implementation of the primary care pathway for the...
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Implementation of the Primary Care Pathway for the Prevention and Management of Obesity (3PMO) within Calgary Foothills Primary Care Network (PCN)Sonja WicklumMartha Nystrom
March 6, 2020Rimrock HotelACFP
Presenter: Sonja Wicklum• Speakers Bureau/Honoraria: N/A
• Consulting Fees: N/A
• Grants/Research Support: Chief Medical Officer-AHS CMO QI Grant, Alberta Government Division of Parks RPAD Grant, CFPC DM Robb Grant
• Patents: N/A• Other: Salaried position University of Calgary
Team:
Sonja WicklumDepartment of Family Medicine, Sheldon Chumir, Calgary Foothills PCN, physician member
Martha Nystrom, Project CoordinatorAdaeze Nwigwe, Data AnalystAllison Fielding, Director Service Delivery
Calgary Foothills PCN
Sasha Wiens, ManagerCalgary Adult Bariatric Surgery Clinic Manager, Alberta Health Services
Laurie Blahitka, Executive DirectorAlberta Health Services
Ashlee McGuire, Research ScientistDepartment of Family Medicine, Alberta Health Services
Collaborators:
Petra O’Connell, DON SCNKerry McBrien, University of Calgary, Dept of FMRichdeep Gill, University of Calgary, Dept of SurgeryYunqi Ji, AHSYazid Hamarneh, ABSPORUDenise Campbell-Scherer, University of AlbertaThea Luig, University of AlbertaDawn Hatanaka, Obesity CanadaMicheal Vallis, Dalhousie UniversityKelly Mrklas
67% Albertans struggle with overweight or obesity
Costly 1.27 billion AB (HCQA 2015) Our understanding is recent/rapidly
growing
Action Study (Sharma et al, Clin Obes. 2019)
2000 people with obesity
395 healthcare providers
150 employers – offering health ins. To >20 employees
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0
10
20
30
40
50
60
70
80
90
100
THERE ARE MOREIMPORTANT
HEALTHISSUES/concerns to
discuss
I DO NOT FEELMOTIVATED to lose
weight
The APPOINTMENTIS NOT LONG
ENOUGH/I amrushed
I DO NOT VELIEVE IAM ABLE TO LOSE
WEIGHT
I am in good healthand DO NOT HAVEWEIGHT-RELATED
HEALTH PROBLEMS
I am NOTINTERESTED inlosing weight
Resp
onde
nts (
%)
Reasons for not discussing weight management
PwO (n=2,000) HCPs (n=395)
Sharma AM, Bélanger A, Carson V et al. Perceptions of barriers to effective obesity management in Canada: Results from the ACTION study. Clin Obes. 2019;9(5):e12329
Challenge for Family Doctors
Lack of organized care, more research needed
Provider education improves weight loss MDT improves weight loss
- Flodgren et al.. 2017
Lack of tools Time burden Knowledge deficit Resource issues
- Potter et al., 2001; Dietz et al., 2015; Bleich et al., 2011
Leverage
Relationships family doctors have with patients Strong team members Organize care
Team: DFM, CFPCN, CABSC, AHS
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Aim
↑ activation/satisfaction of patients ↑ engagement/satisfaction of care providers Improve efficiencies – “the right patient, with the right
provider, at the right time”
Stages
Y1 – developed evidence-based tools and pathway, embed in EMRs and launched!Y2 – patient focus group, expanded into more clinicsY3 – patient interviews, further expansion, focus on health team education
Presently in MedAccess, Wolf, Practice Solutions, Accuro 10 Large Clinics, 81 physicians
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Ask for permission to discuss weight
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Permission not given• Today might not be the right time • Let the patient know you are ready to talk when they are
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If permission is given, explore readiness for change
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Discuss options
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Provide information on programs, services and resourcesPrimary Care Network
• Group sessions
• Individual appointments with health team
Visit cfpcn.ca
Alberta Health Services
• Adult Mental Health and Addiction Services
• Calgary Adult Bariatric Surgery Clinic
• Alberta Healthy Living Program
• Specialty care servicesVisit ahsweb.ca/www/cdmcalgaryzone-asp
Online resources
obesitycanada.ca
ucalgary.ca/cdm/OnlineClasses
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Offer a Personalized Weight Assessment (PWA)- completed by health team or physician/resident
Steps:1. Patient completes an online comprehensive intake form
2. Patient will have a one on one visitwith the PCN Health Team and consider:• Root causes/drivers• Individual priorities• Health belief• Cultural dimensions
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Offer a Personalized Weight Assessment (PWA)
3. Tailored next steps including:
• Collaborative development of an individual plan• Discussion of management options• Referrals to programs and services
4. PWA summary shared with family physicianfor coordination of care.
Evaluation
Patient Activation - PAM®? Patient and provider experience
Why PAM®?
Definition: Individual’s knowledge, skill and confidence managing health and health care
Experience in CFPCN Increases linked to lower HC costs, improved healthy behaviors, improved
confidence in managing own health (Kenney et al., 2017; Green et al., 2015)
Limitations Limited use specifically with obesity Variability of results in countries other than the US Costing from US studies (economics data may not apply)
1: 47.0 or lower2: 47.1 -3: 55.2 -4: > 72
Timeframe N Mean -△ PAM p
Baseline – Post-Assessment 119 (70% response rate) 3.1 (61.5 SD 11.5 – 64.5 SD 12.3)
0.0029
% with ↑ PAM 50%
Post- Assessment – 3 month post
54 (32% response rate) 6.3 (65.8 SD 11.41 –72.1 SD 12.7)
0.0022
% with ↑ PAM 61%
Baseline – 3 month post Assessment
52 (31% response rate) 9.9 (62.08 SD 10.6 –72.0 SD 11.2)
0
% with ↑ PAM 73%
PAM® Score Change
Snapshot of N=60
Subset Demographics Mean (range)Age 53 (19 – 81)Sex Female 47 (78%)
Male 13 (22%)BMI 36.6 (25.3 – 50.3)
Readiness to change Pre-contemplation/contemplation 22%Preparation/action 78%
Baseline PAM score 63 (37-100) n = 37
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67%
75%
83%
92%
33%
25%
17%
8%
The ASK appointment helped me to determine patients’ readiness (n=12)
I am confident that I will integrate this practice into myroutine patient care process (n=12)
The PWA summary identified contributors to weightgain that I was not aware of previously (n=12)
The PWA summary provided enough informationabout the tailored plan developed for my patients
(n=12)
Physician Experience Survey
Strongly Agree/Agree Neutral Stronly Disagree/Disagree
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75%
75%
75%
75%
75%
25%
25%
25%
25%
25%
Completion of the PWA helped me recommend the appropriate services to improve my patient’s health (n=4)
Completion of the PWA helped my patient clearlycommunicate their needs and values (n=4)
Completion of the PWA provided the support and framework to better understand and meet my patient’s
needs (n=4)
Completion of the PWA enhanced the quality of care Iprovide for my patient (n=4)
Having the patient complete the intake form in advanceof the appointments helped focus the discussion on theirroot causes and tailor the development of their plan (n=4)
Inter-disciplinary Health Team Satisfaction Survey
Strongly Agree/Agree Neutral Strongly Disagree/Disagree
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99%
99%
99%
4%
75%
92%
90%
1%
1%
1%
1%
21%
7%
8%
1%
96%
4%
1%
2%
I felt comfortable discussing the topics included in thepersonalized weight assessment with my healthcare provider…
My healthcare provider explained things in a way I couldunderstand during the assessment (n=137)
I felt that my values and needs were heard and considered bymy health care provider (n=137)
I felt that some of my health issues were ignored by my healthcare provider (n=136)
After completing the personalized weight assessment, I feelmore confident in my ability to understand and manage my…
The time spent to complete the personalized weightassessment, both before and during the appointment, was…
I am satisfied with the healthcare plan that my healthcareprovider and I have developed (n=133)
Patient Satisfaction Survey Post Assessment
Strongly Agree/Agree Neutral Strongly Disagree/Disagree
Snapshot from Interviews
“She [health management nurse] was great. . . . I never felt judged. . . . She was an excellent listener. . . . If there’s anything I
wanted to talk about whether it was emotional or health or activity or otherwise, …”
“You could tell that the assessor had read my questionnaire and was looking at me as a person. . . . I would say that … in my 10+ years of looking at external weight loss programs, they were probably one of
the first that were 100% non-judgmental.”
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Pathway appears to be increasing activation What is happening to non-responders? Health team interviews in process – appreciate their
enthusiasm, willingness to learn!! Need more robust IDHT and family doctor education
and, readiness and competency assessment High degree of patient, family doctor and IDHT
satisfaction Process is allowing time for a meaningful and effective,
collaborative approach
Other Challenge: How to support PAM Level 1, 2 patients or patients
“not ready”
Conclusions
Addressing the challenges Expanding
Where we are going…