Post on 11-Jan-2016
description
Building Effective Partnerships to End Childhood Obesity
Stephen Cook, MD, MPH,
Golisano Children’s Hospital at URMC
Disclosures
Grant funding: • NYS Dept of Health,
• Children’s Institute,
• NIH CBPR project
Boards: ABOM, AAP IHCW
..…and I used to work at a TJ’s Big Boy
Host a Community Screening
Declining childhood obesity rates — where are we seeing the most progress?
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DISPARITIES PERSIST
To date, only Philadelphia has reported major progress in closing the disparities gap.
Stigma of Childhood Obesity
“The lot of fat children is a sad one. They are bashful and
ashamed of their shapeless figures, yet unable to conceal
them. Wherever they go they attract attention…..Obesity is
a serious handicap in the social life of a child, even more so
of a teenager. Obesity does not have the dignity of other
diseases…”
5Bruch H. Pediatric Annals: 1975
Adolescents’ Perceptions of Peers Being Teased or Bullied: The Reason Why
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Perceptions of weight-based victimization among N=1555 high school students in Connecticut
Percentage of teen girls who report frequent weight teasing
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Neumark-Sztainer. J Adolesc Health.
2009;44:206-213.
ObesityAlgorithm
1) Example – medical risk or behavioral risk
2) 10 years and older every 2 years
3) Progress to next stage if no improvement in BMI/weight after 3-6
months and family willing
4) Age 6-11yr = 1 lb/month, Age 12-18yr = 2 lbs/week average
5) Age 2-5yr = 1 lb/month, Age 6-18yr = 2 lbs/week average
Healthy Weight
BMI 5-84%ile
Overweight
BMI 85-94%ile
Obese
BMI 95-98%ileBMI >=99%ile
Assess Behaviors & Attitudes - Eating, Physical Activity, Sedentary Time, Motivation
Assess Medical Risks - Family History, Review of Systems, Physical Examination (BMI, BP)
Assess Fasting Lipid Profile
YesNo
Assess ALT, AST, Fasting Glucose(2)
Other Tests as Indicated by Health Risks
Prevention Counseling - Empathize/Elicit - Provide - Elicit
Stage 1 Prevention Plus(3)
Stage 2 Structured Weight Management(3)
Stage 3 Comprehensive Multidisciplinary Intervention(3)
Stage 4 Tertiary Care InterventionTreatment
Prevention
Assessment
Health Risks?(1)
Maintain Weight Velocity & Reassess Annually
Maintain Weight or Gradual Loss(4) &
Reassess Every 3-6 Months
Maintain Weight or Decrease Velocity & Reassess Every
3-6 Months
Gradual to Moderate Weight
Loss(5) & Reassess Every 3-6 Months
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Children and Adolescents age 2 to 18 years of age
In Our Backyard
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Health Foundation Healthy Weight Strategy
GOAL: Reduce the prevalence of overweight and obesity from 15% to 5% of Monroe
County children ages 2-10 by 2017
[from 12,144 kids to 4,081 kids]
GOAL: Reduce the prevalence of overweight and obesity from 15% to 5% of Monroe
County children ages 2-10 by 2017
[from 12,144 kids to 4,081 kids]
Increase physical activity and
improve nutrition
Engage the clinical
community
Advance policy and practice
solutions
Execute a community
communications campaign
Evidence-based Behavioral Strategies
•Breastfeed
•Limit sugar-sweetened beverages
•Consume the recommended fruits and vegetables
•Eat daily breakfast
•Limit fast food
•Use appropriate portion size
•Eat meals together as a family
•Limit television and screen time and keep televisions out of children’s bedrooms
•Encourage moderately vigorous physical activity of 60 min/day or more
•Ensure adequate sleep; 1-3yr: 12hr, 3-5yr: 11hr, 5-12: 10hr and try to get teens
after 8.5 hrs of sleep at night
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Parents estimation of child’s weight status vs. measured weight, 2-9yo
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Estimation of weight 193 parent/child dyads from Strong Pediatrics
Tschamler, et al, Clin Peds, 2010;49:470
GROC Breakthrough Series (12 Months)
Select Topic
Planning Group
Develop Framework & Changes
Participants
Pre-work
LS 1
P
S
A D
P
S
A D
LS 3LS 2
Expert Meeting
Stages of Improvement
-test
-implement
-hold the gain
-spread
Beyond LS 3
How well do successful teams “hold the gains”
after LS3?
Supports
-Emails
-Office Visits
-Phone Conferences
-Monthly Team Reports
-Assessments
Borrowed from IHI
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18
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Percentage of Charts With Counseling on Nutrition and Physical Activity
95% 95%
0%
20%
40%
60%
80%
100%
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11
Cycle 1
Cycle 2
Goal
Some Results from Our Practices
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OBESITY CHRONIC CARE MODELSelf Management
SupportDecision Support
Delivery System Design
Clinical Information Systems
Emphasize the patient’s central role
Organize resources to provide support
Use effective self-management strategies that include assessment, goal setting, action planning, problem solving, & follow up
Embed evidence-based guidelines into daily clinical practice
Integrate specialist expertise and primary care
Use proven provider education methods
Share guidelines and information with patients
Define roles and distribute tasks among team members
Use planned interactions to support evidence-based care
Provide clinical case management service for high risk patients
Ensure regular follow-up
Give care that patients understand and that fits their culture
Provide reminders for providers and patients
Identify relevant patient sub- populations for proactive care
Facilitate individual patient care planning
Share information with providers and patients
Monitor performance of team and system
Healthy Weight
BMI 5 - 84%ile
Overweight
BMI 85 - 95%ile
Obese
BMI 95 - 98%ileBMI >=99%ile
Healthy Weight
BMI 5-84%ile
Overweight
BMI 85-94%ile
Obese
BMI 95-98%ileBMI >=99%ile
Assess Behaviors & Attitudes - Eating, Physical Activity, Sedentary Time, Motivation
Assess Medical Risks - Family History, Review of Systems, Physical Examination (BMI, BP)
Assess Fasting Lipid Profile
YesNo
Assess ALT, AST, Fasting Glucose(2)
Other Tests as Indicated by Health Risks
Prevention Counseling - Empathize/Elicit - Provide - Elicit
Stage 1 Prevention Plus(3)
Stage 2 Structured Weight Management(3)
Stage 3 Comprehensive Multidisciplinary Intervention(3)
Stage 4 Tertiary Care InterventionTreatment
Prevention
Assessment
Health Risks?(1)
Maintain Weight Velocity & Reassess Annually
Maintain Weight or Gradual Loss(4) &
Reassess Every 3-6 Months
Maintain Weight or Decrease Velocity & Reassess Every
3-6 Months
Gradual to Moderate Weight
Loss(5) & Reassess Every 3-6 Months
Primary Care Setting ?
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3yr old WCC w/ pt Not Mykid
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Pt NW, first seen at 3yrs and noted to be obese
PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?
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Pt MN
Dr. Colpoys at Genesee Pediatrics
Penfield Pediatrics
Unity Pediatrics
More Unity Pediatric Pics
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Monroe County, NY – Estimated Birth Cohort = 1,015
Cycle 3 56.0% n= 26
Cycle 2 46.3%
(n = 17)
Extent of Community Reach
Cycle 1 24.8%n=9
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OBESITY CHRONIC CARE MODEL
Community Resources and Policies Health Care Organization
Encourage patients to participate in effective programs
Form partnerships with community organizations to support or develop programs
Advocate for policies to improve care
Visibly support improvement at all levels, starting with senior leaders
Provide incentives based on quality of care
Promote effective improvement strategies aimed at comprehensive system change
Encourage open and systematic handling of problems
Development of agreements for care coordination
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Results
Monroe County, NY
5.0% - 10.0%
10.1% - 15.0%
15.1% - 20.0%
20.1% - 24.0%
Obesity by Neighborhood
Healthy Food
Source
Unhealthy Food
Source
RFEI =
Maps of Parks and Recreation Centers
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“Rec on the Move” comes to the Doc Office
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Foodlink Curbside Market
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Additional Partners / Tools
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Pediatric e-Practice: Optimizing Your Obesity Care
Healthy Active Living for Families
Structured Weight Management
AAP & Academy of Nutrition
and Dietetics (former ADA):
• Set of visits with PCP and RD
• Based on motivation at start
• Self monitoring and uses
tracking forms
One City’s “Communities of Solution”
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Note: Political boundaries, shown in solid lines, often bear little relation to a community’s problem-sheds or its medical trade area.
Adopted from Folsom M. Health is a Community Affair: Report of the National Commission on Community Health Service, 1967
Next steps
• Pediatric Primary Care Practices and using EMR
• Writing reports for data collection
• CDC piloting EMR templates for surveillance
• Linking Resources in Community with Patient Centered Medical Home
• STRONG Pediatrics has medical home designation
• RGH completing pediatric medical home
• Highland FM and Anthony Jordan
• Create Linkage and Test Stage 2: Structured Weight Managment
• STOP Obesity Alliance: Community Health Benefit
• Children’s Hospital Association: Focus on a Fitter Future / Stage 3:CMWM
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4343
4444
Thank you
Department of Pediatrics, GCH@URMC