Weighing in on Primary Care in Yellowstone County

February 13, 2013
By Julie Eisen

In 2010, only 35 percent of the obese residents of Yellowstone County, Montana, were counseled about their weight by a health professional. In a County where 73 percent of adults are overweight or obese, “this jumped out at us as a glaring issue in our community and an indication that there was work to be done in the healthcare field,” recalls Tracy Neary, a Montana Team Member. “Having the Healthy Weight Collaborative grant come on heels of this finding was like magic!”

The Montana Healthy Weight Collaborative is focusing its work on the residents of Yellowstone County, an urban hub three hours northeast of Yellowstone National Park, with a population of 148,000. In an otherwise rural state, two thirds of Yellowstone County residents live in the city of Billings, which faces public health issues similar to larger cities – such as homelessness, sprawl, crime, and access to healthcare. The rest of Yellowstone County is rural and sparsely populated.

Prompted by the County’s low rates of obesity counseling from health professionals, one of the Team’s areas of focus is to build strong partnerships with the primary care providers at Yellowstone County’s three major health centers – Billings Clinic, St. Vincent Healthcare, and RiverStone Health. Starting small, the Team has selected four Physician Champions representing each health center to pilot new resources and practices for weight management and counseling. If the Provider Champions find the changes successful, the goal is to then spread these practices to the other providers. Since 95% of the County’s primary care physicians are affiliated with these three health centers, their providers are well positioned to serve as the messengers and facilitators of individual weight change for most people in this community.

The Healthy Weight Collaborative is one piece of a multi-faceted initiative called Healthy By Design. Launched in 2004, this program aims to transform Yellowstone County into a community that fosters healthy choices. The team is focused on a wide range of issues beyond primary care, including improving road conditions for walkers and bikers or enhancing local businesses’ worksite wellness plans.

Weight Status as a New Vital Sign
When the Physician Champions were asked about the barriers to discussing obesity with their patients, Hillary Hanson, the Montana Team Leader, says that the number one piece of feedback they received is that it is “simply difficult to talk about weight.” Furthermore, says Hanson, it is even more difficult to talk about weight when someone is coming in for a stuffy nose or for other issues that appear unrelated to their weight.

To ensure more reliable implementation, the Team is considering ways to involve nurses and other allied health professionals in these discussions. One solution would be to institute a policy in which weight status assessments are a standard part of every visit, just like checking a patient’s heart rate and blood pressure. The idea is to brand weight checks as “a new vital sign.” By incorporating the weight assessment into the routine start of every visit, nurses would have a natural segue to discussing obesity concerns and healthy changes.

Finalizing Messaging
A key part of the effort to engage the primary care segment was to get clinicians to rally around the 5-2-1-0 messaging that the Team has selected for its campaign (‘5-2-1-0’ suggests five or more fruits and vegetables per day, less than two hours per day of recreational screen time, one or more hours of physical activity, and zero sugar-sweetened beverages). The team has integrated this messaging into their resources, such as their Adult and Youth Healthy Weight Plan forms and the Healthy By Design website. The four Provider Champions at the County’s three health centers are currently testing this messaging to see how it is received by their patients.

Helping Patients Understand What BMI Means
Another piece of feedback that the Team received from the Physician Champions is that patients do not understand the concept of Body Mass Index (BMI). ”Without understanding what BMI means,” says Hanson, “being told that you have a BMI of 29 is of little use.” While hanging BMI charts in doctors’ offices may be standard in other healthcare settings, Neary explains that, “there are a variety of other health issues vying for attention.” Without a standard in place, posting BMI charts in medical offices was “hit or miss” based on preference. The Team plans to change that. They are currently producing BMI charts for physician offices so healthcare professionals can easily show patients where they land and if their BMI places them in an at-risk category. The charts will use the same aesthetic as their other branded material to reinforce the ubiquity of this campaign to the community.

Healthy Weight Plans: Paper to Electronic
Finally, to systematize the procedure for tracking and discussing healthy weight, the Montana Team is working with the health centers’ IT departments to build electronic versions of the Healthy Weight Plans, so they will become a standard part of the patient records in their electronic medical record (EMR) platforms. The electronic version will have the same basic information as the paper forms and providers will be able to see the Plan every time they open a patient’s record. The Team would also like to incorporate reminder flag alerts to help physicians stay on top of at-risk patients.

“We Know This Has Staying Power”
Enlisting the help of primary care is just one piece of the Montana Team’s overall strategy. “Our main goal is to have people start to be aware of all the components that make up a community that’s Healthy By Design,” says Hanson. “When your provider talks to you, it changes how healthy your community is.”

The Healthy Weight Collaborative has enabled the Team, for the first time, to create a unified message. “We plan to stick with this for years down the road. It will spread into the schools, into other sectors, into pieces that aren’t even a part of the current grant phase right now,” says Neary. “We know that this has staying power and is going to live for a long time.”