PartnerSHIP4Health
The Statewide Health Improvement Program (SHIP) in
Becker, Clay, Otter Tail, and Wilkin Counties
Health Care Initiative
MN Rural Health Conference Breakout Session: June 27, 2011
By attending this session you will gain:
*Understanding of the PartnerSHIP4Health - ICSI
Health Care Initiative
*Knowledge of the PartnerSHIP4Health - ICSI
Health Care Initiative successes and barriers
*Answers to your questions regarding the
PartnerSHIP4Health - ICSI Health Care Initiative
*Tools, resources, and motivation to address
obesity and tobacco use/exposure
* Kristin Erickson, RN, BSN, PHN
PartnerSHIP4Health Health Care Initiative Coordinator
Otter Tail County Public Health, Fergus Falls, MN
* Dr. Mary Larson, MPH, LRD, CDE, CHES
Family HealthCare Center (FHC)
Fargo, ND
* Shawn Krause-Roberts, PT, MPT, ATC
Orthopedic & Sports Physical Therapy, Inc.(OSPTI)
Breckenridge, MN
*The Problem
*The SHIP Solution
*PartnerSHIP4Health - ICSI Health Care Initiative
Overview
*PartnerSHIP4Health - ICSI Health Care Initiative
in Three Sites:
*Primary Care Clinic
*Physical Therapy Setting
*Public Health Agency
*Chronic diseases such as heart disease,
cancer, stroke, diabetes, and obesity share
four root causes:
*physical inactivity,
*poor nutrition,
*smoking, and
*hazardous drinking.
*These diseases account for roughly 40% of all
deaths in the U.S. (Vinz & Marshall 2008).
*The Statewide Health Improvement Program (SHIP):
aims to reduce obesity and tobacco use and
exposure through evidence-based systems change
strategies
is a key public health component of the historic
health reform bill passed into law May 2008
appropriated $47 million for fiscal years 2010 and
2011
rolled out competitive grants to Community
Health Boards and tribal governments beginning
July 1, 2009
*SHIP initiatives focus on changes
not just in health care, but also in
school, community, and worksite
settings.
*SHIP initiatives were created by
MDH to bring public health and
health care partners together.
*―It is clear that clinical systems must tackle
chronic disease in a new fashion to reduce the
social and financial burden of chronic disease‖
(Vinz & Marshall 2008).
*Support implementation of the Institute for
Clinical Systems Improvement (ICSI) Guidelines
for ―Prevention and Management of Obesity" and
―Primary Prevention of Chronic Disease Risk
Factors‖ (―Healthy Lifestyles‖ as of 2011) by
health care providers for adults and children
where applicable.
*Primary Prevention via System Redesign
*The 5As to address obesity and tobacco use/exposure:
Ask/Screen
Advise
Assess Readiness to Change
Assist
Arrange
*THE BURNING QUESTION:
Is this even possible in today’s health care settings?
*This initiative sought to
provide support and resources
to incorporate ICSI Guidelines
into provider systems to
reduce obesity, tobacco use,
and tobacco exposure.
*Primary Care Clinics (9):
Essentia Health Clinic in Duluth
Sanford Health Clinics: Pelican Rapids, Perham,
Hawley, Ottertail City, New York Mills, and Ulen
Migrant Health Services, Inc. in Moorhead
Family Healthcare Center in Fargo, ND
*Physical Therapy Clinic (1):
Orthopedic Sports and Physical Therapy, Inc. in
Breckenridge
*Public Health Agencies (4):
Becker, Clay, Otter Tail, and Wilkin Counties
*PartnerSHIP4Health Baseline Assessments
Organizational Assessment
Clinical Team Member Survey
Chart Audit
*PartnerSHIP4Health - ICSI 12 Month Collaborative
 Face-to-face sessions (3), webinars, conference calls
 Partner-specific Action Plan:
 Measurable aims and measures
 Rapid Cycle Plan-Do-Study-Act (PDSA) Cycles
 Submitted every two months for evaluation
*Family HealthCare Center in Fargo,
ND (serving Minnesota Clay County
Residents as well as ND residents)
*Orthopedic Sports and Physical
Therapy, Inc. in Breckenridge, MN
*Otter Tail County Public Health in
Fergus Falls, MN
Family HealthCare
Center
*Rationale
*Overview
*Implementation
*Barriers and successes
*Lessons learned
*Family HealthCare Center service area—Clay County,
Minnesota and Cass County, ND
*FHC Executive Director serves on the advisory board for
PartnerSHIP4Health
*FHC involved in Prevention, Patient Self-Management, and
Chronic Disease Collaboratives
*Need for Lifestyle Medicine in population served by FHC
Patient Demographics
Patients
Age
14,000
12,000
11,064
10,241
11,874
12,476
11,379 11,630
13,021
11,103
10,514
45 to 64
20%
9,984
10,000
65 & Older
3%
0 to 5
10%
6 to 12
9%
8,000
6,000
13 to 19
12%
4,000
2,000
0
2000
2001
2002
2003
2004
2005
2006
2007 2008 2009
25 to 44
32%
20 to 24
14%
*Diversity of Patients
Ethnicity
New Refugees
700
UNKNOWN
8%
648
OTHER
2%
600
SOMALIAN/
SUDANESE
4%
500
438
ASIAN, 1%
403
WHITE
59%
KURDISH, 2%
400
BOSNIAN, 5%
300
NATIVE
AMERICAN
6%
257
275
279
200
182
187
2006
2007
159
HISPANIC
10%
BLACK
4%
100
67
0
2000
2001
2002
2003
2004
2005
2008
2009
*Insurance Status of FHC Patients
SELF PAY
4%
COMMERCIAL
19%
HOMELESS
7%
SLIDING FEE
34%
MEDICARE
5%
MEDICAL
ASSISTANCE
42%
*Patients by Income Level
10,000
8,777
8,000
6,000
4,000
1,528
2,000
1,655
684
377
0
100% and
below
101-150%
151-200% Over 200%
Unknown
*Work with PartnerSHIP4Health and ICSI Staff and
resources to implement evidence-based guidelines:
1) Prevention and Management of Obesity
2) Primary Prevention of Chronic Disease
*Implementation tasks:
Participate in webinars and conference calls
Develop items for EMR forms to build in assessment,
education, referral, and follow-up
Build supportive clinic environment
*Formed our ―dream team‖
*The key here is a medical provider champion
*Simultaneous implementation of EMR
*Vital signs on EMR included tobacco, height and
weight
*Added BMI, questions on nutrition and physical
activity, waist circumference
*Nursing in-service and role development
*Provider in-service and role development
*Resources to address
vital signs within
constraints of clinical
visit
*Scripting
*Educational tools—
translated into various
languages
*Nurses were able to adapt to asking the additional vital
sign questions
*Ht/Wt is taken at every visit
*BMI is automatically calculated at every visit
*BMI material is posted in every exam room next to the
scales
*Health education material is located in the clinical waiting
area and staff hallway
*Healthy eating and activity posters
*Employee wellness initiatives are on-going
*Slow adoption process
of additional vital signs
by medical providers
*Physician champion is
imperative
*Simultaneous
implementation of EMR
Foundational work is critical:
develop and implement a plan for educating all
medical providers and staff about the
organizational goals for primary prevention of
chronic disease
Technical vs adaptive leadership:
implementation of the ICSI guidelines required
both; BUT adaptive turned out to be more
important
* Federal grant requirements:
Ages 2-17
* Weight assessment (BMI recorded)
* Diet and physical activity counseling
Ages 18+
* BMI recorded
* Follow up plan documented if under- or overweight
* FHC moves into new building 2012:
Fitness center
Teaching kitchen
Orthopedic & Sports Physical Therapy, Inc. (OSPTI)
MN Rural Health Conference
Breakout Session: June 27, 2011
*
*Rationale
*Overview
*Implementation
*Barriers and successes
*Lessons learned
*Community Leadership Team (CLT) member
*Involvement with PartnerSHIP4Health - ICSI
*Healthcare setting
*Wilkin County
*Perspective from a therapy setting
*Work together with primary physicians
*2 factors: obesity and tobacco use/exposure
*Assists with healing/recovery
*Focus on how the body moves
*Figure out cause of pain, regain movement, ADL’s
*Extra weight can increase pain on a joint
*Extra weight can make certain movements difficult
*Tobacco use can decrease healing/decrease O2
*CEU’s wellness, body fat, exercise
*Never incorporated height/weight/BMI into patient
visits prior to working with PartnerSHIP4Health - ICSI
*ICSI instruction & interactive sessions
*Informative sessions with OSPTI staff
*Trial and Error stage (PDSAs)
Staff Education, BMI charts location, scale location
Training new staff-processes/scripts
Educational handouts for patients, scripts, location
Communication with primary physicians, etc.
*How do we start this conversation – scripts?
*Health Hx Forms – ask questions to assess readiness, if
at risk continue conversation to discover if primary
clinician is informed and if further information would be
of interest
*Patient Care Clinician (PCC) takes ht, wt; calculates
BMI; provides initial folder with handouts
*Therapist reviews information and sets up plan:
*Folder info, IEP, tobacco cessation, wellness, PT
*Maintaining the focus: as in most health care settings,
we are short on time and want to focus on the problem
presented by the patient. Yet our persistence shows
overall benefit.
*Keeping records:
Number of tobacco referrals-MN or discussed
BMI greater than 25, number on IEP program
Of those participating, decrease in wt and BMI:
*Weekly weigh ins, 1 month IEP, 3 month follow up
*We typically see 200 patients a week
*We see 20 NPs a week-get BMI/Handouts
*We have had 10 pts/month sign up for IEP
therefore approximately 2-3 pts/wk of the 20 NPssome of the NPs Have a BMI below 25, some are
peds, some not appropriate, and some are working
closer with staff
*Patient Ex: male with back pain, 2 months, lost
43lbs, BMI from 50-44 and child contacted us to say
how proud of her dad she was, and we all noticed
an increase in mood and social participation.
*Some observations from staff regarding the past
year and the obesity and tobacco intervention:
Difficulty with reaction that some people have to their
BMI and category of obese- topic still an issue
More willingness to participate in the IEP with back pain
patients, versus a shoulder patient
A noted increased ease to participate in a therapy
session and more positive outlook with those doing the
IEP.
Sometimes difficult to incorporate into patient visits,
but do see the benefits and will keep working on it as
obesity is definitely an epidemic.
*To make a change: need a goal/vision and a plan
*Educate staff and engage them; it’s a must
*Implementation is a slow process, and constant
*Right location, prompts, training, eases success
*Incorporating education on decreasing obesity
and tobacco use seems appropriate in any
healthcare setting, and worked very well in ourssee pts 2x/wk, for usually at least 4 weeks.
*The College of St. Catherine in St. Paul just
conducted an online survey asking current PTs:
 if they bring up, discuss, and/or educate
patients on BMI, tobacco, exercise, etc.
regarding their personal knowledge about
these issues.
*Interesting to see that these issues are being
brought up by other entities, and in this case an
educational setting, which will hopefully impact
future PTs prior to entering the workforce.
ORTHOPEDIC & SPORTS PHYSICAL THERAPY, INC
430 5th Street N
Breckenridge, MN 56520
Telephone:(218) 641-7725
Facsimile: (218) 641-6625
www.ospti.net
It was a great honor to work with
PartnerSHIP4Health-ICSI during the 12
month collaborative. We accomplished
things beyond what we thought was
possible.
OSPTI will continue to promote healthy
*Became a Health Care Partner in the
intervention – working to implement the ICSI
Guidelines in the Public Health Setting…
*As a grantee recruiting clinics to
partner with us to address obesity
and tobacco use/exposure, we
quickly determined that…
*we should not be asking others to
do what we would not consider
doing ourselves!
*Nurses:
* RN, MS, PHN = 3
* RN, PHN = 15
* RN = 3
* LPN = 1
*Support Staff = 7
*Registered Dieticians = 2
*Social Worker = 1
*TOTAL STAFF = 31
Otter Tail County Public Health
Weekly Client Reach: 200
Otter Tail County Public Health:
*Organized a team, led by the director champion, to
participate in the collaborative
*Completed baseline assessments
*Learned about fostering a culture of change
*Learned about the guidelines
*Reviewed the baseline assessment results
*Created and implemented an action plan
*Submitted progress reports and attended
conference calls and webinars
*Implementing the 5As in Public Health:
*Must be done by a solo nurse
*Fall 2010 - Pilot Program
*Four nurses
*Four clients per nurse
*Primary Focus: Overweight/obese clients
*Secondary Focus: Tobacco Users
*OTCPH registered as a MN Fax Referral Program
Site and nurses were trained in this program and
began to refer clients to this program
*Ask/Screen:
*Height and weight and BMI Calculation
*5210 Healthy Habits Survey
*Advise:
*Brochure added: ―BMI: what does it mean to me?‖
*Assess:
*Readiness to change questions added to Healthy
Habits Survey
*Client assessed as ready to change, and states they
want help with specific goal ideas…now what?
*Assess – Resource Needed:
*Specific Goal Idea Options added to Healthy Habits
Survey
*Assist:
*Client wants specific nutrition and physical activity
resources options…
*Assist - Nutritional Resource and Referrals:
*Healthy Plate
*Portion Size
*Calories Burned
*Public Health Dietitian
*Assist – Physical Activity Resource and Referrals:
*Local gym or health club…OOPS…barriers…!!!!!
*Assist – Physical Activity Resource
Handouts/Website:
*Burn Major Calories without the Gym
*Home Exercises
*http://gainfitness.com/quick_workout/
show: Create your own workout session
specific to gender, home or gym, and
body area. Includes pictures!
*Arrange for Follow-up:
*Least implemented of the 5As due to lack of
reimbursement and staff time
*Follow-up visits seldom scheduled just for these
issues. Follow-up occurs when client is seen
again due to a regularly scheduled program visit
(i.e. WIC, NFP, MSHO)
*―Follow-up‖ Resources: I CAN Prevent Diabetes
(16 week program), Healthy Habits Record, BMI
wallet sized tracker card
* “Do you think there’s something wrong with me?”
* “I am really ready for this and I want to do it!”
* “I’m going to take my measurements and exercise every day.
I can
do this!”
* “I know I’m not overweight, but my diet sucks!
I need to start eating
better.”
* “I want to exercise, but when it is cold outside, I can’t go walking.
don’t have anywhere to go.”
* “I was skinny when we met.
I want to look like that again.”
* “I never eat breakfast, but I know it is important.”
I
* Lose 20 pounds:
* stopped eating fast foods
* drinking 8 glasses of water daily
* cut down to 1 glass of soda/juice daily
* changed to whole wheat bread and limiting bread intake (used to
eat up to 10 slices per day)
*
walking in stores
* Walk 30 minutes 5 days/week:
* walked until snow and cold weather. No longer walking.
* states she is going to wait until her significant other’s job benefit
of health club membership becomes available in 2 months and will
then join health club to exercise
“This intervention adds at least 15 minutes to every
client visit that I address it at, which is about ¼ of
the visits with established clients. It is easier with
some clients than others. Those who don’t feel it’s
important to them sometimes can feel offended. At
other times, I have gotten the reaction of “what’s this
got to do with the reason for this visit?”. But I have
also gotten the comment that it opened the door to
changes. I just have to get comfortable and consistent
with it. I think we need to keep connecting on it as a
group. We need to normalize the intervention.”
5As
Ask/
Screen
Advise
Assess
Clinician Intervention
Take height and weight;
Calculate BMI;
Administer survey
Discuss results:
BMI between 18.5 and
25; encourage and
congratulate.
BMI >25; discuss health
risks and benefits of
change.
Assess readiness to change:
If ready, negotiate goals
If not ready, provide
general
educational/resource
materials.
Assist
Refer to resources:
Public Health
Private Clinic
Community
Advocate for evidencebased policy, systems, and
environmental changes in
schools, worksites, and
communities; encourage
clients to do so as well.
Arrange
Schedule follow-up:
Individual or Group
Phone/home/clinic visit
Clinician Resource/Tool
BMI Chart/Calculator
5210 Healthy Habits Survey
ICSI Obesity Guideline
BMI: What does it mean to
me? (brochure)
Client Resource
BMI: What does it mean to me?
(brochure)
5210 Healthy Habits Survey
Combination Ruler and
Prochaska Graphic (scale of
1-5 to match Omaha System
KBS rating scale)
Motivational Interviewing
Algorithm
5210 Healthy Habits Survey
MinnesotaHelp.info (Use to
generate city/county specific
resource list)
ICSI PPCD Guideline
Copy of Healthy Habits Survey
One or more goals checked
Personal health goal stated
Signatures
Healthy Habits Record
BMI wallet size card
BMI: What does it mean to me?
(brochure)
Great Plate
Portion Sizes
Calories Burned
Food Pyramid Information
Burn Major Calories without the
Gym
Home Exercises
http://gainfitness.com/quick_workou
t/show: Create your own workout
session.
MinnesotaHelp.info Resource List
BMI wallet size card
Follow-up appointment reminder
Copy of Healthy Habits Record
*Pilot Program
*Evaluated and tweaked
*Changes embedded into EMR via the
Omaha Documentation System
*January 2011: Agency Roll Out
*Omaha System Training
*Motivational Interviewing Training
*Resources and Tools Distributed
January 2011 – April 2011 Outcomes:
*12
nurses have completed 1 or more interventions
on a total of 71 clients
*Analysis of data indicates staff need continued
training on how to implement and document
interventions
*Ongoing training incorporated into monthly team
meetings with staff
*Following training with one particular department,
all department staff are now completing the
intervention during the initial or annual visit
Public Health Nurse
Client
* PartnerSHIP4Health
and ICSI
Collaborative
* 5As Framework
* 5As Embedded in the
EMR via the Omaha
System
* Omaha System
Training
* Motivational
Interviewing Training
* Client Resources
A collaborative approach keeps partners
accountable and allows for rapid spread of
knowledge and ideas.
Every healthcare setting has a unique
response to guideline implementation.
It sure is nice to have a physician or director
champion to make things move!
Role modeling healthy nutrition and exercise
habits can increase patient/client buy-in.
 Large scale population-based changes in
health behaviors will take time to emerge;
however, this must not deter us from the
continued use of evidence-based methods to
improve population health via policy,
environmental, and systems change in the
health care setting.
 Public health and private health care
agencies can learn from each other and work
together.
When public health and private clinics form
partnerships, and follow evidence-based guidelines,
patient outcomes improve:
…the creation of guidelines, without significant
attention to their adoption, is clearly a sterile
exercise. At worst, it wastes precious intellectual
and human resources. At best, the creation and
adoption of practice guidelines, augmented by
appropriate implementation strategies, can reduce
inappropriate practice variation, improve practices
among [clinicians]…and lead to superior health care
for their patients (Davis & Taylor, 1997).
*For electronic copies of assessments, tools,
and resources, go to
www.partnerSHIP4Health.org and click on
the Health Care Link
*For questions, email
[email protected]
*
Davis, D. &Taylor-Vaisey, A. (1997). Translating guidelines into practice: A systematic review of theoretical
concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Retrieved
from http://www.cmaj.ca/cgi/reprint/157/4/408
*
Institute for Clinical Systems Improvement. (2011). Health care guideline: healthy lifestyles. Retrieved from
http://www.icsi.org/chronic_disease_risk_factors__primary_prevention_of__guideline__23506/chronic_diseas
e_risk_factors__primary_prevention_of__guideline__23508.html
*
Institute for Clinical Systems Improvement. (2011). Health care guideline: obesity, prevention and
management of (mature adolescents and adults). Retrieved from
http://www.icsi.org/guidelines_and_more/gl_os_prot/preventive_health_maintenance/obesity/obesity__prev
ention_and_management_of__mature_adolescents_and_adults___.html
*
Minnesota Clinic Fax Referral Program (2010). Call it quits. Retrieved from
http://www.health.state.mn.us/healthreform/ship/events/policyconference/callitquits.pdf
*
The Omaha System (2011). Solving the clinical-data information puzzle. Retrieved from
http://www.omahasystem.org/
*
Vinz, C, and M. Marshall. July 2008. Battling the Big Four of Chronic Disease. The culprits: inactivity, poor
nutrition, smoking, and hazardous drinking. Minnesota Health Care News 6,no. 7.
http://www.icsi.org/prevention_of_chronic_disease_article/prevention_of_chronic _disease_article_.html