Identifying barriers and facilitators to improving the implementation of weight management services within a patient-centered medical home

BACKGROUND: The Veterans Affairs (VA) Healthcare System uses Patient-Aligned Care Teams (PACT) as part of its patient-centered medical home model. "Teamlets" often consist of an RN, an LPN, a program assistant, and a PCP who are tasked with screening for obesity, providing brief interventions, counseling patients, and advising eligible patients to attend MOVE!, an intensive weight management program. While every VA hospital has a MOVE! Program to address the high prevalence of overweight and obesity among Veterans, less than 10 % of eligible patients attend even one session. Since Veterans visit PACT 3.6 times per year, there are opportunities to improve counseling and service coordination. A single-center, qualitative research study of healthcare team members assessed attitudes and practices as well as elicited barriers and facilitators to care implementation for overweight and obese patients. METHODS: We recruited healthcare team members for individual key informant interviews using a combination of convenience and snowball sampling. We used a semi-structured interview guide with questions informed by the Theory of Planned Behavior. Interviews lasted 30-60 min and were conducted by a general internist in a private office while a research assistant took field notes. The interviews were audio recorded and transcribed by a transcription company. Research assistants reviewed transcripts to correct mistakes and de-identify content. Analysts then used an iterative and directed coding approach, facilitated by NVivo software and structured by an initial coding guide developed from field notes and recollections. The primary coder segmented and coded each transcript, allowing additional codes to emerge. A second researcher then independently coded each segment. The researchers met frequently to harmonize codes and synthesize themes that emerged from coded transcripts. RESULTS: There were 25 participants in the study (11MDor NP, 5 RN, 2 RD, 5 LPN, 2 Other, with 6 holding an additional managerial role); 80%were female, 48%identified as White, 28 % African American, 16 % Asian, and 8 % Hispanic. Emerging themes included: system constraints, patient barriers, and perceived role responsibility.We found that performance measures and reminders motivate and shape current practices by the PACT teamlets. Barriers to treating patients included time, competing demands, and lack of understanding about what happens in the MOVE! Program. Facilitators included having received training in motivational interviewing (MI) and having a personal interest in nutrition and physical activity. Perceptions about role responsibility varied, with some RNs, LPNs, and MDs perceiving that they play important roles in weight management counseling, while others stated that it was the role of other team members. Similarly, perceived counseling competency varied within and between the different professions. For instance, some RNs and PCPs described in great detail how they used MI to counsel patients around weight, while others questioned whether they had adequate time and training. CONCLUSIONS: These data allowed us to identify several approaches to improve weight management by the PACT teamlets and will inform the design of PACT-based weight management interventions. Findings, however, may be organization-specific, so replication of the study at other sites is necessary to determine common implementation issues.