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

Chapter 3: Getting Patients Excited About Crossing the Bridge

Nobody likes to be told to do something because it is "good for them." From their first steps, children challenge their parents and they get better at it as the years progress. Still, like a parent to a child, there is an obligation to deliver a consistent message backed up by role modeling and examples of others who have overcome or are trying to overcome the barriers presented.

 

Sometimes, just telling someone they need to stop smoking, eat better, or exercise more doesn't get the results we seek.

 

Obesity Screening

As mentioned above, the first step in screening for obesity, according to the U.S. Preventive Services Task Force, is measuring the Body Mass Index (BMI) of every patient aged 6 and greater.6 In our intervention, practices found that the standard of obtaining height, weight, and BMI from patients at every visit was the easiest change to implement. Although some staff or clinicians may argue that BMI measures are not perfect, they are the clinical standard in many cases. Heavily muscled people often have BMI's in the overweight or obese range. These patients may need another tool to assess their weight status such as waist circumference or percentage of body fat. 

Clinicians sometimes say their "eye ball" is enough. However, the BMI provides you with an objective measure of obesity status rather than a subjective assessment. Weight is often gradually gained or lost. If BMI is recorded at every visit, it will be more likely that you will catch these changes and be able to praise patients (for weight loss) or provide additional interventions (for weight gain).

Using the results from your chart reviews and observations in Chapter 2, have the Clinician Champion and Intervention Team discuss the protocols in place at your clinic to obtain an accurate weight and height on each visit. Tool 5 is a worksheet that considers elements and personnel required for obesity screening. The worksheet and suggested protocol in Tool 6 will help you frame the issue in a logical way.

The Institute for Healthcare Improvement uses the Model for Improvement as the framework to guide quality improvement. The Model for Improvement is a process that allows you to decide what you want to do, implement it, measure to see if it worked, and then to make adjustments based on testing your change strategy. Links to the Model for Improvement as well as a YouTube video on the Plan-Do-Study-Act (PDSA) cycle are listed in the resource section.

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Documenting Weight Status and Addressing It with Patients

Once an accurate BMI is obtained, clinics are encouraged to note weight status in the problem list (e.g., overweight or obese) and to address the condition with the patient at each visit. You may wonder: "Will that make any difference?" A study published in 2011 in Archives of Internal Medicine found that patients who had been told by a clinician that they were overweight were more likely to perceive themselves as overweight and to have attempted to lose weight in the past 12 months.7 That is a step in the right direction. Once a problem is acknowledged, brief counseling can begin. Two frameworks for approaching this counseling are the Five A's and Motivational Interviewing (MI).

 

Overweight individuals were twice as likely to have tried to lose weight during the previous year if a physician had told them they were overweight.

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Five (or Six) A's and Motivational Interviewing for Health Behavior Change Counseling 

The Five (or Six) A's. The Five A's are: Ask, Advise, Assess, Assist, and Arrange. The 5 A's have been linked to higher motivation to quit smoking among tobacco users. Now, they are being applied to weight loss. Table 2 provides a description and examples for each of the 5 A's.8

Table 2. Descriptions and Examples of the Five A's

"A" Description Example
Ask Clinician asks the patient about weight, nutrition, and exercise.

"Do you exercise?"

"What do you typically eat for breakfast?"

Advise Clinician provides the patient with clear, strong advice.

"You need to get 30 minutes of exercise a day, 5 days a week."

"I think you need to lose about 20 pounds." "Because of your diabetes and hypertension, it is really important that you exercise."

Assess Clinician verbally assesses patient's readiness to change.

"Is attaining a healthier weight something you might want to do in the near future?"

"Do you see yourself getting more exercise in the coming months?"

Assist Clinician assists by providing brief counseling or self-help materials

"What might get in the way of your plans to exercise three times a week?"

"How are you feeling about being able to make this change?"

"Is your family supportive of your attempts to eat better?"

Arrange Clinician arranges for follow-up with health care professional or community-based resource "I will make a referral to (Community-Resource), they have an excellent program to help you attain a healthier weight."

A recent study titled: "Do the Five A's Work When Physicians Counsel About Weight Loss?"8 found that physicians consistently ask and advise patients to lose weight, but often stop there. When physicians arranged for follow-up, patients had a significant increase in weight loss compared to patients whose physicians did not. Moreover, physicians that both assisted and arranged saw improvements in their patients' dietary fat intake. Using the Five A's approach can support patient weight loss efforts in primary care (e.g., increasing patient motivation, confidence, and likelihood of change).

 

Recently a sixth "A" indicating "applaud" was added to the 5A's. It is important for clinicians to recognize even small changes in patient behavior and to acknowledge these changes.

 

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Motivational Interviewing

Motivational Interviewing (MI) is defined as a collaborative, person (patient)-centered form of guiding to elicit and strengthen motivation for change. MI focuses on exploring and resolving ambivalence and centers on motivational processes that facilitate change within the person. MI has evolved over the last two decades. Studies find that MI is efficacious in helping patients make behavior change.

MI is about getting your patient to proceed with a change. It begins with allowing them to commit to a change by having them verbally describe their reasons why the change is good for them. They need to have confidence that they can indeed change. It includes you and the patient establishing a plan that will work for that person. (Don't forget to document the plan in the chart notes). It needs to be a realistic plan that you believe the patient can achieve so when you speak with them next time you can boost their confidence (applaud) in a genuine way. Lastly, you should support their autonomy as they progress with proper affirmation and recognition, and help when they slide.

In theory, this sounds right, but how do you actually carry out this conversation? There is an acronym to help you remember. It is OARS and represents:

  • OPEN-ENDED QUESTIONS.
  • AFFIRMATIONS.
  • REFLECTIONS.
  • SUMMARIES.

Open-Ended Questions. Open-ended questions are those that require the receiver to respond with more than a yes or no answer. They elicit responses that reveal the thought patterns and knowledge of the speaker. They also allow the clinician to say which behavior needs to be changed in a less direct manner. These questions get the conversation focused on "change." Think about the difference between the first closed-ended question and some of the open-ended questions that follow:

Closed Example 1. "You need to achieve a healthier weight. Are you ready to start a diet and increase exercise?" 

No.

Open Example 1. "You need to achieve a healthier weight. What are you already doing to be healthy?"

Well….

Open Example 2. "What is working for you around diet and exercise? Why might you want to make a change in diet and exercise?"

What works for me is….

Open Example 3. "If you decided to try and achieve a healthier weight, how would you go about doing it? What are the three most important benefits you see in making this change?"

I think I could try and …………

The following sets of open-ended questions are from Miller and Rollnick, who pioneered Motivational Interviewing and "Change Talk."9 These questions may help patients identify the harms of not changing behavior or the advantages of change. Table 3 provides examples of these types of questions.

Table 3. Two Types of MI Questions That Support Change Talk

Questions requiring answers that are disadvantages to maintaining the status quo.
  • What concerns you about your weight?
  • What makes you think you need to do something about your weight?
  • What hassles have you experienced in relation to your weight?
  • How has your weight stopped you from doing what you want to do in life?
  • What do you think will happen if you don't change anything about your weight?
Questions that require answers that focus on the advantages of change.
  • How would you like things to be different?
  • What would be good things about attaining a healthier weight?
  • What would you like your life to be like five years from now?
  • What are the main reasons you see for making a change?

 

Gauging the patient's sense of confidence in their ability to make a change is also a part of the MI conversation. Some clinicians like to establish a numerical value to write in the chart. The question would be: 

On a scale from 1 to 10 with 10 being extremely confident, how confident are you that you can (be specific) exercise 30 minutes a day 3 times a week?

Not Very                 Very
1 2 3 4 5 6 7 8 9 10

 

This will give you a sense of the patient's optimism about change. The following open-ended questions may also be used to measure the confidence and optimism about the change.

  • If you decided to make a change in diet and exercise, what would you do to be successful?
  • What do you think would work for you if you decided to change your diet or exercise more?
  • When else in your life have you made a significant change like this? How did you do it?
  • What personal strengths do you have that will help you achieve a healthy weight?

Lastly, here are some open-ended questions that will gauge the patient's intention to change.

  • What are you thinking about your eating and exercise habits at this point?
  • What do you think you might do?
  • What would you be willing to try?
  • What do you want to have happen?

Affirmations. Making an affirming statement can help build the relationship of trust between you and the patient through this change process. An affirming statement confirms that you want the patient to succeed. Affirmations include:

  • Commenting positively on a patient attribute. "You have demonstrated a strong commitment to others."
  • Making a statement of appreciation. "I appreciate your being honest with me about how your spouse is going to make this change difficult for you."
  • Catching your patient demonstrating a positive behavior. "You've been very consistent with your approach to eating breakfast every day."
  • An expression of hope, caring, or support. "With both our efforts we will get your weight to a healthy level."

Reflections. Reflective statements let the patient know not only that you are listening but that you are hearing what they are saying. Empathy is demonstrated through reflective statements. Empathy means understanding, not necessarily agreeing with, the patient's statement. Reflective statements are not questions that require the patient to answer. They restate what the patient says and selectively reinforce change talk. Further, they put the patient in a more active role when discussing behavior change. By making a reflective statement and then stopping, the other person is then "expected" to uphold their end of the conversation and make a statement rather than simply answering an open-ended question. An example may be:

"So, you say your children won't eat vegetables, and they are expensive, but you feel you can prepare them for yourself."

Summaries. The 15-minute visit does not allow for extensive conversation after the physical exam and dealing with the presenting problem. It is important to be able to wrap up the visit and still make the patient feel as if you are not giving them the brush off. First, recognize that patients understand you are trying to serve many others. It is okay to discuss time limitations up front. So a smooth summary statement will not come as complete surprise to them or an abrupt shift in conversation.

Summary statements can be accomplished by collecting material that has been offered by the patient into a conclusive statement. For example:

"You've expressed concern about your weight, hypertension, and family health habits."

Then move to an action step. If the patient seems to be saying the same thing over and over, link their last statement with something discussed earlier and then move to action. Transitional statements help you move to action after drawing together what has happened during the encounter. An example is:

"Let me summarize and see if I missed anything."

Then move to your goal setting action.

"We've talked about a lot of things today; if you had to pick one to work on, what would it be?"

Goal Setting to Support Health Behavior Change

Included in the resource section are two video links that reflect the actions described in the prior narrative. This 5:26 minute video provides a good short overview from Dartmouth University defining the five principles of MI. There is no actual patient-clinician demonstration of MI in this video, but rather it describes the principles:

  • Express empathy.
  • Develop discrepancy.
  • Avoid arguing.
  • Roll with resistance.
  • Support self-efficacy.

Ultimately, the entire conversation detailed above is to establish a mutually acceptable established goal and objectives between you and the patient. A goal is a statement of long-term desires. To achieve the goal, several objectives (short-term limited-duration activities) may be needed. One of those objectives leading to the goal of achieving a healthy weight might be to use the services of a community-based organization dedicated to improving diet or increasing exercise.

After listening to the patient describe what they think might work and considering your knowledge of community resources, if you can suggest a resource that you feel meets their needs, make the referral.

Some clinicians allow the patient to choose. After your summary statement, you might want to say:

"Our clinic has created a community resource inventory. We think these are resources that can help you. The medical assistant is going to share it with you. Before you leave, I'd like for you to tell me which resource you'd like me to refer you to."

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Documenting Brief Counseling and Patient Goals

To remind you of the goals and where the patient decided to go, it is imperative that you document the discussion and record it in your chart notes. Tool 7 is a guide for documenting the discussion.

Some patients may acknowledge that they need to get healthier. They may not want to go to a community resource but will say they want to "try on their own." They may say they want to walk along the pathways near the river or use the track three times a week. They say they'll only have one dessert with dinner and start the day with breakfast. That is fine. The important thing is to establish goals with the patient around diet and exercise and document the discussion and goals in the medical record.

 

Findings on Changes in Documented Discussions on Weight Status in Our Intervention

The number of patients with any documented discussions on weight (16% to 22%, p = 0.1312), diet (23% to 24%, p = 0.9104), and exercise (24% to 23%, p = 0.3393) did not change significantly across all six intervention clinics. However, there was significant improvement in documentation of these discussions by individual sites.

Pre- and Post- Changes in Any Documented Discussions on Weight, Diet, and Exercise by Clinic

Clinic Weight Diet Exercise
Pre Post p-value Pre Post p-value Pre Post p-value
One 14% 9% NS 14% 19% NS 9% 9% NS
Two 35% 42% NS 57% 9% <0.001 (-) 58% 25% <0.0001  (-)
Three 7% 18% 0.0109 (+) 23% 30% NS 14% 29% 0.0037 (+)
Four 4% 15% 0.0190 (+) 6% 18% 0.0091 (+) 4% 21% 0.0021 (+)
Five 25% 27% NS 30% 35% NS 26% 44% 0.0028 (+)
Six 12% 23% 0.0039 (+) 16% 24% 0.0045 (+) 13% 29% 0.0002 (+)

Definitions: + = Increased, - = Decreased, NS = Not Significant.

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Current as of 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 3: Getting Patients Excited About Crossing the Bridge. May 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/obesity-pcpresources/obpcp3.html