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Patient and Provider Engagement in Rural Health Delivery Research: Lessons learned from a primary care obesity treatment trial Christie Befort, PhD University of Kansas Medical Center May 5 th 2017

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Patient and Provider Engagement in Rural Health Delivery Research:

Lessons learned from a primary care obesity treatment trial

Christie Befort, PhD

University of Kansas Medical Center

May 5th 2017

Overview

▪ Description of RE-POWER trial

▪ Patient and provider engagement strategies

▪ Lessons learned

1. Increase awareness of evidence linking obesity and cancer

2. Provide tools and resources to help providers address obesity with their patients

3. Build a robust research agenda

4. Advocate for policy and systems change

Obesity treatment in primary care currently falls short

▪ Only 20-40% of patients get counseled

▪ CMS reimburses since 2012 ▪ Intensive Behavior Therapy (IBT) for

Obesity (G0447)

▪ Poor uptake (< 1% of eligible beneficiaries)

Models to Address Obesity in Primary Care

Fee-for-service

• Traditional face-to-face office visits with PCP

• Medicare IBT model• 15 min face-to-face

sessions

• 14 sessions 1st 6 mo

• Then monthly

Patient-Centered Medical Home

• Team-based care, coordination with in-clinic lifestyle coach

• Group Visits (in-person; option for phone)

• Enhanced access (after hours)

Disease Management

• Referral to centralized phone-based care with obesity treatment specialists

• Integration with PCP through quarterly progress reports

36 practicesn=1440 patients

Fee for Service

12 practices

n=480

Patient Centered Medical Home

12 practices

n=480

Disease Management

12 practices

n=480

Primary Outcome: Weight change at 2 yearsSecondary Outcomes: Quality of life, metabolic syndrome, implementation process measures

BMI 30-45 kg/m2

Age 20-75 years

PCP clearance

Practice RecruitmentPractice Characteristics N (%) or mean (SD) Ownership

Hospital 14 (39%)Private practice 10 (28%)FQHC 11 (31%)VA 1 (3%)

Rural Health Clinic 11 (31%)PCMH Status 19 (53%)Provider FTEs

MD FTEs 5.0 (3.9) range 1-23APP FTEs 2.6 (1.7) range 0-8

Patient panel size 9870 (10810)Electronic Health Record 33 (92%)Behavioral staff

Registered Dietitian 9 (25%)Mental Health 13 (36%)

RUCA codeUrban 1 (3%)Large rural (10,000-49,999) 13 (36%)Small (2,500-9,999) 8 (22%)Isolated rural (<2,500) 14 (39%)

Miles to large hospital 57.2 (46.5)

▪ 77 practices approached

▪ 39 contracts

▪ 36 practices enrolled

Patient and provider engagement ▪ Study design phase

▪ Patient Advisory Board – focus group

▪ Provider stakeholders – interviews

▪ Study implementation▪ Central kick-off meeting

▪ Central trainings

▪ Phone meetings 1-2/month

▪ Weekly Weigh-In Newsletter

▪ Facebook and website

▪ Joint presentations at national and state meetings

PCOR Engagement Principles

Reciprocal relationships

Partnership

Co-learning

Transparency and honesty

Shared vision and

mission

Input on budget

and payments

Patients are experts

in communication,

consenting, and

retention

Informal, everyone on

first name basis

Hard work acknowledged

and celebrated

Sharing of

experiences across

providers and

patients

Evidence gaps

Lessons learned during implementation:

1. Who delivers it

2. How are they trained

3. Where is it delivered

4. How is it paid for

5. What are most important clinic contextual factors for success

Who delivers it

How important were each of the following in your decision to participate? (n = 34)

Very important

Somewhatimportant

Not important

To improve the care you provide to your patients with obesity 29 (85%) 5 (15%) --

To improve overall patient experience of care 19 (56%) 13 (38%) 2 (6%)

To improve your training and experience in weight loss counseling 19 (56%) 11 (32%) 4 (12%)

For the financial incentives* 9 (26%) 17 (50%) 8 (23%)

To gain experience participating in research 8 (24%) 18 (53%) 8 (24%)

• Lesson 1: Don’t underestimate rural PCP’s interest in providing intensive behavioral counseling in-house

– DM least preferred arm

* MDs more like to rate financial incentives as Very Important (47% MDs vs 6% practice liaison)

How trained▪ Lesson 2: Experienced RNs and LPNs are highly

trainable on content

▪ One-day workshop with bi-monthly telementoring

▪ Equal attendance across PCMH and DM arms

Where is it delivered

▪ Lesson 3: Don’t underestimate patients’ willingness to travel for a beneficial service

▪ In PCMH arm, patients preferred to meet in-person rather than by phone

▪ Distance traveled: 10 ±13 miles (range <1 to 161 miles)

How is it paid for▪ Lesson 4: Practice-level transparency in

payments for services produces highest provider and patient engagement

▪ Increased FTE/pay for local interventionists important for patient recruitment and attendance

What are important contextual factors for success?

Consolidated Framework for Implementation Research

construct

Intervention Characteristics

Design

Complexity

Relative advantage

Inner Setting

Learning climate

Climate compatibility

Available resources

Process

Engaging opinion leaders

Planning

Healthcare system

Small private practiceFQHC

Hospital-owned clinic

CollaboratorsCo-Investigators▪ Edward Ellerbeck, MD▪ Kim Kimminau, PhD▪ Allen Greiner, MD▪ Byron Gajewski, PhD▪ Jeff VanWormer, PhD▪ Cyrus DeSouza, MD▪ Mike Perri, PhD

Patient Advisory Board▪ Arla Houck▪ Cherie Herredsberg▪ Luanne Kramer▪ Karen Mason▪ Les Lacy▪ Jaynce Johnstone▪ Margaret Kilpatrick▪ Peg Bayles

▪ Frank Schotenberg

Staff, postdocs, students▪ Stacy McCrea-Robertson, MS▪ Danny Kurz, MPH▪ Leigh Quarles, MPH▪ Tera Fazzino, PhD ▪ Nick Thompson, MPH▪ Susan Ahlstedt, LCSW▪ Lara Bennett, MS, RD▪ Eryen Nelson, MPH▪ Taylor Brumbelow, MPH ▪ Nick Marchello, RD▪ Stephanie Punt, MS▪ Fatima Rahman

Provider Stakeholders▪ Jen Brull, MD▪ Bob Kraft, MD▪ Cindie Wolff, MD▪ Greg Thomas, MD▪ Doug Gruenbacher, MD▪ Krista Postai, CEO▪ Gregg Wenger, MD▪ Bryon Bigham, MD ▪ Bethany Enoch, MD▪ Beth Oller, MD▪ Jen McKenney, MD▪ Libby Hineman, MD▪ Heather Harris, MD