198157 Utilizing the Chronic Care Model in the Management of Obesity In Primary Care Practices Serving an Urban Minority Population Lessons Learned

Tuesday, November 10, 2009

James Plumb, MD, MPH , Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA
Rickie O. Brawer, PhD, MPH , Office to Advance Population Health, Thomas Jefferson University Hospital, Philadelphia, PA
Nancy Brisbon, MD , Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA
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.

Learning Objectives:
Participants attending the presentation will be able to: 1) Understand the application of the Chronic Care Model to management of obesity 2) Learn the challenges of creating effective delivery system change 3) Apply lessons learned to enhance management of obesity

Keywords: Obesity, Chronic Diseases

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been the Principal Investigator of this project for the past three years, and have worked with the targetted population in numerous care, sytem and policy initiatives
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.