Who Partnership between Maryland EFNEP and local safety net clinics. Participants are pediatric patient/parent dyads.

What

Quasi-experimental program to implement Policies, Systems, and Environmental (PSE) approaches to prevent/reduce childhood overweight and obesity in a clinical setting.

Where Community Clinics Inc. (Federally Qualified Health Centers/Safety net clinics) in Montgomery and Prince George’s counties in Maryland

When 2014-present

Why

Expand the scope of practice and referral system of health care providers working in safety-net clinics which serve limited-income families in order to prevent/reduce childhood overweight and obesity

Adult Questions

1. On average, how many days per week do you engage in moderate or greater physical activity, like a brisk walk?

2. On those days, how many minutes do you engage in activity at this level?

Youth Questions

1. How many hours does your child spend watching television or playing video games each day?

2. On average, how many days per week does your child engage in active play? What kinds of activities does your child enjoy?

Building Healthy Systems: A Community-Clinic Partnership Approach for Transforming Lifestyles of Low-Income Families

At-risk for Chronic Disease Mira Mehta, PhD, Linda Ashburn, RN, MPH, Denise Benoit-Moctezuma, MPH, Kavitha Sankavaram, PhD, Hee-Jung Song, PhD, Maribet Brute, MPH

Expanded Food and Nutrition Education Program, Department of Nutrition and Food Science, University of Maryland, College Park, MD 20742

Expanded Food and Nutrition Education Program …• Is a USDA funded nation-wide program that unites federal, state, and local

resources to provide free nutrition education workshops to limited-income families and youth.

• Operates through the Extension/Outreach Mission of the Land-Grant Universities in every state, the District of Columbia, and the six U.S. territories.

What is EFNEP?

Transforming Lifestyles Project (TLP)

Theoretical Model

PSE ChangesPolicy, Systems, and Environmental (PSE) change: A way ofmodifying the larger policy, systems and/or environments ofcommunities to improve healthcare outcomes.Screener questions: Incorporate 2 physical activity questionsinto the clinics’ Electronic Health Record (EHR) as a vital signreading for every patient.Referral: Physician refers overweight/obese pediatricpatient/parent dyads to EFNEP to be enrolled in workshops.Resources: Patients receive information about free physicalactivity resources in their local community.

Preliminary Conclusions and Implications• Outcome data indicates positive change in all key indicators of diet quality and physical activity.• Systems change requires a multi-step process:

• Change in work flow• Integration of PAVS into EHR• Training of staff

• Surveys of Primary Care Providers at entry and exit in the clinics indicate that relatively modest investments can enable changes in the workflow (EHR), and these changes are viewed by providers as being feasible and beneficial for program participants.

• Primary Care Providers emphasized the need for referral programs that build promote healthy lifestyles and facilitate self efficacy for patients in the community setting.

• They also reiterated the need for more training and skill in dealing with obesity in diverse communities.• Both systems change and effective program outcomes in clinical setting (while feasible) require ongoing

training and must be viewed as an iterative and evolutionary process.

Hispanic/Latino Families

Eating Smart Being Active & Cooking Matters for Kids

Change in the work flow

Free/Low cost community resources for physical activity

Educational materials on age specific physical activity

Screen patients for physical activity (PAVS) & engage families in discussions

Pediatric/Primary Care Providers

Identify Children At-risk for Obesity

and Type 2 Diabetes

Indigenous Paraprofessional

Refer to EFNEP

Culturally Tailored EFNEP Nutrition Education Series

EFNEP Evaluation, Physical Activity Assessment, and BMI Measurements

Implement PAVS Screening Questions SYSTEMS

CHANGE

Community Clinic Inc.

InputsPrimary careHealth care systemsClinicsAdministratorsPhysiciansCommunityCommunity organizationsUMD/UMEEFNEPEat Well Be Active Health Care Work Group (Montgomery County)Peer Reviewed Curriculum and Instructional MaterialsOther ResourcesNE-RNECE grant funds Evidence-based physical activity screening questions (Physical Activity as a Vital Sign or PAVS) Suggested physical activity lists in English and Spanish by age group (Suggested PA lists) Resource lists of local community physical activity resources (Community PA Resource List) Evaluation instruments

ActivitiesPrimary careTrain staff and providers in experimental clinics to do PAVS and to use suggested PA lists and resource lists (UME) Screen patients, provide education in the clinics and make referrals (Experimental Clinics) Modify EHR systemsEstablish process for providers to refer patients and families to EFNEP classes in experimental and control clinics (UME and all clinics)Lists of referral resourcesCommunityDevelop and support coalitions and partnerships Establish necessary agreements between UME/EFNEP and clinics (UME)Conduct EFNEP classes and evaluations (UME)

Short-term OutcomesSupportive Policies & SystemsIncrease knowledge of how to incorporate PAVS into clinic work flow and implement related protocolsStandardization of best practicesStrong organizational and institutional partnerships Technical assistance to providers and facilitiesProvidersIncrease awareness of local resources for physical activities and nutrition education (EFNEP)Increase comfort level with discussing physical activity with patientsPatients: Increase awareness of importance of physical activity and its connection to health Increase awareness of recommendations for physical activity for adults and youthIncrease knowledge of importance of eating vegetables, fruits and whole grains; Increase knowledge of food resource management

Mid-term OutcomesEffective Program Delivery

Improved Physical ActivityIncreased physical activity timeDecreased sedentary and screen time

Improved NutritionIncreased fruit & vegetable consumptionDecreased low-quality food consumptionProvidersIncrease screening of patients at risk for obesity and chronic diseasesIncrease education of patients and their families about physical activityIncrease referrals to local resources for physical activity and EFNEP SystemsIncorporate use of PAVS as best practice in all clinics Incorporate simple educational interventions and referrals to local resources in all clinics

Long-term OutcomesImproved child weight status

Improved child quality of life

Improved child health outcomes

Sustained program delivery and effectivenessProvidersIncorporate PAVS and simple educational interventions as best practice at state and national levels

SystemsIncorporate PAVS requirements into county contracts for health care providers (safety-net clinics under Montgomery Cares) and school-based health centersIncorporate PAVS into larger health systems, such as hospital admissions processes.

Health Care System Expansion Model

Transforming Lifestyles: Evaluation Logic Model

EFNEPExpanded Food and

Nutrition Education Program

This study is approved by the University of Maryland IRB (# 785104). Funding is provided by a sub-award granted by the RNECE at Cornell University.

The University of Maryland Extension is an equal opportunity employer with equal access programs.

AbstractMaryland Expanded Food and Nutrition Education Program (EFNEP) offersnutrition education to low income families in partnership with CommunityClinics Incorporated (CCI) with the shared goal of addressing childhood obesityusing Policy, Systems, and Environmental (PSE) approaches. CCI Clinics areFederally Qualified Health Centers that serve pediatric patients in Maryland.The aim of this study was to examine whether system changes, includingassessment of Physical Activity as a Vital Sign (PAVS), electronic health record(EHR) changes and workflow redesign, resulted in increased referrals foroverweight and obese pediatric patients. CCI incorporated two screeningquestions for physical activity and screen time into EHR and integrated referralto EFNEP into the workflow. The screening questions facilitated conversationsbetween physicians and families regarding weight and sustainable physicalactivity. Families also received activity “tip sheets” and local physical activityresources. Feedback indicated that screening was feasible and physical activityassessment made it easier to address physical inactivity and overweight.Referrals to EFNEP nutrition were perceived as vital. This study suggested thatincorporating physical activity screening questions as part of routine screening inhealthcare settings provides a reliable strategy for encouraging physicians toengage families in essential discussions regarding weight and physical activity.

Clinic PartnershipMaryland EFNEP has a collaborative partnership with CommunityClinics Incorporated (CCI) Health and Wellness Services with theshared goal of reducing childhood obesity in the state of Marylandusing the Policy, Systems, and Environmental (PSE) changeapproach. CCI Clinics are Federally Qualified Health Centers thatserve low income, pediatric patients and their families in the state ofMaryland. The partnership began several years ago because there wasa pressing need among these local safety net clinics to have a place torefer children who were at risk for being overweight or obese. Theclinic staff were too overburdened with patient load to thoroughlyeducate children's families about physical activity and nutrition.EFNEP and CCI decided to partner to provide free nutrition andphysical fitness education programming onsite at the clinics. Aftersuccessfully establishing and implementing a referral program forpediatric patients at-risk for overweight and obesity, EFNEPapproached the CCI senior leadership about developing a pilotproject to incorporate PSE change into the clinical obesity preventionstrategy. CCI and EFNEP collaboratively developed the protocols forsystems change. Funding and IRB approval were received in 2015.All staff were trained extensively in project implementation. Theproject has been underway since the end of 2015.

Who

Partnership between Maryland EFNEP and local safety net clinics. Participants are pediatric patient/parent dyads.

What

Quasi-experimental program to implement Policies, Systems, and Environmental (PSE) approaches to prevent/reduce childhood overweight and obesity in a clinical setting.

Where

Community Clinics Inc. (Federally Qualified Health Centers/Safety net clinics) in Montgomery and Prince George’s counties in Maryland

When

2014-present

Why

Expand the scope of practice and referral system of health care providers working in safety-net clinics which serve limited-income families in order to prevent/reduce childhood overweight and obesity

Adult Questions

1. On average, how many days per week do you engage in moderate or greater physical activity, like a brisk walk?

2. On those days, how many minutes do you engage in activity at this level?

Youth Questions

1. How many hours does your child spend watching television or playing video games each day?

2. On average, how many days per week does your child engage in active play? What kinds of activities does your child enjoy?

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