The Agency for Healthcare Research and Quality (AHRQ) has created the AHRQ Health Care Innovations Exchange,  this is the link to the exchange:  http://www.innovations.ahrq.gov/. AHRQ explains the goal of the exchange: The Innovations Exchange helps you solve problems, improve health care quality, and reduce disparities.

• Find evidence-based innovations and QualityTools.
• View new innovations and tools published biweekly.
• Learn from experts through events and articles.

There are presently over 500 innovation s and quality tools published by AHRQ.  There is a rigorous application process to have an innovation accepted and then professional writers prepare the description of the innovation for publication on the Exchange.

AHRQ has accepted SETMA's LESS Initiative for publication on the Innovation Exchange.  It will be three weeks are so before it is published.  On May 31st, I had a 75 minute conference call to discuss the LESS Initiative with the AHRQ writers who are preparing the posting on the LESS Initiative. 

What is the LESS Initiative?

LESS stands for:

L -- Lose weight
E -- Exercise
S -- Stop
S -- Smoking

While no one would argue that each of these is valuable in anyone's life or health, to our knowledge, there has never been a concentrated effort to confront an entire patient group with all three elements consistently every time they seek healthcare. And, to address these three in a single patient is simply, but how do you consistently address these issues in over 500 patient visits a day and in five different clinic settings?

Here's how the Initiative works. Every time a patient is seen in the clinic, no matter what the occasion for the visit is, they will be alerted to the health risk of:

• Their current weight , as measured by their body mass index (BMI) and their body fat content. In the LESS Initiative, each patient will be given a Weight Management Assessment which tells them their BMI and the disease risk associated with their current BMI and waist measurement. They are given their percent body fat and an explanation as to how a 5% to 10% change in their body fat will impact their health and future.
• Their current level of activity. The benefit which their heart and lungs are receiving from their current participation in exercise as indicated by the "aerobic points." The patient is given the level of aerobic fitness which that exercise achieves for them, i.e., fair, good, excellent, etc., and the patient is given a recommend minimum exercise level which they need in order to achieve a "good" aerobic status for their age and sex. This exercise prescription will include information on how to increase the number of steps they take each day in order to have an "active" lifestyle which is defined by taking 10,000 or more steps a day. The average America takes fewer than 6,000.
• The imperative for stopping smoking . Even the tobacco companies' websites now state, "The only way to avoid the health hazards of tobacco smoke is to stop smoking completely." This is clever because with this warning, the tobacco companies, while continuing to encourage tobacco smoking, have immunized themselves from future litigation because they now warn you that their product is harmful. Now, legally, the only one to blame for the harmful effects of smoking is the smoker, even though nicotine is addictive. Also, the initiative includes the questioning of patients about exposure to "environmental tobacco smoke" or "second hand smoke," either at home or at work.

The following documents will be given to each patient, each time they come to the clinic:

1. Weight Management Assessment - one page
2. Exercise Prescription - 7 pages
3. Smoking Cessation - 7 pages

1. Smokers will be given the full smoking cessation document
2. Non-smokers who are at work or at home with a smoker will be given a document on the hazards of what has been variously called "environmental", "second-hand" or "passive" tobacco smoke.

While this initiative may seem to be simple, it is a rather complex undertaking. To do this occasionally is simple, but to consistently do it every time a patient is seen is not. At the end of each day, a report will be run which will determine if the above three documents were generated in the electronic medical record and if they were actually printed. A random sampling of patients leaving the clinic during the day will be used to develop confidence that the documents have actually been given to the patients.

Shared Responsibilities

The LESS Initiative is dependent upon the sharing of responsibility by the various members of SETMA's healthcare team:

1. The IT team (Information technology) has to make it possible to easily and conveniently produce the documents and to audit the performance.
2. The Nursing and support staff have to collect the data - weight, height, waist size, abdominal girth, hip measurements, neck size, chest size, body fat, etc. - which allows the computation of the information used in determining the patient's health risk.
3. The Nursing Staff have to create, print and distribute the documents, as well as initiate the discussion with the patient of the information in each.
4. The Healthcare Providers - physicians and nurse practitioners - have to interact with the patient about the imperatives for change which are indicated by the information in the document, discussing with the health risks of doing nothing and the health benefits of changing the lifestyles...
5. The Nurse Management Staff must audit the charts at the end of the day to make certain that this has been done. It has been established that a 95% effectiveness is the standard for determining success.

In addition:

6. Patients who decide to change their health and their future will be referred to SETMA's Education Department for dietary education for weight management, diabetes, cholesterol, hypertension, the metabolic syndrome and other conditions where improvement is dependent upon patient dietary compliance.
7. Patients who are serious will be referred to SETMA's weight management clinic which has a proved record in helping patients... Utilizing the Adult Weight Management program published by the AMA, SETMA's electronic version of this excellent tool is used to assist patient's in achieve their weight reduction goals.
8. Patients who are serious about cardiac and pulmonary conditioning can be referred to SETMA's cardiopulmonary rehabilitation program for assistance and guidance in that process.

The future of LESS Initiative

At its inception in 2004, some thought this initiative would not change patient behavior, but the record has shown that almost 3,000 people have quit smoking and as a population, SETMA's patients as a group have not gained weight since 2000.

In 2004, we were certain that the auditing of provider performance on completing the LESS Initiative would change healthcare provider behavior, and as is evidenced by the audits below for 2009, 2010 and 2011, it has. The preliminary data shows that fewer of our patients smoke, more of our patients are quitting smoking and that more of our patients are exercising. In the past two years, 15% of our patients who smoke have quit. The following is how eafch of our providers have performed on the LESS Initiative.

It is our hope that other clinics will adopt the LESS Initiative as the cornerstone of their preventive healthcare program.