Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Transforming Your Practice - LESS Initiative
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    Lose Weight, Exercise, Stop Smoking:  Shared Responsibilities -- The LESS Initiative is dependent upon the sharing of responsibility by the various members of SETMA's healthcare team:

    • The IT team (Information technology) has to make it possible to easily and conveniently produce the documents and to audit the performance.
    • 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.
    • 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.
    • 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...
    • 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.

    The first event led to the LESS.  We concluded that EHR was too hard and too expensive if all we gained was the ability to document an encounter electronically.  EHR was only “worth it,” if we leveraged electronics to improve care for each patient; to eliminate errors which were dangerous to the health of our patients; and, if we could develop electronic functionalities for improving the health and the care of our patients.  We also recognized that healthcare costs were out of control and that EHR could help decrease that cost while improving care.  Therefore, we began designing disease-management and population-health tools, which included “follow-up documents,” allowing SETMA providers to summarize patients’ healthcare goals with personalized steps of action through which to meet those goals.  We transformed our vision from how many x-rays and lab tests were done and how many patients were seen, to measurable standards of excellence of care and to actions for the reducing of the cost of care.  We learned that excellence and expensive are not synonyms. 

    After developing, several disease management tools, we realized that in the plan of care for each, we identified three life-style changes which we wanted everyone to make.  One of them was to stop smoking.  Whether it was for diabetes, cholesterol, hypertension or others, it was critical that our patients decrease the inflammatory burden on their cardiovascular systems by avoiding primary, secondary and now tertiary tobacco products.  We want patients to decrease their risk by losing weight and to increase their cardiovascular health with routine, regular aerobic exercise, strengthening and stretching exercise.

    To address these issues with one patient is not problem, but how to do it with 400+ patients a day and how to know that you are doing it, is a different matter.  As a result we designed the LESS Initiative (Lose weight, exercise, stop smoking).  The program included a diabetes risk assessment, a diabetes screening assessment and a hypertension prevention program.

    This tutorial explains the LESS and other tutorials explain the Diabetes and Hypertension Prevention programs.  Those can be found on the web site under Prevention Tools, also.

    The Agency for Healthcare Research and Quality (AHRQ) has created the AHRQ Health Care Innovations Exchange. 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 Quality Tools.
    • 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 and has posted SETMA’s LESS Initiative for publication on the Innovation Exchange.  SETMA’s LESS Initiative is completed on all patients who come to SETMA.

    The healthcare providers and staff of Southeast Texas Medical Associates (SETMA) wish to thank Enterprise Health Affairs writer Ms. Becky Bowman for her piece on SETMA's LESS Initiative. The positive benefits of this program far outweigh the "threat" of firing a patient who refuses to quit smoking. One patient, seen a month ago, called to say, "After receiving the weight management assessment, exercise prescription and smoking cessation materials at SETMA, I have been watching what I eat, walking and making more health-conscience decisions. I feel better that I have ever felt and have really enjoyed reading all the information that was given to me at my/her visit. In only a month, I have noticed a change and I am excited about the future."

    SETMA's LESS Initiative with the potential of dismissing a patient was characterized as absurd by Shane Martinez. The question raised by Martinez is reminiscent of the following comment on the nature of warning:  "Is admonition in a time of peril as authentic an expression of love as assurance in a time of uncertainty? Absolutely! The difficult thing about admonition is that it is rarely recognized as an expression of love. But love must sometimes admonish. The tone of it does not sound like love." (J. W. MacGorman, 1981)

    If a bridge is out and a 200-foot fall to certain death awaits the traveler, is it kind to wave and shout, "Have a nice day?" Or, should caring dictate that you stand in the way and shout, "Stop"?

    No business wants to offend or lose customers, but as healthcare providers, we must put the health and well-being of our patients above our business interests, even to the point of refusing to continue to enable them to be comfortable in self-destructive habits whether smoking, overeating, alcoholism, neglect of exercise or other.  None of us is perfect and at SETMA we do not require perfection, but we do require a good faith effort to improve your health. If you do not make that effort, we will stand in your way and shout, "Stop!" That is "love in its urgency." That is good medicine and that is effective caring for others.

The Less Initiative is critical to the care of patients with diabetes, hypertension and Cardiometabolic risk syndrome. The following materials address details of Cardiometabolic Risk:

  1. Cardiometabolic Risk Syndrome Part I: Introduction

    One of the most interesting "syndromes" in medicine and one which affects more people than are aware of it has been known by several different names. You may already be suffering from this syndrome which is often overlooked. It's not a deadly new virus, cancer, or heart disease. It's a disease, surprisingly enough, caused by your body's inability to make the most of the food you eat. It is estimated that over 43,000,000 Americans have this condition.

    Because this syndrome is so common and because it is so complex, this week's article will begin a serious of articles which will address each element of the syndrome. If you will bear with us, I believe by the end of this series you will understand a great deal more about how to improve your health and about how to ask your healthcare provider for special attention to this syndrome and its impact upon your health.

    This syndrome was first called "Syndrome X"; then it was called "Insulin Resistance Syndrome," because it is thought that the an abnormal response to insulin is the principle causative factor in the condition. However, because it is associated with a number of metabolic abnormalities, it became known as the "Metabolic Syndrome". It has also been called "The Deadly Quartet" in recognition of the four underlying elements of the condition.

    However, because of this syndrome's contribution to the rise of heart disease, the American Diabetes Association (ADA) has embarked upon a campaign to change the name again to "Cardiometabolic Risk Syndrome". The ADA's Cardiometabolic Risk Initiative (CMRI) is a national effort that stresses the association between diabetes, heart disease, and stroke. CMRI encourages physicians and the public to adopt cardiometabolic risk (CMR) as an umbrella term that will help them better understand and manage all cardiovascular and diabetes risk factors.

  1. Cardiometabolic Risk Syndrome Part II: Insulin Resistance

  2. Cardiovascular Disease Risk Factors - Part III - Obesity

  3. Cardiometabolic Risk Syndrome Part IV: Endothelium Dysfunction

  4. Cardiometabolic Risk Syndrome Part V: Fibrinolytic Dysfunction

  5. Cardiometabolic Risk Syndrome:  Part VI: Plasminogen Activator Inhibitor I

  6. Cardiometabolic Risk Syndrome Part VII: Inflammation - chronic, low-grade

  7. Cardiometabolic Risk Syndrome Part VIII: C - Reactive Protein

  8. Cardiometabolic Risk Syndrome Part IX: Pro-inflammatory and Anti-inflammatory Diet

  9. Cardiometabolic Risk Syndrome Part X: Inflammation Altered by Diet

  10. Cardiometabolic Risk Syndrome Part XI - Healthy Eating:  The Age of Nutrionism

The following articles carry the Cardiometabolic risk syndrome and the Less Initiative into specific cardiovascular risk factors.

  1. Cardiovascular Disease Risk Factors - Part I - Introduction

  2. Cardiovascular Disease Risk Factors - Part II - Sedentary Life Style

  3. Cardiovascular Disease Risk Factors - Part III - Obesity

  4. Cardiovascular Disease Risk Factors - Part IV - Smoking

  5. Cardiovascular Disease Risk Factors Part V - Cholesterol

  6. Cardiovascular Disease Risk Factors - Part VI - Hypertension

  7. Cardiovascular Disease Risk Factors - Part VII - Combined Factors which Begin in Childhood

  8. Cardiovascular Disease Risk Factors - Part VIII - C-Reactive Protein

  9. Cardiovascular Disease Risk Factors - Part IX - Family History

  10. Cardiovascular Disease Risk Factors - Part X - Psychosocial Stress

  11. Cardiovascular Disease Risk Factors - Part XI - Age

  12. Cardiovascular Disease Risk Factors - Part XII - Insulin Resistance

  13. Cardiovascular Disease Risk Factors - Part XIII - Gender - Part 1

  14. Cardiovascular Disease Risk Factors - Part XIV - Gender - Part 2

  15. Cardiovascular Disease Risk Factors - Part XV - Addendum: Questions and Answers About Estrogen Replacement and Heart Disease