Keep somethingsomething from happening” from happening”

However, different notions about what that However, different notions about what that something is:something is:– First Incidence (Use)First Incidence (Use)– RelapseRelapse– Harm (Consequences)Harm (Consequences)– Risk Condition ItselfRisk Condition Itself

Prevention:Prevention:New Directions in DefinitionsNew Directions in Definitions

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Prevention rooted in public health field. Prevention rooted in public health field. (100 years)(100 years)– Concern stopping infectious diseases.Concern stopping infectious diseases.

Codified in 1957 – “Commission on Codified in 1957 – “Commission on Chronic Illness.”Chronic Illness.”– Introduced the terms:Introduced the terms:

PrimaryPrimary

SecondarySecondary

TertiaryTertiary

Prevention:Prevention:New Directions in DefinitionsNew Directions in Definitions

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DefinitionsDefinitions

Primary PreventionPrimary Prevention::– Reduce Reduce incidenceincidence of a disorder (occurrence of of a disorder (occurrence of

newnew cases) cases)

Secondary PreventionSecondary Prevention::– Reduce Reduce prevalenceprevalence

(that is total number of new and old cases)(that is total number of new and old cases)

Tertiary PreventionTertiary Prevention: : – Reduce the Sequelae and Reduce the Sequelae and complicationscomplications

arising from the problem/disorder once it is arising from the problem/disorder once it is manifest.manifest.

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Situations Linked to Health

Consequences

Early Manifestation of

the Behavior/ Condition

Outcome: Total Manifestation of

Behavior/ Condition

The Traditional The Traditional “Public Health” Model“Public Health” Model

Critical Point 1 Critical Point 2

Primary Prevention

(Prevention)

Secondary Prevention

(Intervention)

What is the nature/typical history of the behavior?

Critical Point 3

Tertiary Prevention

(Treatment)

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Assumptions with this ModelAssumptions with this Model

Causal pathways can be identified.Causal pathways can be identified.– Identify specific agents/vectors of disease.Identify specific agents/vectors of disease.– However, not so easy in behavioral/ social However, not so easy in behavioral/ social

science.science.

Early manifestations the problem/ Early manifestations the problem/ condition itself is actually preventable.condition itself is actually preventable.– However, not so easy to demonstrate.However, not so easy to demonstrate.

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Problems with the ModelProblems with the Model

Health/Disease FocusHealth/Disease Focus

Research demonstrates complexity of the Research demonstrates complexity of the association between risk factors and association between risk factors and health outcomes.health outcomes.– Biological, psychological, social biophysical Biological, psychological, social biophysical

factorsfactors

Knowledge about the actual intervening Knowledge about the actual intervening mechanism still not completely known.mechanism still not completely known.

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ConclusionConclusion

This model with its origin in medical This model with its origin in medical science & linear assumption of science & linear assumption of causality is less relevant for those causality is less relevant for those working in non-medical settingsworking in non-medical settings

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Development of Universal/Selected/ Development of Universal/Selected/ Indicated Approach for the AOD FieldIndicated Approach for the AOD Field

Three Steps in the ProcessThree Steps in the Process

FirstFirst:: R. Gordon. 1982, 1987 – R. Gordon. 1982, 1987 – presented model considering presented model considering prevention by prevention by populationpopulation and and riskrisk..

Used the Terms:Used the Terms:–UniversalUniversal–SelectedSelected– IndicatedIndicated

Focus: Still on Health ConsequencesFocus: Still on Health Consequences

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SecondSecond: Institute of Medicine (IOM). In a : Institute of Medicine (IOM). In a major publication in 1994, (“major publication in 1994, (“Reducing Reducing the Risk for Mental Disorder: Frontiers the Risk for Mental Disorder: Frontiers for Prevention Intervention Researchfor Prevention Intervention Research” ” Patrick Mrazek and Robert Haggerty Patrick Mrazek and Robert Haggerty (eds).(eds).

Presented the full Continuum of Care Presented the full Continuum of Care Model:Model:

Focus: Mental HealthFocus: Mental Health

Development of Universal/Selected/ Development of Universal/Selected/ Indicated Approach for the AOD FieldIndicated Approach for the AOD Field

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ThirdThird: Approximately 2000, CSAP adopts : Approximately 2000, CSAP adopts language – mandates use by states language – mandates use by states (2003)(2003)

Focus: Substance Use/AbuseFocus: Substance Use/Abuse

Development of Universal/Selected/ Development of Universal/Selected/ Indicated Approach for the AOD FieldIndicated Approach for the AOD Field

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IOM Approach AssumesIOM Approach Assumes

1.1. The possibility to ‘prevent’ the The possibility to ‘prevent’ the occurrence of a health consequence – occurrence of a health consequence – and that this can occur and that this can occur anytimeanytime. .

– Before ‘onset’ of the behavior/condition Before ‘onset’ of the behavior/condition ‘during’ and with an individual experiencing ‘during’ and with an individual experiencing the ‘full effect’ of the behavior/condition.the ‘full effect’ of the behavior/condition.

2.2. Different strategies and approaches to Different strategies and approaches to ‘prevention’ will be needed – depending ‘prevention’ will be needed – depending where in the continuum you want to where in the continuum you want to address the behavior/condition.address the behavior/condition.

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The Continuum of Care The Continuum of Care ProtractorProtractor

Different levels of prevention are distinguished by the level of risk of disorder/distress in various populations groups targeted.

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Definition of IOM Prevention Definition of IOM Prevention ComponentsComponents

Universal Prevention MeasuresUniversal Prevention Measures: : – Address the Address the entireentire population. population. – Aim is prevent/delay use of AOTD. Deter onset by Aim is prevent/delay use of AOTD. Deter onset by

providing individuals with information/skillsproviding individuals with information/skills

Selected Prevention MeasuresSelected Prevention Measures: : – Targets Targets subsetssubsets of the population considered at risk by of the population considered at risk by

virtue of their virtue of their membershipmembership in a particular segment of the in a particular segment of the population.population.

– KeyKey selected Prevention targets the selected Prevention targets the entireentire subgroup subgroup regardless of the degree of risk of any individuals in the regardless of the degree of risk of any individuals in the group.group.

Indicated Prevention MeasuresIndicated Prevention Measures::– Targets Targets individualsindividuals who are exhibiting early signs or who are exhibiting early signs or

consequences of AOD use.consequences of AOD use.

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Merging ‘old’ definition of Merging ‘old’ definition of Prevention with IOM ApproachPrevention with IOM Approach

UniversalAverage Risk Status of

PopulationAverage Need for

Prevention

SelectedIncreased risk status as a

function of group/class risk – Increased need for

prevention

IndicatedHigh risk status or a

function of individual risk factors

- High need for prevention

Target ConditionBehavioral Manifestation

Implications for Intervention

ComplicationsDirect, Indirect Efforts

Implications for Treatment

Primary PreventionTo reduce new cases

(Incidence)

Secondary PreventionTo reduce existing cases

(Prevalence)

Tertiary PreventionTo reduce complications

(Treatment)

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Some thoughts about IOMSome thoughts about IOM

Advantages:Advantages:1.1. Breaks from a causality model of use.Breaks from a causality model of use.2.2. ‘‘Spectrum of Intervention’ model places great emphasis on Spectrum of Intervention’ model places great emphasis on

the importance of the importance of preventionprevention..3.3. Introduces concept of risk management – importance in Introduces concept of risk management – importance in

knowing proportion of population at risk in turn means knowing proportion of population at risk in turn means most most appropriate prevention strategies can be used.appropriate prevention strategies can be used.

4.4. In turn, this sets up potential for strong evaluation results.In turn, this sets up potential for strong evaluation results.

Disadvantages:Disadvantages:1.1. Driven by focus on Driven by focus on illness illness rather than on enhancing rather than on enhancing

‘wellness.’‘wellness.’2.2. Emphasis on individuals/populations (less so on Emphasis on individuals/populations (less so on

communities).communities).

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Universal PreventionUniversal Prevention

1.1. Targets an entire populationTargets an entire population

NationalNational

LocalLocal

CommunityCommunity

School or NeighborhoodSchool or Neighborhood

2.2. Purpose is to deter the onset of substance use Purpose is to deter the onset of substance use by providing the population with by providing the population with information information and and skills skills to prevent the problem. The entire to prevent the problem. The entire population is considered at risk.population is considered at risk.

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Steps in Developing our IOM Prevention Steps in Developing our IOM Prevention Program for Program for Universal PopulationsUniversal Populations

1.1. What Universal Populations do we want What Universal Populations do we want to focus our prevention efforts on? to focus our prevention efforts on? Identify Universal populationsIdentify Universal populations

2.2. What prevention approaches might we What prevention approaches might we use? use? Identify different approachIdentify different approach

3.3. Why were these approaches selected? Why were these approaches selected? Alignment issueAlignment issue

Group Exercise 1

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Selected PreventionSelected Prevention1.1. You are at risk by virtue of You are at risk by virtue of membership membership in a in a

particular segment of the population particular segment of the population vulnerablevulnerable to to AOD abuse AOD abuse CSAP examples:CSAP examples:

– Children of Adult Alcoholics (COA’s)Children of Adult Alcoholics (COA’s)– Students who are failingStudents who are failing– Youth who live in high drug use neighborhoodsYouth who live in high drug use neighborhoods

2.2. Strategy/Approach Strategy/Approach targetstargets the entire subgroup, the entire subgroup, regardless of the degree of risk of any individual regardless of the degree of risk of any individual within the group.within the group.

– Participants are not assessed for specific Participants are not assessed for specific individual risk factors, but are recruited/referred individual risk factors, but are recruited/referred based on their membership.based on their membership.

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Potential Selected PopulationsPotential Selected Populations

HomelessHomeless

Young OffendersYoung Offenders

Foster YouthsFoster Youths

Drop-outsDrop-outs

Students with social/academic problemsStudents with social/academic problems

Rave party-goersRave party-goers

OthersOthers

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Factors for Creating Prevention Factors for Creating Prevention Programs for Programs for Selected PopulationsSelected Populations

Identification of subpopulation:Identification of subpopulation:– Clear/difficultClear/difficult

Setting and AccessSetting and Access

Alignment:Alignment:– Needs of the subpopulation and the proposed Needs of the subpopulation and the proposed

prevention approach/strategy must alignprevention approach/strategy must align

One Example – Foster YouthsOne Example – Foster Youths

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Foster Youths – A Vulnerable Foster Youths – A Vulnerable Population Selected Population Selected →→ Indicated Indicated

Approximately 90,000 in Foster Care in Approximately 90,000 in Foster Care in CaliforniaCalifornia

Prognosis for Positive Future – GrimPrognosis for Positive Future – Grim– 50% do not graduate from high school50% do not graduate from high school

– 1 in 8 graduate from a 4 year college1 in 8 graduate from a 4 year college

– Only 38% are fully employed 12-18 months after Only 38% are fully employed 12-18 months after leaving programleaving program

– Median salary Median salary lessless than full-time worker making than full-time worker making minimum wageminimum wage

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– 1/3 of youths leaving foster care experience 1/3 of youths leaving foster care experience Emotional and Behavioral problems including:Emotional and Behavioral problems including:

TruancyTruancySocial WithdrawalSocial WithdrawalRunning AwayRunning AwayEngage in Risky BehaviorsEngage in Risky Behaviors

– 50% use drugs50% use drugs– 25% have encounters with CJS25% have encounters with CJS– Higher birth rates among young women Higher birth rates among young women

(40-60% within 12-18 months leaving the (40-60% within 12-18 months leaving the system)system)

– Many experience homelessnessMany experience homelessness

Foster Youths – A Vulnerable Foster Youths – A Vulnerable Population Selected → IndicatedPopulation Selected → Indicated

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Steps in Developing our IOM Prevention Steps in Developing our IOM Prevention Programs For Programs For Selected PopulationSelected Population

Identification of SubpopulationIdentification of Subpopulation– Is this an appropriate subpopulation?Is this an appropriate subpopulation?– Issues – Selected or Indicated or both?Issues – Selected or Indicated or both?

Setting and AccessSetting and Access– Where to go, Who to partner with?Where to go, Who to partner with?

What types of Prevention Approaches might we What types of Prevention Approaches might we considerconsider– Who should we target?Who should we target?– What approaches should we consider?What approaches should we consider?

Group Exercise 2

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Indicated PreventionIndicated Prevention

1.1. Targets individuals who are exhibiting early signs Targets individuals who are exhibiting early signs of substance abuse and other problem behaviors of substance abuse and other problem behaviors associated with substance abuse including early associated with substance abuse including early substance use.substance use.

– Examples:Examples:Binge drinkers, High rate usersBinge drinkers, High rate users

2.2. Strategy/approach Strategy/approach must must have screening process have screening process or other identification processes in place to or other identification processes in place to identify these individuals.identify these individuals.

– The approach involves direct intervention but not The approach involves direct intervention but not formal treatmentformal treatment

3.3. Most ‘indicated’ are part of a selected Most ‘indicated’ are part of a selected subpopulation group.subpopulation group.

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Factors for creating Prevention Factors for creating Prevention Programs for the Programs for the Indicated PopulationIndicated Population

Identification:Identification:– More difficult/complex than selected.More difficult/complex than selected.

Access:Access:– Will vary, more difficult than either universal or Will vary, more difficult than either universal or

selected.selected.

ApproachesApproaches– IndividualizedIndividualized– CostlyCostly– SAP’s represent possible approach for in-school SAP’s represent possible approach for in-school

populations.populations.

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Steps in Developing our IOM Prevention Steps in Developing our IOM Prevention Programs For Programs For Indicated PopulationsIndicated Populations

1.1. What indicated populations in our community do What indicated populations in our community do we want to focus our prevention efforts on? we want to focus our prevention efforts on? – Identify Identify IndicatedIndicated populations. populations.– State State whywhy they are indicated. they are indicated.– Where would we find them?Where would we find them?

2.2. What Indicated prevention approached might we What Indicated prevention approached might we use?use?

3.3. Why were these approaches selected? Why were these approaches selected? – Alignment issueAlignment issue

Group Exercise 3

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IOM PreventionIOM PreventionCircles within CirclesCircles within Circles

Universal Populations

SelectedSubgroups

IndicatedIndividuals

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Intensity Versus Degree of RiskIntensity Versus Degree of Risk

Degree of Risk

Inte

nsi

ty o

f In

terv

en

tion

Universal

Selected

Indicated

Low

Moderate

High

Low Moderate High

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SummarySummaryIOM approach requiresIOM approach requires::

Better understanding of our community – Better understanding of our community – communities within communities.communities within communities.Tired approach in thinking about prevention Tired approach in thinking about prevention services.services.– U.S.IU.S.I

Thoughtful application of prevention approaches Thoughtful application of prevention approaches to the three types of populations.to the three types of populations.

But it gives usBut it gives us::Better focus on AOD problems and individuals Better focus on AOD problems and individuals involved/impacted by AOD use.involved/impacted by AOD use.Potentially better measurements of success.Potentially better measurements of success.

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ConclusionConclusionUse the IOM model to define and target Use the IOM model to define and target populations in need of prevention services.populations in need of prevention services.– Determine whether you are dealing with a Universal, Determine whether you are dealing with a Universal,

Selected, or Indicated populations and what type of Selected, or Indicated populations and what type of problem/condition they are (or could) experience.problem/condition they are (or could) experience.

– Approaches that specifically meet the needs of the Approaches that specifically meet the needs of the populations and AOD conditions of concern.populations and AOD conditions of concern.

Identify potential collaborators/resources to Identify potential collaborators/resources to engage in the prevention approach.engage in the prevention approach.Develop a specific prevention plan for Develop a specific prevention plan for implementing the primary prevention plan.implementing the primary prevention plan.Maintain and evaluate prevention outcomes.Maintain and evaluate prevention outcomes.Target, target, target.Target, target, target.

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This document is a product of the Community Prevention Institute (CPI), This document is a product of the Community Prevention Institute (CPI), a project of the Center for Applied Research Solutions (CARS), to a project of the Center for Applied Research Solutions (CARS), to provide no-cost technical assistance and training to communities provide no-cost technical assistance and training to communities throughout California. CPI is funded and directed by the California throughout California. CPI is funded and directed by the California

Department of Alcohol and Drug Programs. Department of Alcohol and Drug Programs.

For more information about CPI, go to: For more information about CPI, go to: www.ca-cpi.orgwww.ca-cpi.org or or www.cars-rp.orgwww.cars-rp.org. .