Statewide Health Improvement Program (SHIP) Health Care Initiatives Strategies for Preventing Obesity and Chronic Illness in Primary Care Settings

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Statewide Health Improvement Program (SHIP) Health Care Initiatives Strategies for Preventing Obesity and Chronic Illness in Primary Care Settings Speakers: Deb McConnell, MDH Courtney Jordan

1 Statewide Health Improvement Program (SHIP) Health Care Initiatives Strategies for Preventing Obesity and Chronic Illness in Primary Care Settings Speakers: Deb McConnell, MDH Courtney Jordan Baechler, Allina Megan Ellingson and Kristen Godfrey, City of Minneapolis Panelists: Terra Carey, Neighborhood HealthSource Rhonda Eastlund, Cedar Riverside People s Center Lisa Harvey, Park Nicollet Faces of Community Health Conference Bloomington, MN October 27, 2011

2 Learning Objectives Understand how your clinic can have an impact on obesity and chronic disease prevention through defined best practices. Identify community resources, tools, web sites and guidelines for implementing preventions strategies around obesity and chronic disease prevention in your clinic. Articulate local clinics experiences and lessons learned through implementing obesity and chronic disease prevention best practices.

3 Presentation Overview SHIP background SHIP health care initiatives Statewide results from final reports The ICSI guidelines and provider messaging Local health department experiences Clinic process changes and outcomes Community resource connections Clinic panel discussion Q & A and wrap-up

4 Grant funding through health reform legislation Built on work in 4 communities Steps to a Healthier Minnesota (CDC project) Statewide, working with 41 local entities Community health boards (county/city) Tribal groups Multi-grantees

5 4 settings Schools Communities Worksites Health Care Chronic disease prevention and risk reduction Nutrition Physical activity Tobacco use/exposure

Connecting Community Resources to Clinicians & Patients ICSI Guidelines were derived from the practice guidelines of a leading health plan consortium to address obesity and chronic

6 Connecting Community Resources to Clinicians & Patients ICSI Guidelines were derived from the practice guidelines of a leading health plan consortium to address obesity and chronic disease Referrals indicate efforts to link patients to weight management programs in their community for improving nutrition, increasing physical activity and supporting smoking cessation

7 Example of Obesity Guideline Work

8 Example of Referral Work

9 Resulting Policy Change

10 Time for a little insta-survey How many of you work with or in clinics that have engaged in SHIP health care work?

11 Speakers Deb McConnell, RN, MPH MN Department of Health Courtney Jordan Baechler, MD, MS SHIP MD Consultant Megan Ellingson, MHA Minneapolis Department of Health and Family Support Kristen Godfrey, MPH Minneapolis Department of Health and Family Support

12 Clinic Panel Terra Carey, MPH Neighborhood HealthSource Rhonda Eastlund Cedar Riverside People s Center Lisa Harvey, RD, MPH Pak Nicollet

13 SHIP Grant Directed Intervention Uses ICSI Guidelines: Prevention and Management of Obesity (mature adolescents and adults) (Jan 2009) Primary Prevention of Chronic Disease Risk Factors (May 2009) Healthy Lifestyle Guideline 2011

14 Primary Prevention of Chronic Disease Risk Factors Guideline Targets 4 key behaviors Increase Physical Activity Improve Nutrition Decrease Tobacco Use and Exposure Decrease Hazardous Alcohol Use

15 Why? 40% of all deaths in US attributed to four behaviors Poor nutrition Inadequate levels of physical activity Smoking and exposure to tobacco Hazardous drinking

16 Healthy lifestyle - the best medicine! Changing behaviors in previous slide in middle age provides a 40% reduction in mortality compared to those who continue behaviors Correlates with an extra decade of life expectancy

17 Redesign For Results (R4R) Goal: productive interactions between patients and providers Timely information and feedback to patients (tailored treatment plans and self-management) Delivery system design Multidisciplinary team and partnerships Systematic follow-up Public Health teams working with clinic to create systems that support providers in positive patient interactions

18 R4R uses a team approach Different staff have roles in process Rooming staff has BMI available on chart/in record Use MA/LPN to distribute educational materials Staff to help with referrals Use RNs and Health Educators to teach patients and follow-up We already do this with Well Child Checks and other visits

19 Health Risk Assessment Identify health risk factors Screen patients for target behaviors Questionnaire Discussion Checklist Calculate BMI Obtain smoking status Provide feedback on possible behavior changes

20 Feedback Matters! Individualized feedback and health education improve health behaviors and conditions such as: measurements of physical activity reducing dietary intake of fat decreasing tobacco use reducing overall (median) blood pressure measurements reducing overall (median) cholesterol measurements Source: Task Force on Community Preventive Services, 2005a [R].

21 Your role as a provider: name the problem; help make a plan Collaborative decision-making and brief, combined interventions are effective in helping motivate and engage patients in healthier lifestyles Patients see providers as experts Patients assume if we don t mention a problem, it isn t a problem No message sends the wrong message

22 Ask/address topic You ve gained a little weight since your last visit We use weight and height to calculate BMI, yours puts you in the overweight category. I d like to help you make a plan to get that weight off before it causes you health problems

23 Uncomfortable? Remember, only 53 % of overweight patients perceived themselves to be overweight. Many overweight adults become obese. Many patients will not follow through with a referral. We need to diagnose and address the problem and come up with solutions together with the patient.

24 We Are All on a Continuum Optimal Health Goals: don t smoke eat 5 servings fruits and veggies a day exercise 5+ days/week - do not consume excessive alcohol Please consider if all of these are true for you If not, will you commit to one small step to improve your health? What feelings does this raise?

25 Small Bouts of Activity Take the stairs Play with your kids Park further away Activity breaks from TV (during commercials) or computer Start wearing a pedometer Walk 10 minutes a day Get off one bus stop earlier and walk Take an exercise class or join the Y

26 Helping patients choose healthy foods - the big picture Eat fewer processed foods Eat in moderation Portion control Eat a variety of foods Smaller, more frequent meals Learn to read food labels

27 Setting small goals with patients Pack lunch instead of fast food Eat a healthy breakfast Review portion size Add 1 fruit or vegetable per day

28 Minneapolis SHIP Clinical Best Practices Project This collaborative (multi-grantee) project of the Minneapolis, Hennepin County and Bloomington health departments helps clinics implement evidence-based obesity and chronic disease prevention guidelines developed by the Institute for Clinical Systems Improvement (ICSI). This Minneapolis Department of Health and Family Support program is funded through the Minnesota Department of Health s Statewide Health Improvement Program.

29 Mission Through collaboration and partnership, assist selected clinics/clinic systems incorporate and implement the ICSI obesity and chronic disease prevention guidelines into routine patient care including documenting, counseling, referring to community resources and follow-up.

30 ICSI Guideline Components For chronic disease risk factors: BMI Nutrition Physical Activity Tobacco Alcohol Provide: Documentation of risk Counseling Referral to community resources Follow-up

31 Vision Chronic disease risk factors in Hennepin County will be reduced because all Hennepin County providers are: Assessing all patients at preventive and chronic disease visits for Body Mass Index (BMI), physical activity, nutrition and tobacco use/exposure Discussing assessment results with patients, and Referring patients to effective clinic- and communitybased resources ---AND--- Other clinics/clinic systems will use our experiences and models to implement the guidelines in their organizations

32 Goals for Reimbursement Work Outline recommended primary care treatment, services and providers for overweight and obesity Assess and describe current health plan coverage of these recommended treatments, services and providers Identify strategies to improve coverage Develop a brief targeted communication to be shared with clinics on coding for overweight and obesity services Work with partner clinics to maximize their billing through appropriate coding

Partner Clinics Multi-grantee project clinics implementing the ICSI prevention guidelines: Bloomington Lake Clinic (Minneapolis and Bloomington sites) HCMC s East Lake and Brooklyn Center Clinics

33 Partner Clinics Multi-grantee project clinics implementing the ICSI prevention guidelines: Bloomington Lake Clinic (Minneapolis and Bloomington sites) HCMC s East Lake and Brooklyn Center Clinics Neighborhood HealthSource (Fremont, Central and Sheridan) Neighborhood Involvement Program Park Nicollet system (Minneapolis pilot site) The People s Center Medical Clinic Added in May, 2011: North Clinic (Robbinsdale, Osseo, Maple Grove) NorthPoint Health and Wellness Center

34 Process clinic work Baseline Assessment Current Practice Compare to Guidelines Ready to change? 12 Month Collaborative ICSI: face-to-face sessions, webinars, conference calls, action plan review, progress reports review LPH: resources, tools, support Partner: action plan creation and implementation Post-Initiative Assessment

35 Process oversight and reimbursement Health Care Work Group Policy and coding consultants

Example Clinic Goals Measure BMI on: every adult patient at annual physical all patients over 18 years at preventive visits each patient on each visit Develop systems for intervening for BMI >= 30

36 Example Clinic Goals Measure BMI on: every adult patient at annual physical all patients over 18 years at preventive visits each patient on each visit Develop systems for intervening for BMI >= 30 Create an Obesity Team: patient, provider, clinical staff and ancillary support staff For patients with BMI >= 25, assess and set goals for physical activity Provide follow-up to assess change and progress Complete staff education on ICSI guidelines Create documentation and forms; formulate tracking plans

Example Implementation Models Obesity Team (short- or long-term) to assess clinic activities, set goals, develop action steps and measure results On-site MD training (at start, or after

37 Example Implementation Models Obesity Team (short- or long-term) to assess clinic activities, set goals, develop action steps and measure results On-site MD training (at start, or after process redesigned) Pilot with small group of patients (ex: pre-diabetes) and expand to others Use current QI staff and/or incorporate into other QI initiatives (ex: diabetes prevention and treatment)

38 Outcomes Evaluation methods: Chart audits Staff/provider surveys Follow-up stakeholder interviews

Outcomes BMI measurement documented: Baseline = 25-48% Follow-up = 80-95% SHIP helped us gather data more consistently which triggered a chain of events

39 Outcomes BMI measurement documented: Baseline = 25-48% Follow-up = 80-95% SHIP helped us gather data more consistently which triggered a chain of events for patient care in a positive way. Chart audits show massive improvement in BMI, tobacco and alcohol screening all are up to 95%. Clinic representative

40 Outcomes Over 30 clinic staff/providers received training on the ICSI guidelines and quality improvement strategies. Before SHIP staff had ideas for preventive health care, but were having problems implementing them. SHIP changed that. It increased our staff s knowledge, improved the quality of patient care and improved patient health. In follow-up with patients I ve found a number of patients excited about weight loss and feeling better about themselves. --Clinic representative

41 Outcomes Providers also like knowing their practice is evidence based. And from a macro-level of trying to bend the cost curve, it s some of the really basic things like just talking to patients about their weight that makes a difference. --Clinic representative

42 Outcomes Clinics report increased staff and patient engagement in obesity and chronic disease prevention efforts. A patient I have has diabetes, high blood pressure, high cholesterol and is obese. She s lost 10 pounds, is feeling better about herself and is making conscious decisions about her health. She looks at things in a different way, basically changing how she lives and the choices she makes, and she s feeling really good about making those changes. --Clinic representative

43 Outcomes One of our patients was transitioning her family out of a homeless shelter and she used health as the motivator for her kids to be in control of their own destiny. She got them involved in everything she could to improve their health. Now they re thriving. Our success stories are always when the patient is as invested in their health as we are. --Clinic representative

44 Outcomes You can t quantify this. [It s] more of a team concept. We are taking more time with patients during visits. Staff and patients enjoyed it, they [patients] took it as we care and saw us as family. We are creating better rapport with patients which helped with the follow-up. Overall patients like this approach. --Clinic representative

45 Recommendations/Lessons Learned Progress can be made by setting small, achievable goals. Get providers and staff involved in their own lifestyle changes. Clinic team approach was adopted by all clinics. Dieticians and primary care providers are generally reimbursed for counseling time; payment for other clinic team members and phone followup/coaching would be useful additions to current payment models.

46 Recommendations/Lessons Learned Themes from policy scan report: There is no common language used for obesity prevention. Weight management appears most accurate. Organizations are actively offering weight management services, but physicians and clinics rarely refer patients to these resources. Confusion exists on how to code and pay for obesity/overweight related patient care. Determining a minimum primary care clinical intervention may be helpful. Stakeholders reported collaboration with public health and one another is welcomed.

47 Tools SHIP Clinic Toolkit: Reimbursement matrix and health system report will be posted here. Your BMI patient handout Counseling Messages (Hennepin County)

48 Getting Your Clinic Started

49 Getting Your Clinic Started 1. Set a goal to measure and document BMI on all adult patients at preventive and chronic disease management visits. 2. Post BMI charts at scales and in patient rooms. 3. Review Lifestyle Risk Tool and add one or more missing components to your clinic s intake form; use chart audit tool to gather baseline data and measure progress. 4. Share Counseling Messages handout with staff/providers and discuss at staff meeting; identify next steps. 5. Review patient education materials on the Toolkit website and add materials to assist providers in coaching patients (Example: BMI handout and Managing Your Weight Log Book).

for physical activity, and tobacco cessation.

50 Minneapolis SHIP Health Care Referral Project The purpose of this project is to increase patient referrals from clinics to community resources providing high quality nutritious foods, opportunities for physical activity, and tobacco cessation. This Minneapolis Department of Health and Family Support program is funded through the Minnesota Department of Health s Statewide Health Improvement Program.

51 Goals Develop a resource system that health care providers can use to refer patients to clinicand community-based programs and services for obesity and tobacco cessation. Assist 10 clinics to implement and evaluate a resource referral system and increase patient referrals to resources

52 Project Partnerships MDHFS is working with the following clinics to develop, implement, and evaluate a resource referral system: AXIS Medical Center Broadway Family Medicine Neighborhood HealthSource (Fremont, Central and Sheridan) Neighborhood Involvement Program NorthPoint Health and Wellness Center Park Nicollet system (Minneapolis pilot site) Phillips Neighborhood Clinic The People s Center Medical Clinic MDHFS is working with a variety of health care stakeholders, community organizations, SHIP grantees, and the Minnesota Department of Health to broaden the scope and impact of this work locally and statewide.

53 Issue 2010 Baseline Assessment Results indicate: Only 7% of providers and 14% of staff surveyed refer all or most at-risk patients to obesity and nutrition resources 71% of providers and staff surveyed indicate that a referral system or mechanism would assist them in making referrals for obesity and tobacco cessation 63% of providers and staff surveyed indicate they are unaware or unfamiliar with programs and services available Patients are interested in free, accessible resources: Trails; parks; fitness and recreation centers; farmer s markets Walking/running; exercise machines; exercise/nutrition classes Face-to-face counseling/coaching and support groups

54 Key Strategies MinnesotaHelp.info Establish a statewide health and wellness resource database to maintain resources Clinic referral processes and resources Develop clinic-specific resource lists and systematic processes for referrals Direct referral pipelines Build partnerships between clinics and community organizations to offer programs onsite and/or in the community HealthyLiving Minneapolis Develop network of accessible and affordable programs and services to partner with clinics for referrals

55 MinnesotaHelp.info What is MinnesotaHelp.info (MHI)? A searchable online database of health and human services in Minnesota for seniors, people with disabilities, parents and families, veterans, youth, and people with low-income Expanded through SHIP to include heath and wellness resources How can clinics use MHI? Use the Power User Version to easily search, save, print, export, , and map resources Narrow search results by location, zipcode, language, and target group Create customized printable clinic resource directories Link a customized version directly to a website or EMR How can community agencies use MNHelp.Info? Use the Provider Portal to add and update program and service information to keep clinics informed

56 Clinic Process Conduct assessment of patient and provider needs/barriers Create clinic action plan with aims, measures and action steps to increase referrals Review current referral process and identify improvements Conduct changes in clinic protocols and staff roles Develop tools, forms and/or EMR modifications Develop clinic specific list of resources Conduct clinic training on resources and train staff on how to use MNHelp.Info to find patient resources Identify gaps in resources and opportunities for onsite programs and community partnerships Develop ways to track and measure referrals Conduct quality improvement and follow-up assessment to determine outcomes

57 Example Clinic Referral Changes Clinic 1 Patient Advocate provides at least 1 community referral per patient visit using MNHelp.Info and tracks in spreadsheet Clinic 3 Resource list distributed to providers, staff, and CHWs Clinic 4 Developed nurse referral algorithm for exercise/nutrition counseling and resources Clinic 4 Added MNHelp.Info link to internal website and trained providers on use Clinic 5 MA provides patient with BMI card and resources using MNHelp.Info Clinic 6 Dietitian contacts patients with BMI>30, provides counseling, walks with patients and refers to community resources

for Somali patients Community-based programs and services Nutrition cooking class Cooking Matters offered in

58 Direct Referral Pipelines Clinic-based programs and services Childhood obesity program We Can Dietetic Intern support to offer nutrition services and classes to patients Weight management classes Shape-Up Yoga classes Tobacco cessation class for Somali patients Community-based programs and services Nutrition cooking class Cooking Matters offered in collaboration with Community Ed I Can Prevent Diabetes classes in collaboration with Simply Good Eating YMCA Diabetes Prevention Program

59 HealthyLiving Minneapolis What is HealthyLiving Minneapolis? Network of organizations that provide accessible and affordable programs and services for healthy eating, physical activity, and tobacco cessation. Partners with clinics to accept referrals and link patients to resources. Network organizations Participating organization were selected based on patient and provider needs and preferences: Minneapolis Community Education Minneapolis Park & Recreation Board U of M Extension, Simply Good Eating and Cooking Matters WellShare International YMCA of Metropolitan Minneapolis YWCA of Minneapolis

60 Outcomes Overview of PSE changes: 10 clinics made systematic referral process changes to increase referrals, 6 adopted a formal policy change 10 clinics made physical changes to support process changes (e.g. medical record; referral forms; resource displays, signs, calendars, brochures; dietetic personnel) 100 resources were added to MNHelp.Info and the Greater Twin Cities United Way caller database Over 60 clinic staff/providers received training on using MNHelp.Info to link patients to resources 5 new patient education and support classes as a result of partnerships between clinics and community orgs 5 clinics pilot HealthyLiving Minneapolis

61 Outcomes 2011 follow-up assessment results indicate that compared to a year ago: 53% of providers reported increased awareness of community and clinic-based resources for obesity 43% of providers/staff reported increased referrals to obesity resources 28% of providers/staff reported increased referrals to tobacco resources 97% of providers/staff respondents thought MNHelp.Info was a useful tool and would recommend other clinics use it 70% of providers/staff reported the priority level that their clinic places on referrals to resources has increased

62 Outcomes Having something to offer allows me to make the referral. - Clinic Provider I can finally now see that patients are starting to think about their health. Some even ask about their BMI and what that means. Clinic Provider The MNHelp.Info database has cut time spent on finding the appropriate resource. It is a very effective tool! Clinic Representative The warm hand-off is very important for patients to access resources, if they even know the name of someone where they are going, they are more likely to go. Clinic Representative

63 Lessons Learned What will support implementation? Information and training on available resources Paper list and web-based directories of resources Availability of resources to meet patient needs Using a team effort of health care staff to implement Combination of clinic and community based programs through community partnerships What are barriers to implementation? Provider/staff awareness of and access to resources Even when community resources are convenient and available for free, it s difficult to get patients to use them. Perceived barrier of patient/family interest and cooperation What is still needed? A follow-up mechanism Individualized support for lifestyle behavior change

64 Getting Your Clinic Started Develop list of resources and use MNHelp.Info to manage them Provide staff/provider training on resources and MNHelp.Info Review current process for making referrals and identify improvements. Develop clinic processes for linking patients to resources Identify gaps in resources and opportunities for onsite programs and community partnerships Contact community organizations and invite them to your clinic to learn more about their programs and develop a partnership for referrals

65 Tools and Resources United Way My HealthyLiving Goals referral form Minneapolis and clinic-specific resource lists SHIP Health plan and clinic system services grids

66 Clinic Panel 1. Highlight the main changes your clinic made as part of the SHIP project. 2. Highlight your major successes and/or barriers. 3. Where will your clinic go from here?

67 Contact Us Deb McConnel, (651) Courtney Jordan Baechler, (612) Megan Ellingson, (612) Kristen Godfrey, (612)

68 Contact Us Terra Carey, (651) Rhonda Eastlund, (612) Lisa Harvey, (952)

MN Partnership for Pediatric Obesity Care and Coverage (MPPOCC)

MN Partnership for Pediatric Obesity Care and Coverage (MPPOCC) Best Practice Guidelines in Clinic/Community Collaborative Pediatric Obesity Services Presented to: MPPOCC Members and SHIP Grantees January