Utilizing the Chronic Care Model in the Management of Obesity In Primary Care Practices Serving an Urban Minority Population – Lessons Learned

In 2006, Thomas Jefferson University created a Center for Excellence in Obesity Research, involving multiple Academic and Clinical Departments, community organizations and the Philadelphia Department of Public Health. The health services research component of the Center is the Clinic Community Intervention Program (CCIP), which uses Wagner's Chronic Care Model (CCM) to provide a framework for integrating a clinical care model that improves provider identification and management of obesity and related co-morbidities with support that is grounded in lifestyle modification. The CCIP target population has a BMI of 30 or greater, is aged 18-55 and is from inner city neighborhoods that are predominantly African American and Hispanic. In the CCIP's application of the CCM, the patient support component includes a clinic based Lifestyle Counselor, and linkage to a 4 session skills based curriculum that assists study patients to develop healthy lifestyles through improvements in diet, physical activity, stress management and planned exercise. The CCIP uses the CCM as a framework for obesity management by conducting provider education and performance monitoring (using NHLBI Obesity Management Guidelines), providing self-management support, and linking participants to community based resources and programs. Care teams include Primary Care Providers, a Lifestyle Counselor, and a Community Health Educator. To facilitate optimal function of these teams, training was provided to all site personnel who are directly involved with patients. Communication is ongoing between the providers, Lifestyle Counselor and Health Educator. Assessment measures, performed at baseline and at intervals, include a lipid profile, glucose, and chemistry panel; height, weight, BMI; Perceived Stress Scale; Readiness to Change; Physical Activity level (using the International Physical Activity Questionnaire); semi-quantitative food frequency questionnaire; nutrition/weight loss knowledge, attitudes and behaviors and self-efficacy. To date, 2100 individuals have been referred, and 750 enrolled. Outcome measures, compared to a control group, of the first 500 participants and results of a process evaluation, which resulted in several protocol changes, will be presented.