# Presentation: 830543

## Evaluating Adoption and Implementation of the FLAIR Intervention

- M. Diane McKee, MD, MS
- New York City Research and Improvement Group

## Our Team

- M. Diane McKee, MD, MS
- Darwin Deen, MD,MS
- Alice Fornari, RD,PhD
- Arthur Blank, PhD
- Stacia Maher, MPH
- Irina Polanco, MA
- Patricia Lopez, MA
- Adelyn Alvarez, MA
- Jason Fletcher, MA

- Jean Burg, MD
- Robert Clarick, MD
- Staff and clinicians too numerous to mention

## Prescription for Health

- Developing creative, practical strategies for promoting healthy behaviors among primary care patients, targeting
- Lack of physical activity
- Unhealthy diet
- Tobacco use
- Risky alcohol use

## Pediatric Obesity in the Urban Context

- 1.3 million people reside in the Bronx
- 7% below the age of 5
-  32% African-American, 34% Hispanic
- 80 % sedentary; 75% eat few fruits and vegetables, 29% are obese
- In NYC 43% of elementary public school children are obese (24%) or overweight (19%)*

- Thorpe *Am J Public Health* 2004

**Notes:**
In urban poor communities, Hispanic children are 3 times as likely to be overweight at age 3 than white or black children.
[Whitaker RC, Orzol SM. Obesity among US urban preschool children. Arch Pediatr Adolesc Med 2006;160:578-84.]

## The FLAIR Intervention

**Reframe preventive visits for 2-4 year olds to focus on family lifestyle risk assessment**
- Enhance screening for behaviors associated with pediatric (and adult) obesity
- Deliver brief behavior change messages from clinicians for identified behaviors
- Increase visit frequency to address additional behaviors
- Referral to lifestyle counselors to augment clinicians’ efforts

## Research Questions

- Can 2-4 year old check-up visits be successfully reframed to assess risk and initiate counseling for behavior change?
- Can an intervention based on family lifestyle risk assessment change behaviors (for adults and children) that place families at risk?

## FLAIR Tools

- Pre-Visit Screener
- Parental ht/wt
- Family history
- Behaviors associated with pediatric obesity and tobacco exposure
- Goal Setting Action Plan
- Follow-up Forms
- Educational Materials

## Project Characteristics

- Training: workshop and refresher sessions with clinicians at each intervention site
- Brief behavior change counseling
- Use of new screening and chart documentation tools
- Introduction of screener as routine part of health maintenance visits
- Health educator 1 session per week at each practice

## Expected Outcomes

- Learn from practices how to incorporate activities into practices
- Providers can engage families to change behaviors
- 2 year old visit “salient” to families
- Families will participate in follow-up activities
- Change number of contacts focused on behavior change
- Some behavior change (how much?)

## Adoption

*Proportion of intervention agents delivering intervention components*
- Training						√
- Incorporation of health educator		√
- Rooming staff tasks				?
- Physician counseling				√
- Referrals to health educator			√

## Physician Counseling and Referrals

- Goal setting and referrals to lifestyle counselors from what proportion of docs at each site?
-  **Overall****	****	****16/17**
-  Site 1	 	6/7
-  Site 4		8/8
-  Site 5 	 	2/2

## Implementation

*Consistency of delivery of elements of the intervention protocol*
- Screener completion
- Goal setting
- Referral to health educator
- Counseling by health educator

## Implementation

- Screener completion (n=313)
- Determined by chart review
- Visits 12/05 - 3/07
- 			 _of 1224 visits__	__of  825 WCC visits_
**Overall****	****	****      26%****	****       31%**
-  Site 1		      30%	       36%
-  Site 4		      22%	       28%
-  Site 5		      25%	       30%

## Implementation

- Goal Setting (n=195)
- _	__	__	_	   of _all visits__	_	_of screened_
-  **Overall****	****	****18%****	****	****   61%**
-  Site 1			22%		   61%
-  Site 4			20%		   79%
-  Site 5			14%		   48%

## Implementation

- Referrals to lifestyle counselor
- 			_n_	    	_% screened__	__	_
**Overall****	****175****	****	****55% (175/313)**
- Site 1	58		56%
- Site 4	61		68%
- Site 5	56		45%
- Counseling (at least 1) with lifestyle counselor
- 			_n_	_% of referred_	_in-person__	__phone_
- 	 **Overall****	****122**	**69%****	****	****68 (55%)****	****54 (44%)**
- Site 1	39	67%		13 (33%)	26 (66%)
- Site 4	39	63%		16 (41%)	23 (58%)
- Site 5	44	78%		39 (88%)	5 (11%)

## What does it mean?

- Response to initial screen
- Providers worry about time; focus on information
- Staff feel it is important and overall get it
- Most families don’t mind and actually value attention to diet; see the screener as a way to get diet on the clinician’s agenda
- Goal setting
- Many providers see process as focused on “education” and a means to an end (referral to HE)
- Some providers lack commitment to preventive approach

## What does it mean?

- Families willingness to engage with counseling
- Show rate for visits with health educator poor; persistence and flexibility paid off
- Phone contacts well received
- Very positive feedback about counseling sessions
- Better for nutrition than sedentary activity
- Large amount of counseling for difficulties with work, partner, raising children

## Challenges to Overcome

- Intervention never fully owned by the staff
- Too little presence of the health educator
- Physician orientation towards treatment rather than prevention
- Keeping messages positive; avoid suggestion of poor parenting