Baltic, Steven

Bhardwaj, Vartika

DeAngelis, Glenn

Kwarcinski, Thomas, MS

Mcfadden, Kathleen

Psomiadis, Victoria

Ramsooksingh, Meera

Schroeder, Robin S., MD

Weseloh, Adison

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Family MedicineDevelopment and Implementation of IntensiveBehavioral Therapy for Obesity in the Primary CareSettingKathleen McfaddenLehigh Valley Health Network, Kathleen.Mcfadden@lvhn.orgMeera RamsooksinghLehigh Valley Health Network, Meera.Ramsooksingh@lvhn.orgSteven BalticLehigh Valley Health Network, Steven.Baltic@lvhn.orgVartika BhardwajLehigh Valley Health Network, Vartika.Bhardwaj@lvhn.orgGlenn DeAngelisLehigh Valley Health Network, glenn.deangelis@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/family-medicinePart of the Medical Specialties CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtMcFadden, K., Ramsooksingh, M., Baltic, S., Bhardwaj, V., DeAngelis, G., Kwarcinski, T., Psomiadis, V., Weseloh, A., & Schroeder, R.(2016, June 16). Development and Implementation of Intensive Behavioral Therapy for Obesity in the Primary Care Setting. Posterpresented at 2016 AACH ENRICH-FORUM Healthcare Communication Course, Yale University, New Haven, CT.AuthorsKathleen Mcfadden, Meera Ramsooksingh, Steven Baltic, Vartika Bhardwaj, Glenn DeAngelis, ThomasKwarcinski MS, Victoria Psomiadis, Adison Weseloh, and Robin S. Schroeder MDThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/family-medicine/297Department of Family Medicine and the Weight Management Center, Lehigh Valley Health Network, Allentown, PA, University of South Florida Morsani College of Medicine, SELECT MD Program, Tampa, FLKathleen McFadden, Meera Ramsooksingh, Steven Baltic, Vartika Bhardwaj, Glenn DeAngelis, Thomas Kwarcinski, Victoria Psomiadis, Adison Weseloh, and Robin Schroeder, MD, FAAFPDevelopment and Implementation of Intensive Behavioral Therapy for Obesity in the Primary Care Setting  © 2016 Lehigh Valley Health NetworkFigure 1: Team Charter.Preventative healthcare measures often occur in the primary care setting where many patients have a strong therapeutic alliance with their primary care provider (PCP). Intensive Behavioral Therapy (IBT) for long-term weight loss is currently underused nationwide. Following the passage of the Affordable Care Act, Centers for Medicare & Medicaid Services (CMS) now cover IBT to facilitate long-term weight loss in patients who are both overweight/obese (Body Mass Index [BMI] > 25). Currently, CMS will cover up to 22 office visits per year for IBT in the primary care setting. This is a potentially more affordable way for patients to improve their health and wellness. Knowing this, Lehigh Valley Health Network (LVHN) assessed network data which showed that of the 186,754 adult BMIs documented per year in the primary care setting, 127,699 (68%) currently are >25. These are consistent with national data from 2010, which stated that two-thirds of adults in the US are overweight or obese (NIH).  In line with LVHN’s Triple Aim – Better Health, Better Care, Better Cost – the LVHN Weight Management Center and the Department of Family Medicine wanted to make weight management more accessible for patients using a standardized IBT model. IBT incorporates Motivational Interviewing to facilitate self-directed behavioral modifications. This pathway includes 1) an evidenced-based IBT information packet, 2) EMR templates to facilitate documentation and billing, 3) patient education materials, and 4) periodic feedback surveys. Currently, two primary care practices of LVHN are pilot sites for IBT for long-term weight loss.The goals of this quality improvement project were to:•  Identify resources and barriers to implementing IBT in the primary care practices throughout LVHN. •  Create achievable countermeasures to overcome identified barriers to initial implementation of IBT at two LVHN pilot practices.Introduction•  The Lean Six Sigma model used in this project is highly effective in identifying achievable goals based on thorough root cause analysis to make healthcare improvements.•  Incorporating MBTI, ESCI and conflict management styles into implementing the project was beneficial in organizing the team based on individual strengths.•  The perceived need for IBT was supported by outcomes from the physician survey. Despite having limited awareness of the CMS-coverage for IBT, providers were confident, willing, likely and confident to implement this for their patients.Future Work•  Develop tools to measure efficacy throughout the implementation of IBT in the primary care office.•  IBT for weight loss, if proven successful with patients insured with Medicare, could also be transformative for non-CMS patients with obesity in any practice nationwide.•  Current plan for further roll-out within LVHN has been targeted for September 2016. Methodology•  Organizing the team and identifying the problem  –  Developed a problem statement, created a team charter (Figure 1) , and organized team responsibilities using a Gantt chart.  –  Shared individual goals, Myers-Briggs Type Indicator (MBTI), components of the Emotional and Social Competency Inventory (ESCI), and conflict management style among group members. •  Analyzing the problem and identifying solutions  –  Identified current conditions, targeted improvements and implementation barriers using an A3 (Figure 2).  –  Performed root cause analysis to identify barriers to IBT implementation using “The 5 Whys”. This was documented in an Ishikawa (Fishbone) Diagram (Figure 3) with subsequent identification of multiple countermeasures (Figure 4).•  Implementing the countermeasures  –  Facilitated Motivational Interviewing Training Session for practitioners and administered pre- and post- MI workshop surveys (n = 4) (Figure 5).  –  Sent physician survey via email to all Family Medicine physicians of the Lehigh Valley Physician Group (n = 70/150) (Figure 6).  –  Developed supplemental educational materials including a MyFitnessPal tutorial and a pamphlet explaining IBT.  –  Designated medical student practice liaisons communicated for pilot sites to monitor implementation progress.•  Ongoing from start to finish  –  Conducted routine team meetings to check to evaluate goals, deadlines, and accomplishments and adjusted A3 and deliverables accordingly.ConclusionsReferences:1.  Overweight and Obesity Statistics. National Health and Nutrition Examination Survey. National Institutes of Health, 2010. Accessed 20 May 2016.2.  http://www.niddk.nih.gov/health-information/health-statistics/Pages/overweight-obesity-statistics.aspx.Figure 1: Team Charter. A charter was developed to facilitate discussion on team organization and operational processes. Team Norms were based on individual Myers-Briggs Type Indicator (MBTI) and Emotional and Social Competency Inventories (ESCI). Individual Conflict Management Styles were integrated. By signing the Team Charter all were committed to achieving succes through shared accountability.Figure 2: A3 Template. Developed in the Lean concept of Kaizen, or continuous process improvement, the A3 is a documentation tool used to facilitate assessment and analysis of the present state. Figure 3: Ishikawa (Fishbone) Diagram. This Lean Six Sigma tool is a pictorial depiction of the root cause analysis using the “The Five Whys” to assess barriers to implementation of IBT. The countermeasures were determined based on root causes.Figure 4: Countermeasures. The team determined next steps to mitigate the causes of the current condition.Figure 5: Results from the Motivational Interviewing (MI) Survey. Overall, the MI workshop participants reported an average 1-point increase in Likert scores with a right-shift to all survey questions following the workshop.Figure 6: Results from the Physician Survey. LVPG Family Medicine Physicians (n = 70/150) completed a 5-question online survey. Questions were answered on a Likert scale (1-5). Approximately 80% participants (Likert score >3) consider themselves A) confident in their ability address obesity in practice. B) As expected, about 80% of participants (Likert score < 2) were not aware that CMS reimburses for IBT for weight loss in the primary care setting. About 80% of participants (Likert >3) were C) willing to implement and D) likely to use a “ready-made” IBT program with support in their practices. In an open-response question (data not shown) participants indicated that patient education was their most needed resource.Results012341Not confident2 3 4 5Very confident# participantsConfident to help patients achieve long-term weight lossPrePost012341Notcomfortable2 3 4 5Verycomfortable# participantsComfortable using MI to help patients achieve long-term weight lossPrePost012341Not smart2 3 4 5Very smart# participantsKnowledgeable to help patients achieve long-term weight lossPrePostNot knowledgeableVeryknowledgeableA BC012341Not aware2 3 4 5Very aware# participantsAwareness that personal biases may impact interactions with patients, who want to lose weightPrePost012341Not aware2 3 4 5Very aware# participantsAwareness that the language used while interacting with patients may impact how well patients are helped with their weight-loss goalsPrePostC D0%10%20%30%40%50%60%1Not confident2 3 4 5Very confidentConfidence in ability to effectively address obesity in my practice with patients0%10%20%30%40%50%60%1Not aware2 3 4 5Very awareAwareness that IBT in a primary care setting is reimbursed by CMS for up to 22 visits/year0%10%20%30%40%50%60%1Not likely2 3 4 5Very likelyLikeliness to use a “ready-made” IBT program, with support,in my practice0%10%20%30%40%50%60%1Not willing2 3 4 5Very willingWillingness to implement IBT in my primary care practice% participants% participantsA BC% participants% participantsDCOUNTERMEASURES DESIRED CONDITIONEnvironment Materials MachinesPeople MethodsIncrease the use of IBT for weight loss in the primary care setting.1) Develop bias education materials. 2) Provide provider-to-provider teaching.1) Provide pts with Evidence-Based Resources2) Facilitate MI Workshops 1) Develop EMR templates with integration into EPIC dashboard1) Obtain cumulative feedback from pilot practices to obtain buy in2) Assess providers to assess willingness to implement IBT1) MI training sessions2) Standardized pteducation binders3) Simplified billing handoutsROOT CAUSES CURRENTCONDITIONCOMPLIANCE MEASURES/TRACKINGEnvironment Materials MachinesPeople MethodsCULTURE BARRIERS/BIASESNETWORK CULTURESAFE SPACETIMELACK OF EDUCATIONAL MATERIALS EPICMEDICAL EQUIPMENTLACK OF PROVIDER RESOURCESSTAFF TRAINING/KNOWLEDGE BASELACK OF BUY INPRIORITIZATION OF CAREPATIENT VS PROVIDER PREFERENCEPOLICIESBILLINGVISIT IMPLEMENTATIONReferrals Wt Loss ClinicPt Comfort Office PrivacyCommitmentTime to Train PCPsLVHN primary care  practices are NOT using IBT for weight loss.Figure 2: A3 Template.Figure 3: Ishikawa Diagram.Figure 4: Countermeasures.Figure 6: Results from Physician Survey. (A-D)Figure 5: Results from the Motivational Interviewing (MI) Survey. (Continued C-D)Figure 5: Results from the Motivational Interviewing (MI) Survey. (Continued A-C)

Development and Implementation of Intensive Behavioral Therapy for Obesity in the Primary Care Setting

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1306&context=family-medicine

Development and Implementation of Intensive Behavioral Therapy for Obesity in the Primary Care Setting

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