For the past five years, VA has struggled to implement a systemwide weight-reduction program to combat obesity rates among veterans receiving care. More than one-third of veterans receiving care qualified as obese in 2006, and VA believed that lowering obesity also would lower weight-related illness, including diabetes, cardiovascular disease, osteoarthritis and hypertension — all of which occur in high rates among VA’s population. 1
A recent evaluation of VA’s efforts shows only modest effects. However, that may be due to a number of institutional barriers that have made implementation move slowly in most VA medical centers (VAMCs).
VA designed the evidence-based weight-management program (MOVE) and began rolling it out in 2007. By 2009, nearly all of the 155 VAMCs reported having MOVE programs in place. A recent evaluation of the program by the division of VA that created it — the National Center for Health Promotion and Disease Prevention (NCP) — found only modest weight loss after six months of use and implementation coming in fits and starts at many VAMCs.
NCP researchers looked at 10 medical facilities with MOVE programs in place. They discovered barriers that differed from facility to facility.
All facilities either had an existing weight-management program or had participated in the pilot phase of MOVE before issuance of VA policy. According to the researchers, all of the facilities knew that the VA central office soon would hold them accountable for their obesity-screening rates — a key factor leading to increased demand for MOVE treatment.
However, pre-existing weight-management programs at three facilities provided limited preparation for MOVE, because they focused primarily on healthful eating and offered only group education. In one facility, previous programs were perceived as failures, which undermined organizational readiness. Even with pilot-phase experience, two facilities struggled to offer the full range of tiered-treatment options.
Delaying accountability for obesity screening gave facilities time to implement MOVE. However, the delay had the unintended effect of reducing the sense of urgency during the interim period, leading to slower than desired MOVE implementation at at least two facilities.
At two facilities, obesity-screening rates were added to an already long list of performance indicators, which may have diluted the motivational effect of such accountability.
Support among senior management was not consistent, researchers found. In some facilities, management did not begin allocating new resources to the MOVE program until the facility had to become accountable for their obesity-screening rates.
Support among service-line chiefs also was sporadic. According to VA staff interviewed, the attitude of service-line chiefs ranged from support to passive acceptance to skepticism.
All 10 facilities attempted to tailor MOVE to better fit their organization. These modifications included adding or removing clinical reminders for obesity screening, tailoring procedures for enrolling patients and offering various levels of the MOVE program at a facility. Eight facilities noted that primary-care nurses and physicians felt that tasks associated with MOVE, such as the clinical reminder to screen for obesity or attending multidisciplinary meetings, were time consuming and burdensome to already heavy workloads. Two facilities decided to remove the clinical reminder altogether.
The NCP researchers concluded that organizational readiness for change and having a champion for innovation were the two factors most consistent with the success of MOVE implementation. However, they noted that 10 cases do not prove for a strong database.
They suggest two directions for future research. Research needs to be done on the multilayered complexities of management support and how it impacts change at facilities, and how informal innovation champions — those who step outside of their organizationally prescribed roles — help make innovations successful.
MOVE Program Testimonial:
1.Kuwait LC, Lewis MA, Kane H, Williams PA, Nerz P, Jones KR, Lance TX, Vaisey S, Kinsinger LS. Best practices in the Veterans Health Administration’s MOVE! Weight management program. Am J Prev Med. 2011 Nov;41(5):457-64. PubMed PMID: 22011415.
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