An integral part of diabetes treatment is lifestyle management. Patients have to make diet and exercise changes, and several specialized community resources exist for this purpose. However, some patients may be unable to use these tools in their therapy due to several reasons meaning that the solution is not as simple as writing a referral and tracking the progress. The Community Connections Obesity Referral Toolkit was designed to help practitioners find accessible and affordable resources within their community to help patients suffering from obesity. This tool helps them to develop a bidirectional referral process and also creates fruitful relationships with community partners while enhancing the patient’s engagement strategies.
The rising number of diabetic patients in the US places a heavy burden on primary care providers and the future promises that providers would be unable to handle these cases on their own. The framework developed to aid providers in caring with chronic conditions, the Chronic Care Model, used the connection between community resources and patients as its main pillar. This was successful because the community resources are often funded and they can provide available and accessible services. The community resources utilize peer support models that implement self-management and problem-solving that are unfortunately inadequately satisfied by medical officers. This means that referral to community resources is still low, which is why the Chronic Care Model augments this system for improved results.
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The toolkit was a collaborative effort between several bodies and the strategies resulted from the experiences of the individual body members, alongside a health facilitator. The information was gathered over 15 months through interviews and collaboratives after which reviews and feedbacks were made.
There are three prerequisites for the project to be successful; the presence of practice champions, the ability to have the majority of the practice on board, and focus on conditions that are most prevalent or challenging. A project champion is anyone with the mandate to use organization resources outside the facilities to complete the project, although it helps to have more than one champion. A project champion has the greatest responsibility in all the steps of the project. Additionally, a physician champion is necessary for the role of promoting the cause as the advisor and they would also help to solicit support from the administration of the organization. The next step, establishing a knowledge transfer system, may be conducted either by the project champion alone or with the help of another physician, with this decision being based on the size and the style of the organization.
The tool (2) provides a questionnaire to help the project champion determine their primary population interest (as it may turn out to be non-diabetics) and to organize their thoughts before rallying the rest of the practice. The project champion should then garner the support of the physician champion to motivate the entire practice by meeting staff and having them buying into the idea. Subsequent staff meetings would elicit responses on questions gauging the readiness of the team in implementing the tool to effect the treatment of the conditions. Additionally, the meetings provide a chance to set goals thus encouraging full participation.
The next phase of the tool is to find, connect and evaluate a community partner. The community partner needs to have the services that the target patients require. The most recommended way of conducting this is by using a networking group, physical and online. The results would then be recorded in a template spreadsheet to have the information in one place for easier in-depth analysis of the available options. Evaluating and determining a partner is largely a matter of compatibility, ensuring that they are properly staffed and they have the same communication orientation as your team. The tool provides a questionnaire to aid in determining the suitability of a partner (Tool 7).
The next step in the tool would be to identify the patients. The patient has to fit the profile of someone who would benefit from the program and who would also be ready to change. One way of selecting patients is by preemptive identification, which is a wide net search of all those who may be eligible for the program. Another way is via point-of-care identification, where a practitioner may note a patient’s suitability for the program through their markers or by their attitude towards lifestyle changes. However, the most preferred approach is the hybrid of the aforementioned methods, and the tool provides questions that guide this alternative regarding EHR accommodation, outreach, similar programs, and the team’s enthusiasm. Patient progress would then be tracked by a registry which would enable reports to be generated and also enable them to enroll in different healthcare incentive plans.
The next step regards the referral form, which is handy for the community partner since it provides details that they need to initiate contact with the patient. Some questions that need to be addressed about this step are the different roles of the partners and the practitioners, as well as the format of the referral and how it would be documented on the patient’s chart.
The project champion should then integrate the process within patient paths and try to conduct a walk-through the program from the perception of the beneficiary. This includes the outreach, waiting room, exam room, EHRs, and also non-patient areas, like where the staff reside and operate from. Most importantly, all these steps need to be laden with positivity, for example, success stories in the outreach and positive stories in the waiting areas and exam rooms.
Finally, the community partner and the practice should engage in a bidirectional referral process, where each knows the information that would be helpful to the other partner. Both parties should ensure that the information exchange is regular and timely. Some common inquiries should be on whether contact and enrollment by the patient were made, and whether the information may be communicated via some medium. Also, the key to this stage is understanding who should send out the information, and how the credibility would be established and the reception confirmed.
With equal importance to the structure of the tool is linking with the patient, which is reliant on the interest and response of the targeted patients. Patient engagement is important since bidirectional referrals for eligible patients does not mean that they would enroll. The most important aspect here is the interaction of the practitioner and the patient during the referral process. Due to this, the combination of the physiological condition and their individual will to change. To establish the patient’s readiness for the second aspect, several tools are suggested (Tool 12-20).
Primary care is the best preventive therapy in the treatment and prevention of obesity. However, primary care physicians and staff are not in a position to spend time with patients, guiding them on weight loss and lifestyle changes, which is where community resources come in. Although the presence of these resources is well known, physicians may help patients engage in the programs effectively by including them as part of clinical care by linking the clinics to the community and integrating the community members as partners. However, the most important aspect critical for the functioning of the concept is the patient, who must be willing to enroll. The process has many challenges in its implementation that may not be visible when theorizing. The tool would be helpful reduce effort and time by helping the champion examine their practice, reach out to the community, initiate maintainable relations, and apply approaches that would increase the patient engagement and quality of experience.
References
Ahrq. (2019). Chapter 1. Introduction | Agency for Healthcare Research & Quality. Retrieved 20 October 2019, from https://www.ahrq.gov/ncepcr/tools/obesity-kit/obtoolkit1.html
Grossman, S., & Valiga, T. M. (2016). The new leadership challenge: Creating the future of nursing . FA Davis.
