Integrating Primary Care Practices and Community-based Resources to Manage Obesity: A Bridge-building Toolkit for Rural Primary Care Practices

Chapter 1: Attaining Zoning and Building Permits

Before engaging in this bridge building process, it is imperative to examine your clinic's readiness to undertake the project. Start by considering why change is needed from both the clinic and patient perspectives. The obesity epidemic is well documented. The devastating effect of obesity on overall health status is known as well. Diet and exercise are contributing behaviors to preventing heart disease, cancer, stroke, diabetes, mental illness, and overall morbidity and mortality.

Many patients know that being overweight is not good for their health. However, change is hard without the support of family, friends, workplaces, and community. They need your help.

As you determine whether your clinic is ready, note that to change an activity of an organization four things should be in place: leadership, data, a process plan, and allocated resources. This chapter deals with leadership and activities to help attain buy-in from clinic staff. We emphasize:

This bridge-building project relies on local knowledge and relationships. A clinic's staff is generally comprised of community residents and all may have something to contribute to the effort. Sometimes starting to build a change process around a smaller issue can set a strong foundation for future clinic activities. Helping build a bridge may foster positive momentum for practice improvement.

Assessing Clinic Readiness for Change and Leadership Support

Below are some common factors that may positively or negatively affect the process of change in your clinic. They include: low energy level; obesity among clinic staff; multiple contributing factors; fixating on cost; mission statement; collaborative efforts; and clinic spirit. Clinics should understand, evaluate, and address these factors to help move the process forward.

Low Energy Level (Change Fatigue). Scientific journals call the energy and capacity for a clinic to do something other than maintain the status quo an "adaptive reserve."5 You can assess this by thinking about the following questions:

  • Does the clinic keep abreast of evidence-based medicine standards and make a serious effort at staying educated?
  • Is the clinic willing to commit time beyond the basic requirements?
  • Is [this] change seen as an opportunity or a threat?
  • Does the clinic encourage and embrace new projects, programs, and ideas?
  • Are the clinic's decisions and actions proactive or reactive?
  • Do you as a leader find your role fulfilling, challenging, and enjoyable?

If you answered negatively to three or more of the questions, ask yourself: Can this bridge-building process serve to re-energize the group and restore enthusiasm? If resources are adequately allocated, it just might!

Obesity Among Clinic Staff. In more than 10 years of experience working with rural primary care practices, we have found that clinicians and staff normally reflect demographics and health characteristics of the community as a whole. That means some of the clinic's employees are likely overweight or obese, and this may present barriers to implementation. You might consider, from an employer human resource perspective, what your clinic can do to encourage increased physical activity and improved nutrition in the workplace. Demonstrating that you are committed to helping your staff live a healthy lifestyle (and achieve a healthy weight in the process) may inspire your patients to do the same. 

Multiple Contributing Factors (It's Outside Our Scope of Practice). Another sign of inadequate readiness is a group's unwillingness to accept some responsibility for a problem. As the issue of obesity is discussed, do you or your staff look for other conditions or institutions to blame? This might include easy access to fast food restaurants, mass marketing advertising that encourages "supersizing," poor school nutrition programs, the Federal government's farm policies and commodity subsidizations, inadequate parenting, or the time people spend watching screens (e.g., internet, video games, television).

These factors do contribute to the obesity epidemic. But, don't throw up your hands and surrender. As a cornerstone of your community's health system, you can do your part to address the problem. There are many opportunities to get involved in local policies that help contribute to a social environment that supports making the right choices about obesity for your community. As a leader in the local health system, you can do your part within the clinic setting; in addition, many evidenced policies have been identified by the Centers for Disease Control (CDC) that you may support or help implement in the broader context of the obesity issue. A link to the CDC Community Guide is in the resources section.

Fixated on Cost. Cost is always an issue, but it is important to stress the potential value of such an endeavor compared with the costs. Your leadership team should ask: What is the cost of building the bridge to community-based resources for obesity management? Time to participate in planning meetings and do the work is one of the most pressing costs—and these costs vary by clinic staff positions. One key opportunity is to match tasks to staff skills and expertise. Staff not directly involved in patient care might fill some of the important linkage roles with limited additional costs. For example, front desk staff may be willing and enthusiastic about identifying, describing, and communicating with community resources.

Opportunity costs are also involved. You could be doing other work to improve patient health behaviors rather than connecting with resources. Each practice will need to consider the costs and benefits of this work and how they align with overall organization goals.

 

When someone says, "It's not the money, but the principle," it's usually the money. 

 

Aligned Mission Statement. Clinics often have a mission statement that reads akin to: "We provide the highest quality care in a patient-centered, compassionate manner." Providing the highest quality of care and building a relationship with a patient is the intrinsic motivator for most clinicians. This process can help fulfill your mission.

Building on Other Collaborative Efforts. Has your clinic integrated mental health services or made connections to dental resources? Does the clinic have a history of collaborating with public health organizations, schools, or human service groups? Is your clinic implementing care coordination as part of your Patient Centered Medical Home (PCMH) initiatives? If so, your clinic already has created numerous bridges to community-based resources. Developing these relationships demonstrates that you can be successful.

Clinics might also review processes to make referrals to many other subspecialty clinicians and health care institutions. Consider modifying or expanding this process to help facilitate linkages to community-based resources to help patients change their health behaviors and lose weight. 

Clinic Spirit. Does your staff seem happy? Is your staff turnover rate high? Clinic spirit can influence the willingness to participate in change activities. Hopefully your staff celebrates holidays, provides cross-coverage so that people may spend time with their family (work hour flexibility), has a respectful climate, and supports honest communication. These factors contribute to the overall spirit of the organization. Job satisfaction in clinics stems from people perceiving that they can influence decisions and relationships with patients and be recognized and valued by their superiors.

The bridge-building process can build on those factors as staffs are often experts on their community. Many staff members have lived in the communities a very long time. They know the patients as "people in the community" whether they are sick at the clinic or well. They understand the challenges of achieving a healthy lifestyle in the local environment. Often, the clinician may be the newcomer. Inviting staff to help implement this toolkit in partnership with clinic leadership may bolster clinic spirit.

Return to Contents

Developing Strategies to Support Process Leadership for Change

New ideas or products often need a champion (leader) in order to take hold. A project champion believes in the concept and encourages others to put their efforts behind it. This person must be willing to address the concerns, skepticism, confusion, and perhaps anger that new ideas can generate.

In this guide we call this person the Clinician Champion (aka Chief Engineer of Construction). If you are leading efforts to build this bridge, you will need staff input and support. Involving staff in the problem-solving and decisionmaking is different than telling them what to do. To achieve buy-in, staff must agree that the activity is important, know they will have a role in shaping the response and influencing decisions, and know their specific role in the overall goal is meaningful.

Two common qualities emerge in all definitions of leadership. Leadership involves:

  • A group process. In order to lead there must be followers.
  • Influence.

The Clinician Champion may need the support of the office manager or clinic administrator to coordinate the process and planning details. Many strategic Clinician Champions may share this toolkit with a staff champion and small group team and say, "We need to do this, and I'd like for you to help me make this happen." This doesn't suggest abdication of leadership duties. Instead it recognizes that the Clinician Champion needs partners with connections to both front and back office staff to organize practice change. The Clinician Champion still provides direction and vision for the project, helps design tests for process changes, supports staff as they implement "tests" of change, and encourages organizational changes so that the efforts can be sustained over time.

Return to Contents

Building Clinic-wide Engagement (Bridge Building Planning Meeting)

No construction project gets started without a mandatory public hearing. Similar steps should occur when preparing for clinic changes. Clinic staff meetings often serve this function. In initiating this project, clinics are encouraged to host an informational/engagement meeting with all clinic staff. The goal of this meeting is to seek staff input, to educate staff about the importance of this issue for patient health, to decide to make a change, and to establish a foundation for the project.

This meeting agenda should include the following:

  • Overview of the obesity epidemic and associations with medical conditions.
  • Project explanation (i.e., to build linkages between the clinic and community-based resources to manage overweight and obesity).
  • Opportunities for staff to engage in a discussion around the topic and project planning.

It may be helpful for the office manager (or designee) to lead a discussion around the questions in Tool 1. There are no right or wrong answers. We conducted discussions like this (called focus groups) in preparation for our intervention and building this toolkit. Participants included staff from community-based organizations, community members (patients), and medical clinicians and their staff.

 

Findings from Focus Groups with Clinic and Community Partners in Our Intervention  

Two members of our research team conducted hour-long focus groups with clinic staff and community stakeholders. A total of 30 clinic members participated in 6 pre-intervention focus groups, including clinicians (n = 10), nurses (n = 5), medical assistants (n = 11), administrators or managers (n = 6), and other clinic administrative staff (n = 15). Forty-four community stakeholders representing public health, weight loss agencies, hospital services, and other community-based organizations participated in six focus groups and two individual interviews. Select themes are summarized below. 

  • Clinic and community participants identified overweight and obesity as a significant health issue. They indicated that lower socioeconomic status and limited income present barriers to healthy lifestyles and thus contribute to obesity.
  • Weight status was perceived to fall along a continuum, with little distinction between overweight and obese. However, morbid obesity was perceived as distinct. Participants felt that people who are overweight "know it." A few felt that some people don't truly recognize their size (i.e., they may believe they are overweight when they are truly obese).
  • Primary care was seen as a potential resource for weight-related conversations and health behavior change. Both participant groups felt weight was a sensitive subject during patient-clinician conversations. Many found the word "obese" to be offensive. Both clinicians and patients felt that conversations should be framed around promoting healthy lifestyles or healthy eating and not solely weight. Some community members emphasized the importance of paying attention to the emotional and mental issues associated with weight loss – and felt it might be easier to work with a clinician who has struggled with his or her weight.
  • Although clinicians felt that they address weight during the clinical encounter, community members reported that clinicians don't address weight; they address the disease/presenting problem. Clinic staff said it is often the patient who initiates conversations about weight. 
  • Both groups felt that weight-related discussions don't take place because of lack of time in the exam room. Community members wondered whether the issue wasn't discussed because clinicians lacked a ready solution. Many community members and some clinicians felt the topic wasn't covered because of the potential to lose a patient to another provider given the sensitive nature of the topic. Some clinicians and clinic staff even indicated that patients will seek doctors who won't talk to them about their weight.
  • Participants identified many challenges to health behavior changes and the need for intensive support. A clinician saying, "You need to lose weight," is not enough; losing weight requires repeated educational messages and may even require showing a patient how to do something.  Readiness for behavioral change was perceived by both groups to be highest when a patient was confronted with a chronic disease diagnosis or labeled as "at-risk."
  • Most community members wanted time with their doctor to discuss weight-related behavior change. However, they would be receptive to help from other clinic staff if the handoff was smooth and staff had the training/credentials to provide additional help.
  • Clinic staff and community members were receptive to having referrals to community-based resources to support health behavior change. However, both groups recognized that one size doesn't fit all and that patients need to be matched to the right program. Clinicians called making this match "the art of medicine." 
  • While community-based resources would welcome clinician referrals and be willing to provide feedback regarding service utilization to the practice, participants identified the need to raise clinic awareness regarding existing services. Additionally, lack of insurance coverage for these services was seen as a barrier.

Return to Contents

Page last reviewed May 2014
Internet Citation: Integrating Primary Care Practices and Community-based Resources to Manage Obesity: A Bridge-building Toolkit for Rural Primary Care Practices : Chapter 1: Attaining Zoning and Building Permits . May 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/obesity-pcpresources/obpcp1.html