Models for Delivering Weight Management in Primary Care: Qualitative Results from the MOST Obesity Study

Jodi Summers Holtrop; Lauri Connelly; Rebekah Gomes; Laurie Fitzpatrick; Claude Rubinson; Rowena J. Dolor; R. Mark Gritz; Zhehui Luo; Bonnie Jortberg; Andrea Nederveld

doi:10.3122/jabfm.2022.220315R2

Article Figures & Data

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Table 1.

Characteristics of Participating Practices

Practice Characteristic	N (%)
Discipline
Family Medicine	10 (48)
General Internal Medicine	11 (52)
Practice Size
Small (less than 4 providers)	17 (81)
Medium (4 to 6 providers)	1 (5)
Large (more than 6 providers)	3 (14)
Ownership
Private	17 (81)
Health system	4 (19)
Location
Urban	11 (52)
Rural	2 (10)
Suburban	8 (38)
Geography
Northeast	3 (14)
South	9 (43)
Midwest	8 (38)
West	1 (5)

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Table 2.

MOST Study Phase 2 Data Sources for This Analysis

Data Source	Product	Unit
Practice tour	Field notes using template	One per practice
Patient visit observations	Visit summary using template	One per patient (n = 2 to 10 per practice)
Practice member interviews	Recordings made into transcriptions	One per interviewee (n = 1 to 6 per practice)
Cost and resources oral survey	Accounting of resources needed and their associated monetary costs using template	One per practice

All	Practice summary	One per practice

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Table 3.

Weight Management Services Delivery Model Features

Feature	Description	Categories
Visit type	How the visit with the patient was conducted	Individual, Group, Both
Role of provider	Key personnel involved in delivering weight management	Physician, Advanced Practice Provider, Registered Dietitian, Other
Multidisciplinary team	Use of different specialist training in the delivery of weight management	Yes, No
Program development	How the program was developed	External program, Self-developed Program, No Program
Weight loss approach	The diet and/or physical activity and/or other way of obtaining weight loss results	Healthy lifestyle, High protein/keto, Calorie reduction, Other
Methods to facilitate weight loss	The use of other methods or services to facilitate use of the approach	Medications, Meal replacement, supplements, Apps or online tools, Educational materials, Other
Counseling approaches	Approaches for behavioral management of weight loss	Stress, Mindfulness, Therapy, None, Other
Focus of practice	If weight loss services are a focus of the practice	Weight loss only, Blended into primary care, Combination
Method of payment	How the practice financially sustains the weight loss services	IBT for obesity, E&M codes, Patient self-pay, Subsidized

Abbreviation: IBT, Intensive Behavioral Therapy for Obesity.

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Table 4.

Qualitative Categorical Analysis of Model Features by Participating Practice

Practice ID	Visit Type (Individual, Group, Both)	Type/Training of Key Role in Program Delivery (Physician, Nurse Practitioner or PA, Registered Dietitian, Others)	Additional Role Types in Delivery Using an Interdisciplinary Team Approach (yes/no)	Set Program Approach (Purchased Program, Self-Developed or no)	Weight Loss Focus of the Clinic (Blended with other primary care, Partial weight loss clinic, Weight loss only clinic)	Weight Loss Approach	Methods to Facilitate Weight Loss	Method of payment (IBT plus others insurance billing, other insurance billing, self-pay plus ins billing, self-pay only)
Integrated into Standard Primary Care Model
1	IND	PHYS	NO	SELF	BLENDED	HL	EDUC, CSLG	IBT
1	IND	PHYS	NO	SELF	BLENDED	HL	EDUC, CSLG	OTHER
2	IND	PHYS	NO	NO	BLENDED	HL	MEDS, CSLG	IBT
2	IND	PHYS	NO	NO	BLENDED	HL	MEDS, CSLG	OTHER
3	IND	NP/PA	NO	NO	BLENDED	HL, PA	EDUC, MEDS	OTHER
3	IND	NP/PA	NO	NO	BLENDED	HL, PA	EDUC, MEDS	SELF-PAY
4	IND	PA	NO	NO	BLENDED	HL, PA	EDUC, MEDS	OTHER
4	IND	PA	NO	NO	BLENDED	HL, PA	EDUC, MEDS	SELF-PAY
5	IND	PHYS	NO	SELF	BLENDED	HL, CAL RED	EDUC, MEDS, BF, CSLG	IBT
5	IND	PHYS	NO	SELF	BLENDED	HL, CAL RED	EDUC, MEDS, BF, CSLG	OTHER
6	IND	PHYS	YES	SELF	PARTIAL WEIGHT LOSS	HL, PA	EDUC, SUP EX, BF, CSLG	IBT
								OTHER
								SELF-PAY
Other Professional Model
7	IND	PHYS, RDN	YES	SELF	WEIGHT LOSS ONLY	HL, CAL RED	EDUC, MEDS, BF, CSLG	OTHER
7	IND	PHYS, RDN	YES	SELF	WEIGHT LOSS ONLY	HL, CAL RED	EDUC, MEDS, BF, CSLG	SELF-PAY
8	IND	RDN/FOOD SCIENTIST	NO	SELF	BLENDED	HL, CAL RED	EDUC, CSLG, SUP EX	IBT
9	IND	RDN	NO	NO	BLENDED	HL	EDUC	OTHER
10	IND	RDN	NO	SELF	BLENDED	HL, CAL RED	EDUC, CSLG	IBT
10	IND	RDN	NO	SELF	BLENDED	HL, CAL RED	EDUC, CSLG	OTHER
11	IND	RDN	NO	SELF	BLENDED	HL	EDUC	OTHER
12	IND	RDN	NO	PURCHASED	BLENDED	HL	EDUC, CSLG, SUP EX	IBT
12	IND	RDN	NO	PURCHASED	BLENDED	HL	EDUC, CSLG, SUP EX	OTHER
Purchased (or Developed) Program Model
13	IND	PHYS	NO	SELF	BLENDED	HP, PA, IF	MEDS, MEALS	IBT
13	IND	PHYS	NO	SELF	BLENDED	HP, PA, IF	MEDS, MEALS	OTHER
14	IND	HEALTH COACH	NO	PURCHASED	PARTIAL WEIGHT LOSS	HP	APPS, EDUC, MEALS	IBT
								OTHER
								SELF-PAY
15	IND	PHYS/NP	NO	SELF	WEIGHT LOSS ONLY	HL, CAL RED	APPS, MEALS, SUPP, EDUC, MEDS, CSLG, BF	IBT
								OTHER
								SELF-PAY
Group Model
16	GROUP	HEALTH COACH	YES	SELF	BLENDED	HL, CAL RED, IF, HP	EDUC	IBT
								OTHER
								SELF-PAY
17	GROUP	NP	NO	SELF	BLENDED	HL	EDUC, CSLG	IBT
Multiple Models
18	IND	PHYS	NO	SELF	PARTIAL WEIGHT LOSS	HL, CAL RED	EDUC, MEALS, MEDS, SUPP, BF, CSLG	IBT
18	IND	PHYS	NO	SELF	PARTIAL WEIGHT LOSS	HL, CAL RED	EDUC, MEALS, MEDS, SUPP, BF, CSLG	OTHER
19	BOTH	PHY/RDN/BEH HEALTH PROVIDER/FITNESS	YES	SELF	WEIGHT LOSS ONLY	HL, PA, HP	APPS, EDUC, MEALS, SUP EX, MEDS, CSLG	SELF-PAY
19	BOTH	PHY/RDN/BEH HEALTH PROVIDER/FITNESS	YES	SELF	WEIGHT LOSS ONLY	HL, PA, HP	APPS, EDUC, MEALS, SUP EX, MEDS, CSLG	OTHER
20	BOTH	RDN	YES	PURCHASED	BLENDED	HL	EDUC, CSLG	IBT
								OTHER
								SELF-PAY
21	BOTH	PHYS	YES	SELF	PARTIAL WEIGHT LOSS	HL, CAL RED, HP	APPS, EDUC, MEALS, REP, SUPP, BF, CSLG, SG	IBT
								OTHER
								SELF-PAY

Abbreviations: IBT, Intensive Behavioral Therapy for Obesity. EDUC = Education; APPS = Web Apps; MEALS = Meal Replacements; MEDS = Prescribed Meds; HL = Healthy Lifestyle; SUPP = Supplements or vitamins; HP = Keto or other high protein; SUP EX = Supervised Exercise; PA = Physical Activity; BF = Biofeedback; CAL RED = Calorie Reduction; CSLG = Counseling; IF = Intermittent Fasting; SG = Support Group.

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Table 5.

Predominant Weight Management Delivery Models in Participating Practices

Distinguishing Feature	Description	Classification of Features	General Description of Model in Practice
Integrated into Standard Primary Care Model
Medical provider delivers weight management interspersed with other patient care	Medical provider provides individualized weight management counseling within the daily care of other patients	Visit type = individual Role of provider = Physician or APP Multidisciplinary team = Not usually Program development = Self or other Weight loss approach = Variable Methods to facilitate weight loss = Meds, apps, ed materials Counseling approaches = Variable Focus of practice = Blended Method of payment = Variable, usually E&M	Usually a physician, although can be an APP External program not needed due to professional expertise Focus on healthy lifestyle approach usually although some focus on high protein diet Other methods often included apps and use of medications Paid for by insurance billing and some patient co-pay
Other Professional Model
Another provider that is not the medical provider delivers the care	Medical provider identifies and refers internally to another professional to provide individual weight management counseling	Visit type = usually individual Role of provider = RDN, BHP, other Multidisciplinary team = Sometimes Program development = Self Weight loss approach = Lifestyle Methods to facilitate weight loss = Ed materials, Medications Counseling approaches = Variable Focus of practice = Variable Method of payment = Variable	Usually an RDN, although can be another knowledgeable provider External program not needed due to professional expertise Focus on healthy lifestyle approach Other methods usually not needed, but sometimes apps and educational materials utilized Paid for by insurance billing and some patient co-pay
Purchased (or Developed) Program Model
Following a program developed externally or self-development of a program that follows similar protocols	Practice contracts (purchases license) with a provider of weight management services to deliver the specified program within their practice	Visit type = individual Role of provider = physician, APP Multidisciplinary team = Sometimes Program development = other Weight loss approach = Often keto/protein, other Methods to facilitate weight loss = Ed materials, meal replacement, supplements Counseling approaches = Variable Focus of practice = Often full weight loss or partial weight loss Method of payment = Variable, often self-pay	Usually provided by a combination of visits with medical provider occasionally and health coach or medical assistant for regular check-ins External program licensed Focus on high protein/keto Other methods usually include meal replacement and/or supplements, and educational materials utilized Mostly paid for by patient self-pay, some insurance may cover physician visits
Model: Group program
Group delivery distinct from all other models	Patients gather together for a group educational and support program led by someone from the practice with group facilitation skills and knowledge and/or using a weight loss curriculum	Visit type = group Role of provider = APP, RDN, other Multidisciplinary team = Sometimes Program development = Self or other Weight loss approach = Lifestyle Methods to facilitate weight loss = Ed materials Counseling approaches = Variable Focus of practice = Blended Method of payment = Variable	Facilitator was usually an APP or health coach, but could be any knowledgeable provider Either developed program (not purchased) or self-developed if professional expertise Focus on healthy lifestyle approach Uses educational materials Paid for by IBT group visit, patient self-pay