Obesity Treatment for Uninsured/Low Income Populations

State: FL Type: Model Practice Year: 2015

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The public health issue addressed by this practice is overweight and obesity. 2010 BRFSS data shows that 65.6% of Pinellas adults are overweight or obese, higher than both the U.S. (63.9%) and FL (65.0%). The obesity rate in Pinellas is 24.0%, increasing to 30.5% among adults making <$25,000 annually. A diagnosis of obesity in the indigent and low income population carries additional challenges of accessibility to affordable healthy foods and environments amenable to exercise. The goal of the practice is to reduce the financial and health burdens of obesity for DOH-Pinellas primary care clients whose BMI is over 25 and who indicate a willingness to improve their lifestyle.  These clients are adults 18-64 who are uninsured and living at or below 200% of the Federal Poverty Level (FPL).

The practice is implemented though an obesity clinic that includes monthly visits with a bariatric physician and registered dietician at the client’s medical home in addition to regular office visits with their primary care provider. Monthly visits include evaluating weight, blood pressure, exercise type and routine, and diet, with recommendations for dietary and exercise changes, journaling, and continued education.  No weight loss (anorexiant) medications are utilized.  In January 2014, additional activities were added to strengthen the practice including monthly support groups, healthy cooking demonstrations, and financial assistance in the form of vouchers from a local non-profit organization to aid clients with the purchase of fresh produce at a local market.

To date, 500 clients have been enrolled in the clinic. Results show that goals and objectives have been met, with 5-10% weight loss demonstrated without the use of anorexiant medications. Clients are losing weight, maintaining weight loss, and lowering their blood pressure, A1C levels, and fasting lipid panels. A retrospective study of 153 clients showed that those participating in all three added activities (support groups, cooking demonstrations, and vouchers) had significantly greater weight loss that those who participated in only one or two. Of the three activities, participation in cooking demonstrations resulted in the most significant weight loss.

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Pinellas County Health Department
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Obesity Treatment for Uninsured/Low Income Populations
The Florida Department of Health in Pinellas County (DOH-Pinellas) has more than 600 employees providing health services in six health centers throughout Pinellas. Staff provide personal health, WIC and nutrition, maternal and child health, family planning, immunization, chronic disease prevention, school health, communicable disease control, public health preparedness, and environmental health services. DOH-Pinellas maintains a budget of $46.5 million and administers $13.7 million in federal, state, and local grant funds. More information can be found at http://pinellas.floridahealth.gov/. DOH-Pinellas has public health jurisdiction for Pinellas County, an urban county with 916,542 residents located on the central west coast of Florida. Pinellas is Florida’s sixth most populous and most densely populated county with 3,348 residents per sq. mile, nearly ten times the state rate. The median age is 46.3 with females accounting for 52% of the population. The racial and ethnic composition is 82.1% White, 10.3% Black, 3.6% Asian, and 8% Hispanic (U.S. Census Bureau, 2010 Census and 2008-2012 ACS). The public health issue addressed by this practice is overweight and obesity. 2010 BRFSS data shows that 65.6% of Pinellas adults are overweight or obese, higher than both the U.S. (63.9%) and FL (65.0%). The obesity rate in Pinellas is 24.0%, increasing to 30.5% among adults making <$25,000 annually. A diagnosis of obesity in the indigent and low income population carries additional challenges of accessibility to affordable healthy foods and environments amenable to exercise. The goal of the practice is to reduce the financial and health burdens of obesity for DOH-Pinellas primary care clients whose BMI is over 25 and who indicate a willingness to improve their lifestyle.  These clients are adults 18-64 who are uninsured and living at or below 200% of the Federal Poverty Level (FPL). The practice objectives are for participants to make lifestyle changes to improve nutrition and increase physical activity leading to weight loss. For successful participants, this translates into improved self-esteem, decreased obesity-related morbidity and mortality, and decreased use of medication. The practice is implemented though an obesity clinic that includes monthly visits with a bariatric physician and registered dietician at the client’s medical home in addition to regular office visits with their primary care provider. Primary care providers from four medical home locations refer appropriate and willing clients to the obesity clinic. Monthly visits include evaluating weight, blood pressure, exercise type and routine, and diet, with recommendations for dietary and exercise changes, journaling, and continued education.  No weight loss (anorexiant) medications are utilized.  This model is based on the physician as motivator and educator, backed by the dietician’s nutritional information, which many studies have proven effective. The obesity clinic first opened its doors in February 2011 as a pilot and received a Promising Practice designation from NACCHO last year. Beginning in January 2014, additional activities were added to strengthen the practice including monthly support groups, healthy cooking demonstrations, and financial assistance in the form of vouchers from a local non-profit organization to aid clients with the purchase of fresh produce at a local market. To date, 500 clients have been enrolled in the clinic. Results show that goals and objectives have been met, with 5-10% weight loss demonstrated without the use of anorexiant medications. Clients are losing weight, maintaining weight loss, and lowering their blood pressure, A1C levels, and fasting lipid panels. Further, for clients who have lost 10% or more of their body weight, the number and/or doses of medications including antihypertensives, hypoglycemics, and statins have been decreased. Clients have also reported increased energy and self-esteem and decreased symptoms associated with arthritis, GERD, OSA and depression. A retrospective study of 153 clients showed that those participating in all three added activities (support groups, cooking demonstrations, and vouchers) had significantly greater weight loss that those who participated in only one or two. Of the three activities, participation in cooking demonstrations resulted in the most significant weight loss. The public health impact demonstrated by this practice is motivated overweight and obese residents who are uninsured and low income, a population with disproportionate rates of overweight and obesity, can lose weight and maintain it without medication. This impact can be achieved with education, motivation, and support provided by a trained physician and dietician. The greatest impact is achieved when addressing additional barriers such as accessibility to affordable healthy foods and environments amenable to exercise.
The problem and public health issue addressed by this practice is overweight and obesity and related chronic diseases. Obesity levels have dramatically increased in the last 20 years in the United States, particularly in the southeast region of the country, including Florida.  Overweight and obese adults cost an average of $1,429 more a year in health care costs than normal weight adults. 2010 BRFSS data shows that 65.6% of Pinellas adults are overweight or obese, higher than rates in both the U.S. (63.9%) and FL (65.0%). Pinellas also has a higher percentage of overweight adults (41.6%) than the U.S. (36.3%) and FL (37.8%). Pinellas has a lower percentage of obese adults (24.0%) than the U.S. (27.6%) and FL (27.2%). Pinellas rates are worse than the state for many obesity-related chronic health conditions, including for adults with hypertension (36.6% Pinellas vs. 34.3% FL), stroke (4.4% Pinellas vs. 3.5% FL), heart attack, angina or coronary heart disease (11.8% Pinellas vs.10.2% FL), and diabetes (12.4% Pinellas vs. 10.4% FL). The target population is indigent and low income adults 18-64 who experience a disproportionate burden of obesity. A diagnosis of obesity in the target population carries additional challenges of accessibility to affordable healthy foods and environments amenable to exercise. In Pinellas, 117,956 residents (13.1% of the population) are living below poverty level, including 12.9% of adults 18-64. Additionally, 291,300 residents (32.3% of the population) are defined as low-income, living below 200% of the Federal Poverty Level (US Census Bureau, 2008-2012 ACS). In Pinellas, the obesity rate increases to 30.5% among low-income adults making <$25,000 annually (BRFSS, 2010). The target population served by DOH-Pinellas Primary Care clinics is adults 18-64 who are at or below 200% of the Federal Poverty Level (FPL) and uninsured. As of September 2014, DOH-Pinellas has 6,100 clients enrolled in primary care. In the last quarter, 72.4% were overweight or obese as evidenced by a recorded BMI ≥ 25. Since its inception, 500 primary care clients have been referred to the obesity clinic. In the past, DOH-Pinellas primary care providers cited BMI and related concerns to clients, but had few resources and supports to offer overweight and obese clients who were motivated to change. Resources and supports are of particular importance in the target population which faces additional challenges with access to healthy foods and exercise given financial constraints. The primary care clinics did have an in house dietician available to clients in the past, but this person covered five sites throughout the county and was often unable to meet the demand. The current practice of an obesity clinic with a dedicated bariatric physician and dietician is better for many reasons. First, clients are referred based on their BMI and on their self-reported willingness to improve their weight.  Second, the schedules of the physician and the dietician are coordinated so that clients can see both providers on the same day. The physician can also address clients’ primary care needs when appropriate.  Third, clients are offered a monthly appointment with both providers that includes evaluating weight, blood pressure, exercise type and routine, and diet, with recommendations for dietary and exercise changes, journaling, and continued education. Thus, obesity clinic clients have much more frequent visits with providers and these visits are more comprehensive than a traditional primary care visit. Additionally, since being selected by NACCHO as a Promising Practice last year, activities have been added to strengthen the practice.  Since January 2014, obesity clinic clients have access to monthly support groups, healthy cooking demonstrations, and financial assistance in the form of vouchers from a local non-profit organization to aid clients with the purchase of fresh produce at a local market. It is innovative because it is new to the field of public health and is a creative use of existing practice.  Most public health chronic disease programs focus on children, schools, and/or the environment.  While this focuses on the individual in a primary care setting, it has public and private health implications as a model for reaching patients to improve their health without medications.  It is a creative use of existing practice in that the bariatric physician and dietician now have specific times when they are focused together on clients who are ready to make changes in their weight.  Scheduling the two of them in the same clinic location at the same time throughout the county has made it very convenient and accessible to clients at their medical home location. While many components of the practice are rooted in evidence, the practice itself is not evidence based.
Nutrition, Physical Activity, and Obesity
The goal of the practice is to reduce the financial and health burdens of obesity for DOH-Pinellas primary care clients whose BMI is ≥25 and who indicate a willingness to improve their lifestyle.  These clients are adults 18-64 who are uninsured and living at or below 200% of the Federal Poverty Level (FPL). The practice objectives are for participants to make lifestyle changes to improve nutrition and increase physical activity in order to lose weight and maintain that weight loss. For successful participants, this translates into improved self-esteem, decreased obesity-related morbidity and mortality, and decreased use of medication. To achieve the practice goal and objectives, DOH-Pinellas established a pilot weight management program in February 2011 in one clinic site led by a bariatric physician. After successful implementation, the clinic was expanded to four sites countywide over the next two years. Beginning in January 2014, additional components were added to the practice including monthly support groups, healthy cooking demonstrations, and financial assistance in the form of vouchers from a local non-profit organization to aid clients with the purchase of fresh produce at a local market. The first step in establishing the clinic at each site was to establish the dates, times and locations of appointments, coordinated with the clinic managers, physician, and dietician at each of the four locations.  The next step was to set up the appointment schedules in the electronic scheduling system.  Providers in the Primary Care clinics were instructed on how to best identify and refer candidates among their clients and make electronic referrals to the bariatric physician and dietician.  The Medical Assistants at each site are responsible for completing the electronic referral process and making appointments. The timeframe for full implementation at each site was approximately three months. Support groups started in October 2013 and now occur on a monthly basis at each location. All obesity clinic clients are offered to attend, with the goal of approximately 10-15 participants at each session. The physician opens the discussion at each support group, with the participants leading the support group as they provide feedback and ideas to one another about healthy eating and exercise. The registered dietitian provides information at each support group that includes healthy eating and weight loss tips, recipes and exercise tips. The Fruit and Vegetable Prescription Pilot (FVPP) began in January 2014. FVPP provides vouchers to aid clients with the purchase of fresh produce at a local market, funded by local community partner Bon Secours through a grant. Clients of the obesity clinic at all four clinic locations were invited to participate in the FVPP. When the participant agreed to participate in the FVPP, a pre-survey was provided for the participant to complete. As part of the pre-survey, each participant answered how many family members lived in the household they reside at. Each participant was provided with a FVPP voucher that had 5 weeks of Saturday dates the participant could use the voucher to receive free fruits and vegetables at the St. Petersburg Saturday Market. The amount provided to each participant was determined to be $1 per day, per each person in the household. For example, if the client lived with three other family members, they received $7 for all four family members, including the participant, which equaled $28 per week to purchase fruits and vegetables at the St. Petersburg Saturday Market. At clinic visits every four to six weeks, each participant is provided with an updated FVPP voucher to use at the St. Petersburg Saturday Market. In addition, beginning January 2015 biweekly healthy cooking demonstrations are offered at the Mid County clinic location. Clients from all locations are invited to attend the cooking demonstrations, which are sponsored by a local community partner, the University of Florida Pinellas County Extension. Beginning in January 2015, cooking demonstrations will be offered on a biweekly basis at the Mid-County and St. Petersburg clinic location. The initial practice stakeholders were primarily internal with many departments and locations involved.  From the County Health Department Director to the support staff, numerous individuals and departments assisted in both the planning and implementation of this practice.  The Director supported the concept and allowed the bariatric physician to implement it on a pilot basis.  Clinic managers worked with the physician on a schedule that adequately covered the county.  Primary care physicians eagerly began to make referrals and support staff assisted clients with appointments. The initial community stakeholder was Pinellas County Health and Community Services, the funder of the Pinellas County Health Program of which most DOH-Pinellas primary care patients are enrolled. The State of Florida is also a stakeholder though it’s Low Income Pool program which funds both primary care services and weight management activities. Since that time stakeholders have been expanded to include Bon Secours and the University of Florida Pinellas County Extension who were directly involved in the planning and implementation of the FVPP and cooking demonstrations respectively. These relationships have allowed DOH-Pinellas to expand the obesity clinic and address additional barriers to weight loss for the low income population including accessibility to affordable healthy foods resulting in greater weight loss for participants. Start-up costs were minimal, involving primarily planning time and the purchase of a body composition monitor and scale ($50).  The practice largely pays for itself through reimbursements from Pinellas County Health and Community Services based on an encounter rate and current state Low Income Pool funds designated for weight management. The practice is also thought to reduce the overall cost of providing services to overweight and obese clients by reducing the number and/or doses medications and improving obesity-related chronic disease morbidity. Other costs for the voucher program and health cooking demonstrations are provided in-kind by community partners as described above.
The goal of the practice is to reduce the financial and health burdens of obesity for DOH-Pinellas primary care clients whose BMI is ≥25 and who indicate a willingness to improve their lifestyle.  These clients are adults 18-64 who are uninsured and living at or below 200% of the Federal Poverty Level (FPL). The practice objectives are for participants to make lifestyle changes to improve nutrition and increase physical activity in order to lose weight and maintain that weight loss. For successful participants, this translates into improved self-esteem, decreased obesity-related morbidity and mortality, and decreased use of medication. To date, 500 clients have been enrolled in the clinic. In 2013, an initial review of 85 clients who participated in obesity clinic for two years showed positive results as follows. The BMI mean for the group went from 39.54 to 36.69, the group lost a mean of 7% of their weight (1% - 24%), and a mean of 17.68 pounds were lost (3-57 lbs).  Systolic BP went from a mean of 134.18 to 128.84, and Diastolic BP went from 84.9 to 81.11.  The HgbA1C was lowered from 7.27 to 5.15.  Using the means, the practice met all of its objectives. In reviewing the data, it was discovered that the reduction of BMI of individuals directly correlated to the number of clinic visits they had, and that weight loss had a significant impact on lowering SBP, DBP and HgbA1C to healthier levels.  It was also found that whites, females, and persons age 45-60 were the most likely regular participants.  This data was collected from the participants’ electronic health records (all primary data) and analyzed by internal evaluation staff.  Staff looked at correlates of the number of clinic visits to weight loss and performed a sample paired t-test to examine changes in BMI, BP and HgbA1C from initial visit to last date of service. After initial evaluation, modification were implemented to strengthen the practice including the addition of support groups, cooking demonstrations, and vouchers to aid clients with the purchase of fresh produce at a local market in January 2014. Additional evaluation was completed in October 2014 and results continue to be positive documenting that practice goals and objectives have been met, with 5-10% weight loss demonstrated without the use of anorexiant medications. Clients are losing weight, maintaining weight loss, and lowering their blood pressure, A1C levels, and fasting lipid panels. Further, for clients who have lost 10% or more of their body weight, the number and/or doses of medications including antihypertensives, hypoglycemics, and statins have been decreased. Clients have also reported increased energy and self-esteem and decreased symptoms associated with arthritis, GERD, OSA and depression. Recent evaluation included a retrospective study of 153 clients to assess the effectiveness of new practice activities added in 2014- support groups, cooking demonstrations, and vouchers to aid clients with the purchase of fresh produce at a local market. Results showed that clients participating in all three added activities had significantly greater weight loss that those who participated in only one or two. Of the three activities, participation in cooking demonstrations resulted in the most significant weight loss. Again, this data was collected from the participants’ electronic health records (all primary data) and analyzed by internal evaluation staff. As 2014 evaluation was just completed last month, modifications have not yet been made to the practice. Some changes being considered are initiation of cooking demonstrations at additional sites and expansion of the clinic to one additional location.
The primary lesson learned in this practice is that weight loss and weight management can be accomplished without anorexiant medications among low income, uninsured residents.  Resources all in one location, familiar to the patient, also seem to have a positive effect as do the motivation and focused attention coming from a physician and dietician.  Since the evaluation showed that certain groups are more likely to participate, and participation leads directly to weight loss, more research needs to be done with the groups less likely to participate to better assist them.  Partner collaboration has provided the project with vital resources to address additional barriers to weight loss for the low income population including accessibility to affordable healthy foods resulting in greater weight loss for participants. Partner collaboration has also increased sustainability of the project. While the obesity clinic is offered to Primary Care clinic clients at DOH-Pinellas, the practice and its interventions and support can be adapted for many setting and clients within a health department. Successful interventions such as cooking demonstrations, support groups, and vouchers can be offered individually or in combination through collaboration with community partners and providers.  Overweight or obese primary care clients are sometimes told they need to lose weight.  There are limited resources available and providers are not given many specific tools to assist clients in this area.  This practice provides those clients who are ready to change a resource to assist them.  The practice is financially self-sustaining at this time.  While a formal cost/benefit analysis has not been completed, it provides an estimated cost savings of $1,429 per year per patient for that demonstrate weight loss. With 500 participants to date, that is up to $714,500, much less than the annual cost of the program. The Florida Department of Health is committed to improving the health of its residents, including by addressing obesity.  In January 2013 the State Surgeon General, Dr. John Armstrong, launched the Healthiest Weight Florida initiative.  According to the Healthiest Weight website, “By bending the projected BMI (Body Mass Index) curve by just 5% from the current trajectory, hundreds of thousands of new cases of chronic disease can be prevented while saving millions in healthcare costs.”  This practice has already demonstrated it can lower BMI by 7%, so it can become a model for other Florida LHD’s. DOH-Pinellas was also recently awarded a CDC Partnerships to Improve Community Health to address obesity related issues. Also, this practice continues to receive expanded funding from partners as stakeholder commitment is high.  DOH-Pinellas was recently ccontacted by a local Pinellas restaurant to work together to provide clients with healthy food options when dining out. DOH-Pinellas is also looking to work with local gyms, YMCA’s , and/or recreation centers to get our clients memberships at gyms to help with the exercise component.
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