Step-by-Step Guidance for Prescribing Low carb in an Office Setting

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Step 1: Referral

Patients:

• Seek referral from your healthcare provider 

Healthcare Providers:

• Make it know to your colleagues that you are taking referrals to help  patients adopt a low carbohydrate, high fat ketogenic lifestyle pattern. 
• You  may wish to use this referral form and add yourself to The MetabolicHealth Program Referral Network. 
• In the Canadian setting, a referral allows you to bill consultation codes (OHIP: A005, if at least 50 minutes then A911, if at least 75 minutes then A912). 

Step 2: Meet and Greet

Patients:

• Meet with your healthcare provider for the first time to introduce  yourself, discuss your goals and build rapport. You’ll be presented with reading (The MetabolicHealth Program Handbook and The New Atkins for a New You), video watching, reflecting and learning objectives to accomplish before your next appointment, which is the consultation. 

Healthcare Providers:

• This is a quick appointment (10-15 minutes) in which you will build rapport, measure the patient's waist (see the Heart and Stroke Foundation video for how to do this accurately), weight, height and blood pressure and layout the steps for success in adopting this dietary prescription. The MetabolicHealth Program Toolkit has a "Meet and Greet" chat tool to help you set expectations with your patient and  clearly list ‘next steps’. 
• I send these 'next steps' to the patient's email using the Oceans platform by   CognizantMD directly from my EMR during the visit. 
• The First Appointment Questionnaire can be completed as an Oceans e-form  (contact:   info@cognisantmd.com ) or using the PDF in the toolkit package.  Please note that I have NO financial affiliation with Oceans by CognizantMD other than paying my monthly subscription like any other user.
• The Homework includes baseline lab work. Metabolic markers to follow are at your discretion but I monitor: 10 hour fasting lipids and blood sugar, HbA1c, ALT, CBC, Cr, Na, K,  Albumin, TSH, Urea, B12 level, microalbumin creatinine ratio and urinalysis every 3 months or so.
• It takes patients about 1 month to comfortably complete the following Homework.
• Request a deposit from the patient (~$100) to prevent no-shows, which is refundable upon completion of the 5-appointment series. Far from a cash grab, this deposit will motivate your patient to stick-with-it if off-the-wagon and considering walking away from the program.
• Please see the "MetabolicHealth Program Appointment Note Templates" document below for a Meet and Greet Letter Template to send back to the referring provider.
• Please see the "Preparing for the Meet and Greet" and "Meet and Greet Appointment" videos below for my approach to using the resources and conducting these appointments. 

Step 3: Homework

Patients:

1. Complete  the baseline lab work immediately  (if you wait until after you have started to make dietary change, we will miss the opportunity to measure your baseline laboratory profile).

2. Buy  The New Atkins for a New You by E. Westman and read to at least page 115.

3. Watch  the MetabolicHealth Program Patient Video Series

4. Read the MetabolicHealth Program Handbook twice, cover to cover

5. Complete the First Appointment Questionnaire in The MetabolicHealth Program Toolkit or using Oceans by CognizantMD platform.

• Please see the "Patient Next Steps" video below for how the patient will complete these steps. 

Healthcare Providers:

• Make sure your patient knows it is your expectation the homework will be completed  prior to the consultation. My experience is that patients consistently complete these steps. 

Step 4: Consultation

Patients:

1. Discuss your past medical and surgical history

2. Discuss  your previous lifestyle change strategies

3. Ask  questions that arose during reading and video watching

4. Talk  about low carb recipes and "instead-ofs".

Healthcare Providers:

1. Collect  completed Informed Consent

2. Review  First Appointment Questionnaire responses

• Consider redflags for triggering eating disordered behavior

3. Review lab work

4. Perform physical exam

5. Assess patient preparation for lifestyle change

6. Medication management

7. Set goals for next follow-up appointment:

- Emphasis on recovery from metabolic sickness  over weight loss (ie. Decreased blood pressure, reduced central obesity,  lower blood sugars, lower triglycerides, higher HDL)

- Arrange  follow-up appointment interval (~2 months)

- Send  note back to referring provider

• Please see the "MetabolicHealth Program Appointment Note Templates" document below for a Consultation Note and Letter Template to send back to the referring provider.
• Please see the "Consultation Appointment" video below for my approach to using the resources and conducting these appointments. 

Step 5: Follow-up Appointments (At least 1 Every 2 months for 3 Appointments)

Patients:

1. Complete  self-assessment  Pre-Appointment Questionnaire before each appointment

2.  Be prepared to share concerning symptoms as well as successes and struggles

Healthcare Providers:

1. Be  sure to distribute your patient self-assessment Pre-Appointment Questionnaires  about 7 day before the follow-up appointment. This can be done in a number of  ways: 

- By giving the patient printed copy to complete at the previous appointment, 

- By  emailing a PDF,

- By sending a link to Oceans by CognizantMD platform Pre-Appointment Questionnaire e-form (my EMR does this automatically for me 7 days before appointments). 

2. Discuss the patients Pre-Appointment Questionnaire answers, help the patient troubleshoot common complaints (See the MetabolicHealth Minute and MetabolicHealth Program Handbook's Self-Serve Problem Solving for solutions to the most common problems my patients encounter), offer motivational counselling to help the patient stay on tract and arrange a follow-up appointment (~every 2 months).

• Please see the "MetabolicHealth Program Appointment Note Templates" document below for a Follow-up Appointment Note and Letter Template to send back to the referring provider.
• Please see the "Follow-up Appointment" video below for my approach to using the resources and conducting these appointments. 

Step 6: Maintence/Ongoing Support

For Patients and Providers:

- When does a patient with alcoholism stop being at risk of relapse? I suspect the answer is never.

- If you had a patient who had stopped smoking but subsequently restarted, what counselling would you provide? I suspect you would help the patient explore the reasons for relapse, listen supportively, encourge the patient to make another quit plan and arrange a follow-up appointment.

It is important for us as patients and providers to understand that those who are trying to recover from obesity and diabetes will always be at risk of relapse and will require our ongoing support to stay on the wagon.

Arrange regular follow-up with your patient to check-in, offer support and troubleshoot those forces trying to pull him or her off the low-carb wagon