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Erin Martin, High Touch, Low Tech: Reversing Disease with Lifestyle Medicine
1. High Touch, Low Tech:
Reversing Disease with
Lifestyle Medicine
Erin Martin D.O., MPH
TrueMed Institute
Center for Integrative Medicine
Hood River, Oregon
12. Here’s the Big Problem...
• Physician involvement in promoting therapeutic lifestyle
change (TLC) therapy is too low:
• 2007 National Ambulatory Medical Care Survey showed pharmaceutical
medications were prescribed at 73% of visits in which high cholesterol was
initially diagnosed vs. 8-12% of visits in which counseling or education
services related to diet or nutrition and exercise were ordered or provided.1
• Why is this?
• “At present, dietary counseling by clinicians in primary care does not typically
contain consistent, clear suggestions for specific change, how these could be
achieved, and how progress would be monitored.”2
• “Most primary care providers believe physical activity (PA) counseling is
important and that they have a role in promoting PA among their patients.
However, providers are uncertain about the effectiveness of counseling, feel
uncomfortable providing detailed advice about PA, and cite lack of time,
training and reimbursement as barriers. Providers are more likely to counsel
their patients about PA if they are active themselves, or if they feel their
patients' medical condition would benefit from a lifestyle change.”3
13. So Why Do We
Think We Have to
Do it All Ourselves?
Because We Don’t!
15. WHY A TEAM-BASED
APPROACH?
Brief advice (involving five minutes or less of counseling),
including repeated advice to quit smoking during
healthcare visits, may be effective in some patients.
However, to achieve moderate changes in diet and
physical activity, medium (30-360 min) or high
intensity (>360 min.) counseling is usually required.4
16. Medium/High Intensity Diet and/or Physical
Activity Counseling: Does It Work?
• Primary outcomes
↓% energy saturated fat: 2.8–3.7%
↑fruit and vegetable:
• 0.4–2 serving/day
(Conventional Model)
↑PA: 38 min/week
17. Hallmarks of a Successful TLC Program
Initial Visit
TLC Panel:
•Advanced Lipid Panel
•hs-CRP
•HgA1c
•Fasting Insulin
•Homocysteine
•CMP, CBC
•25-OH Vitamin D
Follow-up Visit #1
•Review Labs (60 min.)
•Provide Resources
•Initiate TLC Program
•Exercise Rx (150 min./wk)
•Make Appt. w/Health Coach
Health Coach Program
•Custom Nutrition Program
•Bi-monthly visits (50 min.)
•Goal-setting
•Monthly BIA’s
•Stress Management **
•Lifestyle Change Support
•Accountability
6 wks
Follow-up Visit #2
•Evaluate & Intensify
•Diet
•Weight Loss
•Exercise
•Stress Management
•Complimentary Therapies
6 wks
REPEAT
LABS
Follow-up Visit #3
•Evaluate & Intensify
•Revise Custom Nutrition Plan
•Revise Exercise Rx
•Trouble Shoot Road Blocks
•? Repeat HgA1c, Glycomark
Provider Conference
with
Health Coach
6-12 wks
Maintenance vs.
Consider
Pharm.
Therapy
19. What it Looks Like
• Fewer Patient Visits
• Longer Visits (30-60 min.)
• A Plan & Commitment to Educate
• Get Educated Yourself!
• Health Coaches/Lifestyle Educators
• Goal Setting
• Group Classes (possibly)
20. How Does It WORK?
• Many Models
๏Hybrid Practices
๏Out-of Network
๏? Opt-out of Medicare
๏Fee for Service
๏Insurance with other
Services
21. But TLC can Benefit
so Many Patients,
How Do I Choose
What to Focus On?
22. Target Specific Disease Populations
• Many Diseases Affected by Lifestyle
• You Can’t Be the Jack-of-All-Trades
• Become the EXPERT in what your Patients need
MOST.
• Use Ancillary and/or Mid-Level Providers to cover other
areas as needed.
(Example: Physician provides cardiometabolic basic
training and health coach/lifestyle educator addresses
stress management, etc.)
23.
24. How Does It Actually
Happen?
Getting the Train
to Leave the Station...
25.
26. Making It Happen
✓You’re Committed You’re Staff is Committed
✓Make Small Changes Toward Goal to Start
➡Schedule longer visits to review labs with patients
➡More Frequent Follow-up Visits
➡Start Looking for Help - Ancillaries/Mid-Levels
✓Get Trained & Stay Focused (Don’t get distracted by “fancy
medicine,” most of it has no evidence that it makes long-term difference)
✓Don’t Take the Easy Way Out
27. It Takes: More Time,
More Focus,
More Energy
To Do Things Right
But...
28. You’ll get more high fives, more patient buy-in,
more job satisfaction, better patient outcomes,
less work in the long run...
38. References
1. US Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommendations
and rationale. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=3494&nbr=2720.
2. Phillips K, Wood F, Spanou C, et al.; PRE-EMPT Team. Counselling patients about behaviour change:
the challenge of talking about diet. British Journal of General Practice 2012;62(594):e13−21.
3. Hébert ET, Caughy MO, Shuval K. Primary care providers' perceptions of physical activity counselling in a clinical setting:
a systematic review. British Journal of Sports Medicine 2012;46(9):625−31.
4. Lin JS, O’Connor E, Whitlock EP, et al. Behavioral Counseling to Promote Physical Activity and a Healthful Diet to
Prevent Cardiovascular Disease in Adults: Update of the Evidence for the US Preventive Services Task Force. Rockville,
MD: Agency for Healthcare Research and Quality; 2010. Available at www.ncbi.nlm.nih.gov/books/NBK51030.
The system pushes doctors to work faster – the only way to push more patient volume through a pipe that is not getting any wider.
Reimbursements are shrinking, and getting harder to collect and the impact on small practices is catastrophic.
How many of you are as excited about this as I am?
How do we keep up with the needs of our patients at a time where so much more is being demanded of us outside of the realm of patient care?
The timing couldn’t be worse. We have what some have called a generational tsunami crashing on our health care system with the aging of the baby boomers.
Add to that now the burden of health care reform and another 37 million newly insured people, and we have a full blown supply and demand crisis on our hands. This problem seems to be of primary concern to the system. And in response…
Until very recently, conventional wisdom told us that our health was largely predestined by our genetics. Health care was therefore geared to react to the effects of the genetic hand we’ve been dealt as things inevitably go wrong as we age.
Today we understand the magnitude of our misperception. Our genes are important. But the way they govern our health is nothing like we thought. Our genetic code, which never changes through our lives, is like computer hardware.
As it turns out, our hardware also comes equipped with software which largely dictates how our genes express themselves. And the good news is – we can pretty much write our own software with the decisions we make.
In fact, 80% of our health is determined by the lifestyle we create for ourselves. How we eat, exercise, sleep, manage stress, and connect with the world around us.
So given that the great majority of our health is a product of our own decisions, caring for patients with lifestyle-related illnesses should dedicate itself to building competency to MAKE GOOD DECISIONS. And we’ll do it in fun ways.
AHA makes statements such as this, and have been for over 20 years. That’s not working out so well for the American public. One of the main reasons for this is that no one can seem to agree on what “good nutrition” means and how much physical activity produces the outcome of reduced risk. Physicians are as confused as patients are.
Some of the biggest reasons physicians give for not implementing more TLC counseling into their practices is the lack of time, reimbursement, or resources (aka knowledge). It is true that in order to provide effect lifestyle management of chronic issues we can’t practice in the same way we always have. That would be absurd. So let’s take a look at the HOW’s of this model of care.
Let’s look at Reimbursement first, since that’s usually one of the biggest concerns and the biggest frustrations physicians have. After-all, we do have to make a living and keep the practice solvent in order to do any good in the community, right?
To help with the feeling of being overwhelmed, some of the most loved advice I give my patients when we’re looking forward towards their goals and talking about lifestyle changes is to make the commitment to themselves to everyday do a little more of what they want to be doing, and a little less of what they don’t want to be doing, until eventually their goals become reality.
The first question is what is the value you want to offer your patients. This new structure respects VALUE above all else. So you need to create and present to your patients real value to justify the investment.
Related to the first question is this. Who do you want to serve? Practices in this new marketplace need a far greater awareness of who it is that they are most trying to serve. What does the ideal patient of this practice look like?
Once you have defined the value you want to create and the audience for your vision, you need to realistically assess the time and other resources that will be required to live up to what you offer. Ultimately, this will tell you how many people you can responsibly serve, and it will enable you to price your service appropriately.
Finally, you must create your financial structure. Most doctors think this is a matter of deciding to accept or not accept insurance. That is a gross over-simplification of this issue.
Remember, structure determines behavior. And this is your chance to create a structure that produces health sustaining behavior on the part of the practice and your patients.
You CAN create, exactly what you want. It’s possible and it doesn’t have to take 10 years or a million dollars.