Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education at the American Psychiatric Association. I'm pleased that you are joining us today for Amy Cohen's webinar on addressing obesity in the population with schizophrenia. The Clinical Support System for Serious Mental Illness is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's presentation has been designated for one AMA PRA Category 1 credit. Following this session, you must complete a program evaluation to be eligible to claim your credit. Credit for participating in today's webinar will be available until February 28, 2019. For those watching this webinar live, please feel free to submit your questions through the presentation platform by typing them into the question area in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for questions and answers. Now without further delay, I'd like to introduce you to the faculty for today's webinar, Dr. Amy Cohen. Dr. Cohen serves as Implementation Scientist and SMI Psychological Treatment Expert for the SMI Advisor Initiative. She is an Associate Research Psychologist in the Department of Psychiatry and Behavioral Sciences at the University of California, Los Angeles. Dr. Cohen, thank you for leading today's webinar, and I'm going to turn the presentation over to you now. Thank you, Tristan. I appreciate the opportunity to talk about addressing obesity in the population with schizophrenia today. I wanted to let the audience know that I have no relationships or conflicts of interest related to the subject matter of this presentation. So let me start by talking about my plan for today. First we're going to talk about the obesity epidemic and schizophrenia. And after that, I'm going to spend the bulk of today talking about the implementation of an evidence-based psychosocial weight management program for the population with schizophrenia. I'm going to talk about how to present how to implement the program, and I'm also going to talk about its impact that we found in a recent study in terms of service utilization and weight. I hope that by the end of today, you'll be able to recite the impact of obesity on mortality in the population with schizophrenia. You'll be able to list the steps involved in calculating body mass index, or BMI, and describe the patient, clinic, and organizational level data used in quality improvement for weight management programs. So as you know, schizophrenia is the most common serious mental illness, and the disorder can include a variety of symptoms, including positive symptoms like hallucinations and delusions, negative symptoms, allosia, anhedonia, abolition, affective flattening, disorganized symptoms in terms of speech, behavior, and attention. And remember that there are cognitive deficits that are seriously problematic for these patients in terms of problems with attention, problems with memory, information processing, and executive functioning. The prevalence of the disorder is 1% of the population, but it accounts for 10% of all permanently disabled people and $22 billion annually in health care costs. Now the good news is that behavioral and pharmacological evidence-based practices exist, which improve outcomes for those in schizophrenia found in clinical trials. However, it's been really difficult to implement evidence-based treatments in usual care practices, and even when implemented, many patients do not utilize the treatments available. And as a result, the outcomes are worse than we would expect. The literature suggests, and our experience supports, the idea that to improve utilization and outcomes, we must deliver evidence-based services tailored to the symptoms and deficits of this disorder. The causes of obesity in those with schizophrenia are from a complex interplay of genetic and familial risk factors, lifestyle factors, illness-related factors, and side effects of psychopharmacological treatments. These are things like poor diet, inactivity, alcohol consumption, and you can probably think of many other things that you've noticed in your practice. As well, we know that there can be up to 10 pounds a month as a consequence of some of the most popular antipsychotic medications used today. To assess obesity, we really need to be able to calculate BMI in every one of our patients on a regular basis. And I've added the calculation here in the bottom right of this slide. So you need to know their weight in pounds and their height in inches to be able to calculate BMI, and then you can categorize their BMI into categories there on the left of your screen as underweight, normal weight, overweight, or obese. Here are some of the important indications of the obesity epidemic. There is a significantly higher average BMI in the population with schizophrenia versus controls. From the literature, we know that the BMI of that population with schizophrenia falls around 32.1. That's solidly in the obese range. Versus controls is around 27. That's in the overweight range. Additionally, a significantly larger percent of the population with schizophrenia is obese compared to those who are controls. Look at these numbers. In those with schizophrenia, the population, about 58.5% fall in the obese range, whereas in controls, it's around 27.5. That's a big difference. Now obesity leads to poor outcomes like type 2 diabetes, coronary artery disease, hypertension, osteoarthritis and chronic pain, dementia, and several cancers. You probably know this from your practice, but did you also know that obesity in this population has also been associated with lower medication compliance, increased psychotic and depressive symptoms, worse clinical outcomes, poorer quality of life, and early mortality? In fact, based on whichever research study you look at, we see early mortality being around between 15 and 20 years earlier than controls. That's a lot of years lost. So what are the interventions for obesity? Well, we can change to a different antipsychotic medication with less weight gain potential. We can augment with a weight loss medication and or provide a psychosocial weight management intervention. But let's look at some of the data. So this is a chart from a paper that our group published about the prevalence of problems in the population with schizophrenia and appropriate medication changes associated with those problems. So you look on this chart on the x-axis, that's the bottom axis, you see a number of problems, psychosis, tardive dyskinesia, weight, depression, etc. On the left-hand side or the y-axis, you see the percentage of patients. The black bars indicate those percentage of patients with the problem indicated. And the white bar is those who have no appropriate medication management changes associated with that problem. And given our interest today, I want to focus on these weight, weight cons. 1996, weight was not such a big issue. Now that we have the second generation psychotics, we're tracking it much more. Look at the percent of patients with the problem and look at the bar of no appropriate management. There's not much difference between those two bars and that's where we're concerned. In fact, in the study that I'm going to present today, what we found in across 800 patients was that only 5% had a medication change associated with weight management to a lower weight gain potential med. But 6% had a medication change to something with an even worse medication weight gain potential with it. And 89% had no change at all. So what we know is that even with educating of clinicians, talking to patients, talking to their families, they're highly resistant to changing medication, which is understandable. If the medication is working on the psychotic symptoms, they're not as concerned about the weight. So this avenue is a challenging, challenging avenue. The avenue of changing the medication for weight gain potential. So what I would suggest is we really need to focus on delivering a really good psychosocial weight management intervention to combat the obesity epidemic. So reviews and meta-analyses indicate that there are effective psychosocial weight interventions specifically designed or tailored for individuals with schizophrenia. When we look across seven recently randomized controlled trials, the data indicates that the intervention group who's getting this kind of a program is consistently superior to the control groups. Both individual and group formats seem to be effective. Programs last from three to six months. And across these studies, we see a weight loss of around six pounds on average. And although this weight loss seems modest, without interventions like this, the average patient continues to gain weight. And that is a real problem. And even modest weight loss has been associated with health benefits. So it's not surprising that individuals with schizophrenia who are overweight or obese, as determined by their BMI, should be offered a psychosocial weight loss intervention that is at least three months in duration to promote weight loss. And that was included in the Schizophrenia Port Guidelines published by Dixon and colleagues in 2009. So now we're going to share with you a poll question before we move forward. So here's the poll question. Which best describes your institution's approach to psychosocial weight management? Please select one of the following. Our program is well attended by those with schizophrenia. Or our program is not well attended by those with schizophrenia. Or we don't currently have a program. Terrific. It looks like most of the responses have stopped coming in. We have good results. So why don't we look at those? So hey, just the exact right audience we wanted today. 79% of you said we don't currently have a program. And 13% of you are doing great. You have a program and it's well attended. And 8% of you have a program and it's not well attended. This is exactly what we're looking for so that we can talk to you about a program that we've got that's had some success. So let me talk to you a little bit about our program. It's called the Enhancing Quality of Care in Psychosis. This is the overarching program that included a wellness component. We call this program EQIP. EQIP was supported by a Veterans Administration Health Services Research and Development Quality Enhancement Research Initiative grant as well. It was supported by the VA Desert Pacific Mental Illness Research, Education and Clinical Program called a MIREC. Also the VA Greater Los Angeles HSR&D Center of Excellence and the UCLA RAND NIMH Partnered Research Center for Quality of Care. Now EQIP was a research network partnership in four VA regions. This partnership was a critical foundation for this study. So the VA, the Veterans Administration is broken up into networks or regions as you can see by the numbers circled on the map there. We went to four regions and said can you give us two medical centers in your region that are really struggling to get evidence-based practices up and utilized by the patients with schizophrenia. And of course they said no problem. So here are the eight sites that were nominated by the regional leadership. We randomly assigned one of the pair to the intervention site and one to control in each region. And we started strategic planning for evidence-based care targets within each region. So we offered them a menu of a number of evidence-based services that were appropriate for people with schizophrenia and said can you pick two that we'll help you with in terms of implementing and utilization. And what was surprising to us was that separately each region actually picked the same two care targets and those were wait services and employment services. So what we ended up doing was a clinic-level controlled trial where we helped them implement wait services and support employment. I'm going to talk about that and the wait services in a minute. We enrolled 801 patients with schizophrenia and 201 clinicians and administrators who had a role or responsibility taking care of patients with schizophrenia at the enrolled sites. The intervention for this project was to implement a chronic illness care model led by a nurse care manager to increase the use of evidence-based practices for individuals with schizophrenia. It was a 15-month long trial where we helped support wait services and supported employment. And as I mentioned we're going to talk about wait services. Now let me talk to you for a minute about the control. So across the VA every site has a wait management program already implemented called MOVE. Now this program is required at every site. It's not tailored for people with schizophrenia or the cognitive deficits or symptoms of schizophrenia. But both the intervention and the control were reminded that MOVE existed and therefore the control, although it's usual care, they did have access to in-person wait services that were not tailored. For everybody enrolled we talked to patients and clinicians at baseline, midpoint, and at the follow-up which was 15 months. So we started out with what are the challenges to implementing an uptake of a psychosocial wait intervention for those with schizophrenia. I'm sure much of the audience here today will resonate with several of these problems. First of all at the system level the medical record had limited tracking of outcome data. Sometimes there would be waits in there, sometimes there wouldn't. Height was not in there, BMI was not calculated. There was limited support at the system level for uptake or utilization or marketing of such a program and there was limited space to deliver group practices. As well many clinicians felt that they lacked key competencies to be able to deliver a psychosocial wait management program and had limited time. As well at the patient level there's the presence of symptoms and cognitive deficits that I mentioned earlier, limited literacy, very limited knowledge about diet, exercise, and cooking and skills in that area were also limited. They were also poor advocates to ask for wait services. They didn't think they needed them. When did they need them? They didn't know to ask for these things or even who to ask. So we started with what we needed the most which was data. So we developed and placed in waiting rooms a patient assessment system called the PASS which was simply a patient facing kiosk and here's a picture of it on the left side of your screen and there was a scale next to it in the waiting room. This kiosk contained a touchscreen computer with headphones, a color printer, and a scale. Patients came in. Every time the clerk would tell them please go sit down at the kiosk and answer some questions while we're waiting for your provider to be ready to see you. And on this kiosk there were a number of questions but the important ones for this presentation today was that they entered their weight from the scale that they just stepped on. They were asked if they had received a referral to a weight group and if they had received a referral had they been attending. If they had not been attending and asked some questions about why haven't you been going. At the end when they push the last button on the kiosk assessment this kiosk summary report printed out from right underneath them and they were able to take this summary report with them to their clinical encounter. I want to point out a couple important key points on this summary report that the patients received. First their weight. This one for example said your body mass index is 27.6. That means for your height you're overweight. Medications you are taking for your illness could be making this worse, so we're giving them a little education. Two, helping them advocate for themselves by giving them the words to say. What can you do? Talk to your doctor about switching to medications that don't have weight gain side effects. Two, talk to your doctor about a referral to your local wellness program. This program can help you lower your BMI by helping you eat a balanced diet and get enough exercise. Lastly, we gave them data. We helped them self-monitor by giving them their current today's weight plus the weight of the last two times they used the kiosk and there was an ideal weight indicated by a line. This was the top of the normal BMI category. Patients printed this out and hopefully took it to their clinical encounter to discuss issues around their weight. Every quarter, around every quarter when they did the kiosk, the kiosk also printed out the following form, one pager, after it printed out their summary report. This was one page front and back and we called it the fast facts. So on the left side was the front of the page which said, so how can I tell if I'm overweight? Why should I be concerned about my weight? And often patients would say, oh yeah, those things that are listed there, I have a lot of those. What can I do if I am overweight? So again, giving them ways to advocate for themselves. On the flip side of this educational page was this nice big body mass index table and at the top it reminded them what body mass is, showed them how to use it using their height and their weight and what we did was color-code it. The red is the obese range, yellow was we're worried about you, it's the overweight range and green is the normal range. So patients often like to find where they were on the BMI table and look for the weight that they needed to get to to be in the next category down. So that gave them like a little target like, oh I need to get to 163 to move into the yellow range, for example. The other thing that was included on this was portion size and you're going to hear in a few minutes that the wellness program that we implemented relied heavily on portion sizes. And so here at the bottom you can see some little cheat sheets like for salad dressing, half of a ladle of dressing at a salad bar. Cereal, about a half to one cup depending on the type of cereal. And so patients really found that to be quite helpful. And clinicians were also a target in this effort and we provided some fast facts or quick facts for clinicians as well. You can see here on the clinician page it started off by talking about mortality problems, medical side effects of obesity, what is metabolic syndrome, and about switching anti-psychotic medications. This was delivered mostly to psychiatrists but also psychiatric nurses or other clinicians on the team for patients in the specialty mental health clinics. So now let's get into the meat of it. We also of course delivered a wellness program. This was evidence-based and tailored for the patient population with schizophrenia. We located it in the mental health clinic. It's a 16 session 45 minute weekly in-person sessions. Patients could join any week and they could repeat it. The program is 16 weeks so that's four months. And so during the life of this project which was 15 months long, this went through several cohorts and sometimes patients would come back for one or two sessions that they'd missed during their cohort. It's facilitated by a clinician. That is someone who feels comfortable with this population and who also is aware of weight or obesity programs. We really allowed for creativity and I'm going to give you some examples of that and really wanted it to be something new and different for patients to participate in and also for clinicians to deliver. I'm going to present the content now. So this is the first eight of 16 sessions and you can see really in the first three what we're talking about is a lot about portion sizes. This program does not count calories, does not talk about foods you know that are absolutely off-limits or beef up on you know meat or anything like that but really focuses on portion sizes. Around session six we introduce the idea of exercise. Start talking about fiber, water, fat and at eight we actually say okay now we're going to talk about starting exercise. An exercise in this program is largely focused on stretching and walking. Second half of the of the sessions sugar, more walking, controlling hunger and limiting salt, expected lifestyle changes, you know where are you going to be shopping now, how can how can walking be part of your daily routine, how can you take the bus but get off one stop earlier, etc. Avoiding alcohol, exercise is a daily routine and then a summary session. One of the things that is our mantra throughout teaching and delivering this program is that patients should see it, hear it, say it, write it, use it. We talk about that lots and lots and lots. So we had handouts for every session using large font with space for patients notes and we actually made notebooks that they could add the sheets every week. We let them either take the notebook home or we would keep it for them and give it back to them every week. It was up to whatever the patient wanted. We used rooms with whiteboards or chalkboards. We did lots of frequent summaries every few minutes sort of talking about what did people hear, what about what I just talked about, what what do you think were the key points that we just made, what do you feel like is sort of still confusing about what we've talked about in the first 15 minutes. We let patient lead parts of the session. This may be just reading part of the handout. It may also be something that they want to we say who who really ran into a real problem this last week and let them stand up and talk about that and get support from others and ideas from others. So there was a lot of talking by the patients. We also use lots of examples and prompts and so let me show you some of the things we used. So on the left side of your screen you're going to see a page that says food models. We got these from the National Dairy Council. They're pretty cheap. What you'll see is that on the sheet this is sort of one sheet that comes. They pop out like a paper doll. So each of those little food models pops out and what's beautiful about it is that they're each the size of a portion. So a patient can hold that and sort of see in their hand what is a portion like what does a hamburger look like, like one portion of a hamburger. What does an amount of baby carrots, what's an average size apple and on the flip side of each it tells about the nutritional content. So there's a lot that you can use with these food models. We also brought in a lot you'll see the Ritz box there. We brought in a lot of different cans and boxes for the food label class so that we could look at those and one of the things that's a big learning sort of light bulb that goes on with people is they'll say for example well I just had soup last night so that was great I thought but they didn't realize that the soup can that they bought at the grocery store actually contains three servings and so that calorie thing that they looked at or that fiber or that sugar or that sodium needs to be tripled if they ate the whole can. So this was a light this is a light bulb for some people so it's really important to bring in lots of different boxes and and cans and things like that. Dice for example we bring in a pair of dice because a pair of dice is about one ounce of cheese. We bring in a thing of cards because if you hold a deck of cards that's about three ounces of meat. We bring in serving spoons to talk about dressing. We bring in other things to show how much cereal they need to eat and this is a picture of a pedometer that we handed out. We did a lot of testing to find a really simple pedometer where there was not a lot of buttons not a lot of you know showing all kinds of things just simply how many steps they took a day and patients love these. It's very self-motivating to see your numbers go up and to share in class how many numbers you've got and so that was something that was really worth the investment. So we also did tailoring for the clinic and community and I really encourage you to think about this as you drive to your clinic every week and you think about like where your patients live what does that community look like. We did a lot to try to change the clinic climate putting up posters in the waiting room about healthy eating putting things even in the bathrooms you know so that they there were things to look at in there that were about healthy eating and exercise. We did a lot of marketing. We really have leveraged the peer specialist community at the clinics to talk about the program to be the person to remind people that the that the group is this week to call people afterwards who missed it to talk about you know what what kind of problems you having with the clinic what with the group what's happening with you what's going on with the diet exercise full clinical team involvement and by that I mean talking about it and the clinical team to say hey where's your your summary report that you just would have gotten at the kiosk you know asking for the patient for that. Thinking about the day and time of the groups and linking it to a specific clinic you know the clozapine clinic or maybe there's a day that there are psychiatrists who see a lot of patients with schizophrenia is there a way that the group could be linked to those in in terms of time also exercise is there a way to make exercise linked to the group for example one of our nurses at one of our sites she brought in an old DVD player and played Richard Simmons dancing to the oldies and she did it right after the group every week for 15 or 20 minutes patients loved it we also had another site bring in an old Wii and they did Wii golfing or Wii bowling for 15 or 20 minutes after the group every week again getting people up getting them moving another site we had had a peer take the group on a walk after the group every after the wellness group every week and it really helped with bonding plus they got exercise improved social skills there was a lot to it so be see if you can be creative in terms of the exercise component also we had people talk about farmers markets many of these patients had never been to a farmers market felt uncomfortable at farmers markets so sort of talking about that you could even do a up here might be able to do a little trip to a farmers market with individuals we also made fast-food handouts and these were a big big big hit and a really good starting place for conversations in the groups talking about what can you pick at the fast food how can you adjust what you order at the fast food to be better because the bottom line is these guys were still going to go to fast food restaurants so how could they pick better leaving the bun off scraping off the mayonnaise using less of the salad dressing there were just a lot you know when they get their order cutting it in half putting half of it in the bag to take home for another meal there were just a lot of different ideas there that they had not thought of and still sort of I think recognize the fact that they were going to go to these places but how could we make it better so again this is the kind of tailoring that I think you can be really creative on so here are some pictures left side is a poster a similar you know we used posters like this to place around the clinic barrier veggies you know sort of surprising they may think of one or two veggies like I have you know I just hate broccoli like no problem there's like a ton of different veggies you can look at and so they hadn't really thought of the breadth and or maybe they didn't know how to make it or they never grew up in this house that made a lot of veggies so this was something that you know we talk a lot about eating the rainbow etc here's a picture of a walking path that one of the clinics handed out these can be right at your check-in desk at your clinic walking paths for areas that are around you maybe there's a university by a public park and you can hand out walking paths that are there around the time that we were delivering the equip wellness program much of the VA was also considering changing their vending machines to healthy vending so look around your clinic you know do you have vending machines are these you know if you do for sure patients are probably getting things out of there you could take a little trip down your vending machines and say hey what's in this vending machine is there anything in here that we could pick that would be better than something else or maybe you can even advocate for your clinic to change your vending machine to have one or two items that were more healthy and again I can't say it enough that testimonials are so important we got people from past cohorts to come back to next cohorts we got patients in the in the cohort that we were in to stand up and talk about what was working or not working it's just really important for them to hear from each other and so I really recommend that so remember those kiosks I talked about at the beginning well those data don't just use aren't just used in summary reports that the patient gets we roll up those data and give it to clinicians managers and administrators so let me show you that other data so here is a picture of a caseload tracking report that a particular psychiatrist would get showing their panel of patients so again this is patient level data none of this is real these aren't real names but this is what the tracking report looks like so this would be a report that would be received by the psychiatrist Alex Young and it could also be sorted and given to a case manager and on the left you can see the patient's name and in VA we use their socials but you may have a medical record number on the left and you see on the right the weight issues now why would someone get a check there a patient would get a check there because they were either overweight or obese they would get a check they could get a check because they were overweight and obese and they had not gotten a referral yet or they were overweight and obese had gotten a referral but had checked that they were not going so all of these patients need a conversation from either their case manager or their psychiatrist or an assigned peer to talk with them about the weight issue that was going on we also use the kiosk data to provide information across the panel of patients across the whole clinic so here's an example of a report a clinic manager might get so and this these are actually real data from one of the clinics in the project so you see at the top how many patients are overweight or gaining weight then you also see at the bottom how many were referred to a wellness program so a manager might say ooh look at that drop from 65 to 40 what's going on there and then you see another drop from 40 being referred to 18 going regularly so now you see I've got 65 people in the denominator who need this service and I've only got 18 who are going that's concerning to me as a manager so you as the manager then may dig down and go back to these psychiatrist reports of panels and find out which psychiatrists or case managers have a lot of people who are contributing to my numbers on my clinic report so so there's a lot of data here that's that's helpful we also gave clinic administrators and hospital administrators information on their site versus other sites who are enrolled in the project so it allows them to see here these percentages represent the patients receiving the intervention over the number of overweight or obese patients okay so those numbers are low what I would say about these reports what I found in the equip project was that these reports were used by clinic managers and administrators to advocate for time for their clinicians to actually deliver the wellness program some of them actually gotten got additional full-time employees out of this so that they could actually deliver the programs so these were actually used not only to change behavior of the existing clinicians but also to get more backup and more support in order to get these wellness programs going so all I have to say is data data data you need it so overall care was reorganized we have a new care flow diagram at these sites weigh each patient at each visit you need a scale that the patients can actually have access to immediate information on weight for this session and the last two sessions that allows the patient to see if they're reaching their goals routine referral to the weight program and routine feedback both to the patient the clinician the manager the administrator we train staff to lead the equip wellness program we freed up staff time to deliver the program identified rooms large enough identified other weight and exercise programs change position descriptions and trained varied disciplines trainees and new hires so let me run through the impact 571 patients out of 801 were eligible for weight services they had a BMI overweight or obese the average age was 54 of these patients 91% male that's very typical in the VA 45% white 46 african-american and let's you know many of them were overweight but a lot even more were obese in terms of service utilization, weight service utilization, prior to the start of the program, we found it to be low. At the intervention sites, it was on average 13% had actually gone to at least one weight service appointment and at the control site, 18%. So no difference between intervention and control and overall, very low. In terms of initiating weight services, going to one appointment. Intervention status was a significant predictor of having a weight management visit after controlling for demographics and weight category. In fact, overweight individuals at intervention sites were 2.3 times more likely than controls to have a weight service appointment. And remember, controls still had move and could go to weight program, just not tailored. Individuals receiving in the intervention were more likely to use weight services. Intervention status was a significant predictor of the number of days to the first weight management visit. How long does it take them to start? Individuals at control sites averaged 136 days from referral. Individuals at the intervention sites, 98 days. Still too long, but much faster at those at the intervention sites. Intervention status was a significant predictor of the number of weight management. This is retention in services. Control sites before EQIP, about four visits in 15 months. After, four visits in 15 months. No change. Intervention sites though, three visits before and 12 visits after. So individuals receiving the intervention continue to use the services, but three times more than controls. Now, what about weight outcomes? The control group was on average 13 pounds heavier than the intervention group at the end of the study year. Why do I say it this way and not say weight loss? Well, because what happened was the individuals receiving the intervention stopped gaining. So both intervention and control were on a trajectory of gain prior to being in EQIP. Those who were at the control sites continued to gain, while those who were at the intervention sites stopped gaining and maintained. By the end, the difference between those two groups was 13 pounds. What about the kiosk? Well, patients liked them. 76 reported they enjoyed it. Here's a quote, sitting at the computer was one of the highlights of the project. 71% reported that they liked getting the summary report. It helped me see my progress in black and white. Many noted that the kiosk questions promoted self-reflection. Quote, it kept me in check with myself. Another quote, it helped me connect the dots. And clinicians, the availability of the computer has made it easy for patients to monitor how they're doing with their weight. Another quote, we weren't doing a bad job before, but now we're doing an enhanced job. And others commented on giving data clinicians was essential. And what I would say here is, it doesn't have to be a fancy kiosk or a tablet. It could be a piece of paper that is then taken to the, you know, that is printed out from the medical record that shows their weight over time. There's a lot of different ways to do it. It could be a questionnaire in the waiting room. But what I'm saying is that it's really, the data is one of the important components of a really good weight loss program. So let's review our learning objectives again. Obesity and its consequences lead to early mortality. Remember we said about 15 to 20 years early in the population with schizophrenia. Measurement of body mass index requires height and weight. And treatment guidelines recommend intervention for those who are overweight or obese. And patient clinic and organizational data really drive care quality improvement. So EQIP was one of the largest quality improvement efforts in specialty mental health to date. Working in a partnered way between frontline staff and administrators was critical to the success of weight intervention, as well as including peers and patients in that discussion. Care reorganization, including integration of routine data from patients, resulted in timelier and greater utilization of services and improved patient outcomes. So how can you get started at your clinic? Number one, partner with leadership. And if you're a leader, partner with your line staff. Address capacity. Train clinicians and consider peers as supports to the program. Address patient preferences in terms of timing of the groups. And address your clinic climate. Posters about weight and diet and exercise. Educating clinicians and patients and families. Think about your vending machines. Set up a clinical data registry, and maybe you already have one, or you might wanna use PsychPro from the American Psychiatric Association or any other one that's offered. Deliver evidence-based tailored weight services and be creative. You can also visit us at www.smiadvisor.org for tools and consultation on weight services. Thank you so much for listening and joining me today. Thank you. Well, and thank you, Amy, for such a wonderful presentation. I know we learned a lot listening to what you had to teach us about weight management and health, not just for those with SMI, but I think there's a lot of good advice for all of us in there and for all of our patients. I'm wondering as questions come in, I encourage everyone, please go ahead and type them into that question box. I just wanted to invite people to visit the SMI Advisor website at www.smiadvisor.org and join our newsletter. At the bottom of the page there, there's a sign-up box, and we welcome your email addresses so that we can keep you informed about webinars like Dr. Cohen's. So Dr. Cohen, let me start with a question that we received from one of our attendees around working in low-resource environments. The question really says, you presented a lot of strategies. If you were going to pick three for SMI patients, which would you pick? I guess the question here is really around assuming you didn't have a big infrastructure, where might you start? Right. I think, let's say you don't have a lot of money, and resources are tight in terms of clinicians. I might think about, for sure you've got to implement a weight program. Is there a way to maybe leverage trainees with supervision from a clinician? Maybe also using your peer supports? I would also, I really recommend this climate thing. So really, a couple posters around, maybe some walking path handouts. Something to just make them more aware that weight is important would be really critical. And I think those props really help. Yeah, you don't have to buy them online, but everybody's got some old boxes at home from Ritz crackers, and cereal, and a pair of dice, and things like that. So you can do a little, how somebody brings some of those in. So I would say, think about trainees, think about peers, use props, and try to change the climate a little bit. Great. And you mentioned something that leads right into our next question. And this writer wrote, can you talk more about peers, and what education might be involved in training them for this program? So I think that's a really great question. We used peers in a number of ways. In terms of training them, I think they need to be supervised, probably by the person who's leading the wellness group, because things come up particular to the attendees in the group, or to the leader's particular style. And so there needs to be some weekly debriefing. Maybe if they attend the group, there could be debriefing between the clinician and the peer. But the peer could definitely call people to remind them of the group. They could also call people who missed the group, and say, we missed you this week, and we talked about salt, and they could even give them a couple of the tips. Peers could also encourage people around using the kiosk, or collecting data, weighing themselves frequently. But I think peers really are a good resource, because patients usually react well to them, and differently than they do to clinicians. They may reveal more. In some ways, in that supervision with the clinician leader, the peer may have more information about what's going on with the patient than the clinician may. They may have found out from the patient, well, my real problem is that I eat a lot of Stouffer's every week. And so they may not have felt comfortable bringing that up in the group, but it's something that the clinician could then talk about boxed meals. They may not specifically talk about Stouffer's, but again, there's information flow between these two people that could be really beneficial to the groups. Thinking of information, we have a question around some of the resources that you've developed, particularly for equip. Are the handouts available to the general public, such as the fast food handouts? Okay, that's a really good question. So, interestingly, the fast food handouts, and I can do a little research on that, but we actually bought those online. And it was, the reason I know that I bought them online was there were some fast food restaurants in there that are not in Southern California. So I remember specifically that we must have bought them online. They were really helpful. We also have all of the resources from the Equip Wellness Program, including the handouts for the classes, what's covered in each class, et cetera. And that's gonna be available on the website, the smiadvisor.org website. So check back frequently. We're gonna have those there, as well as handouts. And again, I'm happy, and there are other members of the SMI Advisor team that can consult with your site in order to sort of get this up and running. I don't know, Tristan, if you wanna say anything more about having these assets on the SMI Advisor site. Right, yeah, I think, I just let all of our attendees today know that the SMI Advisor website is in evolution as we're rolling out this initiative. There are features that are gonna be added to the website in the coming weeks, specifically a knowledge base, which has access to lots of resources that have been peer reviewed by our interprofessional group of clinical experts. And later in February, we will also be accepting consultation questions from clinicians where you can reach out to one of our experts and ask questions like the one we just talked about, and to really support the implementation of evidence-based programs within your own program. So please, you know, sign up for the newsletter, visit the website as that will be the best way to keep abreast of the things and the features that we're offering on SMI Advisor through the clinical support system for serious mental illness. Right, and I would just say to that person who wrote in, I'm super, super excited that you asked about the tools because we really wanna share those with you and it will make your implementation so much easier to have those. So please, let's connect and get those, you know, check with our website and we're gonna have those in just a few weeks. Dr. Cohen, let's take another question. We have one from an attendee who says, can you explain the connection between SMI Advisor and can you explain the connection between obesity and increased psychotic symptoms and depression? So let's talk about why obesity matters, not just in terms of physical health, but also mental health. Right, so, you know, I'm not, what I would say is that those probably go through another, you know, the obesity can lead to, you know, different kinds of symptoms that may lead then to medication noncompliance, slowed down, things like that. So I think it's moderated by that, but yes, you're right, that I think those other problems, not just medical problems exist and people have found those associations in recent studies. Great, and I imagine that on the SMI Advisor website, as part of the consultations, we'll be having an answer engine, a knowledge base, and I think that's a question that maybe we can summarize those data around in the future. So I think we're going to have a big section devoted to weight management and I think that's a great question for us to be able to dig down further and give the clinicians advice on. Yes, that sounds good. You mentioned in one of your slides the challenge and listing challenges for clinicians that one of the challenges was around competency and the other was around time and certainly educational programs like this really are trying to address the competency issue. I'm wondering if you could talk about time. How much time does it really take to help patients manage weight in the context of a clinical appointment? Okay, so outside of delivering the group, I guess that person is asking. Right. I would say that it may take, it could be as short as a few minutes during the clinical appointment, you know, five, 10 minutes. Depends on what the clinician and the patient see as the priority for that clinical encounter. But if you believe as a clinician that it's a key component to many of the other problems that the individual is having, then of course you would devote more of your maybe 15-minute appointment or 10-minute appointment to it. But what really helps is if the patient has some background knowledge or is tracking their weight, that sort of allows you to talk about it a little bit quicker. You don't have to give some background about looks, like you've been gaining weight or whatever. If the patient knows that, then they're sort of primed to talk about it and are probably thinking about that it's a problem and noticing they're eating, et cetera. But if you really think that it's a part of, like for me, I really think of it as a part of their whole recovery, then of course a decent amount of minutes in that clinical encounter should be devoted to it. I think also clinicians will be maybe surprised a little bit or at least I was surprised when I started talking to patients more about diet and exercise and what was really going on with their diet. Like sometimes I would talk to somebody and they would be like, well, I think I've really been cutting back. I've been eating a lot of fruit. And I said, oh, that's great. Like how much fruit have you been eating? They're like, oh, well, like sometimes for lunch I'll just eat like five bananas. So I'm like, oh, okay, this is something that we need to talk about. And so sometimes they'll say I'm eating better, but you have to dig a little bit deeper. And I'm sure many of the clinicians on this call do that about what is eating better as defined by this person. And I think that's important to uncover. All right, Amy, why don't we take one last question? And this is a question that may have to do with the timing of equip or it may have to do with kind of the changing models, but the writer wrote, I noticed that the equip program listed the food pyramid, wondering if it now uses MyPlate. And so I guess it's a bigger question of around all the different models around how much people should be eating of different portions. Do you have an opinion on which models are more or less relevant for this group of patients? I'm really glad that this person asked that. And that means that they're really paying attention to what's going on around diet and exercise. And we do use MyPlate now. And so it's interesting that later iterations of this have switched over to MyPlate, which I think patients resonate with better. And we actually do bring in plates. And one thing that's been very interesting is patients are like, oh, this plate's much smaller than the plates I use at home. So that's step one. And then dividing the plate and helping them think about it. And just like portion control, looking at the plate and seeing what the plate should look like is very, very helpful for this patient population. So yes, we do use MyPlate now. And we do try to stay on top of the changes and thinking about that. I don't think the pyramid was that helpful for patients because sometimes they didn't even know, is this a grain or not a grain? Which part of the pyramid did this go in? And I think MyPlate's a lot easier. All right, well, thank you for that wonderful presentation and for all your wisdom in the Q&A. I'd like to just end today's presentation with an invitation to all of you to join us next week on February 8th from 12 to 1 p.m. Eastern time. Dr. John Torse, who is our SMI technology expert, is going to be talking about meeting the challenges of security and privacy when using digital technology tools with patients. And you can learn more about this presentation by going to smiadvisor.org slash tech tools, pre-register for next week's webinar. I'm sure for all of you who have smartphones and use apps with your patients, you think you're gonna find this talk to be enlightening on many, many levels. This free webinar, as I mentioned, will be held Friday, February 8th from 12 to 1 Eastern time. So write it down in your appointment books now. Thank you all so much for joining us. And again, special thanks to Dr. Amy Cohen for her presentation today. We look forward to seeing you all again soon next week in our presentation with Dr. Torse. Until then, be well.

Dr. Amy Cohen

psychosocial weight management program

schizophrenia

obesity

mortality risk

clinic climate

data-driven strategies

patient assessment system

SMI Advisor website