Care Model Program Research Articles

Oncology care model cost data for breast, lung, and multiple myeloma: Influence of outpatient rehabilitation therapy services.

14 Background: High value cancer care is defined by access to coordinated, appropriate healthcare services that achieve optimal outcomes at a reasonable cost. Evidence supports outpatient cancer rehabilitation (physical, occupational or speech therapy) as a mechanism to improve outcomes such as health-related quality of life, suggesting that integration of these services is beneficial for cancer survivors. However, the impact of outpatient rehabilitation services on healthcare costs is unknown. We aimed to compare cost segments between those who attended community-based outpatient rehabilitation therapy services (Rehab) versus those who did not (Non-rehab). We hypothesized that healthcare costs would be lower for the Rehab group in the following cost segments: emergency department (ED), part D drugs, home health services, skilled nursing facility services (SNF), inpatient rehabilitation facilities (IRF), and hospice. Methods: This is a retrospective cohort study of Medicare beneficiaries who received chemotherapy at a large community oncology practice that participated in the oncology care model (OCM) program from 2018 to 2021. Two data sources were linked, OCM cost data and the rehabilitation medical record. This yielded sufficient sample sizes for analysis of breast, lung, or multiple myeloma (MM) cancer types. Rehab cases were then matched to Non-rehab cases 3:1 based on cancer type, stage, and sex. Cost variables included total cost of care (TCOC) and cost segments using OCM methodology. Mann-Whitney-Wilcoxon statistic (p<.05) was used for analysis. Results: Cases (N=3,033) primarily had early-stage cancer (0 to 2, 74.8%) and were 70.4±7.3 (Rehab) or 71.6±8.5 years old at diagnosis (Non-rehab). Most had breast cancer (81.2%), followed by lung cancer (11.7%) and MM (7.2%). TCOC was $32,387 and $26,257 for the Rehab and Non-rehab groups, respectively. Costs were significantly lower for the Rehab group in five of the six segments analyzed; IRF costs were lower, but not statistically significant (Table). Conclusions: To our knowledge, this is the first study to explore the influence of real-world, outpatient cancer rehabilitation therapy services on the cost of cancer care. Community-based therapy services were associated with significantly lower costs in ED, part D drugs, home health, SNF, and hospice segments. Future studies examining rehabilitation services as a relatively low-cost supportive care option to meet patient needs and enhance high-value care are warranted. Healthcare segment costs for rehab vs. non-rehab cases. Rehab Non-rehab Between-group Difference Mean, (SD) Mean (SD) p-value ED $85 (260) $104 (372) .019 Part D drugs $4,813 (18,221) $5,675 (18,797) <.001 Home health $433 (1,600) $705 (2,118) <.001 SNF $160 (1,988) $386 (3,943) .046 Hospice $75 (770) $198 (1,529) <.001 IRF $245 (2,275) $384 (3,277) .434

Understanding and supporting change in health systems using the strategic action fields framework: the availability and origin of sources of authority

ABSTRACT Policy-driven change in public service systems is difficult to implement. We focus upon ‘sources of authority’, which figure within the Strategic Action Fields Framework (SAFF) as resources mobilized by socially skilled actors to catalyse and sustain change. Drawing on qualitative case studies evaluating a large-scale policy-driven change in the English NHS, the Vanguard New Care Models programme, we (1) expand the definitions of ‘sources of authority’ and (2) argue that ‘sources of authority’ vary across two intersecting dimensions. This expands the utility of the SAFF beyond understanding and evaluating policy impact, and offers practical opportunities for achieving change.

Prognostic Impact of the UMIPIC Program in the Follow Up in Patients with Heart Failure and Cardiorenal Syndrome

Background: Individuals suffering from heart failure (HF) and cardiorenal syndrome (CRS) represent a special group of patients considering their age, multiple health issues, and treatment challenges. These factors make them more susceptible to frequent hospital stays and a higher mortality rate. UMIPIC is a multidisciplinary care model program for patients with heart failure follow up provided by internists and nurses who are experts in this entity. Our study delved into the effectiveness of this specialized care program (UMIPIC) in mitigating these risks for HF and CRS patients. Methods: We analyzed the medical records of 3255 patients diagnosed with HF and CRS types 2 and 4, sourced from the RICA registry. These patients were divided into two distinct groups: those enrolled in the UMIPIC program (1205 patients) and those under standard care (2050 patients). Using propensity score matching, we ensured that both groups were comparable. The study focused on tracking hospital admissions and mortality rates for one year after an HF-related hospital stay. Results: Patients in the UMIPIC group experienced fewer hospital readmissions due to HF compared to their counterparts (20% vs. 32%; Hazard Ratio [HR] = 0.48; 95% Confidence Interval [95% CI]: 0.40–0.57; p < 0.001). They also showed a lower mortality rate (24% vs. 36%; HR = 0.64; 95% CI: 0.54–0.75; p < 0.001). Furthermore, the UMIPIC group had fewer total hospital admissions (36% vs. 47%; HR = 0.58; 95% CI: 0.51–0.66; p < 0.001). Conclusions: The UMIPIC program, centered on holistic and ongoing care, effectively reduces both hospital admissions and mortality rates for HF and CRS patients after a one-year follow-up period.

What makes a socially skilled leader? Findings from the implementation and operation of New Care Models (Vanguards) in England

PurposeThe article aims to argue that the concept of “distributed leadership” lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the “Strategic Action Field Framework” (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar.Design/methodology/approachUsing the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019.FindingsWhile literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting.Originality/valueThe SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of “social skills” required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.

The effect of continuous care model on infant sleep habits in Bint Al-Huda educational and medical center in Bojnourd in 2019

Background: Sleep is one of the essential and vital needs of human and a factor that affects the growth and development of children. The basic learning of sleep habit is formed in childhood and the person tries to maintain it throughout life. Therefore, considering the importance of childhood in the formation of appropriate sleep habit, this study was conducted to investigate the effect of continuous care model on infant sleep habits in Bint Al-Huda medical center in Bojnourd. Methods: This interventional study was performed on 66 mothers attending the Bint Al-Huda Hospital in Bojnourd in 2019. Sampling was done by available method and the samples were randomly assigned to the intervention and control groups. The intervention group received a continuous care model program in 4 sessions. Each session lasted for of 45-60 minutes. Data collection tools included the demographic characteristics questionnaire and the Infant Sleep Habit Scale (ISQ). The collected data were analyzed by SPSS software version 16 using Fisher and Rapid Major statistical tests at the significance level of p <0.05. Results: The results of Rapid Major test showed a significant difference (P = 0.01) between the intervention and control groups at 1, 2 and 3 months after the intervention, so that sleep habits did changed in the intervention group at different times after the intervention, but in the control group, sleep habit disorders were observed. Conclusion: According to the obtained results, it is suggested that teaching mothers proper sleep habits in the long run can improve their knowledge and performance in improving sleep habits of their infants. Key words: Continuous Care Model, Sleep Habits, Infant

Ambiguity and Conflict in Policy Implementation: The Case of the New Care Models (Vanguard) Programme in England

AbstractPolicy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland’s (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid learning, scale and spread. We suggest that future programmes for large-scale policy implementation initiatives could be crafted differently to take account of the environment of implementation and render ambitions more realistic. Rather than aiming to create a set of definite products and templates, it may be that a set of principles for design and implementation should be developed and spread.

Development of a Transitional Care Model Program for Patients with Pneumonia, Asthma, and Chronic Obstructive Pulmonary Disease: In-depth Interviews with Readmitted Patients.

Community-based health management policies are needed considering societal aging. We aimed to develop a transitional care model (TCM) program for patients with pneumonia, asthma, and chronic obstructive pulmonary disease. First, we conducted in-depth interviews with patients who were hospitalized, released, and readmitted for those three conditions to identify issues with the current hospitalization/discharge system and post-discharge processes. Next, we developed a new TCM program suited to the realities of the current medical environment. Interviews revealed problems including inadequate awareness of disease and health management; insufficient information exchange between patients, caregivers, and primary medical institutions; and absence/low usage of community-based care services. The investigation applying the new TCM program to patients and following up on readmission rates and life satisfaction after discharge is ongoing. Reviewing these results and conducting further studies in the future will allow improvements to the model.

Lessons learnt from the implementation of new care models in the NHS: a qualitative study of the North East Vanguards programme

ObjectiveTo examine lessons learnt from the implementation of five Vanguard initiatives in the North East of England.DesignData collection comprised semistructured interviews with key informants at each site.SettingThe study took place...

Community oncologists perceptions and readiness to implement Medicare Access and CHIP Reauthorization Act (MACRA).

e18374 Background: The Medicare Access and CHIP Reauthorization Act (MACRA) was introduced in 2015 with the intention of transforming healthcare administration to improve the quality of care and lower its cost. Understanding challenges facing physicians in how to implement MACRA and recognizing their perceptions regarding these challenges are critical steps to the success of this program and future transformation efforts. Methods: In this study, US oncologists attending live meetings were surveyed on their perceptions of MACRA. Data were collected in 2 time periods: period 1 spanned Nov 2016 to Jun 2017 and period 2 spanned Sep 2018 to Nov 2018. Each physician attended a live meeting in each period. Data were collected in period 1 using audience response system technology and web-based surveys; period 2 data were collected using web-based surveys only. We aimed to compare responses between periods 1 and 2 to assess whether perceptions and challenges changed. Results: There were 97 community oncologists and/or hematologists who responded to both periods. Of the responding physicians, 31.2% were participating in the Oncology Care Model program. A greater proportion of physicians expressed some level of confidence in executing MACRA requirements and achieving financial success in period 2 compared to period 1 (74.2% vs 52.4%; P< 0.01). Additionally, more physicians in period 2 reported having the resources and staffing needed to manage changes required by MACRA (24.7% vs 11.4%; P= 0.02). Strategies in place to improve on compliance with MACRA did not significantly change between both periods (34.2% vs. 28.9%; P = 0.45). Confidence that MACRA would improve patient outcomes in the long-term was expressed by 33.0% in period 2, which was significantly higher than in period 1 (17.6%; P= 0.02). However, most physicians in period 1 were not confident that MACRA would reduce cost of care (89.6%), but this improved to 61.9% in period 2 ( P< 0.01). Conclusions: Over time, oncologists seem more confident about their practices’ readiness for implementing MACRA. However, they remain skeptical of MACRA’s likelihood of improving quality or cost of cancer care and appear to need better strategies to assure sustainability.

Implementing new models of care: Lessons from the new care models programme in England.

In 2014, the body that leads the National Health Service in England published a new strategic vision for the National Health Service. A major part of this strategy was a three-year-long national programme to develop new care models to coordinate care across primary care, community services and hospitals that could be replicated across the country. Local ‘vanguard sites’ were selected to develop five types of new care model with support from a national team. The new care models programme provided support for local leaders to enable them to collaborate to improve care for their local populations. We interviewed leaders in the vanguard sites to better understand how they made changes to care locally. Drawing on the insights from these interviews and the literature on cross-organisational change and improvement we devised a framework of 10 lessons for health and care leaders seeking to develop and implement new models of care. The framework emphasises the importance of developing relationships and building capability locally to enable areas to continuously develop and test new ideas.

Building workforce capacity and capability for integrated working

Introduction: Context – The NHS England (NHSE) Five Year Forward View (2015) aims to improve health, the quality of care and the predicted financial gap of 30 billion pounds by 2021. Strategic initiatives include prevention and self-care; enhancing primary care; efficiency measures; technology and innovation; workforce development; ‘local’, ‘joined up' services delivered ‘out of hospital’. In 2015, 29 ‘vanguard’ sites were chosen as part of the NHS New Care Models Programme to develop and test different, innovative, local models of integrated care. These models include ‘multispecialty community provider’, ‘enhanced health in care homes’, ‘acute care collaborations’,’ urgent and emergency care collaborations’ and ‘primary and acute care’ systems. The Sunderland ‘multispecialty community provider’ site is in the northeast of England (high deprivation). Risk stratification shows that 3% of the population account for 50% of the health/social care spend (frail elderly with 2 or more co-morbidities with high risk of hospital admission). Three models have been developed in Sunderland – Enhanced primary care; Community integrated teams (one in each of the 5 areas of the city); a Recovery at home service to facilitate early discharge and prevent re-admission. The problem – Workforce planning ‘across the system’ had not been addressed. Key issues - Historic recruitment challenges, workforce engagement, change management and governance. Practice change implemented: The University of Sunderland was commissioned to carry out action research to support the development of an integrated workforce strategy and planning process Aim and theory of change: Research questions: What are the skills, knowledge and behaviours which staff need to work in integrated care to deliver high quality effective care for patients? How can current workforce development and planning approaches be improved and delivered? Action research includes phases of action and evaluation, with findings fed back into the service developmental process. It is useful when there is little evidence of best practice, where new roles/services are being developed, or there is potential for tension across services. It can also support behavioural change. The research includes documentary analysis, semi-structured interviews and focus groups. Targeted population/stakeholders: System leaders, frontline health/social care staff, patients/carers Timeline: January 2016 - April 2017 (3 phases) Highlights: This final phase is focussing on the patient and carer perspective of the new workforce for integrated care. Early themes about skills required for integrated care are linked to developing 'teamness', managing increasing demand and need, and the challenges of developing holistic care (including psychological support) across the system. Workforce planning to address these challenges is still not evident within the integrated care system. The skills to support workforce planning are in short supply Sustainability: The outputs of the research are being built into the strategic. operational, and workforce planning processes to enable integrated workforce planning and development. Transferability: Research findings are fed back to the national NHS New Care Models workstream to share learning across vanguard sites and to develop the evidence base. Conclusions: Overall themes: The need to develop impact measures for new roles in integrated care to ensure there are no unintended consequences in the ‘system’ Governance and accountability across the system - setup a ‘system wide workforce group’ The need to develop an organisational development strategy to ensure staff engagement and leadership skills A plan for ‘upskilling’ staff The development of a dataset for the ‘system’ workforce To develop a compact to support the development of future workforce planning approaches The workforce group to commence modelling of the future workforce using evidence based tools provided by NHS England A system wide training needs analysis Workshops to be held with locality leads to support future workforce modelling To pilot ‘care co-ordination’ and to agree a local definition Lessons learned: Action research to support integrated workforce development and planning is an approach which can raise awareness of the challenges across a range of sectors

Using action research for workforce development and planning in integrated care

Introduction: Context – The NHS England (NHSE) Five Year Forward View (2015) aims to improve health, the quality of care and the predicted financial gap of 30 billion pounds by 2021. Strategic initiatives include prevention and self-care; enhancing primary care; efficiency measures; technology and innovation; workforce development; ‘local’, ‘joined up' services delivered ‘out of hospital’. In 2015, 29 ‘vanguard’ sites were chosen as part of the NHS New Care Models Programme to develop and test different, innovative, local models of integrated care. These models include ‘multispecialty community provider’, ‘enhanced health in care homes’, ‘acute care collaborations’,’ urgent and emergency care collaborations’ and ‘primary and acute care’ systems. The Sunderland ‘multispecialty community provider’ site is in the northeast of England (high deprivation). Risk stratification shows that 3% of the population account for 50% of the health/social care spend (frail elderly with 2 or more co-morbidities with high risk of hospital admission). Three models have been developed – Enhanced primary care; Community integrated teams (one in each of the 5 areas of the city); a Recovery at home service to facilitate early discharge and prevent re-admission. The problem – Workforce planning ‘across the system’ had not been addressed. Key issues - Historic recruitment challenges, workforce engagement, change management and governance. Practice change implemented: Action research to support the development of the workforce to deliver integrated care. Aim and theory of change: Research questions: What are the skills, knowledge and behaviours which staff need to work in integrated care to deliver high quality effective care for patients? How can current workforce development and planning approaches be improved and delivered? Action research includes phases of action and evaluation, with findings fed back into the service developmental process. It is useful when there is little evidence of best practice, where new roles/services are being developed, or there is potential for tension across services. It can also support behavioural change. The research includes documentary analysis, semi-structured interviews and focus groups. Targeted population/stakeholders: System leaders, frontline health/social care staff, patients/carers Timeline: January 2016 - April 2017 (3 phases) Highlights: Documentary analysis and scoping interviews with ‘system leaders’ in phase 1 elicited themes/challenges which have been translated into actions and are being implemented and evaluated (report Autumn 2016). Sustainability: The process/outputs will be evaluated as part of the final report Transferability: Findings are fed back to participants for validation and the New Care Models workstream to share learning and develop the evidence base. Conclusions: Phase 1 themes/challenges: • Day-to-day management • Team-working • The change process • Technology skills • Mental health skills • Patient/carer engagement and co-production • Clinical pathway development • Care co-ordination • Holistic care skills - prevention and self-care Discussion: Phase 1 results have provided a focus for the development of a workforce strategy for integrated care. Action research appears to support the engagement and development of the workforce – this will be tested further in phase 2/3. Lessons learned: To date: Building trust to share information/learning between partner organisations from the onset

COMPREHENSIVE CARE FOR JOINT REPLACEMENT PATIENTS: HISTORY AND NEW ACHIEVEMENTS

Talk #1 Content Outline: Bundle Payment Model is a mechanism to accelerate the health care system’s transition to alternative payment model and value-based care. Bundle payment aims to align incentives between payers and the various providers and suppliers to improve quality, outcomes and reduce costs. The importance of coordinated care across provider settings is a critical component of care transformation. The session will provide insights as to the experience in the Montefiore Health system in the implementation of the Bundled Payment program and lessons learned. Talk #1 Speaker Expertise: Eliza Ng, MD, MPH is a Senior Medical Director, Care Management Organization, Montefiore Health System, Adjunct Professor New York University School of Medicine Dr Ng provides leadership in medical and population health management of the ACO and Value Based Care Programs. She provides management leadership in Montefiore’s BPCI for joint and the Oncology Care Model Program, a CMS demonstration project in oncology bundle payment,

A Chronic Care Model Program Incorporating Group Office Visits for Obesity Treatment in Primary Care

Background. Obesity is a chronic disease of epidemic proportions. Primary care providers are on the front line of diagnosing and treating obesity and need better tools to deliver top-notch obesity care. Methods. A pilot randomized trial was conducted to test a chronic care model (CCM) program for obesity compared to usual care. Primary care patients, 18 years and older, with a body mass index (BMI) between 27 and 45 were enrolled. Sixteen weekly 90-minute group office visits were structured with the first 30 minutes encompassing individualized clinical assessments and the final 60 minutes containing the group-based standardized intensive lifestyle training. The primary outcome was weight change at 16 weeks. Secondary outcomes were weight change at 24 weeks, change in diet and physical activity behaviors, self-efficacy for weight control behaviors, and physiologic markers of cardiovascular risk at 16 and 24 weeks. Results. The participants (19 in the active arm and 10 in the control arm) were 49.8 ± 11.5 years old (mean ± SD), 97% women, 55% white, and 41% black. Weight change in the control arm at week 16 was 0.25+ 2.21 kg (mean + SD) and that for the active arm was -5.74 + 4.50 kg (n=16). The difference between the two arms was significant (p = 0.0002). Both the intent-to-treat analysis using the last observation carried forward approach and the analysis including completers only provided similar siginificant results. Conclusions. This study demonstrated that a CCM program incorporating group office visits was feasible and effective for obesity treatment in primary care settings.

The Effect of a Holistic Program on Health-Promoting Behaviors in Hospital Registered Nurses

The purpose of the study was to examine the effect of a holistic program, the Collaborative Care Model (CCM) Program, and the development of a self-care plan on health-promoting behaviors in hospital nurses. A quasi-experimental, pretest, posttest, repeated measure, comparison-group design was used. The study was conducted in a large, academic medical center in the northeast. The experimental group included registered nurses (RNs) from units in one institution introduced to the CCM and development of a self-care plan in an 8-hour program. The control group received no intervention. Data were collected using the Health Promoting Lifestyle Profile II instrument (HPLP II); a 52-question Likert-type scale with six subscales examining health-promoting behaviors. Using repeated measures analysis of variance there was a significant increase (p = .02) in the overall HPLP II mean, spirituality ( p = .04), interpersonal relations (p = .04), and nutrition scores (p = .04) of the experimental group as compared over time with the control group. The CCM plus the development of a self-care plan significantly increased overall health promoting behaviors, and spirituality, interpersonal relations, and nutrition scores in these RNs.

Outcomes of Comprehensive Heart Care Programs in High-Risk Women

The purpose of this study was to improve the fund of knowledge, reduce cardiovascular disease (CVD) risk, and attain Healthy People 2010 objectives among women in model women's heart programs. A 6-month pre/post-longitudinal educational intervention of high-risk women (n = 1310) patients at six U.S. women's heart programs consisted of comprehensive heart health counseling and use of American Heart Association/American College of Cardiology (AHA/ACC) Evidence-Based Guidelines as enhancement to usual care delivered via five integrated components: education/awareness, screening/risk assessment, diagnostic testing/treatment, lifestyle modification/rehabilitation, and tracking/evaluation. Demographics, before and after knowledge surveys, clinical diagnoses, laboratory parameters, and Framingham risk scores were also determined. Changes in fund of knowledge, awareness, and risk reduction outcomes and Healthy People 2010 objectives were determined. At 6 months, there were statistically significant improvements in fund of knowledge, risk awareness, and clinical outcomes. Participants attained or exceeded >90% of the Healthy People 2010 objectives. Proportions of participants showing increased knowledge and awareness of CVD as the leading killer of women, of all signs and symptoms of a heart attack, and calling 911 increased significantly (11.1%, 25.4%, and 34.6%, respectively). Health behavior counseling for physical activity, diet, and diabetes as CVD risk factors increased significantly (28.3%, 28.2%, and 12.5%, respectively). There was a statistical 4.1% increase in participants with systolic blood pressure (SBP) <140/90 mm Hg, a 4.7% decrease in participants with total cholesterol (TC) >240 mg/dL, a 4.5% decrease in participants with TC >200 mg/dL, a 5.9% decrease in participants with high-density lipoprotein cholesterol (HDL-C) <50 mg/dL, a 4.4% decrease in participants with HDL-C <40 mg/dL, and an 8.8% increase in diabetics with low-density lipoprotein cholesterol (LDL-C) <100 mg/dL. CVD prevention built around a comprehensive heart care model program and AHA/ACC Evidence-Based Guidelines can be successful in improving knowledge and awareness, CVD risk factor reduction, and attainment of Healthy People 2010 objectives in high-risk women. Thus, these programs could have a dramatic and lasting impact on the health of women.

Kansas Primary Care Weighs In: A Pilot Randomized Trial of a Chronic Care Model Program for Obesity in 3 Rural Kansas Primary Care Practices

Obesity is a chronic disease of epidemic proportions in the United States. Primary care providers are critical to timely diagnosis and treatment of obesity, and need better tools to deliver effective obesity care. To conduct a pilot randomized trial of a chronic care model (CCM) program for obesity care in rural Kansas primary care. We enrolled 107 participants to a 6-month, 2-armed, randomized trial comparing a CCM for obesity with usual care. The primary outcome was weight change at 90 days. The usual care arm received educational weight loss materials and outcome assessments at day 0, 90, and 180. The active arm received the same elements as the usual care arm plus a multicomponent obesity CCM. The Day 90 mean +/- SD weight change for the active arm (n = 34) and control arm (n = 33), respectively, was -4.5 +/- 7.7 pounds and -2.4 +/- 8.1 pounds (P = .27 for difference). The Day 180 mean +/- SD weight change for the active (n = 27) and control (n = 27) arms, respectively, was -9.4 +/- 10.3 pounds and -2.1 +/- 10.7 pounds (P = .01 for difference). There was no significant change in physical activity, or fruit and vegetable intake at day 90 or day 180. Improving the recognition and treatment of obesity in primary care settings is a critical initiative. Rural populations suffer disproportionately with obesity, and better methods of delivering obesity care are needed for this population. Further research is needed to establish the effectiveness of a CCM approach for obesity care.

Integrating cancer rehabilitation into medical care at a cancer hospital

In spite of national health care legislative and model program initiatives, cancer rehabilitation has not kept pace with rehabilitation for patients with other medical problems. This article discusses, from a historical perspective, unsuccessful health care legislation related to cancer and problems in establishing and expanding cancer rehabilitation programs. The attempts to establish a cancer rehabilitation program at the Texas Medical Center and the University of Texas M. D. Anderson Cancer Center are reviewed. Lessons learned over past 40 years and strategies for maintaining the success of a cancer rehabilitation program are discussed.