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By Traci Haynes MSN, RN, BA, CEN, CCCTM

Homelessness in America occurs in every state and has many causes. According to the January 2017 Point-in-Time (PIT) count by the National Alliance to End Homelessness, the most recent national estimate of homelessness in the United States identified 553,742 people experiencing homelessness.

The PIT count is a count of sheltered and unsheltered homeless persons on a single night in January. Like all surveys, the PIT count has limitations. Results are influenced by the weather, availability of overflow shelter beds, the nature of the volunteers, and the level of engagement of the people being interviewed.

Most of this population lives in some form of shelter or transitional housing. However, approximately 35 percent live in places not meant for human habitation. The nature of homelessness makes it difficult to quantify the true size of the homeless population, not to mention the Point-in-Time methodology (although generally acknowledged to be the most accurate way to establish valid trend data).

It is challenging to calculate the exact number of individuals who are homeless, because many live in hidden areas in parks, vehicles, or abandoned houses, and because numbers fluctuate, based on weather.

Health Problems Faced by the Homeless

Homeless individuals are at a relatively high risk for a range of acute and chronic physical and mental illnesses. Some health problems precede and may contribute to homelessness, while others are often a consequence of being homeless. And homelessness complicates treatment of many illnesses.

One example of a health problem that can cause homelessness is a major mental illness, such as schizophrenia. Without therapeutic interventions and supportive housing arrangements, such an individual may become homeless.

Another example is an accidental injury, including job-related injuries. Even with benefits under employer programs, these individuals may experience major economic costs leading to loss of housing.

Diseases of the extremities, skin disorders, malnutrition, degenerative joint diseases, dental and periodontal disease, communicable diseases, and the possibility of trauma are other health problems that may result from, or frequently occur in, the homeless population. Medical care and treatment for acute or chronic illness can be extremely difficult.

Bed rest may be non-existent for a homeless individual who has no bed or only has a bed in a shelter at night. Special diets and medication adherence are impossible to maintain for a person who is homeless.

Contact centers have long been known for assisting their organizations in offering triage, coaching, remote patient monitoring, and care management for an identified population. Some contact centers have also assisted other community agencies or services in filling a need or gap.

Triage Call Centers Can Help Address Health Concerns of the Homeless

So we all know homelessness exists, and it is a tremendous problem, but what does that have to do with triage call centers?

A community triage contact center at EvergreenHealth in Kirkland, Washington implemented a program around 2000, in which they began to offer low-level acuity triage for their regional 911 dispatch centers. The dispatchers would go through their algorithms with the caller, and once they ruled out any emergent or urgent issue, the caller was offered the option of speaking with a nurse. If the caller preferred, she or he could be connected with an appropriate unit or the individual could be transported to the Emergency Department (ED). This program proved a huge success in both caller/patient satisfaction and dollars saved.

A study was published in 2015 for a comparable 911 program in two cities with similar outcomes. Fort Worth, Texas (MedStar) provided nine months of 911 call data, and Louisville, Kentucky (LMEMS) provided thirty-four months of 911 data. The study reported that the 911 program had a significant reduction in callers routed to the Emergency Department (ED) at a cost savings of 1.2 million dollars in payments, as well as a decrease in emergency ambulance transports resulting in a cost savings of 450,000 dollars, and a resultant increase in access to alternative care. Overall, patient satisfaction was 91.2 percent.

As a result of the involvement with the regional 911 dispatch centers, the contact center was asked to become involved with yet another identified need: The growing population of homeless individuals. County shelters and housing facilities for the homeless population needed a resource for individuals with low to moderate acuity symptoms, when medical/nursing personnel were not on site.

The fire department was handling 90,000 incidents per year, which resulted in overuse or misuse of the emergency medical response (EMR) system. And while the county shelters were not the majority of the calls, they were a contributor.

Addressing the Concerns of the Homeless

A very important concern to the homeless individual is whether they will lose their shelter bed for the night, if they are transported. The fire department is not authorized to make a medical diagnosis on the scene, to provide advice or guidance about disease management, to make a referral to other medical resources, such as a primary care doctor, or to provide transportation anywhere except an ED.

The contact center had the system and tools in place to assist the RN with the individual at the county shelter’s assessment and make recommendations of care. “Right care, right place, right time,” which is the fundamental premise of contact center RN triage. Their service provided a much-needed solution to an ongoing gap in care. They currently support five dispatch centers in providing contact center RN triage for thirteen shelters.

The contact center educated the staff at the shelters and facilities. They provided training on when to call 911 (a red flag list), and when to call the contact center’s health line. Each homeless individual received HIPAA information that included “understanding and agreement that a copy of the information discussed during the call interaction would be shared with the residence so that they may further assist the individual with their care.”

The workflow included one number for all facilities to dial into the Healthline contact center. The case manager and the resident had to be available at the time of the call. The RN in the contact center triaged the individual, and then the case manager determined the best non-EMR transportation based on the disposition. The triage note was then faxed to that facility.

Challenges included the individual wishing to remain anonymous, the individual being a vague or poor historian, individuals declining triage or the recommendation, availability of OTC meds, and their psych/social needs.

The Results

Eighteen months after the start of the program, the facility staff was queried, and all were either very or somewhat comfortable in knowing what situations required 911. Over 85 percent of the staff felt the service was very important to the facility.

By far, the majority felt the nurses at Healthline were very knowledgeable (83.33 percent). Beyond 85 percent also felt the nurse line process was easy-to-use, and felt the residents were satisfied with the service. Most of the staff felt very satisfied once the resident had talked with the nurse, and 100 percent indicated the importance of having the service available 24/7, adding that it was practical and helpful to the residents in the facility.

Traci Haynes MSN, RN, BA, CEN, CCCTM is the director, clinical services at LVM Systems, Inc. and has been involved in the contact center industry for over twenty-five years. (Traci thanks Cheryl Patterson, BSN, RNC—TNP, clinical manager—quality and education, Healthline, for her contributions to this article.)

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By Richard D. Stier, MBA

Patient experience failure, the incentivized reduction of avoidable readmissions, increasing rates of physician burnout, and the escalating priority of revenue cycle management, have all combined to incubate an unexpected solution. The patient experience contact center is born. Exit the call center. Discontinue generic transactions.

Enter the era of thoughtfully deployed patient experiences beginning at the first point of contact. In contrast to yesterday’s call centers, which processed physician referrals and class enrollments, today’s patient experience contact centers are a health network’s communications nerve center. They deliver intentionally memorable experiences that strengthen preference, mitigate risk, reduce unnecessary readmissions, serve as physician practice extenders, and solidify patient loyalty.

Patient Experience Failure: Currently healthcare has a 29 percent patient experience failure rate, according to research by Hospital Compare. Only 71 percent of inpatient patients receiving care report that they received the “Best Possible Care.”

In what universe is a 29 percent failure rate acceptable? Could we miss revenue projections by 29 percent? Be over budget by 29 percent? Would it ever be acceptable to miss quality standards by 29 percent? “We only dropped 29 percent of newborns, so we met the standard.” Seriously?

“Best Possible Care” experiences begin before a patient receives care and continues after the patient returns home. Healthcare contact centers are uniquely positioned. They serve as the virtual front door for personalized support and referrals before using a clinical service and for individualized follow-up and coaching after discharge.

With the launch of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program by CMS in 2006, hospitals have dedicated significant time and resources to improving the results of CAHPS surveys. The shift from a transaction-focused call center to an experience-driven contact center is an investment to improve the experience of care beginning at the first touchpoint when someone new to the community calls to request a referral to a primary care physician (PCP), to after discharge when a contact center navigator calls to confirm a follow-up visit with that PCP.

That first touchpoint is critical. According to SHSMD (2012), the first three seconds of that initial interaction influences hospital selection and preference. Whether on the phone or online, healthcare contact centers can intentionally deliver a transformative first patient experience.

Patient experience contact centers respond: A large, backlit sign at the entrance to a leading healthcare contact center boldly proclaims: “We own the patient experience.” At another, team members wear purple t-shirts that announce in large white letters: “I give phone hugs!”

Yet another patient experience contact center conducts their own ongoing patient satisfaction surveys to identify opportunities for improvement before the next CAHPS survey is conducted. By the time the CAHPS results are published, they have proactively improved their scores.

Incentivized Reduction of Avoidable Readmissions: One-half of all hospitals in the United States (2,597) will be penalized by the Centers for Medicare & Medicaid Services (CMS) for unnecessary readmissions in FY 2017. In 2017, penalties will total $528 million, over $100 million more than in FY 2016. During 2016 forty-nine hospitals received the maximum penalty of 3 percent withholding from Medicare funding. A total of 1,621 hospitals have been fined over each of the five years. (Source: HealthStream SUMMIT 2016)

Preventable readmissions represent a substantial portion of unnecessary medical spending. According to data from the Center for Health Information and Analysis (CHIA), the estimated annual cost of this problem for Medicare is $26 billion annually, $17 billion of which is considered avoidable. (Source: Provider Advisor 2016 Volume 2, Issue 2 p 4.)

It’s about to get even harder. For FY 2017, CMS is adding open-heart surgery—a more complex, longer stay procedure—to the list of clinical conditions monitored for avoidable readmissions.

Patient experience contact centers respond: A leading Midwest health network was fined $2.5 million for excessive preventable readmissions. The patient experience contact center became an intentional, centralized source for reducing avoidable readmissions. Here’s what they achieved:

• Readmission rate declined from 25 to 15 percent
• $2.5 million fine from CMS was reduced by $1.9 million over two years
• The contact center asks patients at discharge for permission to contact a family member or caregiver—and store that information in the patient record—to be accessed when it’s time to make certain they are able to get to their follow-up physician appointment. They have raised the kept appointment rate for post-discharge physician visits to 87 percent.

Increasing Physician Burnout: Nine out of ten physicians discourage others from joining the profession. Currently about 300 physicians commit suicide every year. (Source: Daniela Drake, The daily Beast, 2014.)

As many as one in three physicians is suffering from burnout, which is linked to a list of pervasively negative consequences including lower patient satisfaction and care quality, higher medical error rates, greater malpractice risk, higher physician turnover, physician alcohol and drug abuse and addiction, and physician suicide. (Source: Dike Drummond, MD “Stop Physician Burnout”)

Physicians face increasing burdens including the complexities of ICD-10 coding; new billing models; responding to new government regulations; dealing with a changing landscape of health plans; sharing information across the network; inefficiencies of credentialing, provider enrollment and onboarding; documenting quality, cyber security, loss of autonomy, threats from alternative providers; and the “retailization” of primary care.

And, here comes the value-based reimbursement plan for physicians: MACRA (Medicare Access and CHIP Reauthorization Act). Beginning in 2019, physicians will be reimbursed on various performance metrics including quality, advancing care quality, resource use, and clinical practice improvement. According to Deloitte, “Providers are in for a notable awakening when the law takes place in 2017.”

On top of this avalanche of stressors a physician must keep up to date clinically, build practice volume, and improve their patients’ experiences. Are you exhausted yet?

Patient experience contact centers respond: Patient experience contact centers are providing resources to serve as practice extenders: decreasing the burden and filling their practices. One locates a contact center ambassador in each of their emergency departments to capture patients without a PCP, and keep them in network. It has become a gift that keeps on giving with a steady stream of newly aligned patients referred to in-network primary care physicians.

Another built a network of family medicine centers and established a patient experience contact center to fill the practices. Still another focused their contact center on physician-to-physician consults for referring physicians to the health system’s specialists and sub-specialists. They received physician-to-physician referrals from dozens of states and several foreign countries. Annual multimillion-dollar results prompted the organization’s president to declare the contact center as her “secret weapon.”

Several patient experience-focused contact centers now include patient ratings and the comments in online provider directories. The scores and comments about a particular physician from previous patients give prospective patients vital information and increase the likelihood of a good match between patient and provider.

Growing focus on Revenue Cycle Management: The Affordable Care Act (ACA) and Medicaid expansion has created an influx of previously uninsured patients that has left healthcare organizations scrambling to accommodate increased demand while simultaneously experiencing lower margins. Because consumers are assuming greater financial responsibility for their own healthcare, healthcare delivery networks have to shift from a wholesale to a retail environment where they are interacting directly with patients on issues including pricing, billing, and payment. Unfortunately, hospitals and health networks are experiencing a strong correlation between the use of high deductible plans and the amount of bad debt they are incurring. (Source: HealthCare Finance, 2016)

Concurrently, few healthcare organizations have taken the steps necessary to integrate the many information systems that support revenue cycle management. Systems are incompatible across service lines, locations, and functionality. Different software solutions are frequently employed to support disparate functions such as registration, clinical documentation, and billing.

Even worse, some of these functions may be done manually or are only partially automated, making data analysis incomplete or impossible. As the industry migrates toward value-based care, healthcare organizations are entering new collaborations, taking on risk contracts, exploring alternative sources of revenue, and being pressured to document outcomes.

Patient experience contact centers respond: A leading patient experience contact center offers a patient hotline that strengthens patient trust while managing the organization’s revenue cycle. Contact center agents work with patients to understand their best health plan for them to remain in-network, secure financial clearance, and arrange for a deposit prior to the visit.

This organization celebrates “phone hugs” and is shifting the culture from processing transactions to building relationships with patients through transformative, empathetic conversations.

Summary: Patient experience contact centers are a timely response to a myriad of industry pressures. Redeploying a legacy transaction-focused call center as a patient experience contact center can strengthen preference for your organization, mitigate risk, reduce unnecessary readmissions, serve as a physician practice extender, and solidify patient loyalty.

Richard D. Stier, MBA is vice president marketing for Echo – A HealthStream Company. He is a passionate and results-proven proponent of delivering transformative patient experiences.

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The healthcare call center is a vital cog in the strategic success of the health system

By Mark Dwyer

Throughout my thirty years in the healthcare call center industry, I’ve had the pleasure of working with hundreds of quality individuals. Understandably, many have moved on to other roles or retired. Surprisingly though, a good number are still on the job serving as call center managers and call representatives, ten, twenty, and even thirty years later. These dedicated women and men continue to help their local communities connect with necessary healthcare services.

Last month I visited a local call center and ran into a phone representative I had trained on their initial healthcare call center software back in 1993. And she’s not a lone exception. For years, I’ve had the opportunity to watch a number of call centers expand the functions they offer to their communities, while generating additional revenue for their organizations. Today, more than ever, the healthcare call center is not only a nice to have community service but a vital cog in the strategic success of the health system.

My experience last month made me consider how comforting it must be for long-term callers of a local call center to reach out to the same warm, familiar voice with whom they have spoken to for years. And when local patients call the representative, she’s not just another voice on the phone. Instead she’s someone the caller has come to know and trust, someone who is empathetic to her specific needs and engaged in her care.

Over the past three decades, along with personnel changes, health care call centers have undergone many modifications in the communication methodologies used to interact with patients. Now, the once exclusive phone system has been supplemented by emails, text messages, web chats, social media, and more. Interestingly, despite the addition of these new communication methodologies, as recently as five years ago, results continued to show that telephone calls still represented the favored method of interacting with the call center.

Even more interesting, statistics show that speaking over the phone was still the preferred communication tool among adult cell phone owners who use text messaging.

But times are changing. According to a 2014 Workforce Optimization (WFO) market report by DMG Consulting:

• The entrance of Millennials into the workforce is driving overdue changes in how people are managed, including innovations in workforce management solutions.
• Enterprises are finally starting to build multichannel contact centers that handle calls, emails, and SMS, with use of social media expected to grow over the next three to five years.
• Within five to eight years, DMG predicts the number of social media interactions will equal the number of phone calls.

So whether it’s new hardware technologies, product capabilities or communication tools, call centers continue to evolve to remain focused on the importance of enhancing the patient experience. This is more critical now than at any time in our industry’s past. Today, just a few cryptic messages over social media by a disgruntled patient can severely damage the hospital’s or physician’s reputation. Uplifting the patient experience can, and should, be the goal of every call center interaction whether the call is taken by an operator, referral representative, triage nurse, or care coordinator.

Mark Dwyer is chief operations officer at LVM Systems, providers of healthcare call center software.

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By Katie Owens, MHA, and Richard D. Stier MBA

A large, backlight sign at the entrance to a leading healthcare contact center boldly proclaims: “We own the patient experience.” At another, a team member wears a purple t-shirt that announces in large white letters: “I give phone hugs!”

What’s Going On? Exit the call center. Enter the patient experience (PX) hub. Currently, healthcare has a 29 percent patient experience failure rate, according to research by Hospital Compare. Only 71 percent of inpatient patients receiving care report they received the “best possible care.” In order to positively impact outcomes, it is imperative for healthcare leaders to recognize that an “always” experience begins before a patient receives care and continues after the patient returns home.

Healthcare contact centers are uniquely positioned as the virtual front door for personalized support and referrals before using a clinical service and for individualized follow-up and coaching after discharge. In contrast to legacy call centers that process transactions, today’s patient experience hub is the new nerve center of the organization. It delivers intentionally memorable experiences that mitigate risk, reduce unnecessary readmissions, and solidify loyalty.

With the launch of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program by CMS in 2006, hospitals have dedicated significant time and resources to improving the results of CAHPS surveys. Increasingly, improving the effectiveness of a health network’s contact center is viewed as an investment to improve the experience of care. This begins at the first touchpoint where someone new to the community calls for a referral to a primary care physician (PCP). It extends to after discharge when a contact center navigator calls to confirm a follow-up visit with that PCP.

This first touchpoint is critical. According to SHSMD (2012), the first three seconds of that initial interaction influences hospital selection and preference.

What Do Patients Want? CAHPS surveys reveal that effective, two-way patient-centered communication is the key differentiator. Here’s the summary.

• Patients want to be heard.
• Patients want their concerns validated and responded to with respect.
• Patients want to be able to trust those who care for their health.
• Patients need to understand their treatments and be confident that their care is coordinated.
• Patients want to be cared for by engaged employees who make them feel like a top priority. They desire candor and straight talk about what’s going on with them. They want to be assured of responsiveness to ongoing needs.

“Voice of the patient” audio files, recorded with patient permission, provide revealing snapshots of patient perceptions. Here are examples of verbatim patient comments.

Audio transcription #1: “The doctor who did the surgery, his assistant (I guess the nurse), all the nurses that came and worked with me during the night, during my stay, was absolutely fantastic. Each one of them was always smiling and each one of them was always helpful.

“The PT staff that walked with me around the hospital, the staff, the nurse’s staff that I met in the hallway that was always polite and courteous and encouraging. I have never been treated better, and I’ve been in and out of hospitals a lot.

“(This hospital) was absolutely the best place that I have ever received treatment. That’s because of all of the doctors and the nurses and all those that contributed to my care. I just thank you, and God bless you.”

Audio transcription #2: “From beginning to end, it was a totally dissatisfactory performance. They did not register me properly; they did not mail the application information in advance. When I got there, they blamed me that they had mailed it to me. I had to fill out the information while I was there. Even when I gave it to them, the information in the computer was actually information relevant to my father, who had been a patient twenty-six years previously.

“So they had my address listed as his address, which was twenty-six years out of date.

“The actual care that I received was absolutely worthless. The person with whom I spoke had no idea how to respond to any of my questions, and quite frankly, I feel like I know more about sleep apnea than the person to whom I spoke. It was a complete waste of time; I wish I had not gone; and then, finally, I got billed 370 something dollars for the visit. I spoke to somebody for maybe fifteen minutes, and because of insurance, the bill to me ended up being adjusted to $132, which was a total waste of money.”

Delivering What Patients Want: More than eighty-five percent – 85.7 percent of senior healthcare executives surveyed during the first quarter of 2016 – indicate that, “Our organization will be focused on improving patient experience during 2016.” In a separate study, the Deloitte Contact Center Survey found that 62 percent of organizations view customer experience provided through contact centers as a competitive differentiator.

Significant financial consequence secures the priority of improving patient experiences. Based on reports from CMS regarding national healthcare expenditures per capita, the cost of the loss of loyalty – of just one patient deciding not to come back to a specific healthcare organization for the rest of his or her life – could account for $400,000.

By 2020, customer experience will overtake price and product as the key brand differentiator, according to Customer’s 2020 Report. Additional research by The Executive Report on customer experience indicates that 79.7 percent of respondents believe the contact center is involved in defining the customer experience.

FUEL Patient Experiences: The acronym FUEL provides an easy-to-remember guide to enable transformative patient experiences:

Focus Through the Patients’ Eyes: Patient experience (PX) mapping creates a flow chart of every single touchpoint from the patient’s perspective. It identifies all the people, processes, environments, and technologies the patient encounters including call transfers, paperwork, and wait times. PX maps identify how contact centers can strengthen trust and improve handoffs of care.

One leading healthcare contact center conducts their own ongoing patient satisfaction surveys to identify opportunities for improvement before the next CAHPS survey. By the time the CAPHS results are published, they have proactively improved their scores.

Unify Actions With Budgeted Priorities: Contact center PX hubs can choose to support only mission-critical priorities. They can drive physician referrals to the practices of newly employed physicians. They can also serve as a part of the standard of care for reducing preventable readmissions. As reported in the Q2 2016 issue of Provider Advisor, one leading healthcare contact center reduced the organization’s readmission rate by 25 percent, decreased CMS fines by nearly $2 million, and raised the kept appointment rate for post-discharge physician visits to 87 percent.

Energize With Innovation: One organization focused their contact center on physician-to-physician consults for referring physicians to the health system’s specialists and sub-specialists. They received physician-to-physician referrals from dozens of states and several foreign countries. Annual, multi-million dollar results prompted the organization’s president to declare the contact center as her “secret weapon.”

Another organization locates a contact center ambassador in each of their emergency departments to capture patients without a PCP and keep them in network. This initiative that provides a steady stream of newly aligned patients referred to network primary care physicians. Another innovation is the inclusion of patient ratings and comments in online provider directories. The scores and comments about a particular physician from previous patients give prospective patients vital information and increase the likelihood of a good match between patient and provider.

Leverage Technology and Personalize the Experiences: Contact centers can include in the patient record a list of the patient’s health goals for proactive outreach. At discharge they can ask patients for permission to contact a family member or caregiver – and store that information in the patient record – to be accessed when it’s time to make certain they are able to get to their follow-up physician appointment.

One leading healthcare contact center offers a patient hotline that embraces patient trust while managing the organization’s revenue cycle. Contact center agents work with patients to understand their best plan for them to remain in network, secure financial clearance, and arrange for a deposit prior to the visit. That organization celebrates “phone hugs” and is shifting the culture from processing transactions to building trust with patients through transformative, empathetic conversations.

Empower your contact center – your patient experience hub team – to personalize the experiences they provide for callers by thinking carefully through the words they incorporate into their conversations. Ask team members to take the CAHPS survey most closely aligned to the patients they serve. Encourage them to take the survey as a typical patient based on a recent experience they have personally had as a patient. Inquire of each team member:

• what they liked about the survey,
• what was most challenging about the survey, and
• what are three ways the contact center (patient experience hub) can assure the best possible experiences for patients?

Opportunities Await: These examples are a snapshot of the consumer-driven shift that is transforming healthcare contact centers into centralized patient experience hubs. How would your patients benefit from integrating access touchpoints into a patient-centric communications center? How can your organization’s historically generic transactions be replaced with personalized connections that build trust and create loyalty? Perhaps the intersection of contact centers and patient experience is precisely the right destination.

Katie Owens, MHA is vice president and practice leader, HealthStream Engagement Institute.

Richard D. Stier, MBA is vice president marketing Echo, a HealthStream Company.

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By Traci Haynes, MSN, RN, BA, CEN

Obesity is one of the greatest public health challenges of this century. It affects more than 600 million people worldwide. The United States leads the world in the number of obese individuals (Khan, 2016). By 2025, a study in the Lancet estimates 43 percent of women and 45 percent of men in the United States will be obese (Lancet, 2016).

There are many tools used to assess for obesity. They include body mass index (BMI) also known as the Quetelet Index, waist circumference, waist-to-hip ratio (WHR), duel-energy x-ray absorptiometry (DEXA), underwater weighing (hydrostatic weighing), isotope dilution, skin calipers, and bioelectric impedance analysis (BIA). The most commonly used tool is BMI, although there is increased use of waist circumference and WHR because of their significance to certain comorbidities.

BMI is weight divided by height in inches squared. There are graphs to calculate BMI or if Internet access is available, then the two measurements can be typed into a BMI calculator. Results less than 18.5 indicate underweight, while 18.5-24.9 is normal, 25-29.9 is overweight, 30-34.9 is obese level I, 35-39.9 is obese level II, and over 40 is extreme, severe, or morbidly obese. For people with severe obesity, life expectancy is reduced by as much as twenty years in men and by about five years in women. The greater reduction in life expectancy for men is consistent with the higher prevalence of android (abdominal) obesity and the higher percent of body fat in women.

BMI is not a perfect measurement, however. Although it typically correlates closely with percent of body fat, some important caveats apply to its interpretation. In mesomorphic or muscular individuals it is not considered accurate as muscle weighs more than fat. It’s important to note that athletes typically skew higher on their BMI index. Also, in some individuals a typically normal BMI may conceal underlying excess adiposity characterized by an increased percent of fat mass and reduced muscle mass.

WHR is calculated as waist measurement divided by hip measurement. The WHO defines obesity in females as being greater than 0.85 and greater than 0.90 in men. Waist circumference should not exceed 35 inches in women and 40 inches in men. Waist circumference and WHR have been used as an indicator or measure of health and the risk of developing serious health conditions. Research shows that people with “apple-shaped” bodies (more weight around the waist), face more health risks than those with “pear-shaped” bodies who carry more weight around the hips. The WHR has been shown to be a better predictor of mortality in older people than waist circumference or BMI. However, other studies have found waist circumference, not WHR, to be a good indicator of cardiovascular risk factors and hypertension in type 2 diabetes.

Obesity carries a negative connotation in numerous societies because of the emphasis that society places on the importance of physical appearance. As a result, individuals with obesity often face prejudice and discrimination (stigmatization) at work, at school, and in the community. Consequently, they may engage in maladaptive eating patterns, binge-eating behaviors, avoidance of physical activity, and increased calorie consumption.

Stigmatization can also occur in the healthcare setting. Physicians, nurses, and other healthcare professionals have self-reported bias and prejudice against overweight and obese patients. Patients who feel stigmatized are more likely to avoid routine preventive care or they may cancel appointments. They may receive compromised care, or there may be a delay in seeking medical attention, which can lead to delayed discovery or treatment of a comorbid condition.

The Rudd Center for Food Policy and Obesity in association with Yale University developed a toolkit for healthcare professionals to help improve clinical practice. Another resource is the Stop Obesity Alliance, which offers “Why Weight? A Guide to Discussing Obesity & Health With Your Patients.” Appreciating the complexity of this disease is an important prerequisite for productive and positive conversation about weight. More and more resources are available for individuals with obesity. One example is the National Obesity Care Week, which is a collaborative effort of the STOP Obesity Alliance, the American Society for Metabolic and Bariatric Surgery (ASMBS), the Obesity Action Coalition (OAC), and the Obesity Society (TOS).

Now, more than ever, healthcare professionals, policymakers, industry, and patient communities must examine their personal perspectives and biases related to obesity and take action to treat obesity as the serious and complex disease it is. The bad news is 80 percent of all diets fail. Of the 20 percent of dieters who do lose weight, approximately 95 percent regain what they lost (or more). Only 5 percent of dieters who lose weight maintain weight-loss. Many diets are not nutritionally balanced, fast food and convenience foods are readily available, and passive entertainment has become the norm (Kline, D., Goedkoop, S., & Bhimji, S., 2014).

The good news is weight loss will bring added energy and better health. A weight loss of 3 percent will reduce blood glucose levels, while a weight loss of 5-10 percent will begin to lower blood pressure, raise HDL, and diminish sleep apnea. A sustained weight loss results in significant health gains. Losing weight and sustaining weight loss is a challenging balance. The average weight loss for most people is 5 to 15 percent and research shows that weight loss takes longer than expected. It sometimes takes a year or more (Kline, D., Goedkoop, S., & Bhimji, S., 2014).

Treatment includes behavior changes especially related to diet and exercise. Unless an individual acquires new eating and physical activity habits, long-term weight reduction is unlikely to succeed. Behavior therapy includes reinforcement that changing eating and physical activity habits will result in a change in body weight. Patterns of eating and physical activity are learned behaviors and can be modified. To alter these patterns over the long term, the environment must be changed.

Learning self-monitoring, stress management, stimulus control, problem solving, contingency management, and cognitive restructuring, especially in setting specific goals, will result in a greater chance of being accomplished. Evidence from the National Weight Control Registry (NWCR), which tracks indices and predictors in individuals who have lost at least thirty pounds and have maintained weight loss for at least one year suggests that patterns associated with successful weight maintenance include self-monitoring of weight, consumption of a low-fat diet, daily physical activity of approximately sixty minutes, minimal sedentary “screen time,” and consumption of most meals at home (NWCR, 2015).

Beyond changing eating habits and increasing physical activity is becoming educated about the body and how to nourish it appropriately, engaging in a support group or extracurricular activity, and setting realistic goals. Individuals who are more actively involved in their healthcare experience have better health outcomes and incur lower costs. This requires educating individuals about their condition and involving them more fully in making decisions about their care, engagement, and activation.

There are numerous diets available. However, it is important to note that many diets don’t provide adequate nutrition. An excellent source for assessing the myriad of diets is available from WebMD. The best way to lose weight and keep it off is a commitment to a lifelong process of proper diet and regular exercise. A diet should include all of the recommended daily allowances (RDAs) for vitamins, minerals, and protein. It should contain plenty of water and fiber and be low in calories. A weight loss program should be directed toward a slow, steady weight loss and include plans for weight maintenance after the weight loss phase is over.

One pound is equal to 3500 calories. Therefore, an individual has to burn 3500 calories more than they consume to lose one pound. Current guidelines recommend lowering energy intake by 500-1000 kcal per day to achieve a weight loss of one to two pounds per week (Goldsmith, C. & Lehrman, S., 2014). Paying attention to the energy value of different foods is essential. Energy dense foods generally have a high caloric value in a small amount of food, while low energy dense foods contain relatively few calories per unit of weight or fewer calories in a large amount of food. Examples of high-energy dense foods include foods that contain animal fats, fried foods, fast foods, sweets, butter, and high-fat salad dressings. Low energy dense food includes vegetables, fruits, lean meat, fish, grains, and beans. It is important to keep in mind portion control and portion distortion and how it has dramatically changed over the years contributing to this disease.

Recommendations for physical activity include at least thirty minutes of moderate-intensity aerobic activity at least five days per week for a total of 150 minutes. Or at least twenty-five minutes of vigorous aerobic activity three days per week for a total of seventy-five minutes. Or a combination of moderate- and vigorous-intensity aerobic activity and moderate- to high-intensity muscle-strengthening activity at least two days per week for additional health benefits.

For lowering blood pressure and cholesterol, an average of forty minutes of moderate- to vigorous-intensity aerobic activity three or four times per week is recommended. Benefits of exercise include improved blood sugar control, increased insulin sensitivity (decreased insulin resistance), reduced triglyceride levels, increased HDL levels, lowered blood pressure, reduction in abdominal fat, reduced risk of heart disease, and release of endorphins (AHA, 2015).

Treatment may involve the addition of medications or ultimately surgery. Medications may amplify adherence to behavior change and may improve physical functioning or make increased physical activity easier in those who cannot exercise initially. However, they are only used in individuals who have health risks related to obesity and only used as an adjunct to dietary modifications and an exercise program.

If an individual’s response to weight loss medications is deemed effective (a weight loss of greater than or equal to 5 percent of body weight at three months) and safe, it is recommended that the medication be continued. If deemed ineffective, or if there are safety or tolerability issues, it is recommended that it is discontinued.

Medicare does not cover medications for obesity, nor do most other insurers. Currently, the three major groups of medications to manage obesity are: 1) centrally acting medications that impair dietary intake; 2) medications that act peripherally to impair dietary absorption; and 3) medications that increase energy expenditure. There are medications that cause weight loss as a side effect and include a diabetic medication an anti-depressive medication and an anti-seizure medication (Endocrinology Advisor, 2015).

Weight loss surgery, known as bariatric surgery, is recommended for people who have clinically severe obesity and have failed to lose weight through diet and exercise. It is recommended for people with a BMI of 40 or greater or BMI over 35 with a serious health problem linked to obesity, men who are one hundred pounds overweight and women who are eighty pounds or more overweight. Weight loss surgery provides clinically significant and relatively sustained weight loss in individuals with severe obesity associated with comorbidities. However, it is expensive, highly procedure, and surgeon specific and not the solution for the growing obesity epidemic.

Emerging research suggests that some complementary and alternative medicine (CAM) therapies may help manage obesity-related conditions. More can be found at The National Center for Complementary and Alternative Medicine’s website, which is part of the National Institutes of Health (NIH).

The disease of obesity is recognized as a growing epidemic, and there is a tremendous amount of research being conducted for the population affected. Building awareness of the disease has also contributed to support groups, coalitions, an increase in educational resources, and health coaching.

Care delivery through an integrated mix of healthcare providers and practitioners, such as physicians, nurses, and dietitians, could play an effective role in combatting obesity and its related chronic diseases. Having a health coach that has knowledge of this disease, its etiology, and contributing factors as well as associated comorbidities, an understanding of stigmatization and bias, past behaviors and those behaviors necessary for change can engage and activate the individuals with obesity and make an enormous impact on helping them to achieve and maintain change for a healthier lifestyle.

A health coach can also provide resources of all types, such as support groups, social services, referrals, and educational documents. A key part of health coaching is utilizing motivational coaching techniques in seeking to understand the person’s frame of reference. The objective is not to solve the individual’s problem but to help them begin to believe change is possible. Techniques are designed to help motivate the individual in a collaborative nature, understand their perspective, and assist them in finding their own solutions, while affirming the freedom to change, thereby allowing them to discover their own motivation.

Having a software solution that provides the framework for coaching interactions and allows the frequency of contact specific to the individual’s needs is one approach in care delivery. It should also include comorbidity coaching, health information, referral capabilities, and a mechanism to set goals and follow-up on these goals, outcome reporting including adherence, and follow-up letters to both the patient and their providers.

The prevalence of obesity continues to grow in the US and worldwide. It affects everyone in some way, but most profoundly affects those with the disease. Interventions are necessary to help control and reverse this epidemic. Health coaching is one way in which to facilitate ongoing interventions with the individuals whom so desperately need clinician oversight.

Traci Haynes, MSN, RN, BA, CEN, is the director, clinical services at LVM Systems, Inc.

[Part 1 of this article was in the April/May issue of AnswerStat.]

References

• American Heart Association (AHA). (2015). American heart association recommendations for physical activity in adults.
• Endocrinology Advisor (2015). Guidelines on pharmacological management of obesity released.
• Goldsmith, C. & Lehrman, S. (2014). Weight management: Facts not fads. com. 27(8), 44-49.
• Khan, A. (2016). America tops list of 10 most obese countries. US News & World Report.
• Kline, D.A., Goedkoop, S., & Bhimji, S. (2014) Regulation of body weight. com. 27(7), 42-47.
• National Weight Control Registry (NWCR). (2015).
• Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis of 1698 population-based measurement studies with 19.2 million participants. The Lancet 387(10026), 1377-1396.

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