CHRONIC CARE MANAGEMENT PLAN

OBESITY OVERVIEW

Obesity is a complex, multifactorial condition in which excess body fat
may put a person at health risk. Basic treatment of overweight and obese
patients requires a comprehensive approach involving diet and nutrition,
regular physical activity, and behavioral change, with an emphasis on
long term weight management rather that short term extreme weight
reduction. Obese persons have a greater mortality risk, compared with
non-obese persons. In particular, obesity increases the risk of multiple
co-morbid medical conditions, including hypertension, dyslipidemia,
coronary artery disease, type 2 diabetes via insulin resistance,
gallbladder disease, sleep apnea, osteoarthritis and various forms of
cancer. Obesity often affects self-esteem, self-confidence and emotional
health. Obesity via all of these health risks may affect employability.

**Diagnosis:**

Obesity is defined as a body mass index (BMI = weight in kilograms
divided by height in meters squared), but if weight is measured in
pounds and inches, the BMI is calculated as \[weight (in pounds)/height
(in inches)^2^\] multiplied by 703 (conversion factor).

-   A BMI of 25.0 to 29.9 kg per m^2^ is defined as overweight.

-   There are three classes of obesity severity:

-   Class I (BMI of 30.0 to 34.9 kg per m^2^),

-   Class II (BMI of 35.0 to 39.9 kg per m2) and

-   Class III (BMI of equal to or greater than 40.0 kg per m^2^)

**Plan:**

Successful management of the overweight and obese student involves
multiple treatment strategies, most focusing on modification of the
student's lifestyle (e.g., diet and physical activity habits).

Behavior modification techniques include:

-   Self-monitoring with stimulus control and avoiding triggers for
    unhealthy food choices, which may mean avoiding the desert tray with
    baked pies and cakes and sticking to fruit or jello

-   Portion control with less food on the plate with discouraging second
    helpings where ½ of the plate should be fruits and vegetables with ¼
    of the plate lean meat/protein source (1/4 starch or carbohydrate if
    desired)

-   Stress management that encourages exercise activities; remind them
    that motion/activity produces weight loss and promotes energy

-   Social support for weight management and the buddy exercise system
    are also an integral part of intervention.

-   Replace calorie-dense fried food choices with lower calorie/ lower
    fat substitutes.

-   Work with the food services manager at your center to provide
    healthier menu options on a daily basis

-   Offer students non-food incentives that participate in this program
    such as fun filled field trips (allow students to suggest what they
    would like to do) to help motivate them.

-   Many students may need to start with very small steps. With these
    students, the importance of avoidance of weight gain should also be
    stressed. Weight loss goals can be introduced gradually.

-   Aim for a weight reduction of 1 to 2 pounds per week. Remind
    students that a weight reduction program that is gradual and
    sensible is more likely to be sustainable and long-lasting.

-   Educate students that health and weight issues affect employability

**Pre-arrival Activities:**

-   Review height and weight and calculate BMI when possible.

> Note: this information may not be available unless the student has
> other co-morbid disorders such as asthma, hypertension, sleep apnea,
> diabetes type 2 or a musculoskeletal disorder.

-   When possible, obtain previous weight and pattern of weight status
    (weight gain vs. weight loss) over time.

**Upon Arrival on Center:**

-   During admission physical, obtain accurate height, weight and
    calculate BMI. Students who are noted to fall within any category of
    overweight or obesity should be offered help in managing their
    weight.

-   They should return for a scheduled follow-up session to discuss
    weight loss/weight management.

-   Diet preferences, triggers to overeating, a history of eating
    disorders (anorexia or bulimia), weight history including weight
    loss attempts in the past, drug and/or alcohol use, health history
    of co-morbid disorders (such as asthma, hypertension, diabetes,
    sleep apnea, etc), and emotional/ psychological disorders (such as
    depression, anxiety, bipolar disorder) should be assessed and
    treated.

-   Concurrent symptoms (shortness of breath, chest pain, and decreased
    exercise tolerance) that may occur with exercise should also be
    assessed.

**Documentation of CCMP Implementation:**

-   In addition to appropriate entries on the chronic problem list, the
    progress note should annotate all on-going care and interaction.

-   An Obesity Management flow sheet can be used to document ongoing
    care (see sample).

-   Student weigh-in frequency may occur weekly, bi-weekly or monthly at
    times and frequencies agreed upon and convenient for student and
    staff.

**Transition to Employability/Community:**

-   A post-weight and BMI assessment should occur and be recorded prior
    to separation from Job Corps.

-   Students should be encouraged to continue lifestyle changes that
    have helped them to manage their weight loss.

-   A copy of the flow sheet may be given to the student as a reminder
    of progress and success.

**References:**

"Successful Management of the Obese Patient" American Family Physician
Vol. 61/No. 12 June 15, 2000

"Obesity: Assessment and Management in Primary Care" American Family
Physician Vol. 63/No. 11 June1, 2001

CHRONIC CARE MANAGEMENT PLAN

### OBESITY

#### OUTREACH AND ADMISSIONS PERIOD

Please provide us with the following information.

1.  Date of diagnosis:

2.  Age of onset: Severity:

3.  List current medications and/or treatment including dosage and
    frequency prescribed.

4.  Has applicant been compliant with medications and treatment? If no,
    please explain.

5.  List past hospitalizations for co-morbid conditions including dates,
    reason for admission and discharge summary.

# 

6.  What is current status and prognosis for co-morbid conditions?

7.  Will the applicant need to continue follow up under your care? If
    yes, please list the date and/or frequency of follow up
    appointments.

8.  In your opinion, will the applicant be able to self-manage his
    medications unsupervised and participate in a vocational training
    program. If no, please explain.

9.  In your opinion, will the applicant be appropriate to reside in a
    dormitory style residence with minimal supervision? If no, please
    explain.

10. What is the applicant's current regimen of diet and exercise?

11. Is there an anticipated need for bariatric surgery?

12. What is the applicant's smoking history?

##  

## Does the applicant use hormonal contraception? (females only)

## 

## Does the applicant have health insurance documentation?

Please sign below and return the form in the attached addressed
envelope.

####### Print Name and Title Signature

**Phone Date**

> For any questions, please call

### Admission Counselor/Health and Wellness Staff 

##### Phone

CHRONIC CARE MANAGEMENT PLAN

### OBESITY

**Goals:**

1.  Enhance employability by optimizing weight management.

2.  Educate the student regarding self-management.

3.  Reduce the likelihood of long-term complications.

4.  Optimize therapy with diet and exercise.

5.  Implement regularly scheduled follow-up visits.

+----+----+------------------------------------------------------------+
| #  |    |                                                            |
|  * |    |                                                            |
| *C |    |                                                            |
| AR |    |                                                            |
| EE |    |                                                            |
| R  |    |                                                            |
| PR |    |                                                            |
| EP |    |                                                            |
| AR |    |                                                            |
| AT |    |                                                            |
| IO |    |                                                            |
| N  |    |                                                            |
| PE |    |                                                            |
| RI |    |                                                            |
| OD |    |                                                            |
| ** |    |                                                            |
+----+----+------------------------------------------------------------+
| #  | #  | #                                                          |
|  * | ** |                                                            |
| *Y | NO |                                                            |
| ES | ** |                                                            |
| ** |    |                                                            |
+----+----+------------------------------------------------------------+
| #  | #  | # Establish an obesity action                              |
|    |    | plan for obese students defines as BMI [\>]{.underline} 30 |
+----+----+------------------------------------------------------------+
| #  | #  | # Weekly                                                   |
|    |    | visits initially when engaged in weight management program |
+----+----+------------------------------------------------------------+
| #  | #  | # Visits every 2-3 months for monitoring if not engaged    |
+----+----+------------------------------------------------------------+
| #  | #  | # Assess vocational training match                         |
+----+----+------------------------------------------------------------+
| #  | #  | # Mandatory TUPP/smoking cessation enrollment              |
+----+----+------------------------------------------------------------+
| #  | #  | # Annual influenza vaccination in October or November      |
+----+----+------------------------------------------------------------+
| #  | #  | # Emergency response plan                                  |
+----+----+------------------------------------------------------------+
| #  | #  | #                                                          |
|    |    | **Educate student about potential obesity complications**  |
|    |    |                                                            |
|    |    | ## Ca                                                      |
|    |    | rdiovascular (hypertension, hyperlipidemia, cor pulmonale) |
|    |    |                                                            |
|    |    | ## Diabetes mellitus, type 2                               |
|    |    |                                                            |
|    |    | ## Pulmonary (sleep apnea)                                 |
|    |    |                                                            |
|    |    | ## Liver (steatohepatitis)                                 |
|    |    |                                                            |
|    |    | ## Gallbladder (gallstones)                                |
|    |    |                                                            |
|    |    | ## Reproductive (PCOS)                                     |
|    |    |                                                            |
|    |    | ## Orthopedic (SCFE)                                       |
|    |    |                                                            |
|    |    | ## Skin (acanthosis Nigricans, striae)                     |
|    |    |                                                            |
|    |    | ## CNS (pseudotumor cerebri)                               |
|    |    |                                                            |
|    |    | # Psychosocial/quality-of-life issues                      |
+----+----+------------------------------------------------------------+
| #  | #  | # **Educate student about lifestyle choices**              |
|    |    |                                                            |
|    |    | ## Weight management                                       |
|    |    |                                                            |
|    |    | ## Encoura                                                 |
|    |    | ge whole fruits, vegetables, low fat milk, increased fiber |
|    |    |                                                            |
|    |    | ## Avoid soda and fruit juices                             |
|    |    |                                                            |
|    |    | -   Encourage aerobic physical activity (exercise 30       |
|    |    |     minutes per day, 5 days per week)                      |
|    |    |                                                            |
|    |    | ## Avoid sedentary lifestyle (limit TV)                    |
|    |    |                                                            |
|    |    | # Avoid smoking                                            |
|    |    |                                                            |
|    |    | # Limit alcohol use                                        |
+----+----+------------------------------------------------------------+
| #  | #  | ###### Educat                                              |
|    |    | e student on weight management as it relates to employment |
+----+----+------------------------------------------------------------+
| #  | #  | ###### Encourage parti                                     |
|    |    | cipation in a weight management program (on or off center) |
+----+----+------------------------------------------------------------+
| #  |    |                                                            |
|  * |    |                                                            |
| *C |    |                                                            |
| AR |    |                                                            |
| EE |    |                                                            |
| R  |    |                                                            |
| DE |    |                                                            |
| VE |    |                                                            |
| LO |    |                                                            |
| PM |    |                                                            |
| EN |    |                                                            |
| T  |    |                                                            |
| PE |    |                                                            |
| RI |    |                                                            |
| OD |    |                                                            |
| ** |    |                                                            |
+----+----+------------------------------------------------------------+
| #  | #  | # **Monitor adherence issues**                             |
|    |    |                                                            |
|    |    | # Medication regimen                                       |
|    |    |                                                            |
|    |    | ## Medication refills                                      |
|    |    |                                                            |
|    |    | ## Routine medical care                                    |
|    |    |                                                            |
|    |    | ## Urgent medical care                                     |
|    |    |                                                            |
|    |    | ## Environmental control                                   |
|    |    |                                                            |
|    |    | ## Self-monitoring                                         |
|    |    |                                                            |
|    |    | ## Physiotherapy                                           |
|    |    |                                                            |
|    |    | ## Rest                                                    |
|    |    |                                                            |
|    |    | ## Exercise                                                |
|    |    |                                                            |
|    |    | ## Nutrition                                               |
|    |    |                                                            |
|    |    | ## Tobacco, alcohol, drug use                              |
+----+----+------------------------------------------------------------+
| #  |    |                                                            |
| ** |    |                                                            |
| CA |    |                                                            |
| RE |    |                                                            |
| ER |    |                                                            |
|  T |    |                                                            |
| RA |    |                                                            |
| NS |    |                                                            |
| IT |    |                                                            |
| IO |    |                                                            |
| N  |    |                                                            |
| PE |    |                                                            |
| RI |    |                                                            |
| OD |    |                                                            |
| ** |    |                                                            |
+----+----+------------------------------------------------------------+
| #  | #  | # Conduct a Wellness Center exit in                        |
|    |    | terview approximately two weeks before program completion. |
+----+----+------------------------------------------------------------+
| #  | #  | # Identify potential sources of primary health             |
|    |    | care, and specialty care if needed, in the work community. |
+----+----+------------------------------------------------------------+
| #  | #  | # Obtain signed HIPAA authorizations for the transfer of s |
|    |    | tudent health records to identified health care providers. |
+----+----+------------------------------------------------------------+
| #  | #  | # Assist the student in enrolling or maintaining e         |
|    |    | nrollment in a public or private health insurance program. |
+----+----+------------------------------------------------------------+
| #  | #  | # Provide the student with a c                             |
|    |    | opy of the SF-93, SF-88, immunization records, and a copy  |
|    |    | of the chronic care management plan, including flowsheets. |
+----+----+------------------------------------------------------------+
| #  | #  | # Provide the student with an a                            |
|    |    | dequate amount of medication(s) and supplies at departure. |
+----+----+------------------------------------------------------------+

# 

# 

# **Barriers to Weight Management**

## Lack of access to healthy food choices

## Inadequate knowledge of the health consequences of obesity

## Lack of cultural emphasis on healthy eating

## Lack of access to exercise facilities 

## Inadequate knowledge of the health benefits of physical activity

## Low levels of peer support and time to exercise

# 

# **Promising Practices**

## Weight improvement programs

## Nutrition education

-   Partner with Food Services staff\-- Gather student input on foods
    offered in the cafeteria through tasting parties, surveys, and
    informal conversation; Allow student preferences to guide the menu,
    while ensuring the food is nutrient-rich

## Survey students on physical activity preferences and implement these preferences

## "Heart Healthy" logo on food choices

## Exercise classes offered [\>]{.underline} 3 times weekly

## Involvement of personal trainers and registered dietitians

## Involvement of center staff

## Student incentives

-   Make learning about nutrition fun through strategies such as playing
    games, hosting a cooking club, or through fieldtrips to grocery
    stores

-   Teamwork on centers. Students who are interested in weight
    management can benefit from the involvement of health staff,
    recreation staff, food service staff, RA's and instructors.

# 

# **Principles of Weight Management**

## "Eat different, not significantly less"; change the way your plate looks: think of a plate in four sections and try a plate with ½ fruit and vegetables with ¼ lean meat/protein, ¼ starch/carbohydrate if desired 

## Three meals, including breakfast!

## Scheduled, healthy snacks.

## Fruit, vegetable and fiber-rich foods

## Limited calorie-dense foods

## Increase time and intensity of physical activity

## Decrease sedentary activity

## Establish social support/reinforcement

**See Obesity Flow Sheet to track student progress.**

**CHRONIC CARE MANAGEMENT PLAN FLOWSHEET**

OBESITY

+-------------+-----+---+-----+-------------+-------------+-------------+
| ### St      |     |   |     |             |             |             |
| udent Name: |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| ###         |     | # |     |             | ### Dat     |             |
| Sex: M or F |     | # |     |             | e of Entry: |             |
|             |     | # |     |             |             |             |
|             |     |   |     |             |             |             |
|             |     | D |     |             |             |             |
|             |     | a |     |             |             |             |
|             |     | t |     |             |             |             |
|             |     | e |     |             |             |             |
|             |     |   |     |             |             |             |
|             |     | o |     |             |             |             |
|             |     | f |     |             |             |             |
|             |     |   |     |             |             |             |
|             |     | B |     |             |             |             |
|             |     | i |     |             |             |             |
|             |     | r |     |             |             |             |
|             |     | t |     |             |             |             |
|             |     | h |     |             |             |             |
|             |     | : |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| ###         |     |   |     |             |             |             |
|  Co-Morbid  |     |   |     |             |             |             |
| Conditions: |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| ### Me      |     |   |     |             |             |             |
| dications:  |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| Height:     |     |   |     |             | ### Init    |             |
|             |     |   |     |             | ial Weight: |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| Initial     |     |   | G   |             | ### G       |             |
| BMI:        |     |   | oal |             | oal Weight: |             |
|             |     |   | B   |             |             |             |
|             |     |   | MI: |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| ### W       |     |   |     |             |             |             |
| eigh-in Fre |     |   |     |             |             |             |
| quency: Wee |     |   |     |             |             |             |
| kly Monthly |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
| Date        | ### |   |     | ### Weight  | ### We      | ### BMI     |
|             |  Bl |   |     |             | ight Change |             |
|             | ood |   |     |             |             |             |
|             |     |   |     |             | +/-         |             |
|             | ### |   |     |             |             |             |
|             |  Pr |   |     |             |             |             |
|             | ess |   |     |             |             |             |
|             | ure |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+
|             |     |   |     |             |             |             |
+-------------+-----+---+-----+-------------+-------------+-------------+

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