| On-site primary care staff interviews regarding the MA referral process and EHR-based coaching |
Theme 1: Most MAs worked primarily with 1-2 providers in a close-working relationship. Daily huddles occurred with only a few providers. MAs roomed patients, measured vital signs, measured weight and height, performed medication reviews, documented the reason for visit, and reviewed and pended health maintenance needs using protocolized orders sets. They reported doing informal counseling: “When Dr. V comes in, we do a huddle. Every morning, and she lets us know if she wants us to add something to it, or you know, what she wants to add to the previous a planning sheet.” “I’m always with Dr. XX usually but if she’s not here and I’m here that I will help with other providers but when she’s here I’m with her.”
Theme 2: Workflow is distributed throughout the visit timeline. Review of health maintenance needs, pending orders, and chart review were often done prior to the patient intake, making the alert activation on visit intake too late: “A lot of times patients will talk a lot. And then I completely forget about health maintenance, because it took so long to go through the questions. So, I tried to pend it all (orders) before or just at least review.”
Theme 3: MAs worry about offending patients by bringing up weight. It might not be typical of the MAs tasks: “But like, if I were to ask a patient, I see that you have lost weight over the two years, I don’t know if they’re gonna take that, like, Do I look sick? Or do I? Did I look fat to you?” “We kind of found that it was something that was better brought up by the physician; patients would get like offended when the MA would talk to them about it and then be completely okay with talking to the physician about it, which happens quite a lot.”
Theme 4: Referring patients to a new program might be adding a lot of added work: “It just depends on what it entails after the training cause I sort of don’t like it when they keep adding extra things for us to do at check in especially when they tell us they want us to be checking in faster and I’m like what you’re having me review this this this this this this this and asking these additional questions like at first with the care gaps I hated asking those it added like another 5 minutes to my checking in process.”
Theme 5: MAs and RNs viewed the program as valuable: “We see that weight loss maintenance could be a real benefit to a lot of people. So that’s the reasoning behind talking to them.”
Theme 6: RNs served as care managers in most clinics. The RNs interviewed reported that coaching was part of their normal scope of practice: “Yes, just because that’s quite often somebody’s health goals, whether they’re diabetic CHF, or you know, so many things. So, it’s kind of a natural fit.”
Theme 7: MAs (about 30%) showed interest in coaching and felt like it was in their scope of practice. They perceived additional time or support would be needed: “Yeah, they’re usually pretty good about if we have stuff like this, they can find someone to cover me or whatever. So as long as it is scheduled.” “Yeah, um, I don’t do as much online. But I’m sure if [manager name], my manager thought it was good I did. Yeah, no problem.”
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| On-site primary care administrator interviews |
Theme 1: Administrators experienced significant stress in maintaining adequate staffing due to COVID, either because there were more MAs out sick, high turnover, or because telehealth visits took more time to set up. However, they expected stress levels to be temporary: “Interviewer: And then do you have a lot of turnover of your medical assistants? and nurses here?” “Manager: Have COVID going on? Yes. A significant amount of burnout. But typically no.”
Theme 2: Administrators reported a favorable impression of the program and thought that it aligned with the clinic’s mission, but worried about adding another improvement project onto many: “Yeah, yeah. And of course, you want to do the best we can for the patients on everything. So just you know, there’s, there’s always, there’s always room for improvement.” “… there’s usually there’s usually four or five projects that we’re doing all at once. And, and so whenever we’re talking about adding another project, there is a fair amount of fatigue.”
Theme 3: Using MAs as coaches could cause extra burden as MAs already do many tasks. No prior rules were put in place regarding how and when coaches could work, other than they had to complete the coaching during work time: “Okay, yeah, we might be able to do that for MAs, or, you know, that’s a resource that’s very limited. There’s always downward pressure on reducing the number of MAs that you have a clinic. So, so we don’t have an abundance.”
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| Provider interviews on Zoom |
Theme 1: Dealing with weight issues requires persistence as they are common, time consuming, and linked to many other chronic diseases: “I would say, these days, it seems like every at least two or three to eight times a half-day session, so say 20% to 30% of the time because a lot of folks have gained weight within the context of COVID. And so, a lot of folks are finding that their weight is higher than it was last year. And so, it prompts the discussion.” “So, I think it really depends on what is the comorbidity for which they are being evaluated, if it was purely a weight-based discussion, and they don’t have any, they don’t have hypertension, yet, they don’t have diabetes, they don’t have sleep apnea, they don’t really have problems with, you know, terrible back pain or arthritis related complications from obesity, then, you know, we might touch base again, and something between three or four months from our original visit.”
Theme 2: Tailoring and targeting: strategies to help patients with weight management must be patient-centered, tailored to their personal motivation, and contextualized: “What I’d see is what I’d say with this example is that, um, is that their lifestyle, meaning like their husband works first shift, they work second shift, they’ve got teenagers in the house, there’s so many competing social factors that we’re looking for kind of small gains or small wins…” “And it’s pretty much whatever you choose to do needs to be something that you can live with.”
Theme 3: Weight management with a patient requires a partnership over time with the whole team involved: “I’ve been caring for her for over a year. So, I see her many times, and we correspond via email and MyChart and all that kind of stuff” “I would say something maybe, you know, closer to a month or so, three weeks or four weeks at the earliest, oftentimes would kind of give them you know, three months, usually, or up to six months to really, to follow up, if on the longest, but usually kind of a two-to -three-month interval… And then that would be an appointment. And yeah, yeah, generally a follow up phone, yeah, follow up appointments. And sometimes they’ll say, you know, keep a weekly log…”
Theme 4: The MAINTAIN PRIME program could be a valuable addition to the current available tools to help with an important problem: “You know, like, for example, like, that (MAINTAIN) can be a carrot at the end of the stick for a lot of people when you’ve talked about improvements in the blood pressure and diabetes control and things like that improved with, you know, modest weight loss” “Yeah, I have. I certainly have given many referrals for a dietitian, and it is very rarely followed, followed through.”
Theme 5: Having MAs be the first point of contact about a weight issue should be carefully considered: “I would say I have two very good MAs who’ve been with us a long time… I guess the people who qualify for this have lost weight, which is a good thing. But weight is so emotional. For so many of the patients, I have to say I’m not sure my MAs would feel comfortable with it. And I also think they don’t have time in their flow to do this.” “Sure, I think they could do it with a script.”
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