2007 Model Practice Application (Public)

The CCBH "DIET" Program - Dietitians Involved in Education & Training

Cuyahoga County Board of Health (CCBH)

The CCBH "DIET" Program - Dietitians Involved in Education & Training targets healthcare providers including physicians and residents and addresses the issue of childhood obesity. The goal of the program is to increase the knowledge and enhance the skills of healthcare providers (HCPs) in preventing and managing pediatric obesity and related chronic diseases. The program objectives include:

• Objective 1: By September 2009, engage and motivate 850 HCPs to participate in the program to improve knowledge of screening, assessment and management strategies of pediatric obesity and related chronic diseases.
  
  
• Objective 2: By September 2009, disseminate 300 toolkits as part of the CCBH “DIET” training to improve HCPs application and utilization of the toolkit materials.

Outcomes of practice include:

• Improved knowledge by HCPs related to CCBH “DIET” training program as evidence by pre-post tests.
  
  
• Forty pediatric providers within the NorthEast Ohio Neighborhood Health Centers are now required to utilize the Pediatric Over-Weight (POW) flowsheet assessment form provided and created by the CCBH “DIET” program.
  
  
• Providers trained are utilizing the toolkit of resources with staff, patients and families.

Childhood obesity is a public health crisis. According to the Assistant Surgeon General of the United States, obesity, not bioterrorism, is the fastest growing threat to American health. The Cuyahoga County Board of Health (CCBH) assessed childhood obesity locally in Cuyahoga County by conducting a random local survey for the Child Family Health Service Community Health Indicators Project, 2003. The results revealed that 35% of the children enrolled in kindergarten were overweight and obese. This finding supported national concerns of the growing obesity epidemic and demonstrated the need for childhood obesity management in Cuyahoga County. In a separate survey (2003) sent to local healthcare providers (HCPs), CCBH identified that nearly 43% of HCPs reported a lack of training to adequately treat overweight pediatric patients. These findings spurred the development of the CCBH “DIET” Program. Research shows that medical providers are among the most important health messengers and that patients are more likely to adopt new behaviors when instructed to do so by their health practitioners (Logsdon, Lazaro, and Meier, 1998). In a 1995 study, physicians identified lack of time, patient noncompliance, inadequate teaching materials and lack of knowledge and training about counseling as important barriers to adequately addressing obesity with their patients (Kushner). The CCBH “DIET” program provides HCPs with a one hour training session focusing on prevention and management of childhood obesity with strong nutrition and physical activity components. The training sessions include the most current, best practices in assessment and the latest motivational interviewing techniques which can facilitate positive behavior modifications. The goal of the training is to assist HCPs in assessing their patient’s readiness to adapt and self monitor realistic healthy lifestyle goals.

An expansive web-based search in 2003 was conducted to determine that this childhood obesity provider education program was innovative. In addition, program partners collaborating with the project supported the program as an evidence based and creative means of educating and enhancing the skills of local healthcare providers. An influential partner and program supporter is Dr. Robert Murray, MD, from The Children’s Hospital of Columbus, Ohio. Much of the inspiration for this program stemmed from Dr. Murray’s key messages advocating for the need for physicians and healthcare providers to take an active role in obesity prevention among children and their families. Although both programs target healthcare providers, each addresses different aspects of childhood obesity prevention and management. The CCBH “DIET” is unique in that it emphasizes the most current and the latest motivational interviewing techniques which can facilitate positive behavior modifications among children and families. This technique assists HCPs in assessing their patient’s readiness to adapt and self monitor realistic and healthy lifestyle goals. Although the toolkit concept is not a new one, the CCBH “DIET” toolkit was designed in response to HCPs identified need for easily accessible and culturally appropriate educational materials and evidence-based resources. The toolkit is continually updated, locally adapted and well organized according to the Steps grant priority areas including obesity, diabetes, asthma, physical activity, nutrition and tobacco prevention and cessation. The toolkit is provided as a hard copy expandable file case and as a mini CD. An innovative component of the toolkit is the nutrition, physical activity and tobacco prescription pads which were created using picture icons that are easily comprehended by all literacy levels. These prescription pads provide HCPs with an easy to use tool to recommend healthy lifestyle practices to children and their families. Several practices have requested these pads by the hundreds.

A large consortium of partners exists through the Steps initiative which offers ongoing support to the CCBH “DIET” program. The “DIET” program key stakeholders include the Cleveland Department of Public Health, Greater Cleveland area hospitals, Case Western Reserve University, Greater Cleveland Asthma Coalition and The NorthEast Ohio Neighborhood Health Center. The “DIET” program works collaboratively with the community health worker (CHW) project of the Steps program to cross train HCPs and CHWs. This collaboration is most beneficial to HCPs in that they will have access to trained health educators providing community level education and outreach. This provides an additional member to the healthcare team. The project director collaborated with Dr. Jeff Turell, a CWRU MPH resident/intern. Dr. Turell provided valuable technical support from the physicians perspective, for the creation of the HCP training and the prescription pads. A stronger partnership was formed with the Diabetes Association of Greater Cleveland to meet the growing demand among HCPs for current diabetes guidelines, resources and educational materials. Through this collaboration HCPs receive 30 to 45 minutes of the “DIET” program and an equal amount of time of the Diabetes Management program. The “DIET” program was integrated into the CCBH cardiovascular health program as an effort to expand the program beyond the City of Cleveland into Cuyahoga County. This expansion allows the program to reach a larger number of HCPs and to create new partnerships within the cardiovascular health program network. The CCBH “DIET” program through the Steps and the CVH projects collaborate with the OUNCE of Prevention Program developed by Dr. Robert Murray. The project staff have been trained on the OUNCE program and incorporates their information into the trainings and disseminates the OUNCE materials as a compliment to the toolkits.

This program was funded by the Cleveland Department of Public Health’s Steps to a Healthier Cleveland Grant which is funded by the U.S. Department of Health and Human Services as part of Steps to a HealhtierUS. Funds have also been leveraged through the Cuyahoga County Cardiovascular Health Grant. Since 2004, the CCBH "DIET" program has received $253,000 for program development and implementation within the city of Cleveland.

The CCBH “DIET” Program – “Dietitians Involved in Education & Training” was developed in 2004 as part of the five year Steps to a Healthier Cleveland initiative. Steps to a Healthier Cleveland is funded by the U.S. Department of Health and Human Services as part of Steps to a HealthierUS. Over the past three years the CCBH “DIET” Program has developed into a well established and successful project under the healthcare provider education piece, of the Steps to a Healthier Cleveland Initiative. The goal of the program is to increase the knowledge and enhance the skills of at least 850 healthcare providers (HCPs) over five years in preventing and managing pediatric obesity and related chronic diseases. For this program, healthcare providers include physicians, residents, medical assistants, nurses, dietitians, social workers, community health workers and students.

Year one targeted 50 HCPs and subsequent years target 200 per year. Year one focused on identifying and engaging HCPs. In addition, the HCP training, pre- and post-tests and accompanying toolkit were developed. The one hour training session focuses on the prevention and management of childhood obesity with strong nutrition and physical activity components. The training sessions include the most current, best practices in assessment (i.e. calculating Body Mass Index) and the latest motivational interviewing techniques which can facilitate positive behavior modifications. The goal of the training is to assist HCPs in assessing their patient’s readiness to adapt and self monitor realistic healthy lifestyle goals. The toolkit of literacy appropriate and culturally diverse educational materials, resources and references on obesity, diabetes, asthma, physical activity, nutrition and tobacco prevention and cessation is continually updated with the most current evidence-based resources. A unique component of the toolkit is the nutrition, physical activity and tobacco prescription pads which were created using picture icons that are easily comprehended by all literacy levels. The prescription pads were very well received and continue to be in high demand by school nurses, physicians and community health workers. The goal for the distribution of the toolkits is 300 in five years or 50 per year. Due to limited resources, for large groups toolkits are distributed to participating health organizations as opposed to individual participants.

In year three, the “DIET” program continues to build on existing relationships with local HCPs and developing new relationships in additional neighborhoods. HCPs communicated the need for additional diabetes education and resources, thus, the program has recently partnered with the Diabetes Association of Greater Cleveland (DAGC) to meet this need. A new service to year three is the development and maintenance of waiting room bulletin boards reflecting positive health messages to improve patient awareness. Four healthcare facility bulletin boards will be developed and maintained per year for the next two years. In an effort to expand the CCBH “DIET” program, it was incorporated into the CCBH Cardiovascular Health Grant which is funded by the CDC and administered by the Ohio Department of Health. Through this grant, cardiovascular health related strategies are provided in communities in Cleveland and Cuyahoga County.

The project director is utilizing the mini CD toolkits as a resource to encourage HCPs receiving training through the CCBH “DIET” program to train other office staff through the train-the-trainer concept. The HCP education program power-point, resources, educational materials, ordering forms, etc. are provided on the mini CD toolkit. This is an important piece of a plan for sustainability as the Steps program moves into year 4. Providers trained have shown commitment to institutionalizing training concepts, skills and resources. For example, the NorthEast Ohio Neighborhood (NEON) Health Center has had providers trained by the Steps and CVH program staff. In turn, NEON has required all pediatric providers to utilize the Pediatric Over-Weight (POW) flowsheet assessment form provided and created by the CCBH “DIET” program. Through follow-up visits, the project director was able to determine that providers trained are utilizing the toolkit of resources with staff, patients and families. The CCBH staff understands the importance of developing a long-term sustainability plan for the “DIET” program, thus years 3 - 5 will emphasize cross promoting the program, with other Steps projects. In an effort to expand the reach of the “DIET” program, it was incorporated into the CCBH cardiovascular health (CVH) grant. Through this grant, cardiovascular health related intervention strategies are provided in target Cleveland and Cuyahoga County communities. The current partnership with DAGC will foster improved sustainability in that future funding possibilities will be sought collaboratively. The project director, in partnership with DAGC, is currently seeking local foundation funding to expand the program county-wide. The project director continually seeks opportunities to promote the “DIET” program as a model childhood obesity provider education initiative both locally and nationally through committee meetings, poster sessions and presentations. In addition, the program will be featured in the May/June issue of the Northern Ohio Physician Magazine.

Goal of the practice: Increase the knowledge and enhance the skills of healthcare providers (HCPs) in preventing and managing pediatric obesity and related chronic diseases.

Objective 1: By September 2009, Engage and motivate 850 HCPs to participate in the program to improve knowledge of screening, assessment and management strategies of pediatric obesity and related chronic diseases.

Performance Measures: Between 2004 and 2006, the CCBH “DIET” program trained more than 330 HCPs placing the program on target to meet or exceed the established goal.

Outcome: Improved knowledge by HCPs related to CCBH “DIET” training program.

Objective 2: By September 2009, disseminate 300 toolkits as part of the CCBH “DIET” training to improve HCPs application and utilization of the toolkit materials.

Performance Measures: Between 2004 and 2006, the CCBH “DIET” program distributed 184 toolkits which is on target to exceed the established program goal.

Outcome: Forty pediatric providers within NEON health centers have required all pediatric providers to utilize the Pediatric Over-Weight (POW) flowsheet assessment form provided and created by the CCBH “DIET” program. Providers trained are utilizing the toolkit of resources with staff, patients and families.

Lessons learned include:

• HCPs requested more diabetes education and resources; therefore, the program partnered with the Diabetes Association of Greater Cleveland to fulfill the requests of HCPs for further diabetes education.
  
  
• HCPs expressed the need for the toolkit to be locally adapted, continually updated and provided in a CD version. The toolkit is now continually updated with more local resources and includes a mini CD version.