This chapter will address the following American College of Graduate Medical Education competencies: systems-based practice and practice-based learning and improvement.

Systems-Based Practice: This chapter will help the pediatric health care provider understand systems level models of care and increase his or her awareness of the larger system of health care delivery that will improve their ability to interact with the system to optimize patient outcomes.

Practice-Based Learning and Improvement: This chapter will help the pediatric health care provider engage in ongoing QI in order to address childhood obesity and obesity-related comorbidities systematically in practice using advances in medical knowledge, epidemiology, and psychosocial and behavioral factors.

Systems of care is defined as a family-centered framework to guide optimal care for an individual by providing individualized targeted care and coordinating community-based services to achieve an outcome driven by shared responsibility and participation between the child, family, community, and health providers.¹ Systems of care is particularly relevant to children because they are not independent, cannot fully participate in making decisions, or ensure care is carried out as recommended and must rely on a supportive system to prevent and treat disease. Obesity is a chronic disease characterized by risk factors which are affected by the interplay of influences among family, school, community, and society in the child’s life. This is depicted in the adaptation of Bronfenbrenner’s ecological model² and care of the child with obesity and aligns with the systems of care framework (Figure 21-1).

Brief history of systems of care framework

The systems of care framework began as a mandate to the National Institute of Mental Health (NIMH) from Congress in 1983 to create a guide to care for children with serious mental health impairments. Once developed, the NIMH disseminated the guide through the Child and Adolescent Service System Program, providing funding and technical assistance to the states. Over the next 3 decades, several initiatives funded by the federal and state governments and private entities such as the Robert Wood Johnson Foundation (RWJF) and Anne E. Casey Foundation helped further fine tune, strengthen, and implement a system of care based on the following core values.¹

1. 
   

   Type and mix of services provided must be dictated by the child’s and family’s needs.

   
   
2. 
   

   Strength-based services, case management, interagency collaboration, and decision making should be provided in partnership with the family.

   
   
3. 
   

   Agencies, programs, and services must be responsive to the cultural, racial, and ethnic differences of the population they serve and provide culturally competent care.

With these values, the characteristics of care provided become cohesive, patient directed, and effective, as shown in Table 21-1. In summary, systems of care is not a model but rather a structure within which different models and techniques can coexist and be adapted to meet the child’s needs.

The Patient Protection and Affordable Care Act

In March 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA), the widest-ranging reform of our system of care in the past 4 decades.³ ACA is a comprehensive reform of the health care system, with provisions to expand access to insurance, increase consumer protections, emphasize prevention and wellness, improve quality and system performance, expand the health care workforce, and decrease health care costs. It has the potential to significantly impact the way health care is provided, especially for chronic conditions such as obesity.

Two sections of the ACA, Improving the Quality and Efficiency of Health Care (Title III) and the Prevention of Chronic Disease and Improving Public Health (Title IV), are especially relevant to childhood obesity.³ Components of Title III include the creation of an Innovation Center within the Centers for Medicare and Medicaid Services to test, evaluate, and expand different payment structures and methodologies to reduce program expenditures, while maintaining or improving quality of care. To evaluate current care, identify research priorities and conduct research that compares the clinical effectiveness of medical treatments; the ACA emphasized comparative effectiveness research and mandated the establishment of a nonprofit Patient-Centered Outcomes Research Institute (PCORI). Additional initiatives include community-based collaborative care networks referred to as accountable care organizations (ACOs) and support for patient-centered medical care.

Through these initiatives, Title III seeks to shift how care is provided to a more patient-centered, need-based approach that recognizes the link between lifestyle behaviors and disease, while being sensitive to the cost, effectiveness, and quality of care. Title IV supports the establishment of the National Prevention, Health Promotion, and Public Health Council to determine and coordinate a national public health strategy on prevention and wellness. Other components include increased access to clinical preventive services, enhanced reporting of racial or ethnic data for analysis of disparate outcomes, funding for childhood obesity demonstration projects, and nutrition labeling of standard menu and vending items.

Lifestyle behaviors have an enormous impact on health outcomes; the advantage of the ACA for childhood obesity is its national mandate to address lifestyle behaviors at both an individual and population level, while incorporating public health policy and community programs into our current system of health care. When implemented, this mandate has the potential to support reimbursement for lifestyle counseling provided by pediatric health care providers, allied health professionals, for example, dietitians and community-based health workers and coaches. More importantly, the ACA recognizes the importance of prevention as the first step of obesity management through its funding support for obesity demonstration projects, support for patient-centered care, and QI within the healthcare system.

In the next section, we will review the Ecological Model² (EM) and the Chronic Care Model (CCM).⁴ Both models are critical to understanding, preventing, or treating childhood obesity and relevant to establishing a system of care as outlined within the ACA.

The ecological model

The modified EM (see Figure 21-1) provides an ideal approach to the evaluation of behavioral and environmental assessments in clinical and nonclinical contexts.

The EM embraces the following core principles:

1. 
   

   Factors within multiple levels of intrapersonal, interpersonal, organizational, community, and public policy influence specific health behaviors.

   
   
2. 
   

   Influences on behavior interact across these different levels.

   
   
3. 
   

   Ecological models should be behavior-specific.

   
   
4. 
   

   Multilevel interventions should be most effective in changing behavior.

Historically, the EM has its origins in Bronfenbrenner’s micro-, meso-, and macro-levels of influence,² and has evolved to demonstrate the interactions between familial, cultural, community, organizational, and policy levels of behavior (see Figure 21-1). Because obesity is the result of complex interactions between genetics, behavior, and environments, the ecological model framework highlights the interactions of these influences. For example, lack of access to fresh fruits and vegetables (community, policy) will limit a parent’s likelihood of purchasing these food items (family) and the child’s consumption and preference (child).

This case illustrates that information obtained using an ecological approach can provide a more complete picture of the child’s risk factors, help in individualizing recommendations, and allow the child, family, and pediatric health care provider identify interventions most likely to be relevant or effective. At the individual or family level, family schedules, perceptions, and behaviors provide potential areas for education, goal setting, and skill-building. Zoning issues (advocacy opportunity) may not be immediately addressed, but alternatives for indoor physical activity such as specific timed exercises and DVDs can be recommended and negotiated. Physical activity can even be integrated into homework break times. The family’s monthly biking activity provides an opportunity to provide suggestions for more frequent activities. Information about nearby county or city walking paths, or parks and recreation facilities from his city or county public health department can be used to make the family more aware of other options for activity or to map a better route home from school.

Other evidence-based topics for discussion include the importance of “together” family meal times, healthy, non–fast food, snacks, and the relationship between increased screen time and increased BMI. Despite living in a food desert, more vegetables can be introduced into Peter’s diet if his mother understands that frozen and canned vegetables are adequate replacements for fresh ones, and is introduced to planning and preparing meals in advance (skill-building). These educational opportunities can lead to direct shared goal setting around screen time, minutes of daily physical activity, vegetable and fruit consumption, and family meals eaten together. In addition, this personalized information can help Peter, his mother, and health care provider to be more efficient in shared decision-making processes, because it is an opportunity to tackle scheduling, cultural, knowledge, and perception barriers. At another level, parents, through their experience of exploring their child’s health problems in relation to an EM, can be encouraged to become strong advocates for healthier lifestyles in the school and community.

The relationship between the ecological levels, behavior, and intervention is often complex. Personal characteristics related to eating behavior, physical activity, sedentary behavior, perceptions of weight status, or self-efficacy are elements which influence behavior change and shared goal setting. Perceptions, behaviors, and resources within the family as well as factors such as the family’s daily, weekly, or monthly work or school schedules, prioritization of healthy lifestyles, coping strategies, income, and mealtime behaviors all affect the child and family lifestyle behavior.

At the community and/or societal level, location of the family dwelling, community assets, socioeconomic level, proximity to and concentration of fast-food restaurants, availability and quality of grocers, parks, recreational facilities, and neighborhood safety are all factors that exert an additional level of influence on the child’s and family’s lifestyle behavior. It is important to recognize that there are often several pathways through which each factor can exert its influence on the child or family. For example, federal school policy on academic performance and standards usually define school schedules, limiting opportunities for physical activity during the school day. State-level budgetary policy may mandate a specific funding regimen that leads to fewer school nurses and decreased ability to conduct BMI screening, limiting the potential to use the school BMI screening as an avenue to communicate concern about the child’s weight to the parent and encourage intervention.

Other factors at a societal level that are important include diversity of resources available to the child, access to the health care system, and the stability of the community. For instance, state and local policies for schools, zoning, joint use agreements between schools and the neighborhood, farm to school programs, walk to school programs, workplace wellness, and safety policy may hinder or facilitate potential strategies for intervention that eventually affect the child’s weight. Understanding these interrelationships and consequences within the EM is also an opportunity for advocacy, community collaboration, and capacity-building.

While the EM is an excellent framework to understand etiology of the problem, it provides limited guidance on integrating the framework into a broader administrative setting. Another framework, the CCM, addresses this gap.

The chronic care model

The CCM, an evidence-based approach to chronic diseases, provides an opportunity to use a systems level approach to address socioecological influences and maintain continuous QI.⁴ The framework is broad enough to address the social contexts of disease and flexible enough to accommodate individual customization. Tenets of the CCM are emphasized in Healthy People 2020, with its emphasis on shared decision-making between child, family and providers, personalized self-management strategies and resources, improved health literacy, cultural competency, and outreach to diverse and underserved populations.⁵

The CCM was created by Edward Wagner and colleagues at the Group Health Cooperative of Puget Sound, Seattle, WA based on a review of interventions in chronically ill populations. Systematic reviews on the use of CCMs in obesity, diabetes, and cardiovascular disease have demonstrated a positive correlation between the number of components of the model used and the effectiveness and quality of care.^6,7

In this section, we will review strategies for integrating the 6 components of the CCM into the evaluation, prevention, and treatment of child and adolescent obesity (Table 21-2).