Approximately one in three Veterans in the VA health system are obese and at high risk for obesity-related comorbidities. Prevention and management of obesity is a VA patient care priority. However, most VA weight management programming is facility-based and many Veterans find it difficult to access these services due to employment, transportation, or travel distance barriers. The Home Telehealth - Weight Management (HT-WM) program was specifically developed to address these issues in patients diagnosed with obesity. HT-WM is a telehealth intervention that utilizes in-home messaging devices for daily weight self-monitoring practices in conjunction with an 82-day, guided psycho-education curriculum designed to promote weight loss. Patients respond to daily device prompts regarding weight and other health issues that are transmitted asynchronously to a care coordinator who monitors patient progress and safety. In FY2010, researchers from the Diabetes QUERI partnered with the National Center for Chronic Disease Prevention and Health Promotion (NCP) to conduct a mixed method evaluation of the implementation and effectiveness of the CCHT-WM program.
The objective of this RRP study was to examine the variability in implementation of the CCHT-WM program across nine VA facilities located in three VISNs that volunteered to pilot program protocols prior national dissemination of CCHT-WM throughout VHA. The study was exploratory and investigated the following research questions:
1)How does the CCHT-WM program's reach (i.e., cumulative number of patients enrolled in the CCHT-WM) vary across sites?
2)What is the effectiveness of the CCHT-WM program on short-term patient outcomes?
3) How do contextual differences distinguish sites with high reach ("high program uptake") from those with low reach ("low program uptake")?
4)How do contextual differences distinguish sites that demonstrate high effectiveness in improving short-term patient outcomes versus sites with low effectiveness?
A longitudinal observational mixed methods design was used to evaluate implementation of MOVE! HT-WM during FY2010 at nine VA medical centers. VHA administrative data was used to evaluate program enrollment rates, patient adherence, and clinical outcomes. Weight loss outcomes for Veterans who enrolled in HT-WM were also compared to Veterans enrolled in MOVE!, the VA's facility-based weight loss program.
Quantitative analyses included calculations of descriptive statistics and paired t-tests analyses between MOVE! and HT-WM participants which adjusted for clustering by site. Analyses calculated the following for each facility: 1) Cumulative number of patients engaged in HT-WM in FY2010 per site, defined by having greater than two visits over 180 days; 2) mean weight loss per patient achieved after 6-months of program participation; and an overall measure of population effectiveness (reach x total mean weight loss/Veteran). Twenty-eight facility- and VISN-level stakeholders were recruited to participate in two rounds of semi-structured interviews, first by phone and subsequently onsite about aspects of implementation processes, context, and daily program delivery. Interview questions were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were recorded and transcribed verbatim. Interview transcripts was then reviewed by qualitative analysts, who coded the quotes according to the CFIR constructs, which consisted of factors that have been shown in previous research to affect implementation success.
Six of nine facilities implemented the pilot as planned and three sites experienced implementation delays. Mixed methods findings focused on the six facilities participating in interviews, categorizing two as "high uptake" sites and four as "low uptake sites"; sites not interviewed were considered "late adopters." Program participants were primarily recruited from MOVE! with HT-WM often used to extend MOVE! participation. During FY2010, high uptake sites enrolled a mean of 135 Veterans whereas a mean of 56 and 13 patients were enrolled at low uptake and late-adopting sites respectively. Dropout rates averaged 11% at high uptake sites compared to 37% at low uptake sites.
At 6 months post-enrollment, mean weight loss was comparable for HT-WM (n=417) and MOVE! (n=1543) participants across sites at -5.2 lbs (SD=14.4) and -5.1 lbs (SD=12.2) respectively (p=.90). HT-WM produced clinically significant weight loss ( 5% of baseline weight) in 22% of participants compared to 24% for MOVE! (p=.31). HT-WM participants were more likely than MOVE! participants to be White (81% vs. 65%, p=.0001) or from rural settings (57% vs. 42%, p=.0001). High uptake sites were characterized by high enrollment and modest mean weight loss of 5.9 lbs/patient with an average of 10 visits. Comparatively, low uptake sites had variable enrollment rates but averaged only 3.5 lbs/Veteran based on a 6 recorded HT-WM visits.
Qualitative interviews found high uptake sites had prior experience using telehealth programs for weight loss. Consequently, CFIR constructs that were strongly related to high uptake sites included Compatibility with existing processes of care to implement quicker, incrementally Piloting new methods to identify problems, and a culture of Reflecting and Evaluating based on a measurement-based approach to monitor program outcomes and increase provider buy-in. In contrast, lower uptake sites had trouble with Networking and Communicating among HT-WM staff and relevant facility providers to coordinate implementation efforts and had less Leadership Support to innovate. Notably, stakeholders across all sites reported high program Complexity because the HT-WM required more staff time per participant than conventional MOVE! programming due to logistical and technical assistance issues related to the devices.
Lessons learned from this study can be used to improve system design and expand the reach of future home telehealth programs for Veterans. Preliminary evidence suggests that HT-WM helps obese Veterans achieve short-term weight loss
To remedy identified barriers to program implementation, we recommend adapting the current program to a more efficient and user-friendly platform (i.e., interactive voice response or smart phones). In addition, efforts should be made to improve real time program feedback into medical records for patients and their care teams.
- Goodrich DE, Lowery JC, Burns JA, Richardson CR. The Phased Implementation of a National Telehealth Weight Management Program for Veterans: Mixed-Methods Program Evaluation. JMIR diabetes. 2018 Oct 9; 3(3):e14.
- Goodrich DE, Davis JA, Elliott HA, Damschroder LJ, Lowery JC, Richardson CR. Evaluation of CCHT-Weight Management (Tele-MOVE) Program Implementation. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.