Working as a team to help patients become healthier for life Chronic Condition and Lifestyle/Weight Management in Primary Care

Why is chronic condition management and promoting healthy lifestyle choices important to us as a team? What do we want for our practice in this area? What steps have we already taken in this direction? What if every patient and family left the clinic more hopeful about improving their health, more ready to make changes that will make them healthier and happier? Your Clinic Vision

*In a major study, low cardiorespiratory fitness (CRF) accounted for about 16% of all deaths, more than obesity, smoking, or diabetes. (Lee IM et al, Lancet, July 2012) Lifestyle Management: Why Physical activity and other lifestyle factors have a powerful, independent effect on health. Many patients don’t make healthy lifestyle choices. Lifestyle management is aligned with national requirements and with major Intermountain initiatives.

A clinic team is the key to: Coordination and communication with each other, with your patients, and with specialists or group programs Effective coaching and follow-up Achieving the vision with existing time and resources, by agreeing on a goal and creating a team workflow to meet it This approach has proven itself for many clinics in effectively managing chronic conditions such as diabetes, asthma, and depression. Teamwork Makes it Happen

An Effective Team Structure

Intermountain tools help you manage chronic conditions and/or promote lifestyle management more efficiently and effectively: Care process models: current evidence on diagnosis and management Process Tools: help for workflow management and patient assessment Patient education materials: information to engage patients to be full members of the team Intermountain Tools Make it Easier

Implementing new processes will take time. Change isn’t a single event— it’s ongoing. Lasting success comes with many small steps. Start by building an initial team process to meet one achievable goal. The Path to Change

Begin by defining your focus and reviewing supporting materials. Think about these general questions: What Intermountain CPMs, guidelines or other evidence- based materials are available? What materials are available to educate patients? Clinic Team Process Worksheet, page 1 Step 1: Our Focus

Next, define your goal. Think about these questions: What is our team’s goal related to this focus—is it related to patient outcomes or the process itself? Is the goal reasonable and achievable? (It’s ok to start small, experience success, and build from there.) How will we measure success? Clinic Team Process Worksheet, page 1 Step 2: Our Goal

Next, define team roles. Think about these questions: Who will oversee the process and coordinate communication within the team and with specialists? Who will coach and educate patients? How will everyone be trained in the process? How can everyone play a role? Clinic Team Process Worksheet, page 1 Step 3: Our Team Members

Next, define a workflow process for this goal. These questions can help: How would a chart review help? What could happen before the appointment or in the waiting room? What could be done at each stage of the appointment—and by who? How can we get everyone involved to keep the time commitment low for each team member? How and when will we have “team huddles” about these patients or about the process? Clinic Team Process Worksheet, page 2 Step 4: Our Workflow

Finally, plan how to coordinate with resources and specialists. These questions can help: What group programs would be helpful for this set of patients? How and when will we refer? How will we communicate with these programs? For specialists that apply to this focus, can we make communication plans with one or two specific providers? Clinic Team Process Worksheet, page 2 Step 5: Our Resources

After a few weeks or months, review your progress. Celebrate your success, choose the next small goal— and start again. Over time, promoting lifestyle management will become a routine habit at your clinic. Keeping the Change Going