Team-based care and clinical quality improvement initiatives: Implementation of a Clinical Pathway (CPW) Model for the evaluation and management of childhood obesity in Primary Care Safety-Net Clinics in Los Angeles County

Background: There has been a growing recognition that combating childhood obesity requires an array of multi-level, multi-sector approaches. For example, in the clinical setting, identification and prompt referral for both medical and lifestyle management represent critical pathways to stemming behavioral trajectory that can lead to poor health outcomes in adulthood. In underserved populations that rely on safety-net clinics, this is increasingly important, as coordination and linkage to resources are often not efficient with team-based care. The present case study presents an in-depth examination of a county-based pediatric clinical quality improvement and cost-efficiency program, implemented as part of the Early Childhood Obesity Prevention Initiative (ECOPI) in Los Angeles County.    

Methods: We describe the collaboration between large safety-net clinic systems and the ECOPI team at the Los Angeles County Department of Public Health. Launched in 2012, the project sought to strengthen clinic processes and community linkages for pediatric obesity prevention and management. It applies a Clinical Pathways model as a clinical decision-making tool that operationalizes best evidence recommendations into an accessible practice format for health provider teams to promote standardized evidence-informed practices and efficiency in the health system, while at the same time provide these teams with up-to-date information about community resources that can be utilized to promote healthy eating and active living. The case study  utilizes a mixed-methods approach to evaluate program fidelity and progress. The study methods included the use of structured and semi-structured interviews with patients, leadership, management and physicians; EHR review; and analysis of costs related to the implementation of the Clinical Pathways model. Where appropriate, we share lessons learned during the process.

Results: Preliminary data showed selective improvements in obesity identification and management (e.g., from baseline, 42% increase in case identification, 38% increase in follow-up of obese children).  A total of 17 clinics participated in the quality improvement program and was able to implement the model in their practice. Barriers to model adoption included competing priorities in clinical care, limited funding for system-level implementation, and workforce capacity to coordinate care based on a Clinical Pathways model approach.

Conclusion: Early results from the Clinical Pathways model intervention suggest that the multi-level team approach is a promising strategy for early detection and management of childhood obesity, but are attenuated by implementation barriers. These barriers, however, could be mitigated by forthcoming health system changes that support and reimburse for team care under the Patient Protection and Affordable Care Act of 2010.