Sunflower Ob-Gyn—a clinic in Winfield and member of the Kansas Practice Transformation Network—began a program aimed at improving patient outcomes in hypertension, diabetes, and depression through weight loss. They called it "KDM Intense." Over 12 weeks, patients worked with a nutritionist, a trainer, a pharmacist, and staff at Sunflower to improve their diet, activity level, and blood pressure. The early results in the program have been impressive—including dramatic reductions in depression. Dr. Daniel Miller of Sunflower talks with Jill Daughhetee—Quality Improvement Advisor at Kansas Healthcare Collaborative—about the program and its early results.
The Patient-Centered Goal: What Sunflower Hoped to Achieve
The practice hoped to improve patient outcomes in Hypertension, Diabetes, and Depression through weight loss. The Physician and his team focused on Shared Decision Making and Shared Goal setting to determine goals such as improving blood pressure, lowering meds, improved activities of daily living, increased activity, weight loss and measurements. Patients chose a goal that was important to them personally. Patients also worked with the Physician, Dietician and Personal trainer to create personalized meal and exercise plans that met their personal preferences, health needs and physical limitations.
The Intervention
Program focused on the following elements: Patients with BMI >30 or BMI >25 with comorbidities. Enrolling clinic patients and patients referred from local primary care offices (males and female) Monitoring blood pressure, weight, depression scores, HgbA1C, body measurements Program focus on patient education, caloric restriction, increase in exercise and patient centered goals without the use of weight loss medications. Partnerships with Dietician, Personal Trainer, Physician, Nurse, and Pharmacist were key to the program structure: Consultation Appointment, Week 1: Dietician, calorie restriction with provided menus Week 2: Dietitian, food substitutions, reduced sodium Week 3: Physical Trainer, walking groups Week 4: Healthy increase of calories Week 5: Grocery shopping, designing individual menus Week 6: Discuss challenges and accountability after the program Week 7: Meet with Pharmacist who trains patients to self-monitor BP Week 8: Discuss how to maintain progress after the program ends Week 9: Motivation and goals until graduation Week 12: Graduation. This practice focused on the use of the Patient Portal, MyFitnessPal and a private interactive Facebook group all for program participants. Patients were given real-time access to other program participants, nursing staff, personal trainer and the Physician for sharing feedback, asking questions, discussing challenges and successes. These online interactive tools as well as weekly group meetings with the care team and Physician created accountability for both the Care Team and the Participants. The program focused on sustainability during and after the Program graduation by providing ongoing access to the E-Tools used while in the 12 Week Program.
The Role of Data
The practice collected baseline data on PHQ9, Blood Pressure, Weight, Measurements and for some patients, HgbA1c. Data was collected at each face to face encounter with the nurse or Physician as well as at weekly group meetings. Because the practice was transitioning to a new EMR due to the lack of Quality Reporting Capabilities, the practice recorded data manually via spreadsheets during the first four groups of participants. The Practice has recently implemented a new certified EMR and will move forward collecting data through the new EMR’s reporting programs. Practice also used patient feedback and patient results to identify opportunities in for improvement as they continued with each new group of participants.
The Results
65% of patients saw a decrease in systolic blood pressure (n=17) 62% of patients saw a decrease in diastolic blood pressure (n=16) 92% of patients saw a decrease in weight (n=24) 100% of patients saw a decrease in PHQ9 scores. Average Improvement -6 Systolic, -6 Diastolic, -11 pounds weight loss, -6 points on PHQ9. In the most recent group, Group 4 which has not completed the program, one patient has already lost more than 70 pounds in the first 6 weeks of the program.
Patient-Centered Impact
Patients saw tangible improvements in blood pressure, weight, measurements, depression scores and HgbA1C. One patient’s goal (who weighed more than 500 lbs.) was to be able to fit in an airplane seat and on the rides at Disney so he and his wife could take their grandchildren to Disney a year from now. This patient lost over 70 pounds in the first 6 weeks without the use of weight medications. Another patient reports she has been taken off insulin completely. Another patient reports her PCP has discontinued all BP and Depression Meds as a result of her 40 pound weight loss in 12 weeks and reports that her “life is forever changed for the better.”
Lessons Learned
The Physician reports that this program has changed the way he looks at patient compliance. He reports that prior to beginning this program, he was experiencing professional burnout. He credits this project with revitalizing his career and infusing joy into his work. He also reports that by being accountable to his patients for leading by example, he reached his “pre-baby weight”.
Dr. Miller also reports that he saw dramatic results with his patients which could not have been reached by the traditional “in exam room” approach. Encouraging patients to create meaningful personal goals which in some cases didn’t necessarily align with specific data outcomes, such as lowering BP, losing weight, or lowering A1C, allowed patients to focus on their “why” versus the traditional method of asking the patient to meet the Physician generated goal. The improvement project also highlighted a direct correlation between Depression and patients who were unsuccessful in maintaining a healthy weight. All participants saw improvement in their PHQ9 scores.