Coordinating Pragmatic Primary Care Population Management for Obesity (C3PO)

Comparador activo: Basic Resources and Services

Patients will receive outreach engagement in goal setting via MyChart, an electronic scale, telemonitoring of self weighing, and information about linkages to extant intensive lifestyle interventions in the community

Conductual: Outreach Support for Weight Loss Goal Setting and Self-Weighing

Patients will receive a MyChart activation message assessing weight loss interest that invites them to complete a MyChart Survey encouraging a weight loss goal using principles adapted from Brief Action Planning. Patients will then receive a cellular network-enabled electronic body weight scale, and weighing data transmitted by the scale will be received and integrated into the electronic health record for access by the patient's primary care team.

Conductual: Outreach Decision Support to Encourage Linkages to Intensive Community Lifestyle Interventions

Patients will receive via MyChart information and decision support designed to encourage linkages to and participation in intensive lifestyle programs available in the community. Patients who request information or clinical referrals will also receive them. "Refreshes" of community linkage information will be sent by MyChart every 1 to 4 weeks.

Experimental: Coordinated Primary Care Population Management (C3PO)

Patients will receive outreach engagement in goal setting via MyChart, an electronic scale, telemonitoring of self weighing, information about linkages to extant intensive lifestyle interventions, and outreach MyChart messages that are tailored to each individual's pattern of self-weighing and progress towards their weight goal, and more intensive support from a primary care nurse based on self-weighing behavior and weight loss success.

Conductual: Outreach Support for Weight Loss Goal Setting and Self-Weighing

Patients will receive a MyChart activation message assessing weight loss interest that invites them to complete a MyChart Survey encouraging a weight loss goal using principles adapted from Brief Action Planning. Patients will then receive a cellular network-enabled electronic body weight scale, and weighing data transmitted by the scale will be received and integrated into the electronic health record for access by the patient's primary care team.

Conductual: Outreach Decision Support to Encourage Linkages to Intensive Community Lifestyle Interventions

Patients will receive via MyChart information and decision support designed to encourage linkages to and participation in intensive lifestyle programs available in the community. Patients who request information or clinical referrals will also receive them. "Refreshes" of community linkage information will be sent by MyChart every 1 to 4 weeks.

Conductual: Adaptive Tailoring of Information Delivery and Intensity of Primary Care Outreach Support

Data received into the electronic health record from the cellular network-enabled electronic scale will categorize each patient based on their daily self-weighing behaviors and rate of progress towards their weight loss goal. Patients who are not engaged in daily self-weighing or are not making progress towards their goal will receive more intensive outreach support in the form of automated weekly MyChart problem solving messages, more frequent encouragement to access a broader array of community resources, and telephonic support from a nurse care coordinator who is an existing member of the primary care team. Support from this nurse care coordinator will be facilitated by the incorporation of each patient's self-weighing data into an EpicCare patient dashboard accessible to the nurse coordinator and other members of the care team

Number of Participants Who Achieved 5% Weight Loss Goal at 6 Months

Proportion of Participants who Reach a 5% Weight Loss Goal at 6 Months, calculated as the percent of all participants for whom the following calculation is greater than or equal to 5%: (Baseline body mass (kg) - Body mass measured at 6 months (kg))/(Baseline body mass (kg))

Costs to Implement the Intervention

Costs (US$) of Intervention Components, including the costs to fund personnel efforts, technology, and other intervention components

Change in Hemoglobin A1C

Mean change in Hemoglobin A1C levels (DCCT%) from baseline to 12 months

Change in Systolic Blood Pressure

Mean change in systolic blood pressure (mmHg) from baseline to 12 months

Change in Total Cholesterol

Mean change in total cholesterol concentration (mg/dL) from baseline to 12 months

Change in Non-HDL Cholesterol

Mean change in non-HDL cholesterol concentration (mg/dL) from baseline to 12 months

Body Mass Change at 6 Months

Mean Change in Body Mass (kg) from Baseline to 6 Months

Body Mass Change at 12 Months

Mean Change in Body Mass (kg) from Baseline to 12 Months

Number of Participants Who Achieved 5% Weight Loss Goal in 12 Months

Proportion of Participants who Reach a 5% Weight Loss Goal at 12 Months, calculated as the percent of all participants for whom the following calculation is greater than or equal to 5%: (Baseline body mass (kg) - Body mass measured at 12 months (kg))/(Baseline body mass (kg))