The Patient Protection and Affordable Care Act (ACA) has sparked increased support for integrating primary care and public health to enhance care for patients, especially those with chronic diseases such as obesity.
To build on this trend, the Integrated Clinical and Community Systems for the Prevention and Management of Obesity Innovation Collaborative of the Institute of Medicine's Roundtable on Obesity Solutions(iom.nationalacademies.org) recently proposed a model to prevent and treat obesity by integrating clinical and community resources.
The model is explained in an analysis(content.healthaffairs.org) published in the September issue of Health Affairs.
"This public health crisis calls for a transformation in the way we handle obesity, a chronic disorder that is fueling high rates of diabetes, heart disease and cancer in the United States," said lead author William Dietz, M.D., Ph.D., director of the Sumner M. Redstone Global Center for Prevention and Wellness at Milken Institute School of Public Health at George Washington University in Washington, D.C., in a news release.(publichealth.gwu.edu) "We propose a new model for the prevention and treatment of obesity, one that integrates health care in the clinic with resources in the community that make it easier for people to prevent unhealthy weight gain or lose weight and keep it off."
- Members of the Institute of Medicine's Roundtable on Obesity Solutions have proposed a model to prevent and treat obesity that integrates primary care and public health resources.
- One of the challenges of this integrated care approach is training physicians to optimize treatment for obesity while utilizing community resources.
- With Medicare moving toward value-based care, incentives for health insurance plans and clinical programs to invest in community initiatives that improve outcomes are likely to increase.
Dietz and his co-authors, including representatives from leading managed care organizations such as Kaiser Permanente and HealthPartners, propose that this new model include
- a system that is centered on individual patients and family engagement. The authors note that successful obesity treatment models often require behavioral changes such as preparing nutritious foods or increasing physical activity, and families play a key role in these efforts.
- restructured clinical services provided by physicians who are sensitive to the stigmatization of people with obesity. Physicians and staff need to learn behavioral strategies that can motivate patients to change their dietary habits and start exercising.
- better integration between clinical services and community systems that can make it easier for patients to lose or maintain their weight. For example, partnerships between clinics and YMCAs or other community-based resources can provide opportunities for structured regular exercise and/or nutrition counseling.
Family Physicians' Role in This Model
This integrated care model seeks to change the approach to care delivery by supporting primary care physicians with services provided by dietitians, nurse practitioners, social workers, psychologists and even community leaders and others who are not typically considered health professionals.
One of the challenges of this integrated care approach is training physicians to optimize treatment for obesity while utilizing community resources. This training includes instruction in behavior change strategies and up-to-date information about new ways to treat obesity.
"Treatment of these patients, particularly (those) with severe obesity, continues to be essential," Dietz told AAFP News. "We know what we should do and who we should do it for with abundant recommendations. What is missing is how we do that."
AAFP Focus on Integrating Primary Care, Public Health
The Academy has long been active in promoting the integration of primary care and public health to optimize patient care.
This activity includes the release of last year's "Integration of Primary Care and Public Health" position paper, which defined the importance and value of integrated care for family physicians.
The AAFP also has been integral in promoting the Practical Playbook(www.practicalplaybook.org) initiative spearheaded by the CDC; the Department of Community and Family Medicine at Duke University in Durham, N.C.; and the de Beaumont Foundation. The initiative offers an interactive Web-based resource designed to help primary care and public health professionals collaborate to achieve population health improvement and reduce health care costs through preventive care.
In addition, physicians and their associated health care systems will likely need to negotiate written agreements with providers of community services they might not have worked with before. Physicians need to help support these community programs so they can best serve patients.
"It starts with local advocacy," Dietz said. "You cannot expect anyone to be physically active if there aren't safe places for them to do so. Increasing the availability and use of recreational facilities would be effective to reduce comorbidities at a pretty low cost, but it would take the investment of people at the health plan level to invest in those facilities."
Exchanging Data to Best Support Patients
Data-sharing is essential to communicating patients' health information between physicians and community programs.
For example, the authors pointed to NIH's Diabetes Prevention Program(www.niddk.nih.gov) (DPP) a randomized clinical trial that demonstrated intensive dietary and physical activity counseling for weight reduction was more effective than medication in preventing type 2 diabetes in patients with prediabetes.
The program was subsequently adapted to deliver the intervention in YMCAs(www.ymca.net) by trained and certified health care professionals who record data on participants' attendance, weight and self-reported physical and nutrition behaviors. The YMCA DPP uses these data for, among other things, claims submissions to about 30 commercial insurers that reimburse local YMCAs when participants achieve specified attendance and weight-loss goals. The data system also generates periodic letters to primary care physicians detailing the progress their patients are making in lifestyle changes.
"Because this payment (to YMCAs) depends on attendance and weight loss, we could see something like this emerge very easily into a broader programmatic application," Dietz said.
Financing and Policy Support
With Medicare moving toward value-based care, incentives for health insurance plans and clinical programs to invest in community initiatives that improve outcomes are likely to increase, Dietz said.
"Through the ACA, CMS also is increasingly interested in investing in community-based programs," he said. "But the ACA is only one of a number of funding mechanisms."
The authors suggest banks and other financial institutions could fund integrated clinical and community systems to reduce obesity.
For example, the San Francisco Federal Reserve Bank pioneered efforts to identify upstream interventions such as health food markets and community health centers that banks could invest in to satisfy their obligations under the Community Reinvestment Act of 1977.
Finally, the authors suggested the impact of obesity and its associated conditions on health care costs and workforce productivity may help engage corporate support via the design of health insurance plans for their employees and investments in workforce wellness.
Related AAFP News Coverage
Primary Care, Public Health Integration Focus of New Resource
AAFP Position Paper Offers Practical Guidance for Members