Integrating Primary Care Practices and Community-based Resources to Manage Obesity

There is an old marketing model concept called AIDA. The acronym stands for Awareness (Attention), Interest, Desire, and Action. To embrace a new idea or purchase a product you first must be aware that it exists. Once you know something is available, you either have an interest in it or not. Some products that are offered you know about but don't need or want. If you are interested, you need desire. Desire reflects the attributes of the product you are aware of and have an interest in. These could include cost, quality, style, etc. Action is the decision to purchase or embrace the idea.

Are there commercial weight loss programs in your community? Does your hospital have diabetic dietary counseling? Are there weight management resources with an evidence base of success? It is important to refer your patients to programs that are affordable and evidence based, and that meetings are at a time and location mostly accessible to your patients. You will want to learn more about each program before you take the Action step in the model of referring a patient across the bridge. That is what this chapter is about.

Identify Community Resources

Referrals require two decisions. The first is to refer or not, and the second is to whom. Many variables overlap and complicate the decisions. These variables can be attributed to the clinician, the community, and the patient.

For the clinician, the variables include the formal training or the ability to handle the situation within the clinic, the scope of practice of the clinic itself, and knowledge of and involvement in community social and human service-based organizations.

Community variables include the presence (or lack of) an appropriate organization, cost, accessibility, and expected value achieved by the user.

The last and most important set of variables relates to the patient. Clearly one size does not fit all when it comes to increasing physical activity and improving nutrition. Some patients wouldn't like a support group; others would shun any on-line resource; cost is a serious factor for some and not for others; and people need resources that fit their schedules. There is an aquatic-based exercise program endorsed by the National Arthritis Foundation. If you had a 30-year-old male patient who was obese presenting with joint pain in hips and knees, this might be a good program for him, correct? It allows for exercise and weight loss in the water, thus minimizing some pressure on his joints due to his increased weight status. But, it might not really be helpful. Why? When this was explored in one of our pilot communities, we learned that the typical user is a woman more than 70 years of age. Thinking you might know these programs is not the same as really exploring each using a systematic approach.

A Step-By-Step Process to Learn About "the Other Side of the Ravine"

In our intervention the community and clinic partners developed a process to identify community-based-resources and to prepare a resource guide for use by primary care clinics. This process used four key steps and resulted in the creation of a community resource inventory form. An example of a completed inventory form appears in Tool 8. These steps are summarized in Figure 3 and details appear below.

Figure 3. Steps in Learning About Community-based Resources for Weight Management

Step 1. Identify the resources in your community and/or region. Work with your staff to determine what's out there already by looking for existing inventories (Approach A), brainstorming resources lists (Approach B), and scouring the phone book/online directories (Approach C). Combined, these three approaches should give you a comprehensive list of current community resources.

• Approach A. Someone already may have done this work for you. Determine if a resource inventory or directory already exists in the community. Check with your local health department, the hospital's education department, senior citizen centers, community action agencies, parks and recreation departments, or Cooperative Extensions. Consider if a modification of an existing directory will work for you.
• Approach B. Ask your staff to brainstorm a list of the community-based resources. It is important to use a group process for this step to minimize the chanced of missing resources.  
• Approach C. Look in the Yellow Pages or online under headings such as weight loss, nutrition, exercise, gyms, pools, sports, etc. Supplement the list your staff has created. Moreover, should you choose to conduct a survey of patients (Chapter 2), an open-ended question in the survey allows them to identify community-based resources.

Step 2. Contact resources to determine what they offer. Divide the list among staff members equally and ask them to contact each resource. Use or modify the attached form to collect common information from all the resources. It is often best to conduct these reviews in person. The ability to actually see the resource and not rely on a web site or professional photos to determine its cleanliness, professionalism, and value is critical. When contacting the resource, say:

"Good Morning (afternoon), I'm (name) calling from the (name of clinic), here in (name of community). We are starting a program to help our patients achieve a healthy lifestyle through improved diet and increasing physical activity. One way we intend to do this is to refer some of our patients to community resources like yours. We are building a resource directory of all the resources here in (name of the community) that help with diet and exercise. We'd like to learn more about (name of resource) and perhaps build a relationship with your organization. Who should I speak to?"

Then try to establish a time to meet and send them an advance copy of the form so they are better prepared to answer your questions. When conducting the interviews, it is helpful to make notes about your perceptions about how hard or easy the organization was to work with. Did they return messages? Were they on time for the appointment? Would you want to invite this person to make a presentation to your clinicians?

Step 3. Create a resource directory that suits your clinic. Once you have a list of all the resources (step 1) along with details about service availability and costs (step 2) you'll want to compile the information into a directory format that fits your office. It may be a three ring binder or a word document icon on the desktop of each computer screen. It might be 3x5 cards for each resource with a map and contact information on the reverse or a referral link in your electronic health record. Many approaches can work—chose what's best for your practice.

Step 4. Invite promising resources to visit the clinic. Once you've created your resource list, review it as a practice and invite the most likely referral organizations to visit your clinic. Evidence suggests that visits similar to pharmaceutical detailing are effective to inform clinicians about the community program. Studies indicate that the clinician's top concerns were cost to the participant, credibility of the resource, and convenience. Help the community resource prepare by prompting them to be timely and efficient and to leave behind program materials.

Don't forget to ask the community resource if they are willing to provide a discount or incentive to the patients you refer. If they agree, determine how the resource would want to be informed. They might want a note (your Prescription Pad; or use the sample provided in Tool 9) or they may say the patient needs to tell them, "Dr. (name) from the (group) sent me."

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