We used a cross-case comparative analysis to explore elements that appeared to be important in a clinic’s ability to build linkages with community-based resources for weight management. These items are summarized below.
- Leadership Support and Alignment with Organization Priorities—Leadership support was critical for project success. Clinics where there was clear buy-in from the management and resources allocated to support project activities experienced greater success. Notably, these clinics tended to align and enfold the goals of this research project with larger clinic/system initiatives. Further, they allocated resources (time, esteem) so that ancillary staff could help develop and implement project interventions. As such, these sites were able to negotiate the challenges of practice change (e.g., implementing new electronic health record systems, personnel changes) while still making progress on their goals to improve obesity treatment.
- Clinician and Staff Champions—Although a project may be initiated with the support of organizational leadership, having clinician and staff champions was critical for success. A champion does the actual work of moving the project forward by tracking progress of the intervention, calling meetings, reminding other staff about the project, and supporting implementation of clinic change processes. Champions are more effective if they have support from clinic leadership. If a champion is no longer involved, or is called to address other priorities, a project may wither. In our intervention turnover of key clinicians and staff limited participation at several sites. At one practice, a single nurse acted as a champion to advocate for collecting and calculating BMI rates at every patient visit. However, without clinic leadership support this small change didn’t translate into larger project goals.
- Known and ‘Owned’ Resources—Clinician and staff knowledge of and experience with community-based resources to address behavioral health issues was limited, but critically important. Clinicians and clinical staff were more likely to refer patients to resources that they were familiar with. In one county the clinicians referred the majority of their patients to the Coronary Health Improvement Program (CHIP, 52% of Clinic One referrals; 100% of Clinic Two referrals). Lead clinicians in each practice led these groups; noting efficacy and familiarity with the program’s philosophy of lifestyle change as the reason for almost exclusive referral. Program referrals were often triggered by a patient’s negative lab tests, and attendees are there to improve health, rather than just lose weight. Similarly, staff at Clinics Three and Five work with, teach, and have participated in the Living Well program and its Spanish-language version Tomando. Clinic staff referred patients to these resources because they believed them to be of high quality, offering patients tools on healthy lifestyles rather than quick fixes. Although practices received an up-to-date inventory of community resources with information regarding hours, cost, type of program, clients served, history, and effectiveness, personal experience with the community resource appeared to be a stronger predictor of referral patterns.
- Referral Support by Care Managers and/or Community Health Workers—Having staff available to implement the intervention and follow through on project activities was a key element of success. Although all clinics received a stipend for participating in the project, few used these resources to hire additional staff. Instead, existing staff frequently took on project activities. Having staff with allocated time to approach patients, provide information on the referral, and do follow up was critical to intervention success. In the clinic with the highest number of referrals, a community health worker was dedicated to working with patients who were flagged by physicians as needing a referral to a community-based resource. That person went so far as to go to the homes of patients to follow up on referrals. Once this workflow was put into place the number of referrals made by the clinic in the intervention period dramatically increased. At Clinic One, the regional practice facilitator assisted the clinic staff in approaching patients and offering referrals, as well as attended the Coronary Health Improvement Program to follow up with patients. Without this additional support by a person with dedicated time, these activities would not have been accomplished.
- Practice Stability/Capacity for Change Management—All clinics participating in this project faced considerable changes during the course of the study. Five of the six clinics changed electronic medical record systems. Two clinics changed ownership, becoming part of hospital systems. All experienced changes in staffing, including clinicians leaving the practice or changing their practice focus and bringing new clinicians on board. Office managers transitioned at four of the clinics at least once during the study. Frequently other urgent clinic issues took focus away from achieving the study goals. Changes in leadership, staffing, and operations are magnified in small, rural primary care clinics, and these clinics often have limited capacity to absorb change. Some practices handled this better than others, having either adaptive reserve to juggle many change processes at once or having management capacity to keep the project on staff radar despite changes. This capacity had profound implications for project implementation.
- Adequate Time and Practice Facilitation. A 12-month intervention to improve linkages between primary care practice and community–based resources to manage obesity simply lays the foundation. Addressing this problem requires support from individual clinics, the community, and health systems. The use of practice and community facilitation was critical to engaging these diverse partners. We used a participatory approach supported by practice facilitators and practice-based research network staff to engage clinics and community-based health coalitions as partners. Our staff played a critical role in helping clinics identify members of the implementation team, outline intervention plans, and implement and refine the interventions through continuous quality improvement cycles. Additionally, the team helped mobilize community partners to identify resources, conduct outreach visits, and share the list of resources with clinic partners. Thus the research team and regional practice facilitators became a critical part of the intervention.
