Building a Viable Weight Management Program in a Patient-Centered Medical Home

Obesity is a major cause of preventable death and disability, with increasing prevalence globally. Over 30% of US adults meet criteria for obesity (body mass index [BMI]≥30 kg/m2), increasing their risk of cancer, heart disease, diabetes, and arthritis.1-2 Effective obesity treatment requires long-term, high-intensity strategies to address all its dimensions.3 Primary care providers are ideally suited to manage this chronic disease. Two large trials report clinically significant weight loss in primary care settings stemming from high-intensity behavioral therapy (IBT) defined as greater than 12 sessions focused on a reduced calorie diet, increased physical activity, and behavioral strategies to improve adherence.4-5 Guidance is limited on how to translate these findings into real-world settings with practical challenges such as providers’ scant time and training, causing few to deliver IBT as recommended by the US Preventive Services Task Force (USPSTF) and the Centers for Medicare and Medicaid Services (CMS).6-11 Confronted with this challenge, an interprofessional group developed the Weight Management Program (WMP), an evidence-based, financially sustainable program that is scalable to academic primary care settings. This report outlines its inception, components, and initial clinical and financial outcomes.

WMP is located within the family medicine center (FMC) at the University of North Carolina at Chapel Hill. The center completes over 66,000 patient visits annually. This setting allows for an interprofessional team of clinical social workers, physicians, dieticians, and learners to deliver IBT to patients with obesity.

The FMC has operated a Tobacco Treatment Program since 2007. Given the parallel motivational and behavioral changes required to stop tobacco use and maintain weight loss, staff surveyed FMC providers regarding their desire for a similar program to treat obesity. Results revealed an unmet need, spurring a WMP pilot in 2015, which began with one clinical social worker offering four counseling hours per week of IBT to a quarter of FMC patients with obesity. The program expanded to all FMC patients in 2016 and to outside and self-referred patients in 2017 (Table 1). This report gives outcomes throughout the program’s evolution.

WMP’s structure is based on USPTF and CMS guidelines, offering 26 IBT sessions via group and individual counseling over 1 year (Figure 1). Participants first complete a group orientation where they learn WMP’s guiding principles, nutrition guidelines (Harvard’s Healthy Eating Plate)12 and set SMART (specific, measureable, action-oriented, realistic and time-bound) goals to promote weight loss. WMP’s guiding principles are: (1) sustainable change; (2) 5%-10% weight loss; (3) setting goals and taking positive health actions; and (4) self-care.

After orientation, participants choose to initiate individual and/or group counseling. In 30-minute individual sessions, clinicians engage patients using motivational interviewing, help them set SMART goals, and employ cognitive behavioral therapy and mindfulness techniques focused on helping patients maintain clinically significant weight loss (at least 5% from baseline). 13

Sixty-minute group sessions, based on the Diabetes Prevention Program’s “Prevent T2” curriculum occur twice per month.14 The curriculum is repeated allowing for rolling admission.

WMP also offers monthly maintenance group visits beyond the initial year. These groups do not follow a specific curriculum but focus on long-term behavior change strategies.

Current paid staff includes 20 counseling hours per week by clinical social workers. WMP has also integrated preventive medicine and family medicine residents and graduate students into the treatment team. Residents and students work alongside experienced clinicians before working independently. Ongoing education includes biweekly case consultations, guest speakers, and journal article review. WMP clinicians refer patients to registered dieticians, obesity medicine specialists, and bariatric surgeons when appropriate.

We extracted participant health data from the electronic health record and evaluated retrospectively. Analysis was limited to FMC patients with multiple weight, blood pressure, and hemoglobin A1c (HbA1c) values documented over time. Similar to other studies showing sustained program commitment, eligibility for evaluation required completion of at least four visits, though the mean number of sessions completed (11.3, SD=8.1) was closer to the 12 session cutoff for IBT.15 Changes in weight and systolic and diastolic blood pressures were determined by comparing the last value measured within 18 months to baseline. Changes in HbA1c, typically an annual measure, were determined by comparing the last value measured within 24 months to baseline. We used paired t tests to assess changes in HbA1c, weight, and systolic and diastolic blood pressures from baseline (Figure 1).

The University of North Carolina’s Institutional Review Board approved this study (#18-0358).

From September 2015 to June 2019, WMP served 673 individuals over 3,895 visits (Table 2). Participants’ mean starting weight was 248 lbs (SD=58.3) and average weight loss was 6.12 lbs (SD=21.7), or 2.4% (SD=7.7%). Of the patients served, 186 met inclusion criteria for evaluation with at least four visits and a baseline weight, blood pressure, and HbA1c recorded. Participants completed an average of 11.3 visits (median=8, SD=8.1) with 16% participating in group sessions. Average HbA1c decreased significantly (6.7 to 6.5, P=.004). Participants’ systolic and diastolic blood pressures showed significant improvement (mean difference 2.8 mmHg, P=.002, and 1.9, P=.03, respectively). Participants experienced a significant reduction in weight (9.7 lbs, P<.001). See Table 3 for detailed results.

Financial sustainability through billing receipts was not possible with preventive counseling CPT codes exclusively (Figure 2). WMP was initially subsidized by institutional funding for tobacco treatment programs. Consequently, WMP added an out-of-pocket $125 enrollment fee, which nearly covers all expenses when combined with receipts. Paid expenses are 20 counseling hours per week by clinical social workers. In-kind expenses include medical director oversight, counseling and office space, and learner clinic time.

Obesity is the second-leading cause of preventable death globally.16 Primary care providers are well-positioned to treat obesity, but lack time to help patients achieve lasting behavior change. WMP highlights the role nonphysician providers have in comprehensive, affordable, and evidence-based obesity treatment. It provides a model for building weight management into the operations of an academic family medicine department, which can draw from a diverse panel of ancillary providers to extend care delivery, promote interprofessional collaboration, and enhance training. The program appears to demonstrate that IBT sessions are associated with clinically significant weight loss and improvements in HbA1c and blood pressure.

This study has several limitations. Participants were mostly female, making it difficult to discern gender differences. Only one-half of patients completed at least four visits, showing additional efforts are needed to retain participants. Potential factors influencing retention include cost, insurance coverage variability, recommended visit frequency, and the program’s focus on sustainable change over rapid weight loss, which is not aligned with some patients’ goals. While we saw significant changes in HbA1c values, only half of eligible patients had follow-up HbA1c values, which may have limited an ability to detect even larger differences in glucose control. Blood pressure and weight measurement strategies were not standardized as they were obtained by multiple personnel during clinical encounters. Finally, several variables were not measured, such as quality of life indicators.

We learned that existing preventive counseling CPT codes (G0447, 99402-99404, 99412) are insufficient to achieve financial sustainability. Instead, WMP reached sustainability by including an out-of-pocket enrollment fee and in-kind institutional resources. The enrollment fee likely limits low-income patient participation. WMP investigated a sliding scale fee structure and scholarships, however institutional policies have not permitted these solutions. Leadership continues to explore strategies to increase access.

This real-world study of a weight management program within a busy academic practice highlights the applicability for other primary care practices. WMP is undertaking quality improvement efforts to increase retention, including the use of telemedicine. Broader adoption of such evidence-based models is critical in treating obesity, particularly as the US health care system transitions toward a value-based payment model wherein health care systems are paid a set amount per patient to deliver quality care.17 Under this new model, it is vital to assess WMP’s impact on overall cost per patient and quality metrics related to weight loss, blood pressure, and HbA1c.