The PatientCentered Medical Home Utilizing Group Visits to

The Patient-Centered Medical Home: Utilizing Group Visits to Address Pediatric Obesity in Community Health Centers STFM Conference on Practice Improvement San Antonio, Texas December 2010 Erica Mc. Claskey, MD, MS, Amber Koch-Laking, MD Christina Morgner and Jay H. Lee, MD

Goals & Objectives Introduce the scope of pediatric obesity and overweight children in America Describe how the medical home model and group visits can address the needs of patients in underserved areas Share lessons learned from our journey to implement “obesity clinics” at our institutions

The Problem Rates of obesity among children ages 2 -19 have tripled since 1980* National Survey of Children’s Health (NSCH) found that 1/3 of children ages 10 -17 are obese (16. 4%) or overweight (18. 2%) Washington DC: Obesity rate for 10 -17 year olds is 35. 4%. This ranks #9 in all of the cities in the country *NHANES study, 2008

Percentage of Overweight and Obese Children in 2007 Childhood Obesity Action Network. National Initiative for Children's Healthcare Quality, Child Policy Research Center, and Child and Adolescent Health Measurement Initiative. http: //wwww. nschdata. org/contnt/07 obesityreportcards. aspx. * Obesity is defined as body mass index (BMI) at or above the 95 th percentile of the 2000 Centers for Disease Control and Prevention BMI-for-age growth charts. Children with BMI between the 85 th and 95 th percentile are classified as overweight. Children age 10 -17 are included in this data.

Federally Qualified Health Centers Definition: FQHCs are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay

FQHC Facts Approximately 2/3 of patients are minorities 9 out of 10 have incomes below 200 percent of the federal poverty line 4 in 10 health center patients have no health insurance

Challenges in Underserved Populations Lack of Education State of Education study: Washington, DC- 37% of residents are functionally illiterate Resource poor Financial barriers Medication adherence, insurance coverage Environmental Challenges Safety Transportation

Challenges in Underserved Populations Language Barriers Cultural biases Lack of Time Provider interaction

Upper Cardozo Health Center, Washington, DC Part of the Unity Health Care System Unity is currently the largest primary health care agency in the area, with a network of 29 health centers and a mobile medical outreach vehicle Population 29% African-American 43% Hispanic 7% Caucasian 2% Asian 10% Other 9% unknown Income 100% and below poverty: 84% Collectively see approximately 82, 000 patients per year http: unityhealthcare. org

Provider and Patient Needs Lack of culturally and linguistically sensitive patient material Overweight and obese children were being referred across town to a location not easily accessible by public transportation Poor follow up between hospitals Patient adherence poor “Too far” “No time”

The Challenge Provide a environmentally safe, educationally and culturally appropriate service to address the childhood obesity epidemic in an medically underserved neighborhood

What Interventions Have Worked? Comprehensive approach to obesity prevention Medical team, family and community involvement Consistent reinforcement addressing the problem and barriers that exist Diversity of tactics

Process Survey of patients to identify needs and “wants” Results: Prefer to be taught by a clinician or known health care provider Safe or accessible location Learn about different food options available in the area and ways to prepare healthy foods

Medical Home Model AAMC definition: A care of delivery that includes an ongoing relationship between a provider and patient, around-the-clock access to medical consultation, respect for patient’s cultural and religious beliefs, and a comprehensive approach to care and coordination of care through providers and community services

Group Medical Visits Tailor group-based patient care to specific patient populations Incorporate the multiple facets of the medical home health education peer support self-management Aim to increase access, improve quality of care, and optimize patient satisfaction

Group Medical Visits Target patients with common health concerns Offer routine care and education Facilitator Social Worker Nutritionist Community Partner Nurse Physician Coordinate care among providers, families, and communities

GMV for Underserved Populations: Benefits Efficient use of health care resources Increase access to language-concordant medical care and education Approximately 80% of the Westwood population is Hispanic 64% of Westwood mothers lack high school diploma Increase engagement of hard-to-reach patients Transient residence Unreliable contact information

Program Model Medical Team Family Community Prevention of Childhood Obesity

Program Design Location: Upper Cardozo Clinic, Washington, D. C. Instructors: Physicians, Physicians Assistants Participants: All overweight, obese or at risk* children ages 7 -13 referred to obesity clinic through in-house referral system Parents/Families: Invited to participate in adult sessions *At risk: Patients with siblings or parents who are overweight

Community Partners WE CAN!* Modified version of the nationally recognized obesity prevention program curriculum YMCA Volunteered weekly lessons National Diabetes Association Financed meals *Ways to Enhance Children’s Activity and Nutrition

Program Design Program held after hours once a week in four week cycles for 2 hour periods All sessions began with a healthy family dinner and discussions about barriers to exercise and eating healthy during the week Youth and adult sessions run simultaneously All sessions were taught in English and Spanish

Youth Sessions Lessons regarding healthy food choices, taste testing or food identification Exercises led by YMCA instructor Prizes were given to youth at the completion of each session The names of each participant were recorded and forms returned to the patient chart for follow up with the primary care provider

Adult Sessions Yoga Lessons regarding food preparation, portion sizes, food selections and options All lessons were taught in English and Spanish

Healthy Dinner

Evaluation Post program surveys were distributed to both youth and adults: Key Elements Behavior Attitude Knowledge Feedback

Progress Since the pilot program, over 150 patients have participated in the program accumulating 400 visits. Both children and adult visits are coded, and vitals, body mass index (BMI) and health knowledge are recorded. Expansion of the program to other Unity Health Care sites is planned for the near future.

Sustainability The success of the program: all-inclusive model of the medical home Staff “buy in” Must recognize the significance and long term goals of program Utilize community resources Patients are familiar with partners and are more willing to learn from them and participate in activities when not at the clinic

First Lady Visits Community Health Clinic WASHINGTON – First lady Michelle Obama visited a community health center Monday to announce the release of $850 million in stimulus grants to help such clinics across the country provide care. “From the young to the old, from rural … communities to the inner cities, both the insured and uninsured, 17 million Americans rely on community health centers every year to help them stay healthy, ” she said at Unity Health Care Inc. ’s Upper Cardozo Health Center. Mrs. Obama listed obesity, diabetes, heart disease and high blood pressure as diseases that community health centers can fight through preventive care. She expressed particular concern about the importance of teaching children to eat healthily.

The Westwood Family Health Center Part of Denver Health Hospital system One of the oldest community health center networks in the United States Population (the Westwood neighborhood) Greater than 14, 999 Income DPS free lunch program: 80% 1200+ visits/month

Recruiting Used database created from electronic medical record Inclusion criteria: Children between the ages of 7 -11 years who were seen at the Westwood FHC in the past two years with a BMI of 22 or greater Spanish speaking Pre-enrollment requirements: Survey (diet, sweetened beverages, exercise, screen time) Labs (glucose, ALT, and random cholesterol)

Program Design Location: Westwood Family Health Center Instructors: Volunteer nutrition educators and culinary professionals (with RN support) Participants: Previously described Parents/Families: One parent was invited to participate with the pediatric patient

Courses with the Westwood Family Health Center, Denver CO Three 8 -week long courses One hour and a half (4 -530 PM every Thursday) 31 families have participated First course 65% graduation rate Second two courses both had 100% graduation rate! 34

Cooking Matters Share Our Strength's Cooking Matters is a hands-on cooking and nutrition education program that empowers families with the skills, knowledge and confidence needed to prepare healthy, affordable, and tasty meals. Nationally Cooking Matters teaches more than 7, 000 low-income families a year by bringing together local culinary and nutrition professionals and others who volunteer their time to lead these hands-on courses that give participants the know-how to select tasty and low-cost ingredients, stretch them across multiple meals, and use healthy cooking techniques and recipes that help them provide the best nourishment possible to their families. No Kid Hungry, Every Child Healthy

How We Work: Our Collaborative Program Model

Who We Are: Local Programs 26 franchise-style programs in 20 states plus DC Plan to launch 4 more by April 2011 37

Program Highlights Taught by a volunteer chef and nutrition professional Hands on cooking and nutrition lessons Parents and kids eat a meal together in each class Participants take home a bag of groceries and a healthy cooking tool after each lesson 38

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Cooking Matters: Fighting Hunger through Nutrition Education Adults: Kids and Teens: Nutrition Cooking Food safety Food Safety Budgeting Menu planning Grocery shopping 40

Curriculum Overview Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 My Pyramid overview & Nutrition Fundamentals Choosing Fruits, Vegetables and Whole Grains Cooking lean and low-fat proteins & dairy Breakfast, Food Budgeting, & Smart Shopping Grocery Store Tour Recipes for success My Pyramid for Preschoolers, Set a Healthy Example & Kids in the Kitchen Benefits of Fiber for Kids, Fun with Fruits and Veggies, Food Safety for Kids & Feeding through the Stages Calcium Crunch & Benefits of Breastfeeding Shopping with Kids Grocery Store Tour Family Fitness Fun, Drink to your Health & Snacks in a Snap My Pyramid Overview & Family Meal Time Fruits, Vegetables & Whole Grains Label Reading, Healthy Snacks & Eating Out Meal Planning & Breakfast Family Fitness & Healthy beverages Celebrating our Success

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“This was very important for myself and my son, so that he would learn about more nutritious food and know to balance weight and food portions. " 44

Evaluation Tool Post Retrospective Tool Key Elements Behavior Attitude Knowledge Feedback 45

Colorado Outcomes The impact: • 86% of participants graduate our courses • 90% of adults improved cooking skills because of Cooking Matters • 96% of kids reported learning at least one new thing about healthy eating 46

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Lessons Learned Recruitment of participants can be time-consuming Initial attendance can be poor Staff recruitment can be challenging Clinic space can be a limitation Patient follow-up can be difficult

Conclusions The causes of pediatric obesity are multi-factorial and require a comprehensive approach to treatment The group visit model is a unique way to address pediatric obesity in underserved populations in community health centers Consider creative and innovative methods to engage patients and their families to invest in improving their health

References 1. 2. 3. 4. 5. 6. 7. 8. 9. Mc. Claskey, E. The Implementation of Childhood Obesity Programs in Federally Qualified Health Ceners Using the Medical Home Model and Community Collaboratives. Journal of Health Care for the Poor and Underserved. vol 21: 3. August 2010. National Center for Health Statistics. National health and nutrition examination study (NHANES)2008 report. Hyattsville, MD: National Center for Health Statistics, 2009. Available at Http: //www. cdc. gov/nchs/nhanes_products. htm. Data Resource Center for Child and Adolescent Health. National survey of children’s health, 2007 report. Portland, OR: The Child and Adolescent Health Measurement Initiative at Oregon Health and Science University, 2008. Available at: http: //nschdata. org/Data. Query. Results. Aspx. Levi J, Vinter S, Richardson L, et al. F as in fat: how obesity policies are failing in America, Issue Report. Washington, DC: Trust for America’s Health, July 2009. Available at: http: //healthyamericans. Org/report/obesity 2009/Obesity 2009 Report. pdf. Worcester, S. Target body fat early to lower kids’ CVD risks. Family Practice News, , 2007 Aug 15: 37 (16): 11. Monten M. More than one –third of Washington, D. C. residents are functionally illiterate. Denver, CO: Associated content Society, the People’s Media Company. March 19, 2007. Available at: http//www. associatedcontent. com/article/183792/more_than_onethrid_of_washington_dc_html? cat=4. Harris, S. Medical home concept gains momentum. AAMC )Association of American Medical Colleges)Reporter. 2008. Mar. Available at : http: //www. aamc. org/newsroom/reporter/march 08/medical home. htm. Stice E, Shaw H, Marti CN. A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work. Psychological bulletin. 2006 Sep; 132(5): 667 -91. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004 Sep-Oct; 2(5): 445 -51.

References 10. 11. 12. 13. 14. 15. National Heart Blood Lung Institute. About WE CAN Ways to enhance children’s activity and nutrition. Bethesda, MD: National Institutes of Health, 2005 -present. Available at: http: //wwww. nhlbi. nih. gov/health/public/heart/obesity/ewcan/about-wecan/index. htm. Sia CJ, Antonelli R, Gupta VB, et al. Fro the American Academy of Pediatrics, Medical Home Initiatives for Children with special Needs Project Advisory Committee. The medial home. Pediatrics. 2002 Jul: 1 10(1): 184 -6. Sia CJ, Tonniges TF, Osterhus E, et al. History of the medical home concept. Pediatrics. 2004 May; 113(5 Suppl); 1473 -8. Office of the Surgeon General. About the HHS childhood overweight and obesity prevention initiative. U. S. Department of Health and Human Services. Office of the Surgeon General, U. S. Dept. of Health and Human Services, Nov 2007 -present. Available at: http: ///www. surgeongeneral. gov/obesityprevention/about/index. html. Givhan R. First Lady Michelle Obama: ‘Let’s move’ and work on childhood obesity problem. The Washington Post. 2010 Feb 10. Available at: http: //www. washingtonpost. com/wpdyn/content/article/2010/02/09/AR 2010020900791. html. http: unityhealthcare. org

Questions? Contact Information Erica Mc. Claskey, MD, MS, Georgetown University elm 28@georgetown. edu Amber Koch-Laking, MD, Westwood Clinic Amber. Koch-Laking@dhha. org Christina Morgner, Cooking Matters cmorgner@strength. org Jay H. Lee, MD, Westwood Clinic jay. lee@dhha. org