Overview

The Veterans Health Administration (VHA) conducted a pilot study of Goals for Eating and Moving (GEM), a primary-care-based weight management program utilizing volunteer student health coaches, telehealth counseling, and a tablet-based personalization tool. 

Organization Name

Veterans Affairs New York Harbor Healthcare System ; NYU School of Medicine

Organization Type

• Academic Medical Center
• Government organization
• Veteran's Affairs

National/Policy Context

• Obesity in the United States is rising in prevalence, affecting nearly 40% of Americans (2015-2016 data from the CDC).
• Nationally, counseling and coaching around weight loss have been encouraged and incentivized through Medicare reimbursement. 
  • For example, the United States Preventive Services Task Force (USPSTF) advises that health care providers use the 5As method to perform weight loss coaching, which incorporates motivational interviewing. 
• Although overweight patients report wanting weight loss counseling from PCPs, providers may not have sufficient time to provide comprehensive counseling services.

Local/Organizational Context

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Patient Population Served and Payor Information

• Nationally, the median age of the male veteran population was 65 and the mean age of female veterans was 51, as of 2017. 
  • 78% of male veterans and 65% of female veterans nationally are white and non-hispanic, 14.8% of male veterans and 25.3% of female veterans are non-white and non-Hispanic, and 7.1% of male veterans and 9.5% of female veterans are Hispanic. 
• Of the 43 patients randomized in this study,  67.4% were male and 32.6% were female VA patients aged 18 to 69.
• Patients received care from the Manhattan VA in New York and were randomized to the intervention arm (receiving health coaching etc.; n=21) or to “enhanced usual care” (n=22).
• 50% of study participants were Black, 20% were White, 14% were Hispanic, 10% were Asian, and 5% were Alaskan or American Indian.

Funding

• Funding came from a Veterans Health Affairs Health Services Research and Development Career Development Award. 

Research + Planning

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Tools or Products Developed

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Training

• Training for PCPs: One-time, 20-minute academic detailing training to learn about GEM, the role of the Health Coaches, the new EHR reminder tool, and ways to counsel patients on weight management. 
• Training for Health Coaches: 25 hours of training to learn motivational interviewing and understand the GEM intervention workflow.

Tech Involved

• Electronic medical record
• Vista
• Pedometer
• Redcap
• Tablet
• Video conferencing
• Video messaging

Team Members Involved

• Dietician
• Health Coach
• Physicians

Workflow Steps

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Budget Details

• Cost of IT making adjustments to EHR to build PCP reminder feature
• Cost to develop GEM tablet-based technology tool 
• Cost to buy tablets
• Labor costs of health coaches

Where We Are

• The authors are working on a multi-site cluster RCT (NIH # 1R01DK111928) since this pilot demonstrated patient satisfaction with the intervention. 
  • Changes to the future intervention based on the pilot include: 
    • Enhanced provider training to increase PCP buy-in.
    • Pairing of Health Coaches (two paired coaches will work with a patient) to ensure patients receive coaching from the same coaches over time.
    • Increased promotion of MOVE! enrollment. 
    • Use of Spanish translation in study materials to broaden the participant pool.
• The authors are also piloting a new study (VA IIR HX-002119-01A2) using  peer Health Coaches and GEM. 
• Publication Date: February 4, 2019

Outcomes

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Future Outcomes

• Future studies will investigate similar outcomes from GEM in the setting of peer Veteran Health Coaches (VA IIR HX-002119-01A2).
• A future study will also investigate these outcomes in a multi-center RCT (NIH # 1R01DK111928).
• Future studies will also study the cost-effectiveness and effectiveness of GEM.

Benefits

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Unique Challenges

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Sources

• Ames GE, Heckman MG, Grothe KB, Clark MM. Eating self-efficacy: development of a short-form WEL. Eat Behav. 2012 Dec;13(4):375-8. doi:10.1016/j.eatbeh.2012.03.013. Epub 2012 Mar 30. PubMed PMID: 23121791.
• Czajkowski, S. M., Powell, L. H., Adler, N., Naar-King, S., Reynolds, K. D., Hunter, C. M., … Charlson, M. E. (2015). From ideas to efficacy: The ORBIT model for developing behavioral treatments for chronic diseases. Health psychology : official journal of the Division of Health Psychology, American Psychological Association, 34(10), 971–982. doi:10.1037/hea0000161
• CDC Obesity Data: https://www.cdc.gov/obesity/data/adult.html
• CDC Sugary Beverage Survey: https://www.cdc.gov/brfss/questionnaires/pdf-ques/2017_BRFSS_Pub_Ques_508_tagged.pdf
• Jay, M., Gillespie, C., Schlair, S., Sherman, S., & Kalet, A. (2010). Physicians’ use of the 5As in counseling obese patients: is the quality of counseling associated with patients’ motivation and intention to lose weight?. BMC health services research, 10, 159. doi:10.1186/1472-6963-10-159
• Kinsinger LS, Jones KR, Kahwati L, Harvey R, Burdick M, Zele V, Yevich SJ. Design and dissemination of the MOVE! Weight-Management Program for Veterans. Prev Chronic Dis. 2009 Jul;6(3):A98. Epub 2009 Jun 15. PubMed PMID: 19527600; PubMed Central PMCID: PMC2722407.
• Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport. 1992 Mar;63(1):60-6. PubMed PMID: 1574662.
• Simpson K, Parker B, Capizzi J, Thompson P, Clarkson P, Freedson P, Pescatello LS. Validity and reliability question 8 of the Paffenbarger Physical Activity Questionnaire among healthy adults. J Phys Act Health. 2015 Jan;12(1):116-23. doi: 10.1123/jpah.2013-0013. Epub 2014 Apr 11. PubMed PMID: 24733349.
• Thompson FE, Midthune D, Subar AF, Kahle LL, Schatzkin A, Kipnis V. Performance of a short tool to assess dietary intakes of fruits and vegetables, percentage energy from fat and fibre. Public Health Nutr. 2004 Dec;7(8):1097-105. PubMed PMID: 15548349.
• Viglione C, Bouwman D, Rahman N, Fang Y, Beasley JM, Sherman S, Pi-Sunyer X, Wylie-Rosett J, Tenner C, Jay M. A technology-assisted health coaching intervention vs. enhanced usual care for Primary Care-Based Obesity Treatment: a randomized controlled trial. BMC Obes. 2019 Feb 4;6:4. doi: 10.1186/s40608-018-0226-0. eCollection 2019. PubMed PMID: 30766686; PubMed Central PMCID: PMC6360675.
• VA MOVE! Program: https://www.move.va.gov/MOVE/QandA.asp
• Veteran Demographics: https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2017.pdf