COACH - Combating Obesity in Community Health Centers: Network Dissemination of a Group Program for Weight Management
Specific Aims: We know how to treat obesity and prevent complications such as diabetes through implementing healthy lifestyle behavior change programs.1 To date there has been limited implementation of such interventions to address obesity and its complications through clinical settings2-5 or with community organizations.6-9 We can incorporate behavioral interventions into standard clinical care,10 but growing evidence suggests group visits effectively complement individual care to promote behavior change for obesity and related conditions.11-13 Implementation science teaches us how to disseminate, implement and assess sustainability of health interventions in real-world settings with diverse patient populations.14-19 Community health centers (HCs) serve a large “safety-net” population of vulnerable patients at high risk for obesity and its complications.20To date there has not been a significant network approach to collaboratively implement a group weight management program in community HCs. Successful implementation of an obesity lifestyle intervention through a network of HCs would have significant potential to reduce obesity, its complications and related societal costs.
The MidWest Clinicians’ Network (MWCN) is a large network of HCs caring for medically underserved populations which is primed to implement a group program for weight management. MWCN comprises 120 community HCs with over 300 primary care practice sites in 10 MidWestern states, serving diverse patient populations in both urban and rural settings. MWCN has a long track record of partnering successfully with quality improvement (QI) leaders from the University of Chicago (UC) to implement and study QI collaboratives for patients with obesity, diabetes and related conditions.21-34 Recently, MWCN piloted a successful QI collaborative for weight management programs in 5 HCs, the COACH (Combating Obesity in Community Health Centers) collaborative.34 The COACH pilot demonstrated feasibility of the collaborative network approach across geographic distance, involving HCs serving diverse minority and immigrant populations. The COACH pilot supported collaborative QI activities for existing weight loss programs in HCs, but did not disseminate a common curriculum. COACH leaders expressed a strong desire for a common core weight management program which they could tailor and implement at their own HCs, and a current survey of MWCN HCs indicates broad interest in implementing a group weight management program for obese adult patients.
This proposal builds on the productive history of collaboration between MWCN and UC, the extensive existing infrastructure of the MWCN network, and the expressed readiness of HCs to implement a group program for weight management. The COACH healthy lifestyle program is a 14 week group curriculum for adults with obesity, drawn from the Diabetes Prevention Program35 and related resources, and developed, tested and refined previously as the REACH-OUT8 healthy lifestyle program for families. We propose to disseminate and implement the COACH program for adult patients with obesity at 10-15 MidWestern HCs (representing 30-50 primary care practice sites) using the Consolidated Framework for Implementation Research (CIFR)17 to address key constructs, with subsequent dissemination throughout 120 MWCN HCs through state-based Primary Care Associations (PCAs) and MWCN network infrastructure. If successful, the COACH collaborative will demonstrate an effective dissemination and implementation approach for safety-net clinics in dispersed urban and rural settings, with potential for application to other health problems facing vulnerable populations.
Specific Aims: 1. Disseminate and implement the COACH group weight management program at 10-15 HCs (representing 30-50 practice sites) using existing MWCN network infrastructure, with subsequent dissemination to other MWCN HCs through presentations and training at state PCAs and through MWCN network channels.
-Convene 2-3 key leaders from each HC for an in-person Learning Session, followed by monthly webinars and conference calls to disseminate the COACH curriculum and related resources.
-Assist HC leaders as they tailor and implement COACH for obese patients at each participating HC.
-Train staff from 100+ other HCs in COACH program at state PCAs and through MWCN networking.
2. Assessimplementation and sustainabilityof the COACH group weight management program by HCs through qualitative assessment of stakeholders (clinicians, administrators, PCA leaders, and patients) using the CIFRframework, and quantitative assessment of patient outcomes (weight change). For example,
-PROCESS: Can webinar technology successfully disseminate COACH across geographic distance?
-INTERVENTION: Can COACH be tailored to meet the needs of culturally diverse patient populations?
-INNER SETTING: What HC barriers/facilitators affect clinician and patientengagement in COACH?
-OUTER SETTING: What external policies/incentives affect HCs’ ability to implement and sustain COACH?
3. Assess coststo HCs of implementing the COACH group weight management program, including staff effort, training and materials, space and local resources, and financial outcomes.
1. Background
1.a. Need and rationale
To date there has been limited implementation of healthy lifestyle interventions to address obesity and its complications – diabetes, hypertension, arthritis, cancer, and others,through clinical settings.2-5 Obesity complications are very costly to society in terms of disability, lost time from work, and higher healthcare costs. A recent study found we spend $190 billion per year on obesity-related healthcare costs, over 20% of overall healthcare expenditures.36The Veterans Administration used its extensive network infrastructure to implement the MOVE! program37, 38 to address obesity among veterans, but to date there has not been a significant network approach to collaboratively implementing weight management in community health centers. We can incorporate behavioral approaches to decrease obesity in the clinical setting,10 but growing evidence argues for theuse of group visits to encourage behavior change.11-13 Community health centers (HCs) serve a large “safety-net” population of vulnerable patients at high risk for diabetes and its complications.20Successful implementation of a lifestyle intervention to decrease obesity and related complications through a network of HCs would therefore have potential for significant reduction of obesity, its societal costs and complications.
The MidWest Clinicians’ Network (MWCN) is a well-established not-for-profit professional development organization comprising 120 community HCs throughout 10 MidWestern states, serving very diverse, medically underserved patient populations in both urban and rural settings. Most HCs encompass multiple practice sites; MWCN represents over 300 primary care practices serving ~2 million patients, 25% African American and 22% Latino.39In 2008, MWCN identified obesity as a priority area based on survey responses from clinician members. MWCN partnered with the University of Chicago to conduct the ‘Combating Obesity in Community Health Centers’ (COACH) QI pilot collaborative described below. Recent MWCN member survey shows even greater interest in using MWCN network and infrastructure to collaboratively disseminate and implement a group weight management program for obese adults.
Healthcare Reform: As we move away from fee-for-service payments toward population management and global payments under the Affordable Care Act, HCs will need to implement effective programs to improve the health of populations they manage. As a major risk factor for HTN, diabetes, osteoarthritis, cancer, and depression, obesity is a key driver of costs.36 Few HCs have the training and resources needed to develop population management approaches to addressing obesity. The COACH program will guide HCs through developing the QI infrastructure and population management approaches they will need to address obesity.
Implementation Science teaches us how to disseminate, implement and assess sustainability of health interventions in real-world settings.14-19 Key features of such projects include identifying questions of importance to stakeholders (e.g. clinicians, healthcare systems, and patients), using existing networks to implement interventions in heterogeneous, real-world settings, and employing few exclusion criteria.16
Justification and Significance of the Project: Building on the successful COACH pilot, the extensive existing infrastructure of the MWCN network, and the history of highly productive collaboration between MWCN and UC, we propose to disseminate and implement the COACH group visit lifestyle program for patients with obesity at 10-15 core HCs, with subsequent dissemination to 100+ HCs representing over 300 primary care practices in the network. COACH combines an existing evidence-based intervention with a large network primed for dissemination and implementation across geographic distance. The COACH collaborative, if successful, will demonstrate an effective dissemination and implementation network approach for safety-net clinics in widely dispersed, urban and rural settings, and will potentially serve as a model for dissemination and implementation of programs to address other significant health problems facing vulnerable populations in similar settings.
1.b. Evidence base / Prior studies, preliminary work, and history of MWCN-UC collaboration
The primary evidence base is the Diabetes Prevention Program1 and various adaptations growing out of this experience.6 The DPP showed that weight loss and reduction in related health risks can be achieved successfully through a 14-week intensive lifestyle intervention program. Our group has significant relevant experience adding powerfully to this evidence base, much of which has been done in collaboration with MWCN.
PATHWAYS (M Quinn, et al): Designed specifically for African-American (AA) women with or at risk for type 2 diabetes, the PATHWAYS program40-41comprises 14 weekly followed by eight monthly sessions, and includes a comprehensive program manual, instructor’s guide, and all participant materials. One hundred twenty seven (86%) of the 147 who participated in the program completed all 14 weeks; those completing the program had an average weight loss of 6 lb (p = 0.00) from a mean baseline of 196 lb, with 27% showing a clinically significant weight loss of 10 lb or more.
REACH-OUT Chicago Children’s Diabetes Prevention Project (D Burnet, M Quinn, M Chin, et al): REACH-OUT 8 was a randomized study of 130 families in a community-based nutrition and exercise program to reduce overweight and diabetes risk among obese AA youth ages 9-12 on Chicago’s South Side. Lay leaders effectively engaged families resulting in behavior change; however, children’s mean BMI (33.7) did not change significantly over time, suggesting children with this high degree of obesity need a more intensive intervention, more closely linked to the clinical setting.
POWER-UP After-School Obesity Prevention Program (D Burnet, M Quinn, M Chin, et al): POWER-UP 9 engaged 40 elementary school children and their families in an after-school healthy nutrition and exercise program, with text-messaging to extend healthy behavior change into the family setting. Half the children were overweight or obese at baseline. Post-intervention, mean BMI z-scoresdecreased from 1.05 to 0.81 (p<0.0001); changes were most pronounced for overweight and normal weight children. The after-school venue provedfeasible. Use of CBPR principles helped successfully integrate the POWER-UP program into many school activities, contributing to its sustainability.
Health Disparities Collaboratives (M Chin, L Heuer, C Schaefer, M Quinn, et al): The Health Disparities Collaboratives (HDC), a QI collaborative approach incorporating the Plan-Do-Study-Act (PDSA)42 rapid cycle model, the Chronic Care Model,43 and learning sessions, has been implemented in over 1000 HC sites across the country. The HDC have successfully improved quality of care in HCs and are societally cost-effective, but policy reforms are necessary to create a sustainable business case. Our team analyzed the clinical, organizational, and economic outcomes of the HDC, and also implemented a high-intensity HDC model for improving diabetes care throughout Midwestern HCs in collaboration with MWCN, and in West Central US.21-32
Addressing Needs of Latino Patients with Diabetes (A Baig, A Campbell, L Heuer, C Schaefer,M Quinn, D Burnet, M Chin, et al): In collaboration with MWCN, Arshiya Baig surveyed MidWestern HCs to document their services and resources available to Latino patients with diabetes.33 Dr. Baig partners with churches in Chicago’s Latino community to implement real-world (church-based) interventions for Latino patients with diabetes and their families.44,45
Group Visits for Diabetes Care (A Baig, A Campbell, C Schaeffer, L Heuer, D Burnet, M Quinn, M Chin, et al.): Dr. Baig is leading a study with MWCN assessing the perceived benefits of diabetes group visits and the barriers and facilitators to implementing and sustaining them in 5 MidWestern HCs. The study involves site visits HCs and interviews with 26 HC leaders, providers, and staff. Preliminary findings indicate that HC leaders, providers, and staff believe group visits are an effective way to promote patient behavior change, educate patients on diabetes, and provide patients with routine, guideline-driven diabetes care. Essential components of successful group visits include having institutional support, a champion to organize and promote group visits, a multidisciplinary team to run the visits, and a mechanism for reimbursement.
COACH Combating Obesity in Community Health Centers34 (D Burnet, M Quinn, A Campbell, L Heuer, C Schaeffer, L Vinci, M Chin, et al): The COACH pilot comprised 5 MidWestern HCs,with HC staff as primary participants. Participants attended three in-person Learning Sessions to build skills in QI planning and implementation, share best practices, and plan for improvement and sustainability of their heterogeneous existing weight management programs. Tailored coaching and co-development of Learning Session curricula addressed local needs. Monthly conference calls facilitated updates and enabled HCs to share experiences. Topics rated most valuable were patient recruitment and retention strategies, QI techniques,evidence-based weight management practices and motivational interviewing. Most highly valued components were face-to-face Learning Sessions, monthly conference calls and resource sharing. Challenges included difficulty engaging providers, staff turnover and data tracking. HC leaders expressed a strong desire for a common core curriculum that could be tailored as needed for HC settings. The COACH pilot demonstrated feasibility of a collaborative network approach for improving weight management programs at HCs and yielded practical lessons in implementing such programs.
2. Project Plan
2.a. Theory and Conceptual Model
In designing the COACH collaborative we draw from the key domains in the Consolidated Framework for Implementation Research (CIFR)17 to make this dissemination and implementation project as effective, relevant and transparent as possible for future dissemination efforts in safety-net settings. CIFR is a pragmatic, theory grounded model for identifying and documenting key components necessary for successful implementation of health care programs in diverse, real-world settings.
Figure 1 – Conceptual Model:
MidWest Clinicians’ Network – University of ChicagoCOACH Partnership
DISSEMINATION
Network dissemination, training & support via in-person Learning Session and monthly webinar-conference calls with 10-15 core COACH HCs, varying in size, geographic location, and urban / rural setting:
HC1 HC2 HC3HC4HC5 HC6 HC7 HC8 HC9 HC10…(10-15 core HCs
IMPLEMENTATIONrepresenting 30-50 primary care practices)
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Patients participating in the COACH group weight management lifestyle program at each core HC
PHASE 2 DISSEMINATION
Presentations by core HC leaders
at 10 Midwestern State PCAs
PCA1 PCA2 PCA3 PCA4 PCA5 PCA6 PCA7 PCA8 PCA9 PCA10
Training and support for COACH
IMPLEMENTATION at all MWCN HCs
<------120 MWCN HCs representing 300+ primary care practices------
Additional dissemination & support through MWCN newsletter, website, webinars & publications,
and peer coaching of new HC staff from Champions at core COACH HCs
HC = Health Center, PCA = Primary Care Association
The MWCN network itself is part of the OUTER SETTING for HCs, providing training and resources as HCs seek to address obesity for their patients. State-based Primary Care Associations (PCAs) exemplify another key part of the OUTER SETTING, supporting HCs to implement behavior-change programs for patients and providing venues for further dissemination and shared learning among all 120 MWCN HCs with 300+ practices.
The INNER SETTING encompasses the characteristics (size, location, etc.), culture, communications and other key aspects of each individual HC. While characteristics differ, collaborative interactions at the in-person Learning Session and in conference calls support and enable COACH HC leaders to learn from each other and implement ‘best practices’ to influence their HC’s INNER SETTING as they implement the COACH program.
The COACH lifestyle INTERVENTION is built upon a strong evidence base, drawn from the DPP and related resources, and developed, tested and refined previously as the REACH-OUT8 healthy lifestyle program for families. At the in-person Learning Session (LS) and in webinar-conference calls, HC leaders will be trained and supported as they tailor COACH to meet the needs of diverse patient populations at each HC.
IMPLEMENTATION PROCESS occurs on three levels: 1) Planning and executing the DISSEMINATION of COACH program to HC leaders through MWCN network via in-person LS and webinar-conference calls, and 2) Planning and executing the IMPLEMENTATION of the COACH program with obese patients at each of 10-15 participating HCs, and 3) DISSEMINATION of COACH program, experience and training at PCAs and through MWCN network to all 120 HCs. Each level requires thoughtful planning, successful engagement of stakeholders (HC leaders, management, patients, and PCA leaders), committed and supported champions, and opportunities to reflect, assess and learn collaboratively from shared experience.
Likewise, INDIVIDUALS’ CHARACTERISTICS and readiness for change are important on two levels: 1) Knowledge, beliefs and self-efficacy of HC leaders as they learn and implement the COACH program, and 2) Knowledge, beliefs and self-efficacy of individual patients as they learn and implement healthy behavior change as participants in the COACH program at each HC.
CIFR17Domain / Selected CIFR Constructs applied to MWCN context / COACH StrategyINTERVENTION CHARACTERISTICS
Evidence Strength / Quality / Do HC stakeholders believe theCOACH weight management program will have desired outcomes? / Will review evidence base at in-person Learning Session
Relative Advantage / Do stakeholders perceive advantage of implementing COACH vs. continuing with status quo weight management at their HC? / MWCN HCs have already expressed strong interest in new weight management strategies
Adaptability / Degree to which COACH can be tailored to address needs ofparticular patient population at each HC / Will teach tailoring strategies at LS and in webinars
Complexity / Perceived difficulty of implementingCOACH program at each HC / Will address complexity through planning at LS, & in iterative fashion in webinars & conf. calls
Cost / Costs of implementing COACH, including staff effort, training and materials, and financial outcomes / Will assess COACH costs qualitatively and quantitatively
OUTER SETTING
Patient Needs & Resources / Do stakeholders know & prioritize needs of patients with obesity? / Will explore patient perspectives at LS & revisit periodically in webinar-conference calls
External Policy & Incentives / Policies, mandates, guidelines, pay-for-performance, professional organizations and public reporting / State PCAs encourage HCs to implement behavioral interventions & offer venue for dissemination & shared learning
INDIVIDUALS’ CHARACTERISTICS
Knowledge & Beliefs / Individuals’ knowledge & attitudes toward implementing COACH / LS will share evidence behind COACH & empower HC leaders to in-service HC colleagues
Self-Efficacy / Individuals’belief in their own capability to implement COACH / LS will assess participants’ self-efficacy and teach strategies for leading and motivating change
Stages of Change / Stage on continuum toward skilled & sustained COACH implementation / LS will teach Stages of Change & how to empower staff and patients on this continuum
INNER SETTING
Structural Characteristics / Social architecture, size, age, location(urban/rural) of each HC / We will select HCs which differ in key characteristics and analyze effects on implementation
Networks & Communications / Quality of HC’s social networks and communications / Communications strategies will be addressed in LS and webinars, and queried in stakeholder interviews
Implementation Culture / Capacity for change; receptivity of staff to COACH implementation. Contains 5 sub-constructs:
1. Tension for Change / Is current obesity practice in need of change? / Explore tension for change at LS, & how this can help COACH leaders engage providers, management and patients
2. Relative Priority / Stakeholders’ perception of importance of implementing COACH vs. competing priorities / Elicit discussion at LS and assist COACH leaders in aligning priorities
3. Organizational Incentives / Awards, promotions, salary raises, increased stature for implementing COACH/ We will encourage leaders & HC management to recognize and value efforts
4. Goals & Feedback / Are COACH implementation goals and progress feedback clearly communicated? / LS and webinars will address communicating goals and giving feedback
5. Learning Climate / Does HC climate encourage teamwork? Do leaders feel safe to try implementing COACH? Is time built in for reflective thinking and evaluation? / LS and webinars will offer strategies for building a safe & reflective learning environment
Readiness for Implementation / Tangible indicators of each HC’s commitment to implement COACH / Contains 3 sub-constructs:
1. Leadership Engagement / Commitment of HC management to implementing COACH / Documented prior to each HC’s participation and bolstered through strategies shared in webinar-calls
2. Available Resources / HC resources dedicated to implementing COACH, including training, space, staff time, and materials / Commitment documented in advance; reimbursements defray costs
3. Access to Information / Easy access to useful information about COACH program & weight management / Curriculum based on prior studies; collaborative sharing of practical materials
IMPLEMENTATION PROCESS
Planning / How well planned was the COACH implementation process? / We will draw from prior experience, and query needs of COACH participants prior to in-person LS
Engagement / Are providers and patients engaged in COACH? / LS will address strategies for engaging providers to refer patients (e.g.training, social marketing, role modeling);participants share ‘best practices’ in webinars and conference calls
Champions / Leaders committed to supporting and completing COACH implementation / LS & webinars will help leaders align COACH with personal and professional goals to enhance likelihood of success
Executing / Is COACH implemented according to plan? / Timeline and checklists will be reviewed in calls, with trouble-shooting & support for individual HCs as needed
Reflecting & Evaluating / Feedback about progress and quality of COACH implementation; team debriefing / COACH collaborative will share feedback regularly among participants, encourage reflections within HC teams and shared learning across collaborative
2.b. Logistics of Training and Implementation