The Florida Department of Health in Pinellas County (DOH-Pinellas) has five primary centers providing health services for Pinellas County, Florida. Pinellas County is located on the west coast of Florida and is the most densely populated county in the state. The public health issue addressed by this model practice is obesity among our primary care clients. The goal is to reduce the financial and health burdens of obesity for those clients whose BMI is over 25 and who indicate a willingness to improve their lifestyle. The objectives for participants are lifestyle changes to improve their nutrition and increase their physical activity in order to lose weight. For successful participants, this translates into improved self-esteem, decreased obesity-related morbidity and mortality (lower blood pressure, blood glucose and fasting lipid panel) and decreased use of medication.
The practice is implemented through an internal referral process and regular monthly visits. DOH-Pinellas primary care providers refer appropriate clients to the weight management clinic during an office visit. Those clients who are interested are scheduled to see the bariatric physician and the nutitionist at their medical home location. Clients are then scheduled for monthly visits with the physician and nutritionist that include evaluating weight, blood pressure, exercise type and routine, and diet. No weight loss (anorexiant) medications are utilized. This model is based on the physician as motivator and educator, backed up by the nutritionist's information, which many studies have shown is effective.
The results are that clients are losing weight, lowering their blood pressure, A1C levels, and fasting lipid panels, and they are maintaining the weight loss. In the last 2 years, clients in the weight management clinic have lost a mean of 17.68 pounds, 7% of their body weight, and lowered their mean BMI from 39.54 to 36.69. Further, it was discovered that the number of visits directly correlated with the amount of weight lost, and that a greater number of whites, females, and persons aged 45-60 participated than other race, gender, and age groups.
The public health impact is to demonstrate that motivated overweight residents who are uninsured and low income can lose weight and maintain it, in spite of additional barriers such as lack of access to healthy foods, financial constraints, and environments not conducive to exercise. This can be done without medication and with the education and motivation provided by a trained physician and a nutritionist.
To supplement this application, a copy of the poster is attached which was recently presented at the American Society of Bariatric Physicians’ National Symposium on Obesity and Associated Conditions in October, 2013.
LHD: The Florida Department of Health in Pinellas County (DOH-Pinellas) has five primary centers providing health services throughout Pinellas County, Florida. Pinellas County is located on the west coast of Florida and is the most densely populated county in the state. Its jurisdiction is 916,501 residents with an average age of 46.3. All Pinellas County residents are served by this LHD in addressing disasters, disease control, and other environmental concerns. The LHD health centers routinely serve low income, uninsured residents seeking family planning, primary medical care, and dental care services. Approximately 30% of Pinellas residents are low income (living at or below 200% FPL) and approximately 25% of Pinellas adults are uninsured (US Census Bureau, 2010).
Problem statement: The public health issue addressed by this practice is adult obesity. Obesity levels have dramatically increased in the last 20 years in the United States, particularly in the south east region of the country, including Florida. The adult obesity rate in Florida is 27.2%, and 24.0% in Pinellas County. Additionally, 41.6% of Pinellas adults are overweight (37.8% FL). Obesity is also more prevalent in low income, uninsured populations- the obesity rate increases to 30.5% among Pinellas adults with an annual income less than $25,000. Similarly, a majority (58%) of DOH-Pinellas primary care clients are overweight or obese (BMI >= 25). (BRFSS, 2010).
The target population affected by the problem is the obese and overweight clients of the primary care clinics of DOH-Pinellas. To be eligible for primary care, clients must be at or below 200% of the Federal Poverty Level (FPL) and uninsured. Approximately 6,100 residents utilize DOH-Pinellas as their primary care medical home, as of September 30, 2013, resulting in nearly 1,200 visits each month. A majority (58%) of the 4,842 clients with a recorded BMI had one 25 or higher. In the last two years, 350 primary care clients have chosen to participate in the weight management clinic.
In the past, DOH-Pinellas examiners mentioned BMI and related concerns to clients, but had few resources to offer. Clients could see a nutritionist on the day of their primary care visit, but there was no bariatric physician. The current practice is improved for multiple reasons. First, clients are selected based on their BMI and on their self-reported willingness to improve their weight. Second, the schedules of the physician and the nutritionist are coordinated so that clients can see both on the same day. The physician can also address their primary care needs when appropriate. Third, clients are offered a monthly appointment with both providers that includes evaluating weight, blood pressure, exercise type and routine, diet, and review of blood work as appropriate.
The practice is innovative because it is new to the field of public health and is a creative use of existing practice. Most public health chronic disease programs focus either on children, schools, or the environment. While this practice focuses on the individual in a primary care setting, it has public and private health implications as a model for reaching patients to improve their health without medications. It is a creative use of existing practice in that the bariatric physician and nutritionist now have specific times when they are focused together on clients who are ready to make changes to their weight. Scheduling the two of them in the same clinic location at the same time has made it very convenient and accessible to clients at their medical home location.
The current practice is not evidence based.
The practice addressed the CDC Winnable Battle category of Nutrition, Physical Activity and Obesity.
Nutrition, Physical Activity, and Obesity
The goal is to reduce the financial and health burdens of obesity for those clients whose BMI is over 25 and who indicate a willingness to improve their lifestyle. The objectives for participants are lifestyle changes to improve their nutrition and increase their physical activity in order to lose weight. For successful participants, this translates into improved self-esteem, decreased obesity-related morbidity and mortality (lower blood pressure, blood glucose and fasting lipid panel) and decreased use of medication.
To achieve the goal and objectives, DOH-Pinellas set up a weight management program led by a bariatric physician. The first step was to establish the dates, times and locations of appointments, coordinated with the clinic managers, physician, and nutritionist at four locations. The next step was to set up the appointment schedules in the electronic scheduling system. Clinicians in primary care were coached to refer likely candidates among their clients, and make electronic referrals to the physician and the nutritionist. The Medical Assistants are responsible for reading the examiner’s notes and making the referrals and appointments.
Once appointments were scheduled, the clients were interviewed and examined by the physician. Recommendations regarding lifestyle changes, dietary changes, and exercise regime are made on a one-on-one basis keeping in mind that a successful program for each individual is the one that is “sustainable” for each of them. Clients are seen on a monthly basis for follow-up exams, additional recommendations, and evaluation of blood work.
The timeframe for full implementation was 3 months. The stakeholders are all internal, with various divisions and multiple locations involved. From the Director to the support staff, many individuals and divisions assisted in the planning and implementation of this practice. The Director supported the concept and allowed the physician to try it without a sustainable source of funding. Clinic managers worked with the physician on a schedule that adequately covered their four locations. Primary care physicians eagerly began to make referrals, and continue to. Support staff assist clients with making appointments.
Start-up costs were minimal, including primarily planning time and the purchase of a body composition monitor and scale ($50). The practice pays for itself through reimbursements from the County Health and Human Services program for primary care encounters (e.g. 118 encounters x $124 last quarter = $14,632), and the Low Income Pool funds designated for weight management ($3,150 for salary per quarter).
The goal of the practice is to reduce the financial and health burdens of obesity for those clients whose BMI is over 25 and who indicate a willingness to improve their lifestyle. The objectives for participants are lifestyle changes to improve their nutrition and increase their physical activity in order to lose weight. For successful participants, this translates into improved self-esteem, decreased obesity-related morbidity and mortality (lower blood pressure, blood glucose and fasting lipid panel) and decreased use of medication.
A recent review of 85 clients over the past 2 years in the practice found the following. The BMI mean for the group went from 39.54 to 36.69, the group lost a mean of 7% of their weight (1% - 24%), and a mean of 17.68 pounds were lost (3-57 lbs). Systolic BP went from a mean of 134.18 to 128.84, and Diastolic BP went from 84.9 to 81.11. The HgbA1C was lowered from 7.27 to 5.15. Using the means, the project met all its objectives.
In reviewing the data, it was discovered that the reduction of BMI of individuals directly correlated to the number of clinic visits they had, and that weight loss had a significant impact on lowering SBP, DBP and HgbA1C to healthier levels. It was also found that whites, females, and persons age 45-60 were the most likely regular participants. This data was collected from the participants’ electronic health records and analyzed by internal evaluation staff. Staff looked at correlates of the number of clinic visits to weight loss and performed a sample paired t-test to examine changes in BMI, BP and HgbA1C from initial visit to last date of service.
One change made to increase participations is the initiation of support groups at all sites. Another for the future is to have physical therapists available for exercise counseling.
The primary lesson learned in this practice is that weight loss and weight management can be accomplished without anorexiant medications among low income, uninsured residents. Resources all in one location, familiar to the patient, also seem to have a positive effect as do the motivation and focused attention coming from a physician. The recent data that showed certain groups more likely to participate, and participation leading directly to weight loss, has demonstrated a need for more research with the groups less likely to participate, and what would improve their success.
Overweight or obese primary care clients are sometimes told they need to lose weight. There are limited resources available and providers are not given many specific tools to assist clients in this area. This practice provides those clients who are ready to change a resource to assist them. The practice is financially self-sustaining at this time.
The Florida Department of Health is committed to improving the health of its residents. In January 2013 the State Surgeon General, Dr. John Armstrong, launched the Healthiest Weight Florida initiative. According to the Healthiest Weight website, “By bending the projected BMI (Body Mass Index) curve by just 5% from the current trajectory, hundreds of thousands of new cases of chronic disease can be prevented while saving millions in healthcare costs.” This practice has already demonstrated it can lower BMI by 7%, so it can become a model for other Florida LHD’s. Stakeholder commitment is high. This practice is funded through the current fiscal year and is expected to grow to include teens being seen in DOH-Pinellas school-based clinics.