by Jenn Lukens
In the year 2000, Dr. Timothy McKnight came to Trinity Hospital Twin City (THTC) in the rural town of Dennison, Ohio, on a stipend from the National Health Service Corps. Unlike many doctors who leave for a city after their 3-year rural service commitment is up, McKnight put down roots.
A board-certified family physician with a Master of Science degree in nutrition, McKnight has a holistic philosophy when it comes to treating patients. Unfortunately, the average 15 minutes per appointment wasn’t allowing room for a deeper discussion about health.
“I just couldn’t keep up with it. I felt like I was managing disease, not preventing or reversing disease,” said McKnight. Located in the northern tip of the Appalachian Mountains, Tuscarawas County’s exercise facilities and health programs were sparse, lending to high rates of obesity-related illnesses such as heart disease, diabetes, and cancer.
In 2003, McKnight took matters into his own hands. On his own time, he developed a wellness course called Fit for Life (FFL) for his patients and the community to lose weight and improve health. But when the cost of the course was preventing patients from enrolling, he partnered with THTC Grant/Marketing Coordinator Jennifer Demuth to apply for federal funding from the Health Resources & Services Administration (HRSA)’s Federal Office of Rural Health Policy (FORHP) to cover the majority of FFL’s enrollment cost for participants. The application was funded in May of 2006.
Looking Out for the Little Guys
Trinity Hospital Twin City has since received over $1.7 million from FORHP to fund four different components of the Fit for Life program. While the first grant cycle made it possible to offer the course at the hospital to Tuscarawas County community members, the next cycle allowed the program to expand to places of business. Employers allowed employees paid time off or stipends as incentives to sign up for the course. After the second cycle ended, it was THTC’s HRSA Project Officer Nisha Patel and Technical Assistance Provider Beverly Tyler of the Georgia Health Policy Center who encouraged them to apply for additional funding to replicate FFL in three neighboring counties.
When asked why the FFL program caught HRSA’s eye, Patel explained, “They had wonderful, forward-thinking leadership and a keen sense for their community’s needs and how to reach the ‘hard-to-reach.’ I believed all along that they had the resources and drive to have an even more meaningful impact in their community than they had originally envisioned…I am so proud of their success.”
FORHP Grants Received by Trinity Hospital Twin City
Trinity Hospital Twin City has received multiple awards from the Rural Health Care Services Outreach Grant program and the Small Health Care Provider Quality Improvement (SHCPQI) Grant program:
||Budget Period||Grant Amount|
|Fit for Life||Outreach||2006-2009||$375,000|
|Fit for Life – Community Outreach||Outreach||2009-2012||$375,000|
|Fit for Life – Replication for Expansion||Outreach||2012-2015||$375,000|
|Accountable Care Act Special Program (add-on to Replication Project)||Outreach||2012-2015||$ 20,632|
|Diabetes Prevention Fit for Life||Outreach||2015-2018||$555,556|
|Chronic Care Management||SHCPQI||2016-2019||$522,324|
To make FFL a replicable program, the team formalized the curriculum and established methods of measuring its results. It paid off. In 2015, FFL was acknowledged as a promising best practice model by an evaluation team at the Ohio University Voinovich School of Leadership and Public Affairs. FFL also received national recognition as promising by RHIhub’s Rural Models and Innovations.
Comparing the program’s humble beginnings to its current operation, Demuth is grateful. “If someone would have told me we would become a promising best practice, I probably wouldn’t have believed them,” she said. “But because of HRSA, we’ve been able to get to that point.”
They’ve really done a lot to reach out to rural communities. So many other funding sources won’t give rural organizations much thought. I’m so thankful that HRSA looks out for the little guys.
An experienced grant writer, Demuth has noticed an increase in the number of options that HRSA has made available in recent years. “They’ve really done a lot to reach out to rural communities. So many other funding sources won’t give rural organizations much thought. I’m so thankful that HRSA looks out for the little guys,” she said.
Each grant THTC received has allowed for more creativity in addressing their community’s most prevalent health needs. Now in the fourth FFL grant cycle, the program focuses on comprehensive diabetes prevention for those at risk of, or newly diagnosed with, diabetes — a disease that continues to expand throughout Tuscarawas County.
“The rate of diabetes is following the increased rate of obesity. As we get heavier, diabetes rates increase, and we haven’t figured out a way to slow it as a nation,” commented McKnight. “If you attack this the right way, you reverse diabetes and prevent heart disease.”
The FFL team, along with consortium partners Chrysalis Counseling Center, New Philadelphia City Health District, Tuscarawas County General Health District, and the Tuscarawas County YMCA, has been proactive in recruiting low-income residents to the Diabetes Prevention Fit for Life Program. In the first year, they conducted over 100 free health screenings at local sites. During a screening at a food pantry, 15-20 people were found to be at risk of diabetes. About half of them registered for the Diabetes Prevention FFL program.
Although only in its second year of operation, McKnight says that, in comparison with other FFL programs, this one has seen the biggest evolution in helping people lose weight and connect to support systems.
The Health Cheerleader
While McKnight creates and teaches most of the curriculum, Kelly Bowe takes care of the administrative end as the FFL outreach and program coordinator. Bowe, a nationally-certified medical assistant, also serves as a health cheerleader of sorts. “She makes people feel important, loved, and encouraged – like someone believes in them,” commended McKnight.
As a graduate of the FFL program, Bowe can easily empathize with the participants. She confesses feeding too much mac and cheese and hotdogs to her kids when they were young. Now, she frequents the produce section and farmers’ markets. “The way we shop is entirely different…but you don’t know better until you learn better,” she stated. Bowe highly recommends FFL to young families because “it’s easier to make changes when the kids are little.”
FFL participants vary from teens to elderly folks, the oldest graduate being 96 years old. Some drive up to an hour to get to class every week. Many are referrals from physicians who have personally taken the course in order to “see what all the hype is about,” said Bowe.
A Focus on Mindset
While the curriculum includes information from national organizations such as Centers for Disease Control and Prevention and the American Diabetes Association, the bulk of it is generated by McKnight’s training in applied and clinical nutrition.
Topics relate to nutrition, exercise, and health education. Food labels, back pain management, disease prevention, cancer screening, and hormone replacement are just a few of the lessons covered each week. Although participants receive nutrition and fitness plans, McKnight emphasizes that this is not a weight-loss or dieting program. What makes this program unique is its focus on mindset.
As much as we talk about the science, we recognize that underlying this behavior is their choices. Fit for Life helps people make healthier choices by helping them become empowered and realizing that their thoughts, emotions, and relationships have an impact on what they choose for themselves.
“This is about change from the inside out,” McKnight tells every newcomer to the course. “As much as we talk about the science, we recognize that underlying this behavior is their choices. Fit for Life helps people make healthier choices by helping them become empowered and realizing that their thoughts, emotions, and relationships have an impact on what they choose for themselves,” he said.
For instance, participants are taught how to make dietary changes in stages, with a bigger focus on lifestyle changes like shopping, eating, and cooking patterns. Since each person makes progress at different rates, participants set individual goals, track their progress, and complete homework assignments.
The Ultimate Example
I’m the type of husband and father that I’ve always wanted to be but was unable to because of my health. I could not have done it any other way than the way this course was set up.
A highlight of the course for participants is hearing testimonies from former graduates, like Marvin Fete. In 2015, he enrolled in FFL as a diabetic. Starting out, he was barely able to walk two laps around a track without stopping. Fete ended the course regularly running several miles in a row and no longer needing diabetes medications. His wife and two small children were the motivation behind his transformation.
“I’m the type of husband and father that I’ve always wanted to be but was unable to because of my health,” stated Fete in an RHIhub video feature. “I could not have done it any other way than the way this course was set up.” Fete is currently advocating for the remodeling of an old racquetball club into an indoor walking track to encourage exercise in his community. Watch more of Fete’s story in this video:
It’s testimonies like Fete’s that inspire McKnight to continue putting time and effort into FFL. “Marvin’s story is the ultimate example. It is my hope that everybody has that same experience,” he said.
Offering Hope and Direction
Through FFL, McKnight has observed much about rural tendencies. “Rural people are not looking for policies and handouts, but for hope and direction on how to get healthy. If we give them these things, they will take off and take responsibility for their health.”
Through FFL, Trinity Hospital Twin City has found that what works in a city doesn’t always work in the country, especially when it comes to improving health. Because of many barriers to health, rural communities are often at a loss about where to start. Demuth says that FFL can help with that. “As a tried-and-true program, we know this has been successful in rural communities.”
To help other rural communities across the country, THTC has made the FFL curriculum available for purchase at a reasonable rate. For more information, contact Jennifer Demuth at firstname.lastname@example.org.
After several years of success, “the results speak for themselves,” stated Demuth. Since 2003, nearly 2,000 adults have graduated from the Fit for Life program. The two classes offered every fall and spring are maxed out at 50 participants each. Local media outlets are generating buzz through special features, and FFL graduates have become the number one recruiters for the program. Referrals from providers at THTC and other area facilities are pouring in. “Where other programs have a difficult time recruiting, we have a waiting list,” noted Demuth.
Since arriving in Dennison, McKnight has had a big hand in improving the health of a community that desperately needed a change. As a primary care doctor, he has witnessed FFL’s effects firsthand. Participants are reversing their diabetes, losing weight, lowering their cholesterol, and even sleeping better. “It brings great satisfaction. This is really what I want to do as a physician,” he stated.
McKnight is often invited to share about FFL at continuing education trainings and healthcare events around the country. In May of 2012, he represented the THTC FFL program at the White House Rural Council: Rural Stakeholders Meeting. Right now, he and the FFL staff are partnering with the Ohio University Voinovich School of Leadership and Public Affairs to publish an article in the peer-reviewed journal Health Education & Behavior (HEB).
He still devotes two days a week to the development of the FFL program and takes every opportunity to share his experience with others who want to start something similar.
When people leave my class, I want them to feel something that they’ve never felt before – that every person will shed a tear of hope, recommitment, or renewal. I really want that for people.
“You have to be passionate about your message. You have to be comprehensive and provide a service at a level that people resonate with as much emotionally as they do intellectually,” says McKnight. “When people leave my class, I want them to feel something that they’ve never felt before – that every person will shed a tear of hope, recommitment, or renewal. I really want that for people.”