Increasing Patient Enrollment in the MOVE Program at the VA Medical Center: An Evidence-Based Practice Project

Practice Problem: This evidence-based practice project aimed to increase patient referrals to the MOVE program by educating providers about the importance and benefit of the Managing Obesity for Veterans Everywhere (MOVE) Program at the Biloxi, Veterans Affairs (VA) Medical Center. PICOT: In obese, ambulatory care patients, what motivates increased referrals by practitioners to the MOVE Program to decrease BMI compared to the current referral system within two months? Evidence: There was poor participation in the MOVE Program despite the high number of obese patients at the Biloxi, VA Medical Center. According to the data, only sixty of the 18,000 overweight, actively enrolled veterans are currently enrolled in the MOVE Program. Intervention: The project improvement intervention for this project involved implementation of an in-service education for providers about the MOVE Program and the benefit that it can have to the patient regarding weight loss. All primary care providers were encouraged to attend and if unable to do so, they were given the information that was presented to educate them as well. The project was implemented over two months. The expected goal was that there would be a 10% increase in the number of currently enrolled patients. Outcome: Despite the unforeseen consequences of COVID-19, the outcome was still achieved, and the goal was met and at the end of the two-month observation period, MOVE Program referrals increased by more than 10% referrals from the base number of 60 participants. Conclusion: Subsequently, the data reflects that when providers have candid and intimate conversations with their patients regarding obesity and resources that are available to them, they are receptive and willing to participate in the MOVE Program, even during a global pandemic. INCREASING MOVE PARTICIPANTS 3 Increasing Patient Enrollment in the MOVE Program at the VA Medical Center: An EvidenceBased Practice Project The purpose of this project was to increase veteran enrollment in the Veterans Affairs weight management MOVE Program. Often, healthcare providers are burdened by excess workloads and have limited time to spend with the veterans. While the providers are burdened by the complexity of the patients, obesity only magnifies the problem. This project aims at highlighting the growing trend in obesity and the complications that arise, especially in the veteran population. While the Veterans Affairs MOVE Program was created to help patients lose weight, it fails in that there are not enough referrals to the program, and the growing trend of obesity is increasing. Primary care providers play an important role in identifying obese patients that would benefit from a weight loss program (Tseng, Wang, Clark, Appel, & Bennett, 2015). Referring more patients to the MOVE Program helps to determine if patients will have a better chance of weight loss by being exposed to a program they might have not been introduced to in the past. Significance of the Practice Problem Obesity is an ever-growing epidemic that affects many Americans in both the civilian and veteran populations. A significant percentage of the veteran population (77%) are overweight, leading the Veterans Affairs (VA) to create the MOVE Program (Braun, Erickson, Utech, List, & Garcia, 2016). This is a comprehensive program that is geared toward helping veterans lose and keep the weight off. Studies show that long-term commitments result in greater weight loss when using this program for six months or more (Dochat, Godfrey, Golshan, Cuneo, & Afari, 2019). INCREASING MOVE PARTICIPANTS 4 Mental Health Issues Veterans have several issues that they deal with besides physical health problems. Veterans also have social constraints and mental health issues. When these are combined with obesity, the results can be catastrophic. Breland, Donalson, Nevedal, Dinh, and Maguen (2017) performed a study on women veterans and found that the military promoted eating quickly, much like binge-eating due to time constraints. When this pattern of poor eating habits culminated with stressors, veterans tended to overeat as a coping mechanism. The researchers noted that nearly 75% of the veterans that seek care through mental health services reported unhealthy eating habits such as binge-eating. They also found that poor weight loss habits were a trend among veterans due to these eating habits. This behavior was more common in the veteran population than the general population. Adding to these findings, Dorflinger, Ruser, and Masheb (2017) conducted a study and found similarities. They noted that night-eating syndrome (NES) was highest amongst veterans with obesity. Subsequently, veterans seeking weight management reported that one out of ten veterans tested positive for NES. As a result of previous studies, it was found that veterans were more likely to suffer eating disorders and become obese than non-veterans (Santhiveeran, 2019). Researchers found that weight management interventions can improve these stress-related disorders and problematic eating patterns if they are offered. The ability to change eating behaviors and patterns are needed for weight loss; however, the patient needs to be taught these coping skills. Dochat et al. (2019) detailed in their study the importance of creating a weight loss intervention to help these veterans. This project showed the need to offer patients interventions for weight loss so they can learn to diet correctly and lose weight effectively. INCREASING MOVE PARTICIPANTS 5 Effects of Obesity on the Family According to Skelton, Buehler, Irby, and Grzywacz (2012), everyone in the family strata feels the strain when there are issues with obesity within the household. The current guidelines state that family-based treatments are now the option for treating obesity. Unfortunately, familybased dieting and gym memberships can be costly. Often, some veterans are not able to work due to combat-related conditions or illnesses. Many veterans also have service-connected disabilities and rely on that monetary supplement as income. This is often a fixed income that is nominal compared to the working population. With obesity costing the United States 147 billion dollars and individuals paying an estimated additional $1,429 greater annual cost than most non-obese patients, these veterans can feel the economic pressure (Bomberg et al., 2017). Therefore, increasing enrollment in the MOVE Program will not only benefit the patient, but may also benefit the health and wellbeing of the family. Effects of Obesity and Health One of the greatest effects of obesity on a person is related to the deterioration of their health in association with having a BMI greater than 25. Obesity is associated with multiple health issues including diabetes, cardiovascular disease, musculoskeletal issues, depression, and hyperlipidemia (Schwarze et al., 2019). Obesity and Diabetes Week (2016) found a startling trend: as patients’ weight increases, so does their incidence of diabetes, thus leading to the use of insulin. Similar findings were noted in a study by Franklin et al. (2014) that demonstrate that obesity-fueled diabetes can lead to lower limb amputation among veterans with comorbidities. The veteran population depends on The VA for most of their care, regardless if it is dealing with mental health, primary care, or care related to pain management (Maciejewski, ShepherdBanigan, Raffa, & Weidenbacher, 2018). INCREASING MOVE PARTICIPANTS 6 Many veterans suffer from chronic, daily pain (Higgins et al., 2016). According to Dong, Larsson, Levin, Bernfort, and Gerdle (2018), the more obese a patient is, the worse chronic pain they suffer. The culmination of chronic pain in conjunction with obesity can often be more than one’s psyche can handle (Franklin et al., 2014). People with these ailments tend to have exacerbations of arthritis and low back pain. Already plagued with pain from carrying heavy cargo for years, they multiply this ongoing pain by carrying excess weight (Higgins et al., 2016). Another pressing issue that many veterans are diagnosed with is heart conditions that are often worsened by obesity. When combined with diabetes, obese patients have a greater chance of cardiovascular disease and heart failure than those who patients who are of a healthy weight (Rippe & Angelopoulos, 2016). Addressing obesity-related comorbidities can influence their risk for serious health conditions (Higgins et al., 2016). Effects of Obesity on Society Hammond and Levine (2010) noted that healthcare costs are much higher in the obese population. It is estimated that people with obesity have a lifetime medical cost that is 50% greater than those that are considered a healthy weight. Hammond and Levine also stated that nationally 22 million dollars were spent on the overweight population and that 53 million dollars were spent on obese patients due to the compounding medical problems that they have related to their obesity and other comorbidities. Obese patients are more likely to engage in disability claims and payments than those that are of a healthy weight. Lastly, they found that patients who were defined as obese were expected to live 13 years less than those who were not obese, which is a 22% decrease in longevity of life (Hammond & Levine, 2010). INCREASING MOVE PARTICIPANTS 7


Increasing Patient Enrollment in the MOVE Program at the VA Medical Center: An Evidence-Based Practice Project
The purpose of this project was to increase veteran enrollment in the Veterans Affairs weight management MOVE Program. Often, healthcare providers are burdened by excess workloads and have limited time to spend with the veterans. While the providers are burdened by the complexity of the patients, obesity only magnifies the problem. This project aims at highlighting the growing trend in obesity and the complications that arise, especially in the veteran population. While the Veterans Affairs MOVE Program was created to help patients lose weight, it fails in that there are not enough referrals to the program, and the growing trend of obesity is increasing. Primary care providers play an important role in identifying obese patients that would benefit from a weight loss program (Tseng, Wang, Clark, Appel, & Bennett, 2015).
Referring more patients to the MOVE Program helps to determine if patients will have a better chance of weight loss by being exposed to a program they might have not been introduced to in the past.

Significance of the Practice Problem
Obesity is an ever-growing epidemic that affects many Americans in both the civilian and veteran populations. A significant percentage of the veteran population (77%) are overweight, leading the Veterans Affairs (VA) to create the MOVE Program (Braun, Erickson, Utech, List, & Garcia, 2016). This is a comprehensive program that is geared toward helping veterans lose and keep the weight off. Studies show that long-term commitments result in greater weight loss when using this program for six months or more (Dochat, Godfrey, Golshan, Cuneo, & Afari, 2019).

Mental Health Issues
Veterans have several issues that they deal with besides physical health problems.
Veterans also have social constraints and mental health issues. When these are combined with obesity, the results can be catastrophic. Breland, Donalson, Nevedal, Dinh, and Maguen (2017) performed a study on women veterans and found that the military promoted eating quickly, much like binge-eating due to time constraints. When this pattern of poor eating habits culminated with stressors, veterans tended to overeat as a coping mechanism. The researchers noted that nearly 75% of the veterans that seek care through mental health services reported unhealthy eating habits such as binge-eating. They also found that poor weight loss habits were a trend among veterans due to these eating habits. This behavior was more common in the veteran population than the general population. Adding to these findings, Dorflinger, Ruser, and Masheb (2017) conducted a study and found similarities. They noted that night-eating syndrome (NES) was highest amongst veterans with obesity. Subsequently, veterans seeking weight management reported that one out of ten veterans tested positive for NES.
As a result of previous studies, it was found that veterans were more likely to suffer eating disorders and become obese than non-veterans (Santhiveeran, 2019). Researchers found that weight management interventions can improve these stress-related disorders and problematic eating patterns if they are offered. The ability to change eating behaviors and patterns are needed for weight loss; however, the patient needs to be taught these coping skills. Dochat et al. (2019) detailed in their study the importance of creating a weight loss intervention to help these veterans. This project showed the need to offer patients interventions for weight loss so they can learn to diet correctly and lose weight effectively.

Effects of Obesity on the Family
According to Skelton, Buehler, Irby, and Grzywacz (2012), everyone in the family strata feels the strain when there are issues with obesity within the household. The current guidelines state that family-based treatments are now the option for treating obesity. Unfortunately, familybased dieting and gym memberships can be costly. Often, some veterans are not able to work due to combat-related conditions or illnesses. Many veterans also have service-connected disabilities and rely on that monetary supplement as income. This is often a fixed income that is nominal compared to the working population. With obesity costing the United States 147 billion dollars and individuals paying an estimated additional $1,429 greater annual cost than most non-obese patients, these veterans can feel the economic pressure (Bomberg et al., 2017). Therefore, increasing enrollment in the MOVE Program will not only benefit the patient, but may also benefit the health and wellbeing of the family.

Effects of Obesity and Health
One of the greatest effects of obesity on a person is related to the deterioration of their health in association with having a BMI greater than 25. Obesity is associated with multiple health issues including diabetes, cardiovascular disease, musculoskeletal issues, depression, and hyperlipidemia (Schwarze et al., 2019). Obesity and Diabetes Week (2016) found a startling trend: as patients' weight increases, so does their incidence of diabetes, thus leading to the use of insulin. Similar findings were noted in a study by Franklin et al. (2014) that demonstrate that obesity-fueled diabetes can lead to lower limb amputation among veterans with comorbidities.
The veteran population depends on The VA for most of their care, regardless if it is dealing with mental health, primary care, or care related to pain management (Maciejewski, Shepherd-Banigan, Raffa, & Weidenbacher, 2018).
Many veterans suffer from chronic, daily pain (Higgins et al., 2016). According to Dong, Larsson, Levin, Bernfort, and Gerdle (2018), the more obese a patient is, the worse chronic pain they suffer. The culmination of chronic pain in conjunction with obesity can often be more than one's psyche can handle (Franklin et al., 2014). People with these ailments tend to have exacerbations of arthritis and low back pain. Already plagued with pain from carrying heavy cargo for years, they multiply this ongoing pain by carrying excess weight (Higgins et al., 2016).
Another pressing issue that many veterans are diagnosed with is heart conditions that are often worsened by obesity. When combined with diabetes, obese patients have a greater chance of cardiovascular disease and heart failure than those who patients who are of a healthy weight (Rippe & Angelopoulos, 2016). Addressing obesity-related comorbidities can influence their risk for serious health conditions (Higgins et al., 2016).

Effects of Obesity on Society
Hammond and Levine (2010) noted that healthcare costs are much higher in the obese population. It is estimated that people with obesity have a lifetime medical cost that is 50% greater than those that are considered a healthy weight. Hammond and Levine also stated that nationally 22 million dollars were spent on the overweight population and that 53 million dollars were spent on obese patients due to the compounding medical problems that they have related to their obesity and other comorbidities. Obese patients are more likely to engage in disability claims and payments than those that are of a healthy weight. Lastly, they found that patients who were defined as obese were expected to live 13 years less than those who were not obese, which is a 22% decrease in longevity of life (Hammond & Levine, 2010).

PICOT Question
In obese, ambulatory care patients, what motivates increased referrals by practitioners in the MOVE Program compared to the current referral system to decrease BMI within two months? The population for this project was patients at the Biloxi, VA Medical Center. Most patients were male with a small percent of female patients. The comparison was made based on the number of MOVE referrals for the same time period in the preceding year compared to the two months after the education intervention.

Theoretical Framework
The Biloxi VA Healthcare Systems, along with the rest of the United States, have a known obesity epidemic. According to Zamosky (2013), overweight and obese patients create a higher complexity to the already daunting medical conditions that patients face. Roger's Innovation Diffusion Theory is the process used to organize the model of change throughout this evidence-based practice project (Dearing, 2009). This project aligns with the first step of Roger's theory, knowledge, or presenting the information at hand; and making people aware of the problem (Dearing, 2009). Subsequently, Appendix A demonstrated approval and buy-in from the university and facility for this project. The next step in his theory is persuasion (Dearing, 2009). This is implemented in this organization by making the providers aware that if they enroll the patients in the MOVE Program, and the patients lose weight, their health will likely improve, thus decreasing their workload. Patients will not have to see doctors as often, be prescribed fewer medications, and be hospitalized less because of improving health. The third step is the decision (Dearing, 2009). The providers must consider the need for change and determine the pros and cons of being more proactive with the utilization of the referral system. Roger's delineates the fourth step as implementation (Dearing, 2009). Getting the providers to discuss the MOVE Program more often with the patients, ideally at each encounter, and encouraging the patient to enroll and be committed to the program. The last step is the confirmation (Dearing, 2009). This is where there is confirmation that the patient was enrolled, the patient actively participates, and the MOVE Program continues to be referred to even past the two-month project goal timeframe. These were narrowed down to 48, based on the use of veterans in the population search criteria.

Synthesis of the Literature
Using the applied search criteria, it was noted that the evidence to support the PICOT question was strong and readily available with a variety of literature that was easily accessible.
Originally 646 articles were found to be relevant to the search criteria. After screening the articles, it was noted that there were twenty duplicates, and these were removed. Of the remaining 626, thirty were removed because they were not written in English. The remaining 596 articles were reviewed, and of those, 123 met the eligibility criteria based on the keyword criteria. Finally, the search was narrowed down to forty-eight references based on the search criteria using the key terms and topics related to weight loss programs specifically, related to MOVE.
Literature grading was completed to determine the strength and quality of each body of work (Ebell et al., 2004). The literature was reviewed using the Strength of Recommendation Taxonomy (SORT) System to determine the quality and grading of the body of evidence presented for this evidence-based practice project. Figure 1 describes the SORT results. Several articles were reviewed for this project, and similar themes emerged from them. Among all the articles, a generalized consensus was established that increasing participation in a weight loss program helped provide patients with a means of consistent weight loss, and the longer they utilized the program the better they were at keeping the weight off. Veterans are often plagued by multiple medical conditions and those along with debilitating mental health illnesses create a recipe for poor eating habits and coping skills (Kenneth, 2011). If providers at the VA in Biloxi, MS will increase enrollment to the MOVE Program, participants will lose

Practice Recommendations
Based on a thorough and rigorous review of the literature, summarized in Appendix B, the MOVE Program is an effective means of weight loss for veteran patients as long as the providers refer the patients to the program (Kahwati, Trang, Jones, & Kinsinger, 2004). If more providers refer patients to the MOVE Program, patients can sustain their weight loss over time and reduce the incidence of obesity-related comorbidities (Jackson et al., 2015). Rutledge, Skoyen, Wiese, Ober, and Woods (2017) found that whether using the standard MOVE Program or the tele MOVE, the patient still had some form of weight loss. Similarly, Batch et al. (2018) stated that regardless of gender, patients were successful when using the MOVE Program.

Project Setting
The setting for this project was a veteran's hospital located in Biloxi, MS, which was completely funded by government appropriations. This facility is part of an organization that is The stakeholders included: the patient, family of the patient, providers, dietitians, nurses, and hospital leadership. The vision and mission statement for the VA are congruently aligned.
The mission is "Honor America's Veterans by providing exceptional Health care that improves their health and wellbeing." The vision is: VHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patientcentered, and evidence-based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery, and continuous improvements.
Organizational support was achieved by discussing this plan with the facility leadership through verbal discussions and a commitment to see this project through. There was a plan of sustainability by initiating the project in primary care and integrating it throughout the hospital system. By discussing this project with the Director of Food and Nutrition, it will continue to be implemented and followed through by the MOVE facilitator long after the submission of the project has been completed.
A strength, weakness, opportunity, and threat (SWOT) analysis diagram is presented in Figure 2. The findings show that there are strengths in this facility commitment for evidencebased practice, and strong leadership support. Weaknesses include concerns for employee's lack of interest from staff or resistance and the patient's unwillingness to engage in the MOVE Program. Some opportunities are noted as being better benchmarks on reporting local and nationwide for the MOVE Program support and improved health and quality of care for the patients. Threats are identified as potential patient identifier risks, and providers being held accountable for not meeting the MOVE goal of patient enrollment.

Strengths Opportunities
*Stakeholder Support *Evidence based intervention *Low cost project *Increased chance for weight loss among patients * Become a leader in MOVE participation nationwide at this facility Weakness Threats *Lack of participation among patients *Lack of participation among providers *IT might not be able to create reminder in CPRS *Providers may quit to extra workload burden Figure 2. SWOT analysis.

Project Vision, Mission, Objectives
The intended goal of this project was to increase participation in the MOVE Program.
The mission for this project was aligned with the VA mission in that it also strives for exemplary care and improving the overall well-being of the patient. The vision was to utilize a collaborative approach among healthcare providers to demonstrate an evidence-based approach for improved weight loss and well-being that is continuously improving. Objectives for this project included demonstrating an increased enrollment of 5% or greater in the MOVE Program from the baseline enrollment number in the first month benchmark and 10% or greater increase in second month benchmark while the project was implemented. Risks and unintended consequences included issues such as poor patient compliance and disengagement from the staff.

Project Description
The chosen model for this proposed project was based on the fundamental ideas of Rogers. Oturakci and Yuregir (2018) described using Roger's innovation model to create change in an organization that is fluid and well-received. Several steps must be accomplished to fully have an organization accept the change and implement the new procedures (Dearing, 2009).

Roger's Innovation Model
Knowledge. To initiate the project, there must be a baseline of knowledge, or understanding about what is about to happen that is going to make people aware of the problem (Dearing, 2009). For this to happen with this project, a meeting was held, and a PowerPoint presentation was shown to demonstrate the current trajectory of the MOVE Program and ways that it can improve a patient's health and overall wellness. The presentation was given in the meeting of the providers that is held every Thursday.
Persuasion. This was the act of getting the buy-in from the providers. Roger's described this as a means of making the stakeholders understand how this change will not only help the patient but also help the provider as well (Dearing, 2009). During the presentation, it was demonstrated that by increasing productivity to the MOVE Program, the patients will lose weight through immersion and will have fewer health risks that the provider would have to treat. The providers were given in-service training to explain the project plan. They were given a short PowerPoint to describe the current project plan and their role in helping to increase enrollment into the program. Providers were shown the tool that will be used to determine enrollment criteria and enroll each candidate that meets inclusion criteria.
Decision. This step was described by Rogers as making the participant weigh the need for change and understand how it will in turn benefit themselves (Dearing, 2009). The goal here was to get the provider to understand the need to refer patients at every opportunity in their interactions with the patient.

Confirmation.
Rogers determined that after a person has realized that the change was fundamental to creating a better environment, the person is willing to change, and thus the change occurs (Dearing, 2009). This was the time in this project that the number of referrals to the MOVE Program demonstrated an increase because the providers were accepting the fact that there was something to gain for the provider and the patient. This was the time when there was an increase in enrollment in the first month of at least 5% and at least 10% in the second month with active participation of at least 75% of the providers.

Implementing Change
Patients met with their provider, and if they met the criteria, they were enrolled in the weight-loss program. After the consult has been sent, the MOVE coordinator got the consult and alerted the DNP student of the active consult. This data was placed on the excel spreadsheet.
This process was evaluated throughout the month and monitored for the continued support from the providers. If it was noted that the providers were actively participating, they were counseled for any barriers to enrollment. As the process continued throughout the project, the same evaluations were done to determine if the enrollment had again increased in the next month as anticipated for 10% enrollment goal.
Risks and unintended consequences were crucial to look at for any proposed change project. This is especially so when dealing with direct patient care. In this project, to increase referrals to the MOVE Program, there were a few risks and unintended consequences that were examined. First, determining the possibility of poor compliance among the patients and providers was important. The project could potentially have failed if there had not enough active participation on either end of the stakeholder spectrum. Another risk was patient information vulnerability. This was minimized by keeping the patient identifiers and information safe in a secured folder on the government computer interfacing. Lastly, an unintended consequence was provider resignation. If providers felt that the workload burden was too heavy, they could have potentially quit, resulting in a project that again, did not have enough active participation.

Budget
The current budget for this project was nominal as noted in Appendix C. There was a cost associated with printing the information from the PowerPoint for the providers at the initial meeting. The salary of the MOVE director was already budgeted into the formal VA Gulf Coast budget and he did not incur any overtime nor did the DNP student who was completing the project.

Project Evaluation Plan
Acting as the project manager, work was done in conjunction with the partnership of the MOVE coordinator. Utilizing leadership skills, the project plan was implemented and monitored closely. During the COVID-19 pandemic, unforeseen barriers occurred but were mitigated through continued leadership collaboration. The Evaluation for this project was done by looking at pre-and post-enrollment numbers for the time frame in which the project was implemented.
There was a set schedule to which the process timeline would map out the events that would take place during this study as noted in Appendix D. The recruitment of the patients was based on those that are enrolled in care through the primary care clinic at the Biloxi VA campus. The inclusion criteria looked for in participants were those that had a BMI greater than 26 and are eligible for enrollment in the program. Those that are enrolled for any other purposes besides weight loss will not be considered. Subsequently, exclusion criteria included patients who were enrolled outside of primary care or self-referrals.
The purpose of this project was to increase active enrollment among primary care providers. Therefore, the patient population focuses on those that were referred from primary care. Data analyzed looked at enrollment numbers before the enactment of the project and enrollment numbers one month after providers were educated on the importance of enrollment, and, finally, the number of enrolled patients two months after the start of the project.

Data Collection
Data was collected through collaboration with the MOVE Program coordinator.
Collected information included the name of the provider making the consult, provider age, and the clinic from which they were enrolled. The data was stored electronically through a VA Excel spreadsheet that was placed in a password-protected folder on the server that was only accessible by the DNP student, MOVE coordinator, and the education department chair. Limited accessibility protected patient information and aligns with patients' rights to have secured information stored safely. Throughout the project, continuous protection of human rights and privacy of healthcare information was implemented.
The data source came from the computerized record system (CPRS), which was the only system the VA uses to initiate referrals for the MOVE Program. The goal was to have an increase of 5% or greater enrollment in the first month for enrollment, and 10% or more increased enrollment in the second month with a 75% provider participation rate at the end of the project.
The data collected also demonstrated a strong link between interprofessional collaboration. The initial idea for the project was to include only "providers" who were licensed, independent providers. But the data suggested that there is a change to also incorporate other allied health providers in this grouping to further increase referral and participation in the MOVE Program. Allowing for nursing staff to also encourage the patients to enroll in the MOVE Program and having conversations will also help to increase participation.
The findings from this project lend themselves to future discussions about incorporating the use of TELEMOVE programs for situations where the facility is limited to social interactions in close quarters. Similarly, expanding this in-service training to other clinics in the Biloxi, MS VA, and eventually across the VISN to encourage enrollment of veterans to the MOVE Program.
After it has been established that providers are continually making strides to increase enrollment, the next project might focus on keep patients in the program. This project has the potential to lend itself to many other options for increasing participation for the veteran population.

Formative Evaluation
Once the evaluation plan was implemented, the results were analyzed and the outcomes were measured based on the findings from the Veterans at the Biloxi, MS VA Healthcare system.
The evaluation results were based on patients that were referred from the primary care clinic provider in the outpatient clinic. There were 13 providers were who were expected to refer patients to the MOVE Program. The expected outcome measures were to see an increase of 5% for the first 30-day benchmark and 10% for the second 30-day benchmark for patient referrals over the base number of 60 current participants.
The initial presentation was given to all providers in the clinic during the primary care administrative meeting. Those that were not in attendance were given the information verbally and in handout form. Some meetings took place between the MOVE coordinator and myself to evaluate the referrals that were received for inclusion criteria, as I previously mentioned in the plan for dissemination. Those that did not meet the criteria were removed from the project findings.

Summative Evaluation
The project was met with resistance due to the COVID-19 pandemic. The process measures were completed correctly with the initial teaching and follow up planning. However, despite the meticulous process measure completion, there were still unforeseen issues that arose.
Due to the COVID-19, clinic operations were changed, and patients' visits were converted to telephonic visits. This caused many patients to cancel their appointments. With decreased visits, the process measures could not be carried out to their fullest potential.
The initial goal had met its benchmark of 5% for the period during March-April and continued to meet the mark for April-May. The first month saw 63 referrals. During the second benchmark of the project, there was decreased foot traffic in the primary care clinic. Despite this, there were still 13 referrals that occurred even with the decreased number of patient visits, as noted in figure 4. Regardless of the pandemic that took place, there were still referrals that were undeterred by this unforeseen occurrence.
This project analysis was completed with the consultation of a statistician. Based on the frequency count, the expected outcome goals were measured. Utilizing SPSS, A single t-test was performed to determine if the standard deviation p-value <0.05. As noted in Figure 2 in Appendix E, the findings found that the standard deviation and standard mean error are small, meaning that this is good indicator that the data is an adequate representation of statistical findings.
As the data has demonstrated, there was a strong link between patient-provided dialogue regarding obesity education and enrollment in the MOVE Program. When patients were offered enrollment after discussions with their providers about obesity and its long-term effects, the project results demonstrate that they were more inclined to participate. When patients were given information about the program, they were more likely to enroll; similarly, when providers took the time to educate patients, the numbers for enrollment increased. The goal of increased patient referrals correlated with the attempt to change the referral practice. It was successful as the goals were met and more patients were enrollment and the baseline for current enrollees has increased.
Immediately after the in-service and education seminar about the MOVE Program, there was a large surge in referrals. Referrals were somewhat hindered due to COVID-19, but the program increase was still successful, nonetheless. Had COVID-19 not occurred, the assumption was that the numbers of enrollees for the second benchmark would have been just as successful as the first.
When face-to-face visits were no longer allowed and all communication went virtual, it demonstrated that there was a decrease in the propensity of enrollment. This was most likely due to several factors. Virtual Communication did change the implementation, but the data analysis demonstrated that before the virtual component, patients were receptive to enrollment. These findings were important because there was a takeaway component here and that was that patients respond better when there was a candid and intimate conversation where the provider and the patient could have more lengthy discussions about obesity. The telephonic and video visits were often rushed and tended to emphasize the current health conditions that plagued the patient at that given time. Most visits completed in this capacity were traditionally done for focused assessments. This correlates with the findings of Cotter, Bera, Elsemore and Snelling (2018), that patients were already hesitant to communicate about obesity, much less doing so in a sterile environment where there is no social interaction besides communication through a telephone line.
There were limitations observed during this project, one of which was that the sample was a small cohort of providers assigned to the Biloxi, VA Medical Center. This smaller group of provider size was further complicated when COVID-19 limited the number of providers due to Shelter in Place orders; thus, limited face-to-face visits. Likewise, due to the increasing number of providers using telephonic and virtual visits, bandwidth was decreased and created difficulties with communication initially. The difficulties were rectified, but they still hindered the ability to capture more visits initially in this primary care patient population. The primary goal of increasing patient enrollment initially 5% from the baseline and then subsequently, 10% was achieved but certainly could have shown much greater numbers had this issue not taken place initially.
Due to the change in how visits occurred and many patients opting to cancel their appointments until after the COVID-19 situation resolved, balance measures were skewed. When the VA opted to recommend telephonic visits, some patients did not want to conform to this type of visit and thus chose to cancel. While it was effective in creating a safer patient environment due to the reduction in face to face contact and decreased spread of infection, it caused the chance of making a referral to the MOVE Program decrease. As a result, the patient-provider intimacy changed, and patients were not engaging in visits as routinely.
One of the components of the initial Inservice was engaging the patient and trying to sell the MOVE Program not only through statistics but through patient-provider communication. Using telephonic communication does change the intimacy of conversations and it seems to reason that patients were less likely to be persuaded to pursue the program. Thus, there was a decrease in the number of referrals, but the outcome was still successful in meeting the measures.
To sustain longevity in healthcare practice, a patient needs to take an active role in participation. This can be achieved by having conversations with patients and educating them on healthcare resources and allowing them to make informed decisions about correcting negative aspects of their health. Gone are the days of a patient responding positively to paternal medicine: a great impact can be made by educating patients and allowing them to participate in active healthcare, which can perpetuate a trend in increasing referrals. This project has shown that, by educating providers on the importance of utilizing a resource such as the MOVE Program for weight loss, more patients are likely to be enrolled.
VA data from the computerized charting system revealed that there are approximately 28,587 veterans currently enrolled in the MOVE Program at Biloxi, MS VA Gulf Coast System.
Of these patients, there are 15,600 that are considered overweight with a body mass index greater than 25. According to the MOVE director, there are only 60 active participants in the MOVE Program currently. Veterans Administration data demonstrates that approximately 77% of veterans are considered overweight. The current outcome objective is to increase enrollment 5% in the first month and 10% in the second month, thereby yielding two new veteran enrollees in month one, and six new veteran enrollees for the second month.
Analyzing these findings using descriptive statistics including frequencies, percentages, mean, median and standard deviation is appropriate to describe and to organize the data that will observe the variables for this project. Single t-testing was done to determine the consults of patients sent to the MOVE Program before implementing the intervention of the changed referral program and then looking at the number of consults sent after. A p-value =0.05 was used as the criteria to determine the statistical significance of the outcome goal and the clinical meaningfulness of the improvement project.

Internal Dissemination
The presentation on the idea of increased participation in the MOVE Group was completed during the primary care meeting that is held once a month. At this time, all of the primary care providers convene and discuss issues, and someone presents a topic that could improve the current standards in the primary care setting. Considering that the providers are the ones who refer the patients to the MOVE group, logic dictated that the ideal time to complete the in-service for the project was during the provider group meeting, where providers could be enlightened about the importance of referring patients and the benefits of such referrals. The presentation combined a PowerPoint with oral delivery. Tele-link was also used, so the satellite provider was able to see the presentation.

External Dissemination
According to Teplitskiy, Acuna, Elamrani-Raoult, Körding, and Evans (2018), peer review is important because it helps create validity without showing favoritism to any given journal. The informing idea behind presenting the project at a conference was to get feedback to improve the methodology. The project aligns most with a conference that is geared toward obesity and Veterans. This project will be shared to SOAR and the Virginia Henderson Library, and plans to submit an abstract of the findings to the VA Inspire Magazine viewed at this facility are in place.
Similarly, an abstract will be included in the VA Daily Dose online publication. Submission to the Journal of Veterans Studies is also of interest; however, they have not yet begun to take submissions. The Journal of Veterans Studies focuses on topics that are related to veterans and facilitates their learning to create opportunities for them to have media that is related to their experiences. According to Hembrough (2017), veterans need a way to communicate with one another through comradery that, sometimes, only they understand. Creating a journal for this demographic is important, as such will continue to enlighten veterans with stories, studies, and articles in which they are interested.

Conclusion
This project intended to demonstrate a need for increased opportunities to enroll patients in the MOVE Program by emphasizing the necessity to recognize the growing epidemic of obesity amongst the Veteran population. When more providers understand that decreasing weight and increasing participation are important, the overall health of the veterans improves, and healthcare costs can be reduced. Studies have shown that patient counseling by primary care providers and referrals to weight loss programs by a healthcare provider enhances a patient's motivation for weight loss (Banerjee et al., 2018). Obtaining provider engagement and increasing buy-in has shown to increase referral activity among patients and, in turn, create opportunities to decrease the epidemic of obesity that currently plagues the VA. This project opens further discussions for the improvement and use of Whole Health Models to engage in patient participation in their healthcare and to move away from paternal medicine patterns. Allowing patients to have autonomy in choosing how to address healthcare issues is the first step in creating a life-long model for decreasing comorbid conditions, especially in the already vulnerable population of veterans.