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Service Delivery Innovation Profile

Recreation "Prescriptions" Increase Use of Free Community Exercise Programs by Low-Income Patients Who Are Overweight or Obese


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Snapshot

Summary

A physician-developed program called Recreation Rx promotes healthy weight by facilitating partnerships between physicians and recreation providers in underserved communities to increase access to safe and structured activities. Area physicians discuss healthy lifestyles with overweight and obese patients, and then use preprinted pads to write a "prescription" for recreational activities within the local community. These customized pads (with separate versions for children, adults, and seniors) list recreational activities such as swimming, yoga, and other exercise programs that local providers (e.g., the county recreation department) have agreed to offer free of charge to prescription holders. The program has generated increased physician awareness of and referrals to community programs, and hundreds of patients have redeemed prescriptions at these programs.

Evidence Rating (What is this?)

Suggestive: The evidence consists of pre- and post-implementation physician surveys, post-implementation statistics on program utilization, and anecdotal reports from physicians, patients, and providers of recreation services.
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Developing Organizations

R. Christopher Searles, M.D.
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Use By Other Organizations

  • The Chula Vista program is being piloted (with some adaptations) in Tulare County, CA, and in Spring Valley, CA (a city in eastern San Diego County).

Date First Implemented

2006
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Patient Population

Vulnerable Populations > Immigrants; Impoverished; Racial minoritiesend pp

Problem Addressed

Ethnic minority populations, particularly those with low socioeconomic status, have higher rates of overweight and obesity than does the rest of the population. Although physical activity can help in achieving a healthier weight, individuals (particularly children) living in poor urban areas typically do not have safe and affordable options for exercise.
  • A growing problem for low-income minorities, especially children: Ethnic minority populations (especially African Americans, Latinos, and Native Americans) with low socioeconomic status tend to have higher rates of obesity than does the rest of the population. African Americans are 51 percent more likely and Hispanics 21 percent more likely to be obese than are Whites.1 Up to 24 percent of African-American and Latino children rank above the 95th percentile in terms of body mass index, with Hispanic boys and African-American girls having the highest rates of overweight/obesity.2
  • Severe health consequences: A vast body of research demonstrates that overweight and obesity increase the risk of a number of serious health problems, including cardiovascular disease (CVD), type 2 diabetes, and mental health conditions such as anxiety and depression. For example, approximately 60 percent of obese children between the ages of 5 and 10 years have at least one risk factor for CVD, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent have two or more such risk factors.2
  • Barriers to physical activity, especially for children in low-income families: Residents of low-income neighborhoods report significant barriers to engaging in physical activity.3 High crime rates in inner-city areas force parents and children to limit outdoor activities (including walking or biking to and from work and school), while poorly equipped schools and neighborhood designs (e.g., with few nice playgrounds or playing fields) limit opportunities to engage in physical activity. Dr. R. Christopher Searles, a family medicine physician and psychiatrist in Chula Vista, CA, noted that his pediatric patients faced particular challenges in engaging in physical activity, such as reduced physical education time in school, being locked out of school playgrounds after school hours, and being kept indoors due to neighborhood safety concerns. In addition, high costs and a lack of awareness prevented both adults and children in the area from accessing existing neighborhood recreation programs. A survey of local physicians conducted by Dr. Searles found that the majority of physicians embraced the importance of physical and social activity for prevention, but few physicians routinely prescribed these activities, were aware of key resources offered in their community, or lived in the zip codes in which they have worked for years.

What They Did

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Description of the Innovative Activity

Recreation Rx seeks to enhance access to safe, structured physical activities in underserved communities by providing physicians with prescription pads they can use to recommend free, community-based recreational activities to patients. Customized pads (with separate versions for children, adults, and seniors) list recreational activities such as swimming, yoga, and other exercise programs that community providers have agreed to offer at no cost to prescription holders. Approximately 40 physicians in Chula Vista currently participate in the program. Key elements of the program include the following:
  • Point-of-care discussion about need for physical activity: At the point of care, physicians consider whether the patient could benefit from the program. To help make this determination, the physician asks the patient about his home and neighborhood, current level of physical activities, and what types of activities he/she enjoys.
  • Recreation "prescriptions": Following the discussion with the patient, the physician checks applicable activities on a recreation "prescription." Separate color-coded pads have been developed for specific patient populations and times of the year, including summertime children's activities, school-year children's activities, adult activities, and activities for seniors. These preprinted pads list age-appropriate activity schedules, locations, and contact information. Activities vary by age group and reflect a wide range of possibilities, as outlined below:
    • Children: Activities include structured pool activities, running and other sports clubs, tutoring plus physical activity classes, and nutrition plus physical activity classes. Some activities occur in schools in the afternoon, thus making it easy for students to participate.
    • Adults: Activities include walking clubs, aerobics classes, aquatics classes, and yoga.
    • Seniors (over 50): Activities include aquatics classes, walking clubs, tai chi, yoga, "chair" yoga, dance, and social activities geared toward maintaining cognitive health (e.g., bridge, chess, art, and computer classes).
  • Office posters to encourage prescriptions: Posters in the physician's waiting and examination rooms advertise the availability of recreation prescriptions for free programs and encourage patients to ask for such a prescription.
  • Accessing services free of charge: Patients present the prescription to the recreation provider, such as a city/county recreation center, teen center, or senior center, thus allowing them to participate free of charge. In some cases, participating providers of recreation services agree to reduce or waive the normal fees associated with such activities for prescription holders; in other cases, programs are available free of charge to anyone.

Context of the Innovation

Chula Vista, CA, located in San Diego County, lies approximately 7 miles from the Mexican border. The city has a population of 230,000, roughly half of whom are Hispanic, 14 percent Asian/Pacific Islander, and 4 percent African American. Approximately 12 percent of the total population and 15 percent of all children live below the Federal poverty line.4 The impetus for this program came from Dr. R. Christopher Searles, a family physician and psychiatrist who works primarily with underserved, uninsured individuals in San Diego County. Dr. Searles serves on the clinical faculty of University of California San Diego's Department of Family and Preventive Medicine, as co-chair of the San Diego County Childhood Obesity Initiative, and as the Director of Clinical Outreach for a federally qualified health center located in a homeless shelter. He also provides patient care in a mobile clinic and at a local high school. In his work, he noticed that his many overweight and obese patients generally lacked opportunities to engage in physical activity. He wanted to move beyond just counseling these patients to provide them with concrete opportunities to engage in physical activity by directing them to existing community resources. A survey he conducted of area physicians further convinced him of the need for such a program, as results indicated that physicians did not generally direct patients to community resources and often did not even recommend physical activity to patients.

Did It Work?

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Results

The program has generated increased physician awareness of and referrals to community programs, and hundreds of patients have redeemed prescriptions at these programs.
  • Increased physician awareness of community programs: Pre- and post-implementation surveys (conducted in 2006 and 2009) reveal that physician awareness of community-based physical activity programs increased from 22 to 86 percent of respondents; awareness of social activity programs increased from 11 to 81 percent.
  • Increased referrals to recreation programs and strong redemption of prescriptions: The percentage of surveyed physicians making referrals to community-based physical activity programs increased from 19 percent pre-implementation to 95 percent post-implementation, while referrals to social activity programs increased from 0 to 68 percent. Anecdotal reports from providers of recreation services suggest that many individuals are redeeming prescriptions; an effort to track usage over a brief (90-day) period revealed that 1,304 prescriptions were dispensed, 396 prescriptions were redeemed by the local recreation center, and 233 prescriptions were redeemed at the community aquatic center. (Note: Reported numbers of prescriptions received at the participating centers may be underestimated due to heavy staff turnover and variable training regarding prescription collection.)
  • Strong physician and patient enthusiasm: Anecdotal reports from physicians, as well as prescription pad orders (via the program Web site), suggest that physicians have embraced and regularly use the program. Anecdotal reports from patients also suggest high levels of patient enthusiasm about the program.

Evidence Rating (What is this?)

Suggestive: The evidence consists of pre- and post-implementation physician surveys, post-implementation statistics on program utilization, and anecdotal reports from physicians, patients, and providers of recreation services.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Meeting with recreation director: Dr. Searles met with the city's recreation director to discuss opportunities to steer overweight and obese patients to free recreation programs. Dr. Searles and the recreation director reviewed the recreation brochure and identified opportunities to waive program fees or offer new free programs within existing capacity; for example, water aerobics classes could be offered in one-half of the county pool at the same time the high school water polo team practiced in the other half. The recreation director agreed to reallocate part-time recreation center staff to running new activities.
  • Designing, producing, and updating prescription pads: Dr. Searles designed the prescription pads listing available activities and hired a printer to produce them. He meets with the recreation director on a regular basis to identify any changes in available offerings, and then revises and reprints the pads as necessary. This process ensures that the prescription pads remain up-to-date, thus preventing physicians from referring patients to programs that have been rescheduled or discontinued.
  • Meeting one-on-one with physicians: Dr. Searles introduced the program at a handful of medical practices (accounting for approximately 15 physicians); in these sessions, he met with each physician personally to explain the program and to offer guidance on how to engage in activity-related discussions with patients. Over time, Dr. Searles has expanded the program to 40 physicians, continuing this personal approach.
  • Creating wall dispensers: Initially, physicians did not write many recreation prescriptions, as they often kept the pads in their desk drawers and forgot to take them out while seeing patients. In response, Dr. Searles purchased wall dispensers so that pads could be easily accessible in the examination rooms, and also developed posters for the waiting rooms and examination rooms that encourage patients to ask for a recreation prescription.
  • Expanding program: The program expanded to two additional areas in southern California, and has begun to tap into new recreation resources, including local YMCAs and Boys and Girls Clubs. As of 2010, the program is seeking grant funding from health plans and community foundations to support further expansion.
  • Developing measurement systems: Program leaders are currently designing new ways to track the program's use and impact.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff. Dr. Searles personally handles all planning and operational activities, and existing recreation center staff absorb duties associated with additional programming as necessary.
  • Costs: The program costs relatively little; other than Dr. Searles' time, costs primarily consist of Web site development and printing of the prescription pads and posters.
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Funding Sources

California Medical Association Foundation; R. Christopher Searles
The California Medical Association Foundation provided a 2-year, $1,000 grant to help fund development of the program Web site.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Fully use available community resources: Review program brochures carefully to pinpoint which recreation activities can add participants or more fully use available resources at no additional cost.
  • Distribute formal exercise prescriptions: By handing patients a "prescription" for recreation, physicians can elevate physical activity to a health strategy on par with medications. Preprinted pads listing activity schedules and locations make it quick and easy for busy physicians to make recommendations. Furthermore, patients may view the prescription as a tangible form to redeem for free services, making utilization more likely.
  • Personally introduce program to physicians: Explanation of the program and its value in face-to-face meetings will be much more effective than more impersonal modes of communication, such as distributing a written letter with the prescription pads. A personal presentation by the program champion will build enthusiasm for the program by helping physicians understand its potential benefits.
  • Emphasize relevance to quality improvement and measurement: Physicians may express concerns about adopting a program that they perceive will take time during (already brief) office visits. To overcome this concern, convey to physicians that encouraging patients to take control of their lifestyle can lead to improved health outcomes, and hence better performance for their practice on quality indicators tracked by the government and/or health plans (such as those related to blood pressure, cholesterol, and blood glucose levels).

Sustaining This Innovation

  • Ensure ongoing oversight: Ongoing success requires a champion willing to assume responsibility for the program, including "selling" it on an ongoing basis to physicians and keeping prescription pads up-to-date (given frequent changes in recreational program offerings).
  • Formalize program over time: To get the program up and running quickly, program leaders may have to postpone formal fundraising and measurement of program outcomes; over time, as interest and program use increase, developers can seek ways to secure funding and formalize measurement systems.

Use By Other Organizations

  • The Chula Vista program is being piloted (with some adaptations) in Tulare County, CA, and in Spring Valley, CA (a city in eastern San Diego County).

Additional Considerations

  • Consider use outside of primary care: The program can be adopted not only by primary care physicians, but by many specialty physicians as well. For example, neurologists can use the prescription pads to recommend recreational activities for stroke prevention.

More Information

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Contact the Innovator

R. Christopher Searles, MD
University of California, San Diego
200 West Arbor Drive, Mail Code 8809
San Diego, CA 92103
(619) 971-3800
E-mails: rsearles@ucsd.edu, chris@recreationrx.org

Innovator Disclosures

Dr. Searles has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Recreation Rx Web site: http://www.recreationrx.org/san-diego-county-recreation-rx/.

Searles C. Taking it out of the office: recreation prescriptions for the underserved in Chula Vista. San Diego Physician. May 2008. p. 23.

Mannes T. Doc's position on yoga is clear. San Diego Tribune. January 24, 2008. Available at: http://www.signonsandiego.com/news/metro/20080124-9999-1sz24doctor.html

Footnotes

1 U.S. Centers for Disease Control and Prevention. Differences in prevalence of obesity among black, white, and Hispanic adults, United States, 2006-2008. MMWR Morb Mortal Wkly Rep. 2009;58(27):740-4. [PubMed]
2 Institute of Medicine of the National Academies. Childhood obesity in the United States, facts and figures. September 2004. Available at: http://iom.edu/~/media/Files/Report%20Files/2004/Preventing-Childhood-Obesity-Health-in-the-Balance
/FINALfactsandfigures2.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Black JL, Macinko J. Neighborhoods and obesity. Nutr Rev. 2008;66(1):2-20. [PubMed]
4 U.S. Census Bureau. San Diego County, California; Selected Economic Characteristics: 2006-2008. Available at: http://quickfacts.census.gov/qfd/states/06/06073lk.html.
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Original publication: November 10, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 04, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.