Team Care, Referrals, and Practice Resources



Team Care, Referrals, and Practice Resources


Deborah Bade Horn





CLINICAL SIGNIFICANCE

Providing obesity care within a primary care practice can be challenging, but it is essential for successful disease treatment. Just as there will never be enough endocrinologists to treat the 30 million individuals living with diabetes in the United States, there will also not be enough obesity medicine specialists to treat the 93 million individuals living with obesity.1,2 Patients believe it is the “responsibility of the primary care provider” to initiate the conversation about weight management and to do so in a nonjudgmental, knowledgeable and respectful manner.3 Furthermore, delivering obesity care is dependent upon disease recognition and utilization of the essential and varied resources for chronic disease management.

Patient outcomes will vary depending upon how the practice functions. For example, failure to diagnose obesity is associated with a decrease in the likelihood of successfully sustaining meaningful weight loss.4 A healthcare professional’s (HCP‘s) recognition of a patient’s previous attempts at weight loss increases the odds of success. Identifying the disease, acknowledging effort, and providing resources that improve motivation can improve patient outcomes.4 These brief examples highlight the importance of the three key topics covered in this chapter: Team Care, Referrals, and Practice Resources.

In reviewing each of the three key areas, it is important to acknowledge that primary care practice models vary widely. Some practices exist as part of a larger healthcare system or network, while others operate as private practices in single or multiple sites. There are also a wide range of collaborative business models that fall in between. This variation in practice models can result in just as many variations in team member structure, including team members that are practice employed, outsourced, multisite shared, or system/network shared. Regardless of structure, the resources available to patients with obesity should be consistent across all practice models, from team access to referrals to treatment options.


TEAM-BASED CARE

Team-based healthcare is defined by the National Academy of Medicine as “…the provision of health services to individuals, families and/or their communities
by at least 2 health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high quality care.”5 The advantages of team-based care in primary care include improvements in effectiveness and efficiency in delivering patient education, behavioral health, and care coordination.6 The practical advantages of team-based care include increased job satisfaction and provision of high-quality care. Team-based care can be implemented across different practices and for a variety of chronic diseases. For example, an HCP can treat low back pain with basic advice and pain medications, but the implementation of a treatment plan is best provided by a physical therapist.

Obesity is complex, and successful treatment requires frequent patient visits and additional resources beyond the typical brief patient/HCP encounter. This alone drives the need for team-based care. As mentioned above, a team care approach can improve both quality and efficiency of patient care.7 For example, team care is essential in making a diagnosis of obesity which requires an accurate documentation of height and weight, typically performed by a medical assistant, so that a meaningful discussion can be initiated between the patient and HCP.8 Additional team members (registered dietitian nutritionist [RDN], psychologist) can implement treatment and provide individualized resources beyond the brief medical encounter. Additionally, it is recognized that high-intensity behavioral counseling is effective in promoting weight loss and can be delivered by many different types of healthcare team members in primary care.9,10 Obesity care requires a multidisciplinary team to successfully deliver care and take advantage of the strengths of each team member.


The Team Lead

The first step in building an obesity care team is identifying the team lead or champion. Most often this will be a physician, but it can also be delegated to an advanced practice provider (APP: nurse practitioner [NP] or physician assistant [PA]) with physician oversight. In some states, nurse practitioners can practice independently. In a single-provider private practice, the team lead will be the solo HCP. From a team perspective, in a multi-HCP single-site practice, one HCP most commonly is identified to serve as the champion lead. Similarly, in a multisite healthcare system or multisite private practice, an overarching team lead is necessary for consistent obesity care initiatives across multiple sites. In this scenario, each site would identify a champion HCP who works together with the overarching team lead to ensure consistent implementation of practice protocols and improvements.

Ideally the team lead will either have or pursue additional expertise in obesity treatment. This can take the form of continuing medical education (CME), certificates of completion of dedicated obesity-focused CME, or attaining American Board of Obesity Medicine Diplomate status. See Team Education below for more information. The team lead should plan the practice’s approach to patient care and action steps for practice improvement activities for increasing and maintaining quality of obesity care. Examples of practice improvements include engaging all team members in obesity stigma and bias training, adding a question to patient satisfaction surveys already in use, and documenting the diagnosis of obesity in the electronic health record to help encourage providers and teams to treat obesity as a disease. The Healthy Teams Model is one approach to building an effective healthcare team. It is based on six key characteristics of a productive team: purpose, goals, communication, leadership, cohesion, and mutual respect.7 The team lead can build on these key characteristics to help team members engage and adopt new practice procedures regarding obesity care. Examples of these team-focused procedures may include documenting discussions around weight for purposes of quality improvement, or training team members on the principles and techniques of using motivational interviewing to solicit patient change talk. Creating a unified “team” work environment is critical to successful obesity patient care.


Team Members and Team Structure

The obesity care team involves many key players that may have overlapping roles. It is essential to identify and plan for which team members should be employed internally (within the practice) versus referred to externally (remain outside of the practice but still consistently utilized). Many of the team members necessary for delivering obesity treatment are already part of an existing primary care practice. These team members are covered in detail in Chapter 12. For example, these include the front and back office staff, e.g., receptionists, schedulers, patient advocates, and medical assistants. Other important key team members may or may not already be part of an existing practice. These include RDNs, APPs, exercise physiologists/trainers or physical therapists, behavioral specialists (including coaches, social workers, counselors, and psychologists), and clinical pharmacists. There are many options to providing access to this broader network of team members. In a university system or an integrated healthcare system, these team members might exist elsewhere in the practice system and available for referral. In a private group practice, they might be hired by the practice and shared between multiple practice sites. For single private practices, they
might be outsourced to the community via building a referral network of providers with whom the practice collaborates on patient care.

For example, currently it is uncommon for a primary care practice to have an exercise physiologist or a certified personal trainer on staff, and yet physical activity is an essential component of obesity treatment. (The training and skill set of an exercise physiologist are described in Chapter 12.) Therefore, a patient could be referred to resources outside the practice but inside the larger healthcare system or community to receive this component of care. Alternatively, the practice could hire an exercise physiologist or certified personal trainer as a contracted consultant (not an employee) to deliver interactive lectures or workshops to patients in a group setting. Practices that use this strategy often pay a flat class or hourly rate to the exercise physiologist and charge the patients a class fee for attending. This option can keep the cost down for both the practice and patients, provide essential physical activity guidance for patients, and build revenue for the practice. In this example, a resource that potentially costs the practice money is converted into a resource that increases practice revenue.

As the obesity care team becomes defined, it is important to remember that not every patient needs to see every type of clinician in the team; the care plan should be individualized. For example, some patients may need the accountability and additional behavioral support provided by a behavioral coach to build a skill set for long-term success, while others may need guidance from a physical therapist or certified personal trainer to develop a physical activity program that meets their treatment needs and physical abilities. This individualization of care must be considered as a practice determines its patients’ needs and plans for provision of resources.

When a specialty member of the obesity care team is not accessible or available, a practice may be able to train other team members to deliver those aspects of obesity treatment. For example, in some practices, medical assistants receive additional training in nutrition, sleep hygiene, stress reduction, and physical activity guidance. This additional training allows them to teach group classes to patients using a slide deck, leader guide, and handouts. The content delivered has been preapproved by the entire team and provides a consistent message to patients. This consistency is important since it ensures that patients receive the same education regardless of who is available to teach the class on any given clinic day. Practices will need to have some flexibility in staffing, as classes may start or end outside of the normal clinic workday to accommodate patient work schedules.

When considering whether to hire, refer to a resource inside a system, or outsource team members, it is important to confirm that they have a thorough understanding of the practice’s overall treatment goals and philosophy, thus ensuring that patients receive consistent messaging about their disease treatment. If a patient receives one set of instructions from the HCP at a clinic visit but a different set of recommendations in a class or from another provider, it can create confusion, frustration, and inconsistent implementation.


Team Treatment Flow

Treatment flow refers to the frequency and sequence of patient visits within the practice. Questions to consider include whether treatment flow changes based on the intervention chosen by a patient and their HCP, when does a patient see each member of the team, and what health data points need to be collected and when. Each of these decisions will affect treatment flow. High-intensity treatment is the most effective approach to successful obesity treatment, regardless of the nutritional intervention selected. Low- to moderate-intensity treatments often produce minimal results and often fail to meet patient and provider expectations.10,11,12 This evidence can guide decisions around frequency of visits as well as which and when providers are utilized.

What does treatment flow look like in an effective high-intensity treatment plan? High-intensity treatment is defined as ≥14 visits in 6 months that can be individual or group visits13 and including at least monthly contact for maintenance of weight loss. Emerging data support that the HCP does not always have to be the team member delivering this care. Studies demonstrate effective use of medical assistants, RDNs, and psychologists for successful treatment of obesity between HCP visits.14,15 Obesity is a chronic metabolic disease, and the initial assessment and evaluation of the patient should be done by a medical professional (physician, NP, or PA). The ability to delegate care between HCPs and other professionals highlights the need for an effective team.

The treatment flow also depends on the team members available and the structure of the clinic. When considering treatment flow pathways, consider all the possible types of visits: individual visits, shared medical appointments (group visits), intensive behavioral programs (both inside and outside of the practice or healthcare system), peer support groups, or any visit in which the patient’s support network of family/friends might be involved. Some patients may be resistant to group meetings, but clinicians should be aware that group interventions are at least as effective as 1:1 treatment, even among patients who express a preference for individual treatment.16

Being flexible in considering different types of visit structures can alleviate some barriers that a practice may initially perceive in delivering care. For example,
the patient may see the HCP at the start of treatment, and then see an RDN, nurse, or medical assistant for frequent check-ins over a 3- to 6-month period of intensive treatment. The patient then returns to the HCP after a set period of treatment or after achieving a weight loss of 5% to 10% of initial body weight.

While there are multiple pathways to arrange the treatment flow, in general it may be useful for the practice to strive to match high-intensity treatment models (≥14 visits in the first 6 months) that studies have demonstrated to be the most effective. At this frequency, visits could be weekly in the beginning and then less frequent in later months, or visits could be every other week for 6 months. The goal is to provide patients with the opportunity for frequent follow-up to allow for individualized adjustments in their treatment plan as needed over time and supportive accountability as they focus on lifestyle changes.

As a practice evaluates treatment flow for delivering a high-intensity intervention, it is important to consider that patients can also be referred to an obesity medicine specialist or an intensive treatment program that is already in the practice’s healthcare system or community. However, as the patient’s primary care provider, the HCP should remain involved. For example, the HCP may continue to comanage comorbidities as the patient loses weight, reducing the need for diabetes, hypertension, lipid, or pain medications.


Team Communication

Most primary care practices already have a method in place for communicating between providers, allied health professionals, and each of the key front and back office staff members. Obesity care is likely to test the robustness of that communication structure. Unlike a patient coming in for an acute care visit or well patient examination, obesity is like diabetes in that it requires chronic care management. In this sense, obesity has similarities with major depression or chronic low back pain, in that the condition requires frequent contact to produce clinically significant improvement. In the beginning weeks of treatment when frequency of visits and the number of involved providers are higher, team communication is essential. Good team communication involves communication about new or updated processes of care, as well as information specific to an individual patient’s treatment plan.

A simple example of the need for process communication is the delegation of tasks for a practice that has decided to take a small step toward improved obesity care by improving identification of the disease and then referring, known as Assess-Advise-Refer. In this sequence of care, the HCP documents the BMI as normal, overweight, or one of the obesity classifications; reviews the diagnosis with the patient; and refers to a high-intensity intervention. The medical assistant can then follow up with patient education handouts and provide the patient with contact information if they are being referred to an outside treatment program. Finally, the front desk can be trained to recognize when a patient is referred for obesity treatment and scheduled for follow-up with the HCP (e.g., 3 months into treatment). In this well-planned treatment flow, the HCP can maintain a vital connection with the patient and monitor progress. All three team members in this scenario are well prepared for the next step, and the patient has a positive and productive healthcare experience.

Communication between providers is essential in each patient’s plan of care. There are many examples of this collaborative, multidisciplinary care in other areas of medicine. One of the best examples is spinal cord injury care teams and their weekly team meeting to review progress and plan of care. These meetings often involve the physical medicine and rehab physician as the team lead, respiratory therapist, wound care specialist, nurses, social workers, clinical pharmacists, and, at some meetings, the patient and family of the patient. The analogous members in an obesity team meeting could include the HCP, nurse, medical assistant or front desk staff, RDN, and possibly additional allied health team members like the behaviorist or exercise physiologist/physical therapist.

The structure of patient treatment communication can vary widely. At a minimum, team members can communicate through the electronic medical record (EMR) by both reviewing each other’s notes and by messaging within the EMR. However, this can be time consuming. A second option is to schedule team meetings to review patients’ treatment plans, such as a morning huddle, which provides a daily opportunity to quickly review patients coming to clinic for the day and what resources the team needs to deliver effective and efficient care. It helps identify patients that have outstanding diagnostic tests, laboratory test results, medication prior authorizations, or other provider referrals and ensures that the clinician seeing the patient that day has the results and resources ready to review with the patient. Morning huddle for an average clinic day can usually be accomplished in 10 minutes. This affords the team, specifically the medical assistant, time to locate any missing data before the visits begin, as opposed to trying to locate the data in the middle of clinic when many other tasks are going on simultaneously. It also provides efficient exchange between providers. For example, if the team RDN has seen the patient for the previous one to three visits and can be present for huddle, they can offer insights into nutritional changes and goals for which the patient may need encouragement during the upcoming provider visit. This reinforces unified messaging to the patient and can help promote success.


Finally, the practice team might consider a monthly team meeting to review complicated obesity cases or patients that need a referral outside of the practice to a more intensive medical or surgical treatment program. A successful example of this has been seen in bariatric surgery practices. At some surgical practices, the bariatric surgery team and the obesity medicine specialists convene monthly for what is called “Revision Team Meeting.” This meeting focuses on the team review of obesity surgery cases that have had a primary bariatric surgical procedure but are regaining weight. Together as a team of physicians, surgeons, RDNs, psychologists, advanced practice providers, and patient advocates, they discuss which treatment options should be considered to improve the patient’s long-term outcome. This example does not need to be limited to bariatric surgical care. Any practice could consider a monthly or quarterly meeting to discuss patients struggling with initial or long-term successful obesity treatment.


Team Education

Once a practice has dedicated itself to treating obesity, identified the treatment team, and assembled care resources, it is time to plan for obesity education for the team. Up-to-date medical treatment of obesity in the primary care setting is still a novel offering for most primary care practices. Every staff member should have a basic understanding of obesity and the fund of knowledge appropriate for their role on the team.

At the most fundamental level, care needs to be empathetic and free from the bias and stigma that many patients with obesity experience in all areas of medicine. Obesity is different from most other chronic diseases that are treated in primary care settings, in that patients often feel a sense of shame and self-blame about their excess body weight. Even today, many patients and HCPs often do not understand that obesity is a disease and continue to feel that it is a “choice” that a patient needs to correct on their own. Thus, the first step in effective team education is providing resources on how to identify and correct explicit and implicit obesity bias and stigma. See Chapter 12 for additional discussion on weight bias.

HCPs (and the public) need better education on the nature of obesity as a chronic condition. Both patients and HCPs often believe that obesity is a lifestyle choice, rather than a chronic metabolic disease. In the ACTION (Awareness, Care, and Treatment In Obesity MaNagement) study, 82% of patients with obesity felt that losing weight was completely their responsibility.8 Similarly, 72% of HCPs in the ACTION study stated they have a responsibility to “actively contribute to my patient’s successful weight loss effort,” but only 30% of them felt that prescribing antiobesity medication (AOM) was an effective treatment.8 In another study, 51% of HCPs “rarely” or “never” prescribed AOM and only 9% (14 of 160) indicated they prescribe medication in the management of obesity.17 Thus, the HCP belief that obesity is a lifestyle choice translates into a reluctance to use pharmacotherapy as a treatment modality. Unfortunately, the view of HCPs regarding obesity are not consistent with the underlying science. Obesity, once established, is not a lifestyle choice. Rather, it is a chronic, often progressive metabolic disease, with alterations in hormones and neuropeptides that affect appetite control.18 Similarly, metabolism drops disproportionately in response to successful weight loss, thus working against patients’ efforts.19 Research has demonstrated that HCPs do not feel adequately trained to treat obesity and therefore do not feel they have the skills to deliver effective care.20,21,22 Thus, practices can consider additional obesity education that may include fundamental concepts of obesity as a disease for some team members and more advanced training for the HCPs that will be directly delivering care.


REFERRALS


Outgoing Referrals and Referrals Beyond the In-House Practice Team

As discussed earlier in this chapter, a practice is likely to refer some components of care to clinicians/providers outside of the practice. Depending on the practice treatment flow and resources, patients may need to be referred out to see RDNs, exercise physiologists, physical therapists, behaviorists, obesity medicine specialists, or bariatric surgeons. In this situation, as discussed previously, the most important variable is consistent messaging for patient. The HCP should expect and receive reports/feedback from these other HCPs to help manage treatment cohesively.

Like other areas of chronic disease, there will also be referrals for necessary testing that may be outside the scope of the practice, such as sleep studies, stress tests/cardiac evaluations, and imaging/orthopedic evaluations. Many of these referrals are already in the flow of treatment that is provided in a primary care office and thus just needed to be applied to the treatment of obesity. A curated list of specialists that can be used for referrals and shared readily with patients improves efficiency of care. For example, the practice should know which gastroenterologist has expertise in nonalcoholic fatty liver disease, or which reproductive endocrinologist has expertise in obesity and infertility.

Among the referrals that are specific to weight management, there are three that HCPs would be expected to make most commonly. The first is referral to an intensive behavioral program (when the practice cannot provide that service). The second is referral to an
obesity medicine specialist for advanced medical treatment. The third is referral to a bariatric surgeon. How does a provider know when to refer a patient on for these types of specialty care?

The first step is knowing when to consider a referral. Like every other chronic disease, medical providers must make decisions regarding whether they will begin treatment with the patient or refer the patient out for care. Consider diabetes as an analogy. The HCP may feel comfortable with oral antidiabetes agents and once- or twice-daily insulin, but then refer to an endocrinologist to start insulin pump therapy if the patient requests that form of treatment. The same model should be applied to obesity. Perhaps a provider feels comfortable starting a patient on lifestyle intervention and a single AOM (i.e., phentermine or diethylpropion), but might refer to an obesity medicine specialist if a more complex medical regimen is needed. Each HCP must decide their level of provision of care and, if it is insufficient to control the disease, provide the patient with a referral for advanced intervention. Stated another way, the HCP should either treat obesity themselves, or refer to a provider who can treat it.


Referral to an Intensive Lifestyle Program

When is it appropriate to refer for an intensive lifestyle treatment program? Depending on what resources the practice has decided to provide within the office, it is important to remember that high-intensity treatment (≥14 visits in the first 6 months, followed by monthly contact for maintenance of weight loss) provides the best opportunity for successful lifestyle management of obesity.9,10 Thus, following diagnosis, a referral to an RDN for one counseling session is unlikely to help the patient succeed at lasting change. If the current practice resources do not provide for high-intensity treatment, then the HCP should begin the care and education that is available and refer the patient to a treatment program in the system or community that can deliver a high-intensity intervention. For example, the HCP can get the patient started on AOM and refer the patient for more intensive intervention outside of the practice. Similarly, there may be data or assessments that a patient may benefit from during obesity care that can be obtained by sending the patient to a specialized obesity clinic. These might include body composition analysis, resting metabolic rate, or genetic testing.

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Jun 23, 2022 | Posted by in ENDOCRINOLOGY | Comments Off on Team Care, Referrals, and Practice Resources
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