Depression Update

Twyla and I started our depression project in October 2012.  As of March 1, 2013, 60 patients had at least 2 PHQ9 scores and at least one PHQ9 score diagnosing them with depression.  Twenty three of those 60 (38%) had at least a 40% improvement in their scores.  We are identifying them, helping them access treatment, medical, therapy or both, and improving their care.  I like the model so far.

Weight Loss Strategies

I think I can lose weight.

Right now, I'm heavy, ok, I'm obese.  No really, my BMI is 34.8.  I tried two different online calculators and they gave me the same result.

I wasn't always obese.  In HS I wrestled and played football.  I loved sports and played pickup games all year.  I tore my right knee up twice in college and had to stop playing basketball at age 29.  I never did exercise regularly again.  I also never changed my eating habits.  The serving sizes and choices from HS followed me for a long time.  2005 was a stressful year and I grew from 200 pounds to 220.  By last year I was up to 230 and I'm only 5' 6"!

But I've got a plan.  It might help you, it might not.  But I've got a plan.

I'm a numbers nerd.  If I can measure it, I can manage it.  If I can't measure it, I'm in trouble.  Five or 6 years ago, I lost 25 pounds in about 3 months by counting calories online.  I used about.com's calorie count plus.  After a while, entering the foods became tiresome and I stopped.  I looked at livestrong back then and the app wasn't very good.  And like I mentioned, by last year I was up to 230, at home, after drying the shower water off.

I went to see my doctor recently and he told me I weighed too much.  He was very tactful and didn't call me obese.  He told me his doctor instructed him to count calories and that he found an easy tool called My Fitness Pal.  I shared my previous experience and agreed to try it.

So I'm early in the game.  It's definitely easier to use and get graphs (numbers nerds like graphs).  It also has a built in peer support piece.  You can invite friends or others who are trying to lose weight.  MyFitnessPal will send them a message if you've lost weight, logged in or fallen off the horse.  I started on Saturday March 2, 2013 at 224 pounds and after 2 weeks I was down to 215.4.  My BMI has come down from 36.2 to 34.8.  I like the pace and more importantly, I like the feedback from my food choices..

Every time I enter something I ate, I get immediate feedback.  If it tastes good and has low calories, I eat it again.  If it brings too many calories, I eat it less.  If it tastes bad, I don't eat it again.  Ever.   Most importantly, I eat delicious non-diet food.

Below are some of the lessons I've learned.

• Grapes have a lot of calories.  I love grapes.  My wife packs small zip log bags of them as part of my lunch. Two cups of grapes is 208 calories.  No wonder she called them nature's candy.  
• Epicurious.com is awesome.  Sure, I walk through the vegetable isles but I don't see yummy, I see boring.  You must experiment.  Do not just eat steamed or saute'd vegetables.  You will grow tired of them.  With epicurious, I buy what's in the receipe, cook it and get yummy.  I get asian yummy, mediterranean yummy, southwest tex-mex yummy, african yummy and this is just the vegetables. 
• Yummy is important because vegetables are the key to losing weight.  They fill you up, you really feel full and they have super, super low calories and many have super low carbs.
• I eat a lot of meat.  I'm a carnivore which is good as it's low-calorie, low-carb food and takes a while to digest.  Just don't eat too much sausage.  Very high calories.  If you know what scrapple is, well, I warned you.
• I have a low fat diet when I avoid soft flour tortillas.  It is true, they are carbohydrates but, I almost always melt shredded cheese on them.  I'm not eating the tortillas and my fat intake is very low.  Sometimes I think I should replace some of my carbohydrates with fat.  We'll see.
• I eat too many carbs.  I agree with South Beach.  Carbs make me hungry.  And I eat too many carbs.  But carbs are so easy.  They don't go bad.  They come in cute little plastic packages.  You can find them anywhere.  Try walking into 7-Eleven to grab a nice piece of salmon.  Still, I eat too many carbs.  Gotta figure that one out.
• Don't drink so many calories.  Drink water for thirst, drink other stuff for other reasons.  I don't drink black coffee and I need coffee.  Red wine is nice too.  Gatorade only if you were sweating!  I'm glad I don't drink much beer anymore.  Twenty percent of all beer drinkers drink 80% of all the beer.  Beer drinkers are only thin on TV.
• Don't watch TV.  Really, just don't do it unless there's a game on or your watching a second season marathon of A Game of Thrones.  TV commercials are evil.  They are pavlovian.  Repeat, don't watch TV.
• If you get a sandwich at Panera or Subway or somewhere else, eat the first half and stop.  Unless you're Andre the giant, you're full.  Wrap it up and eat it later, even only 20 minutes later.  Just don't eat it all or you'll reach that sub-bursting feeling.  If you feel like you're going to burst, you're gaining weight.
• Cook a lot on Sunday.  Cook a couple different things, then mix and match them for lunch and dinner during the week.  I work hard.  I'm not cooking yummy from scratch on Tuesday night.  Not happening.  I'm re-heating or getting take out.  
• Don't eat take out.  Unless it's a turkey sandwich or sushi.

Cook yummy, eat yummy, count the calories, watch what I drink and no take out.  

Man it's been a long time.  Life gets that way I guess.

I wanted to share a little process we're working on.

We all know that roughly 25% of the patients who visit a primary care office in any given year are depressed at one of their visits.  I work in a Federally Qualified Health Center (FQHC) serving mostly the un- and under-insured and our rates are probably higher than that.  

We also know that depression is vastly under-diagnosed in primary care.  There's a PHQ-2 screening tool for depression and then a PHQ-9 diagnosis and monitoring tool for depression.  Basically, if either of the first two questions are positive, you ask the next seven questions.  If the PHQ-2 is positive, you just added 9-10 minutes to the visit.  Those of us who admit it will tell you that adding 9-10 minutes to a 15-20 minute prohibits using the PHQ2.

Then my medical assistant Twyla Womack took over.  At first, she gave the PHQ-9 form to the patients and asked them to fill it out while they wait for me.  Who cares if they fill out all 9 questions when the first 2 are negative?  She would then leave the form for me to see when I went into the room.  Later, she would enter the results into the EMR.  She easily saved me 8 minutes for every positive PHQ-9.  After a while, she noticed that some patients skipped some of the questions and so she wasn't sure people fully understood the questions.  At that point, she started asking the questions and recording the patients' answers directly into the EMR.

From October 1, 2012 through January 31, 2013, even though I was only seeing patients 16 hours per week, Twyla completed and documented 240 PHQ-9s in our EMR, plus all the negative PHQ-2s!  

We need to crunch more data to see the longitudinal change in PHQ-9 scores to make sure we're having a clinical effect.  However, you can only treat what you can diagnose.

Text Messaging To Improve Adherance

Over the past year, I visited 50 practices in mostly rural PA.  I asked them if they collected email addresses or cell phone numbers from their patients.  Most assumed that patients don't want emails from their doctors or, since I work in Medicaid, that Medicaid patients can't afford to keep the same cell phone number.  The resistance to change was our usual human response.  However, here's an article from the NY Times showing the clinical value of text message medication reminders.

I don't know about you, but if my google calendar didn't text me a reminder, I would forget to get home on time and take my daughter to field hockey practice. 

Enjoy!

http://www.nytimes.com/2009/11/05/health/05chen.html?_r=1

Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home

This study was published in the Annals of Family Medicine back in June 2009.  Some people think that we can increase primary care capacity through pay for performance programs.  There are examples of pay for performance programs where the targeted clinical metrics improved, however, it seems likely that primary care practices in P4P programs shifted attention from non-incentive areas to those with a reward.  There isn't much progress in a zero sum game.  As the baby boomers age and require more care, and if health care "reform" leads to more insured Americans, we must find a way to increase primary care capacity.  This article http://www.annfammed.org/cgi/reprint/7/3/254 discusses the early lessons from attempts to transform primary care practices into Patient-Centered Medical Homes.The Commonwealth Fund summarized the key points well here http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2009/May/Initial-Lessons-from-the-First-National-Demonstration-Project.aspx. 

From the Commonwealth Fund:

Key Findings

• Transforming a primary care practice into a patient-centered medical home requires wholesale practice redesign and continuous commitment to enhancing the patient experience. Transformation will likely include a host of interdependent components, such as new scheduling arrangements, better coordination with other parts of the health care system, more point-of-care services, and development of team-based care, among others. "Change is hard enough; transformation to a patient-centered medical home requires epic whole-practice reimagination and redesign."
• Developing and implementing an information technology infrastructure to support this transformation is more difficult and time-consuming than may be anticipated. Information technology is currently underdeveloped to meet the needs of the patient-centered medical home.
• Transformation involves a shift from physician-centered care to a team approach, in which patient care is shared among office staff.
• Rapid transformation can result in staff burnout, turnover, and financial distress.
• Moving toward the patient-centered medical home model is a developmental process that can take up to five years to achieve; successful transformation is highly dependent on local conditions that affect health care practices and their surrounding health care system.

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Addressing the Problem

Based on their evaluation, the authors make several recommendations to support practices in their efforts to adopt the patient-centered medical home model:

• Pilot programs should include up-front capital to help purchase and implement new information technologies, and ongoing funding to support personnel changes needed to implement better care management.
• Practices must determine the specifications and path toward achieving their own transformation, but facilitation through consultation and other services can play an important role.
• Professional organizations should help doctors acquire the patient and practice management skills needed to make this transformation.
• The National Committee for Quality Assurance may need to revise its process for recognizing patient-centered medical homes to encourage a more developmental approach at the practice level.

 Enjoy!

Increasing the ratio of nurse practitioners to physicians

Many practices have realized that mid-level practitioners can competently provide a subset of the care traditionally provided by physicians.  However, a practice with four physicians and no mid-levels would have to grow significantly to add four nurse practitioners and reach just a 1:1 ratio.  Imagine a large organization with 50 or more physicians and you see one problem with delegating appropriate clinical tasks with any scale.  Of course that is the "Build" answer to the Build vs Buy question.  Allina Hospitals and Clinics have taken a different approach, kind of a rent to own path.  Other large organizations may follow suit if it works well and they are able to shift care from their Emergency Departments to the Minute Clinics while maintaining continuity with their primary care physicians.

The blurb below is from the ACPE Daily Digest.  Enjoy!

Allina, MinuteClinic partner to coordinate care for patients, share EMRs.

The Minneapolis Star Tribune (10/30, Yee) reports that Minnesota's "Allina Hospitals and Clinics is teaming up with MinuteClinic to coordinate care for patients and expand medical services down the road." Under the deal, "Allina doctors will offer medical oversight to MinuteClinic nurse practitioners...and the two organizations will share electronic medical records." Still, "neither organization will take a stake in the other, nor will they pay each other referral fees."

        Allina and MinuteClinic "will forward patients to each other and integrate their healthcare delivery systems," the Minneapolis/St. Paul Business Journal (10/29, Newmarker, subscription required) reported.

Closing The Triangle

Today I drove to Wellsboro, PA.  Wellsboro is in Tioga County, just below the NY border.  The meeting was to share the experiences of the Tioga Partnership For Health with representatives from Altoona, PA.  The folks in Tioga have taken an inclusive, collaborative approach to addressing health and wellness in their community.  The three original leaders of the partnership were the hospital system, the county social service leadership and the President of Mansfield University.  Over the past 12 years, they have developed trust by letting people work on the things that interested them.  Some people worked on smoking in pregnancy, others worked on obesity or school menu choices.  Their community health center participated in three Health Disparities Collaborative projects through the Federal Bureau of Primary Health Care.  They have grant funded staff as infrastructure, providing support to their volunteer work groups and handling day-day tasks.  Remarkably, they have decreased their hospital admissions rate in each of the last three years.

Each of the Tioga representatives reinforced the idea of helping people get past their own perceived limitations of what the partnership could accomplish.  When people said something couldn't be done, they asked "If it could be done, what would it look like?"  This helped people break out of learned helplessness.  They also used phrases like non-linearity, letting people with similar interests volunteer to work together and the trusting relationships formed within the work groups allowed the groups to take chances. 

The Altoona representatives noted that in the past, they had two competing hospitals that each started wellness programs, but rather than work together, they ended up being short-lived, ineffectual tools for driving market share.  Now their hospitals are in one system, so they may have better chances of hospital community collaboration. 


At the end of our meeting today, the Tioga folks agreed to drive to Altoona and share their stories with Altoona community leaders.  Then we get to see what emerges!