SummaryThe Santa Clara Family Health Plan provides comprehensive health care benefits to a diverse population of low-income families. The plan developed a quality improvement project to encourage health care practitioners to document body mass index (BMI) and provide weight management consultation and referral to obese adolescents during well visits. The project included weight management training for the practitioners and free health and fitness programs for adolescents and their families. Although the project was successful in increasing the BMI documentation rate from 23.4 percent in 2007 to 38.7 percent in 2009, this increase was well below the project goal and benchmark of 55 to 65 percent. A slight increase, from 33.6 percent in 2007 to 37.3 percent in 2009, in the practitioner documentation rate of counseling/referral for nutrition, physical activity, weight management, and/or healthy lifestyles meets the benchmark of 36 percent for this intervention, but is still below the health plan's goal.
Developing OrganizationsSanta Clara Family Health Plan
Santa Clara Family Health Plan, Santa Clara, CA
Date First Implemented2008
Patient PopulationAdolescents ages 12 to 21 years. Fifty-nine percent of health plan members are Hispanic and all plan members are socially and economically limited in resources.Age > Adolescent (13-18 years); Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Immigrants; Impoverished; Racial minorities
Problem AddressedObesity among adolescents is increasing at an alarming rate, especially among low-income minority populations. This places them at greater risk for many immediate and long-term comorbid conditions, including type 2 diabetes and hypertension. A lack of health care provider training, incentives, and referral options for weight management leaves these young people with few, if any, options for controlling their weight.
- An alarming increase in obesity: The percentage of overweight adolescents aged 12 to 19 years has increased greatly from 5 percent in 1980 to 17.1 percent in 2004.1
- Significant racial and ethnic disparities in obesity prevalence: In 2007 to 2008, the prevalence of obesity was significantly higher among Mexican-American adolescent boys (26.8 percent) than among non-Hispanic White adolescent boys (16.7 percent). Among girls in the period 2007 to 2008, non-Hispanic Black adolescents (29.2 percent) were significantly more likely to be obese compared with non-Hispanic White adolescents (14.5 percent).1
- Extreme obesity not a rare occurrence: A survey of more than 710,000 children ages 2 to 19 enrolled in the Kaiser Permanente health plan in Southern California found approximately 45,000 children to be extremely obese (7.3 percent of boys and 5.5 percent of girls). The survey also found that 12 percent of Black teenage girls and 11.2 percent of Hispanic teenage boys had extreme obesity.2
- Greater risk for comorbid conditions: Type 2 diabetes has increased dramatically in overweight children and adolescents, and their risk for hypertension is approximately 10 times greater than that of healthy weight children. Other long-term health risks include coronary heart disease, stroke, and osteoarthritis.1
- Physicians lack important weight management information and incentives: At best, half of pediatricians use BMI percentile measurements to assess overweight children and adolescents; however, only 52 percent assess BMI in children older than 2 years. Additional data from a national survey of pediatricians indicated
- Sixty percent said they feel at least somewhat prepared to counsel patients on overweight, but only 38 percent feel counseling is effective.
- Sixty-two percent were unfamiliar with billing codes for weight management services.
- Fifty-six percent thought reimbursement was insufficient
- Sixty-seven percent thought time available to counsel was insufficient.3
Description of the Innovative ActivityThe health plan developed a quality improvement project to encourage health care practitioners to document BMI and provide weight management consultation and referral to obese adolescents during well visits. The project included weight management training for practitioners and free health and fitness programs for adolescents and their families. The project supported these interventions by distributing obesity-related health education materials by mail and at community events to adolescents and their families. Key elements of the program are described below.
- Provider training: The plan's provider services department conducted quarterly, onsite training sessions to educate providers and their staff on BMI documentation, the use of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for BMI, and on best practices for consultation and referral. The department also encouraged practitioners to participate in offsite training on adolescent obesity.
- Onsite training: Training sessions, which were not mandatory, focused on the importance of fully documenting BMI in the medical record. Trainers distributed BMI wheels and graphs to aid documentation.
- Offsite training: To further support the importance of addressing adolescent obesity, practitioners were given the opportunity to receive continuing education credits by attending training programs on obesity prevention during wellness visits. These 2-hour programs allowed practitioners to learn more about and discuss ways to address the challenges associated with adolescent obesity.
- Provider reimbursement for well-care visits: In addition to provider capitation, the plan reimbursed providers for all well-care visits.
- Web site and newsletter materials on obesity for practitioners and members: The plan added pediatric preventive health guidelines that include procedures for BMI documentation as part of well visits to their Web site. They also added modified well-visit forms to include BMI documentation and modified referral forms to include health and education programs. To further promote the program, the plan included articles on obesity prevention in its Spring and Fall newsletters for practitioners and members.
- Free health education programs and classes for adolescents and their families: The plan contracted with local organizations, including the YMCA and Weight Watchers, to provide programs and classes on nutrition, physical activity, and weight management designed for a variety of age groups. All members who received referrals were contacted by the plan's health education staff to first confirm their interest in participating and then to enroll them. Once enrolled, members received a registration letter with other related health education brochures. To monitor attendance, the plan required contractors to submit an attendance record before invoices were paid.
ResultsAlthough the project was successful in increasing the BMI documentation rate from 23.4 percent in 2007 to 33.2 percent in 2008, this increase was well below the program goal and benchmark of 52 percent. The slight increase, from 33.6 percent in 2007 to 35.5 percent in 2008, in the practitioner documentation rate of counseling/referral for nutrition, physical activity, weight management, and/or healthy lifestyles brought the project closer to the benchmark of 36 percent. This observed increase may represent only part of the actual change, however, as difficulties with the recording and capturing of information from the medical record prevented accurate measurement.
Information provided in November 2011 indicates that the 2009 practitioners' documentation of BMI was 38.7 percent. The BMI documentation rate has shown a steady increase from 2007 to 2008 of 9.8 percentage points and another 5.5 percentage points from 2008 to 2009. However, the BMI documentation rate of 38.7 percent is still below the health plan's goal of 55 to 65 percent. Taking into account that the Medi-Cal well-adolescent care visit rate was 41 percent, it appears that practitioners are still not calculating and documenting BMIs at all well-adolescent care visits. In addition, the 2009 practitioner documentation of counseling/referral for nutrition, physical activity, weight management, and/or healthy lifestyles was 37.3 percent. This rate increased by 1.7 percentage points from 2008 to 2009 and meets the benchmark, but is still below the health plan's goal of 55 to 65 percent.
- Be prepared to address cultural beliefs and social dynamics: Plan implementers identified key cultural beliefs and social dynamics that influenced discussions about weight management including:
- The belief expressed by many adolescents and their parents that it is healthy to "bulk up" and have a large figure as part of playing certain sports.
- Older adolescents (14 years and older) were noted to be more receptive to discussions about weight management, due to their heightened concern about their appearance.
- Engage parents as well as adolescents: For behavior change to occur, both parents and their adolescent children must agree to and support the need for weight management interventions.
Obtain funding for all essential program elements: Due to financial constraints, implementers were not able to include several elements that were in their original program design, which program implementers believe could have enhanced the program.
A BMI toolkit
A registry of all children who were at risk for obesity
Provider notification of assigned members who need annual well-care visits
Adolescent well-visit reminder cards to help providers get teens in for checkups
Adolescent incentives for well-care visits and/or for attending nutrition classes
Internet-based tools and social networking on healthy lifestyles and weight management for adolescents
Provider incentives for BMI documentation and/or well-visits
Provider incentives for sharing "best practices" in adolescent well-care/BMI documentation
Consider necessary software changes before program implementation: System software was not completely updated before the project started, causing the documentation of BMI and referrals to be incomplete. Plan developers had to make changes, after the fact, to address this problem.
Consider including case management in programs aimed at weight reduction: Case management provides additional support and accountability for adolescents as they aim to lose weight in a healthy manner. Program managers are now in the process of implementing a Childhood Obesity Partnership and Education Program involving case management of children 2 to 18 years of age with BMI >85th percentile.
Monitor the experiences of providers and participants alike: As part of new programs being implemented, program managers will disseminate a provider satisfaction survey about the BMI training, health education classes, and referral process. Adolescents will also be surveyed about the health education classes they participate in and the referral process. This information will allow program implementers to monitor the successes of their program and make adjustments as necessary.
2 More Children Are Extremely Obese. Los Angeles Times, March 18, 2010.
Voelker R. Improved use of BMI needed to screen children for overweight. JAMA. 2007;297(24):2684-5. [PubMed]
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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: January 30, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 04, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.