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

6

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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13

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

25

26

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…

Sonja.Wicklum@ucalgary.ca

Thank youQuestions?