Outline for CLIFF Notes for



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Healthy Living Program

Facilitators’ Program Guide

Acknowledgements

The Healthy Living Program: Facilitator’s Program Guide and Participant Guide were developed to support a multidisciplinary effort for nutrition, exercise specialists and behavioral health in the Healthy Living Program (HLP) designated in AFI 10-248, Fitness Program. This multidisciplinary group was tasked by the Air Force Medical Service Agency. Our goal was to provide a useful guide, reference and tool for your work with the HLP. The multidisciplinary effort stemmed out of the recognition that these disciplines, working together, have a great deal of expertise that can benefit our population in tackling one of the most difficult public health problems: developing and maintaining adequate fitness.

Our hope is that you will use these materials to allow for a standard program across the Air Force. We recognize that you may choose to tailor them to best meet the needs of your base population but our hope is that you will remain consistent with the basic outline.

TABLE OF CONTENTS

Structure……………..………………………………………………………………...……….… 4

Introduction and Background …………………………………….…………………..………….. 5

Who Attends the Healthy Living Program? ……………………………………………………….8

Behavioral Health Skill Set for Facilitating the Healthy Living Program .………………..….….10

Nutrition Skill Set for Facilitating the Healthy Living Program …….……….….….10

Fitness Skill Set for Facilitating the Healthy Living Program ……………………………….......11

Basics of Motivational Interviewing …………………….……….…………………..….…….…12

Healthy Living Program Weight Screening.....………………………………………………… 13

Coding and Documenting.......………………………………………………… …….......……....18

HLP Evaluation Form ……………………………………………………………………………19

Recommended Readings & References………….………………….……………………..……. 20

Structure

Learning Objectives:

Fitness

Learn the basic components of a good fitness program

Identify personal barriers to following the FITT principle and develop a plan for overcoming these barriers

Develop written plan for improving personal fitness

Nutrition

Optimize performance through good nutrition

Evaluate body weight and associated risk factors to determine risk category and readiness to change

Balance calorie intake through controlling portion size and maximizing nutrient density

Behavioral Health

Increase motivation for change

Refine personalized plan for reasonable fitness and/or dietary changes

Structure:

The provider’s guide to teaching HLP will be found in the speaker notes of the PowerPoint. To teach the class well, it is critical to be familiar with the content of the slides, speaker notes, and the participant’s guide. The presentation’s success depends on being able to be interactive with the clients in setting their own plans.

The HLP is designed to last 2-2½ hours.

11. 30 min each of nutrition and exercise physiology.

12. 60-90 min of behavioral health using Motivational Interviewing techniques.

Includes PowerPoint presentation, education, group interaction, individual assessments and goal setting activities.

Optimally, the behavioral health, fitness, and nutrition professionals will be available for the entire workshop. Given busy work demands, it is recognized that this may not always be possible.

A class size of 10-20 clients is ideal. It is preferable that the class size be closer to ten as group interaction is essential. However, ten clients may not be feasible based on demands at each individual base.

You will need to bring pencils or pens for the clients as the class is designed around personalized and interactive workbook assignments.

Materials Needed To Hand Out

HLP Evaluation - hand out at the beginning of the class and collect at end of class

HLP Participant Guide

HLP Weight Nutrition Screen - nutrition personnel may decide to hand out during

their portion of the class

Materials Needed for Nutrition (if portion control exercise is used)

Bowls of various sizes and measuring cups (full set)

Box of cereal

Introduction and Background

Introduction

The HLP is for individuals who score in the poor fitness categories according to the Air Force fitness standards. It is designed as an interactive class to provide information related to nutrition and exercise that is needed to improve fitness and to identify motivational factors and behavior change strategies needed to implement and maintain a lifestyle change. The workshop is intended as a collaborative effort among behavioral health providers, dietitians, and fitness experts. The first hour is split between nutrition and fitness experts. The fitness expert provides information about the components of a healthy exercise program. Nutrition professional provide information on the components of a healthy diet. Behavioral health providers lead the second half of the workshop, preparing clients for change through the use of behavioral change tools such as motivational interviewing/enhancement, establishing realistic goals, problem solving, and maintenance/relapse prevention. Together, the behavioral health provider, nutrition professional, and fitness expert help the workshop clients develop a comprehensive individualized plan for fitness. Clients in the poor fitness category will be enrolled in the Fitness Improvement Program (FIP) and continue HLP with monthly follow-ups with the exercise physiologist. Also, those clients in the poor fitness category who have an abdominal circumference > 35 inches for women and > 40 inches for men will be enrolled in the Body Composition Improvement Program.

Background

Health and fitness are areas of great importance in the military, having implications for readiness to perform military missions, general population health, utilization of medical care, discipline, and retention. Active duty personnel who are unfit are of particular concern because the health, social, occupational and economic costs are so high. Guidelines released by the National Heart, Lung, and Blood Institute (NHLBI) in 1998 recommend maintaining body mass index (BMI) < 25 with those with BMI > 25 being at increased health risk. Based on these standards, the Air Force has not escaped the same weight management problems that the United States civilian population is experiencing.

The health consequences related to excess weight are well documented and include diabetes, high cholesterol, hypertension, coronary heart disease, stroke, gallstones, and osteoarthritis of knees and hips (Pi-Sunyer, 1993; Willet, 2001). In a recent study examining hospital costs for obesity related conditions in active duty Navy personnel, researchers estimated that nearly 6 million dollars is spent annually just for inpatient care of obesity related diagnoses (Bradham, et al., 2001). Robbins and colleagues estimate over $28 million in annual cost to the USAF as a result of overweight and obesity (Robbins, Chao, Russ, & Fonseca, 1997). Additionally, abdominal circumference has been shown to independently predict poor health outcomes for people with normal and overweight BMIs (NHLBI, 1998; Janssen, Katzmarzyk, & Ross, 2002). Cornier, Tate, Grunwald, and Bessesen (2002) found that abdominal circumference was a better predictor of high health care costs than BMI. Higher levels of abdominal fat have been found to put individuals at increased risk for diabetes, dyslipidemias, and artherosclerosis (Gasteyger & Tremblay, 2002), cardiovascular disease (Sharma, 2002; Zhu, et al, 2002), pancreatitis (Mery, et al, 2002), and high blood pressure (Siani, et al, 2002). Due to these recent research findings, the Air Force fitness standards incorporate BMI with an abdominal circumference measure to evaluate body composition. To reduce the potential health risks and increased healthcare costs associated with higher levels of abdominal fat as measured by abdominal circumference, research has shown that higher levels of physical fitness lead to reduced levels of abdominal fat at all levels of BMI (Ross & Katzmarzyk, 2003). Additionally, Mayo, Grantham, and Balasekaran (2003) found that when people lose weight through exercise, abdominal fat is lost at a faster rate than fat in other areas of the body.

As we know, knowledge about living a fit healthy life does not necessarily lead to behavior change. Readiness to change one’s behavior has been an area of extensive clinical interest and research, and has been applied across multiple domains of health-related behavior (see Weinstein, Rothman, & Sutton, 1998 for a review). Approximately 50% of persons at health risk are believed to be at the precontemplation stage based on the transtheoretical model (Prochaska et al., 1994). Research has provided strong support for the importance of including concepts about readiness for change, balancing benefits and consequences for diet change, weight control, and exercise acquisition in interventions to improve fitness (Prochaska et al., 1994; Rosen, 2000). Additionally, research suggests that including cognitive-affective strategies (such as consciousness raising, considering consequences to self and others) as well as behavioral strategies (such as facilitating commitment to change, encouraging helping relationships and social support, and reinforcement) may promote progress across stages of change (Rosen, 2000). Understanding and weighing the pros and cons of prospective health behaviors was found to be very important to change, with a positive relationship existing between the number of pros versus cons and higher stages of change (Prochaska, 1994).

Motivational Interviewing (MI) methods appear to be a good fit for helping individuals make lifestyle change (Miller & Rollnick, 2002). In a recent meta-analysis, MI yielded moderate effect sizes when applied to problems with diet and exercise (Burke, Arkowitz, & Menchola, 2003). Motivational interviewing is defined as a directive, client-centered counseling style for eliciting behavior change by helping people to explore and resolve normal ambivalence and to reduce discrepancy between goals and behavior (Rollnick & Miller, 1995; Draycott & Dabbs, 1998). Confrontation behaviors by the counselor are avoided because they tend to evoke high levels of resistance in people and make it less likely that behavior change will occur. Rather, the MI counselor expresses empathy through careful reflective listening, and seeks to elicit reasons from the client for behavior change, while maintaining a supportive and nonjudgmental atmosphere. The goal of the interaction is to increase the individual’s awareness of the discrepancies between present behaviors (e.g., lack of exercise and imprudent eating) and future goals. The individual is viewed as responsible for and capable of behavior change, while the counselor is an active supporter.

MI began as a brief intervention for helping people with alcohol problems (Miller, 1983) and has since demonstrated surprisingly powerful effects as a stand-alone intervention and as preparation for more intensive alcohol treatment (Miller, 1996; Noonan & Moyers, 1997). Recent research shows that MI has potential in improving dietary adherence (Berg-Smith, et al., 1999; Mhurchu, Margetts & Speller, 1998) and increasing physical activity (Harland, et al., 1999). Motivational interviewing is showing increasing promise as a brief intervention tool for successful negotiation of health behavior change (Rollnick, Heather, & Bell, 1992). A motivational interviewing component added to a weight-control/fitness program may significantly enhance adherence to recommendations (Smith, Heckemeyer, Kratt & Mason, 1997).

Given what we know about the importance of health, fitness, and associated disease risk factors and the challenges involved in changing behaviors to live a healthy lifestyle, the Healthy Living Program was developed as an interdisciplinary effort to help individuals develop a fitness plan and improve their ability to implement the plan. The remainder of this manual provides facilitators with the resources needed to successfully lead this workshop.

* Note: The PowerPoint presentation that was designed to assist with the HLP includes critical speaker notes to aid the interactive portion of the workshop. The presentation will be maintained in a separate document to allow for more frequent revision and distribution to the field.

Who Attends the Healthy Living Program?

Promoting Improved Fitness in the Air Force

Our expeditionary mission demands that our forces be ready to deploy and support the mission at a moment’s notice, in austere and demanding environments, and for extended periods of time. These stresses demand that our forces be fit to fight, ready for any challenge. Being fit and strong is necessary for the Air Force mission and for the health of our airmen.

The Air Force fitness standards present an opportunity to change the way Air Force members address their own physical fitness. Being physically and mentally fit is critical to an individual’s overall health and ability to serve in today’s Air Force. The goal is to emphasize that individuals have a personal responsibility to be physically fit for themselves, their family, their team, the Air Force and the country that they serve.

Objectives

The Composite Score:

The composite score consists of aerobic fitness, muscular fitness, and a body composition component scores. An Air Force scientific team developed this scoring methodology based on established civilian health and fitness data. The process was then reviewed and validated by an outside panel of nationally recognized experts. The great benefit of the composite score is it places greater emphasis on fitness, while also assessing the member’s health risk.

We know aerobic fitness is the single, best indicator of overall fitness; therefore, half of the score is determined from the aerobic component. Using a 1.5-mile run as the primary method of testing allows units to carry out the majority of the testing.

The second component is muscular fitness. While extremely important for readiness, there isn’t specific scientific research that identifies the number of push-ups and crunches that will result in positive health outcomes. We know strength training is beneficial to long-term health so numbers were determined based on what a normal population could accomplish. Each exercise contributes 10 percent to the composite score. The important point to remember for muscular fitness is that all members will benefit from including strength training in their exercise routine.

The final component, body composition, is an important indicator of long-term health and disease risk. Studies indicate that abdominal circumference is an important factor in weight and body fat assessment. Fat distribution is just as important as body fat that accumulates around the waist and stomach area poses a greater health risk than fat stored in the lower half of the body.

A single abdominal measure is easier to administer and interpret. The member can do this simple measurement anywhere and know the results. To track their progress, all they would need is a string or simply monitor their pants size. Although there is some correlation between the two, we cannot equate abdominal circumference to a specific body fat percentage. Abdominal circumference measures fat concentrated around the abdomen, which is associated with the greatest health risk. Body fat percentage is less specific; it indicates total fat distributed throughout the body. Studies show that the health risk associated with high abdominal circumference is independent of height and age. This may be due to the fact that the abdominal measurement does not include any bones in the measurement so is independent of body frame size.

1. Aerobic assessment—1.5 mile run, 3 mile walk or cycle ergometry (50%)

2. Body composition (30%) Abdominal Circumference

3. Muscular Strength—Pushups (10%)

4. Muscular Strength—Crunches (10%)

The 0-100 scale provides a fitness continuum. An individual’s score is scaled (gender/age neutral) for equal comparison of fitness level. A range of categories allows for more tailored education and intervention.

Categories based on composite score:

Excellent (90-100 points)

Exercise at least 3 times / week

Retest in one year

Good (75-89.9 points)

Exercise at least 3 times / week

Retest in one year

Poor (0-74.9 points)

Attend Healthy Living Program

Enrolled in Fitness Improvement Program

Enrolled in Body Composition Improvement Program if AC is > 40 males; >35 females

Monitored exercise 4-5 times / week

Retest within 90 days

Tiered fitness risk stratification provides the following advantages:

- Greater chance for success by offering tailored intervention

- Focus is more on member health, physical activity and fitness as a lifestyle rather than only a once a year test

- Moves toward evidence-based, health-related criteria vs. arbitrary/traditional fitness test standards

- Moderate risk provides window of opportunity for successful health prevention/intervention before member becomes high risk

- Identifies members at greater risk for disease/injury (high risk)

- Connects physical fitness requirement to members that have extra body fat

- Exercise and nutrition behavior changes are both necessary and interdependent

- Increases test frequency for those members requiring greater follow-up treatment for low-fit/sedentary lifestyle (similar to other medical conditions such as hypertension, high cholesterol)

Skill Sets for Facilitating the Healthy Living Program (HLP)

Behavioral Health

• Personnel from the Life Skills Support Center, or other behavioral health clinic, are the best choice for leading for the behavioral health portion of the HLP. A Life Skills provider should be, at minimum, responsible for approving the behavior change curriculum and workshop facilitators.

• While Behavioral Health providers will often be the ideal instructors, workshop facilitators may be drawn from other health care professionals (e.g. technicians, psychiatric nurses, etc..) with the appropriate skill set.

• Facilitators will need to possess the following skill sets (which may be acquired through a combination of formal courses, on-the-job training and/or self-study):

- Ability to reinforce existing motivation for change and encourage new commitment to healthy behavior (i.e. basic motivational interviewing/enhancement skills)

- Ability to facilitate an interactive group intervention

- Appreciation of the principles of effective educational instruction

- Basic understanding of behavior change strategies and techniques

- Basic knowledge of nutrition, weight loss, dieting, and physical fitness.

• HLP facilitators must be able to demonstrate enthusiasm for teaching the workshop, display empathy for individuals having difficulties achieving fitness goals and embrace the goals of the Air Force Fitness Program.

• HLP facilitators do not need to achieve a particular level of fitness themselves to be qualified to teach, but must be able to credibly persuade the clients they lead a healthy lifestyle or are engaged in appropriate movement towards improved fitness.

Nutrition

• Facilitators must possess the following skill set which may be acquired through a combination of formal courses, on-the-job training and/or self-study:

- A registered dietitian or diet therapy technician/other medical provider who must be authorized by USAF registered dietitian to teach the nutrition component of the HLP and BCIP

- Understanding of behavior change strategies and techniques (e.g., self-monitoring techniques, goal setting)

- Demonstrated ability to reinforce existing motivation for change and encourage new commitment to healthy behavior (i.e. basic motivational interviewing/enhancement skills/advanced counseling skills)

- Knowledge of the principles of effective adult learning

- Be knowledgeable of and apply advanced counseling skills

• HLP facilitators must be able to demonstrate enthusiasm for teaching the workshop, display empathy for individuals having difficulties achieving fitness goals and embrace the goals of the Air Force Fitness Program

• Keep up-to-date with recent obesity literature

• Attend Nutrition In Prevention and Health Promotion Manager's Course

• HLP facilitators do not need to achieve a particular level of fitness themselves but must be able to credibly convey the value of pursuing a healthy lifestyle or are personally engaged in a goal-centered/self-monitored approach toward improving fitness

Fitness

• The Fitness Program Managers (FPM) will be the OPR for the fitness portion of the HLP and the HLP monthly follow-ups. The FPM will be responsible for ensuring that curriculum is appropriate to current fitness trends and research.

• The FPM will be the primary instructor but may use other qualified individuals in assisting with instructing the HLP fitness portion. Other qualified individuals would include Health Fitness Instructors assigned to the HAWC or interns who are completing their degrees in exercise related programs.

• Facilitators will need to possess the following skill sets:

- Ability to communicate appropriate methods of improving fitness

- Ability to facilitate in a group setting with individuals who may be frustrated or angry about their fitness test outcomes.

- Strong understanding and knowledge of fitness programming both for improving health and for training to meet current fitness requirements.

• HLP facilitators must be able to demonstrate an enthusiasm for teaching and must be able to display empathy for individuals who are having difficulty achieving fitness goals.

• While meeting AF standards is not a requirement for the civilian FPMs, HLP facilitators for fitness should be credible examples of leading a fit and healthy lifestyle.

*** Recommended Reading: Rollnick, S. Mason, P., & Butler, C. (1999). Behavior change: A guide for healthcare professionals. Cardiff, UK: Churchill Livingstone.

Basics of Motivational Interviewing

The spirit of MI involves a collaborative posture towards the individual that communicates a partner-like relationship. The goal is to elicit motivation from the person and not prescribe reasons for change. MI involves having respect for the individual’s autonomy and ultimate responsibility for choices about change.

The four general principles below are good guideposts to keep in mind when intervening in a motivational interviewing style.

Principle 1 Express Empathy

• Acceptance facilitates change. Maintaining a respectful stance regarding the individual’s perspective is a key to acceptance

• Skillful reflective listening is fundamental to create an environment conducive to change

• Ambivalence about change is a normal part of human experience and not a sign of defensiveness or pathology

Principle 2 Develop Discrepancy

• Change is motivated by perceived discrepancy between present behavior and future goals or values

• Discrepancy is determined by the importance the individual places on change toward the desired behavior

• The client rather than the counselor should present the arguments for change

• The goal of highlighting the discrepancy between values and current behavior is allow the client to challenge the inertia of the status quo

Principle 3 Roll with Resistance

• Avoid arguing with the client for change

• Resistance for change is not directly confronted

• New perspectives are invited but not imposed

• The client is the primary resource in finding answers and solutions

• Resistance exhibited by the client is a signal for the facilitator to respond differently

Principle 4 Support Self-Efficacy

• A person’s belief in the possibility of change is an important motivator

• The client is responsible for choosing and carrying out personal change. The facilitator’s role is to help them should they wish to change.

• The facilitator’s own belief in the person’s ability to change becomes a self-fulfilling prophecy

From: Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: The Guilford Press

Healthy Living Program Weight Screening

The HLP provides an opportunity to screen our least fit active duty members for overweight/obesity health risk, assess their readiness to make dietary changes and connect members with readiness-based resources to assist them in optimizing their health.

We can not assume members attending HLP want to make lifestyle changes. In fact, studies show that less than half of the public is in the action stage of behavior change. So, as counselors, it is both discouraging and futile to approach all of our clients as though a little information is all they need to solve their weight and fitness challenges.

The objective of the weight screening is to raise the member’s awareness of their weight risk and provide a tool to identify the member’s stage of readiness. In turn, you, the counselor, can engage with the client and provide guidance most appropriate to that stage of readiness. See the tables on the following pages to become familiar with appropriate responses and materials recommended for each stage.

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|Readiness Level |Response |Materials/Referrals |

|“Yes, right now”or “I have already|Praise the decision to change behavior and inform member of |1. Group Class: |

|started” |available support. |Body Composition Improvement Program |

|(Action Stage) | |or |

| |Option 1: Group Class |Voluntary Weight Management Program (on-base/comm) |

| | | |

| |Option 2: Individual Appointment |2. Self-help-Materials: Choose at least one of the following handouts based on your budget and |

| | |programming to provide members who prefer self-help. |

| |Option 3: Self-help Materials (i.e. handouts or web-based |Eat Your Weigh to a Healthy Weight – |

| |tutorial). Provide list of programs/resources available at your|ETS #071 ($.30 each*) |

| |base/in your community with contact information (i.e. HAWC | |

| |calendar, brochure, etc.) | |

| |If there is time to engage with the member, here is an example |Feeling Good About a Healthy Weight |

| |of appropriate dialogue for the action stage. |wellStage Item # HESHW-4 |

| |Based on what we discussed today, what did you identify as your|($.82 each) |

| |first goal? [Reinforce or guide their goal setting-make sure | |

| |it is realistic and measurable] | |

| |So, your initial goal is ______________________" |Weight Change: Getting Started- |

| |"Which family members or friends could support you as you make |ETS #341 ($1.00 each) |

| |this change? How could they support you? Is there anything else| |

| |I can do to help?" | |

| | |Aim for a Healthy Weight |

| | |NIH Publication No.:  05-5213. 36 pages. ($3.00 each) |

| | | |

| | | |

| | |Self-help-Web-based Tutorials: |

| | | |

| | | |

| | | |

| | |(see end of this grid for reproducible master to create web site reference cards) |

|Yes, but I can’t right now. Maybe |Praise the decision to change behavior and inform member of |1. Group Class: |

|next month. |options. |Body Composition Improvement Program |

|(Preparation Stage) | |or |

| |Option 1: Group Class |Voluntary Weight Management Program (on-base or commercial) |

| | | |

| |Option 2: Individual Appointment |2. Handouts: Choose at least one based on your budget and programming to provide members who prefer |

| | |self-help. |

| |Option 3: Self-help Materials (i.e. handouts or web-based | |

| |tutorial). Provide list of programs/resources available at |Weight and Food |

| |your base/in your community with contact information (i.e. |ETS #319 ($.30 each) |

| |HAWC calendar, brochure, etc.) | |

| |If there is time to engage with the member, here is an | |

| |example of appropriate dialogue for the preparation stage. |Eat Your Weigh to a Healthy Weight |

| |“Based on what we discussed today, what did you identify to |ETS #071 ($.30 each) |

| |be an area for improvement that you feel you could take on in| |

| |the near future?” | |

| |“So, you think you should start with… ______________________”|Preparing to Attain a Healthy Weight |

| |"Which family members or friends could support you as you |wellStage Item # HESHW-3 |

| |make this change? How could they support you? Is there |($1.83 each) |

| |anything else I can do to help?" | |

| | | |

| | |Self-help-Web-based Tutorials: |

| | |Direct client to web-sites listed in HLP Participant Guide. |

|No, but I will think about it. Maybe |"I’m hearing/seeing that you are thinking about losing weight|Provide lists of programs/resources available at your base/in your community with contact information|

|in the next 6 months. |but you’re definitely not ready to take action right now. I |(i.e. HAWC calendar, brochure, etc.) |

|(Contemplation Stage) |know that you’re an adult and you will be the one to decide | |

| |if and when you are ready to lose weight. However, I |Weight and Feelings |

| |encourage you to look at the questions on the back of your |ETS #376 ($.30 each) |

| |handout; they are very important to think about before | |

| |starting a weight loss program. Would you be willing to | |

| |finish this at home and come back to discuss this with me at |Is My Weight Healthy |

| |another time? If you do find that you are ready, the next |ETS #R338 ($.30 each) |

| |step would not necessarily be action, we could work on | |

| |preparing you to make changes." | |

| |Then, provide the client some self-help materials (i.e. |The Benefits of Achieving a Healthy Weight |

| |handouts or web-based tutorial) appropriate for this stage. |wellStage Item # HESHW-2 |

| |Provide list of programs/resources available at your base/in |($.82 each) |

| |your community with contact information (i.e. HAWC calendar, | |

| |brochure, etc.) | |

|No, not now. |"I can understand why you feel that way I don’t want to |Is my Weight Healthy? |

|(Pre-contemplation stage) |preach to you; I know that you’re an adult and you will be |ETS #R338 ($.30 each) |

| |the one to decide if and when you are ready to lose weight. | |

| |I believe, based upon my training and experience that this | |

| |extra weight is putting you at serious risk for heart |Thinking About a Healthy Weight |

| |disease, and that losing 10 pounds is the most important |wellStage Item # HESHW-1 |

| |thing you could do for your health. Do you have any concerns |($.59 each) |

| |about your weight?... Everyone who’s ever lost weight starts | |

| |right where you are now; they start by seeing the reasons | |

| |where they might want to lose weight. And that’s what I’ve | |

| |been talking to you about. I know that it might feel as | |

| |though I’ve been pressuring you but it is totally up to you | |

| |to decide if this is right for you right now." | |

| |Provide the client with a one of the brochures appropriate | |

| |for pre-contemplation. | |

Source:

Coding and Documenting Visits

If assessment and clinical interaction are performed consistent with the practices recommended in the standardized PowerPoint presentation and the Facilitator Guide, the Healthy Living Program is clearly a “countable” visit. Coding the visit as a patient care encounter allows for improved accounting of workload and productivity. If you code the visit, you must also document the visit. The work of documentation can be minimized through the effective use of templates.

Behavioral Health Coding

The Healthy Living Program should be coded as follows:  The E&M code should be 99499 and the CPT should be 96153. In terms of diagnosis, ICD-9 V65.41 Exercise Counseling is recommended. Please note that only providers can use these codes. If technicians or nurses give the briefing, they must use the code 99211 which will help track productivity but will not generate Relative Value Units. If non-medical personnel give the briefing, it cannot be coded as a medical visit. The provider should code and document only the time spent during their portion of the encounter.

Behavioral Health Note Template

S- Pt attended a 90-minute group education regarding healthy fitness and diet behavior. Discussed biopsychosocial factors of health and fitness, and strategies of successful health behavior change. Facilitated group discussion and completion of self-assessment tool for enhancement of motivation for fitness. Reviewed skills for setting reasonable and sustainable goals. Assisted group in development of short and long term goals and 4-week plan to progress toward goals. Discussed skills to maintain behavior change and developed relapse prevention plan

O- MSE: Mental Status Exam: Patient appeared alert, oriented, and attentive; no abnormalities noted in dress, appearance, or behavior. Other:

A- No Diagnosis; V65.49 Other specified counseling (health behavior).

P- Pt will complete fitness and diet program developed with HAWC staff. Recommend client follow plan established in class and follow-up with the Body Composition Improvement Program as required.

Nutrition Coding (BALA)

The nutrition portion of the Healthy Living Program will be coded for every member that completed the Weight Screening form. The encounter is coded as follows:  The E&M code is 99499 and the CPT should be 97804, 2 units of service. For diagnoses, use the ICD-9 code V65.3, Dietary Surveillance and Counseling first, followed by the appropriate codes for BMI category. If the member is a normal weight (BMI ................
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