Using Group Medical Visits With Those Who Have Diabetes: Examining the Evidence

Twenty-first century management of diabetes with shared telemedicine appointments

This commentary article discusses the benefits of utilizing telemedicine to conduct shared medical appointments for people with type 1 diabetes and type 2 diabetes. We conducted a literature review of articles about shared medical appointments or group medical visits in people with diabetes with associated clinical data. We identified 43 articles. Models of this approach to care have demonstrated positive outcomes in adults and children with type 1 diabetes. Shared telemedicine appointments also have the potential to improve diabetes self-management, reduce the treatment burden, and improve psychosocial outcomes in adults with type 2 diabetes. Ten key recommendations for implementation are presented to guide the development of shared telemedicine appointments for diabetes. These recommendations can improve care for diabetes.

From Trials to Practice: Implementing a Clinical Intervention in Community Settings

INTRODUCTION/OBJECTIVES

Diabetes increases the risk of complications, especially for vulnerable populations. Our previous randomized clinical trial (RCT), TIME (Telehealth-supported, Integrated Community Health Workers (CHWs), Medication access, group visit Education), showed the efficacy of CHW-led diabetes care. This study aimed to gather data on transitioning TIME from clinical trials to practical implementation.

METHODS

We conducted a 12-month RCT at a nonprofit community clinic using the Consolidated Framework for Implementation Research (CFIR). Participants, Hispanic adults without insurance and with type 2 diabetes (N = 58; 29/arm), were randomized to TIME (intervention) or usual care (control). The intervention included monthly group visits and weekly CHW mHealth contact (6 months, Action Phase), followed by quarterly visits and bi-monthly mHealth contact (6 months, Maintenance Phase). The research team provided tele-mentoring to the clinic team throughout the intervention. Outcomes included implementation measures including acceptability, adoption, appropriateness, cost, feasibility, fidelity, satisfaction, and effectiveness.

KEY RESULTS

The program showed high levels of fidelity (direct observation), adoption (CHW-participant contact: 844 successes of 957 attempts [88.2%]), and feasibility (3.4% attrition). The intervention's net savings was $16,435 ($566/participant). At 6 months, intervention participants had greater HbA1c reductions (-0.85% vs 0.35% [δ = 1.2%]; P = .004; effectiveness) compared to the control. At month 12, more intervention participants improved HbA1c (-0.52% vs 0.25% [δ = 0.8%], P = .062) and preventive care adherence (P < .0001) compared to the control. Surveys revealed high appropriateness (mean = 4.8/5.0 and 5.95/6.0), satisfaction (mean = 4.6/5.0), and acceptability (mean = 4.9/5.0) among providers, CHWs, participants, and stakeholders.

CONCLUSIONS

TIME met key early implementation measures, including strong engagement at both clinic and participant levels, while demonstrating cost savings and significant clinical improvements. These results support the transition of TIME from efficacy trials to practical, community-based diabetes care. Larger studies are needed to further evaluate these findings.

Integrative Group Visits for Sleep Disturbance: A Brief Report

Background

There is limited research on the efficacy of group visits using integrative treatment modalities and for people whose chief concern is sleep disturbance. This quality improvement project delivered integrative health content in group visits for people with self-reported sleep disturbance.

Objective

To describe an integrative group visit for sleep disturbance, explore the evaluation process for several outcomes, and report on lessons learned.

Methods

A group visit series involved 4 sessions over the course of 1 month, covering integrative health topics such as acupuncture, mind-body therapies, and herbal medicine. Participants were administered 2 validated surveys (PSQI and PROMIS-29) at baseline and 1- and 3-months post-intervention.

Results

In 4 4 week GV series,18 people participated in-person pre-pandemic, and 5 people participated virtually during the pandemic. The mean age for the entire cohort was 63.2 years. Of the 23 participants, 18 (78%) attended all 4 GV sessions within their series.

Conclusion

Preliminary findings from this study suggest that an integrative group visit approach to sleep disturbance is feasible yet would benefit from a more rigorous investigation.

Impact of group medical visits on patient engagement and quality of life

BACKGROUND

Group medical visits (GMV) effectively improve patient care and outcomes through interactive education, increased patient contact, and facilitated social support. This quality improvement research examined if patient activation and quality of life correlate with weight, blood pressure (BP), and hemoglobin A1c (A1C) through GMV interventions.

METHODS

Participants were enrolled in GMV Lighten Up for weight management or GMV Diabetes. At pre- and post-intervention, patients completed the Patient Activation Measure (PAM) and the health-related quality of life measure, the SF-12; and were assessed for weight, blood pressure (BP), and hemoglobin A1c (A1C).

RESULTS

Weight and PAM scores significantly improved regardless of group. For patients in GMV Diabetes, A1C significantly decreased. GMV Lighten Up participants had statistically significant declines in diastolic BP. Both groups improved patient activation, but statistically significantly so only in GMV Diabetes participants. SF-12 scores did not statistically significantly improve. There were no predictors of A1C and PAM score change for the Diabetes GMV. However, age, SBP and SF-12 scores predicted PAM score changes in GMV Lighten up participants.

CONCLUSIONS

Participants in this study showed overall improvement in biomarkers and patient activation. Thus, GMV continue to be a viable method for healthcare delivery.

The "Ups and Downs" of Living With Type 2 Diabetes Among Working Adults in the Rural South

The purpose of this qualitative study was to gain a better understanding of the spheres of influence on engagement in recommended diabetes preventive health services among rural, working adults. Additionally, this study sought to understand the unique factors that influence diabetes self-management among rural, working adult populations. The sample included mostly African-American, low-income females with self-reported diabetes, who scored low on the Patient Activation Measure (PAM-10). Semi-structured interviews (N = 20) revealed that most participants struggled with the "ups and downs" of living with diabetes. Four major themes emerged from the data: "the struggle," "doing things together," "diabetes is not the priority," and "we're lucky to have what we have." Most participants were developing individual responsibility and motivation for a healthy future, but were overwhelmed by inconsistency in self-management, diabetes distress, lack of effective coping strategies, and lack of social and economic capital. The findings of this study indicate the need to further address psychological well-being among rural, working adults, yet rural populations often lack sufficient access to mental health care and formalized psychological support. Psychological support and resources are essential to facilitate engagement in diabetes self-management and preventive health services for rural, working adults.

Implementation and delivery of group consultations for young people with diabetes in socioeconomically deprived, ethnically diverse settings

BACKGROUND

Young people with diabetes experience poor clinical and psychosocial outcomes, and consider the health service ill-equipped in meeting their needs. Improvements, including alternative consulting approaches, are required to improve care quality and patient engagement. We examined how group-based, outpatient diabetes consultations might be delivered to support young people (16-25 years old) in socio-economically deprived, ethnically diverse settings.

METHODS

This multi-method, comparative study recruited a total of 135 young people with diabetes across two implementation and two comparison sites (2017-2019). Informed by a 'researcher-in-residence' approach and complexity theory, we used a combination of methods: (a) 31 qualitative interviews with young people and staff and ethnographic observation in group and individual clinics, (b) quantitative analysis of sociodemographic, clinical, service use, and patient enablement data, and (c) micro-costing analysis.

RESULTS

Implementation sites delivered 29 group consultations in total. Overall mean attendance per session was low, but a core group of young people attended repeatedly. They reported feeling better understood and supported, gaining new learning from peers and clinicians, and being better prepared to normalise diabetes self-care. Yet, there were also instances where peer comparison proved difficult to manage. Group consultations challenged deeply embedded ways of thinking about care provision and required staff to work flexibly to achieve local tailoring, sustain continuity, and safely manage complex interdependencies with other care processes. Set-up and delivery were time-consuming and required in-depth clinical and relational knowledge of patients. Facilitation by an experienced youth worker was instrumental. There was indication that economic value could derive from preventing at least one unscheduled consultation annually.

CONCLUSIONS

Group consulting can provide added value when tailored to meet local needs rather than following standardised approaches. This study illustrates the importance of adaptive capability and self-organisation when integrating new models of care, with young people as active partners in shaping service provision.

TRIAL REGISTRATION

ISRCTN reference 27989430.

Perception of benefits and barriers associated with dementia prevention behaviors among people with diabetes

Type 2 diabetes mellitus is a risk factor for developing dementia and a public health concern around the world. Identifying any predictive factors associated with diabetes-related dementia prevention behaviors are of value in helping to prevent dementia. From six community hospitals in Chiang Mai, Thailand, 182 people aged 30-60 years were enrolled in a cross-sectional study and completed a written questionnaire on dementia prevention behaviors and perceptions of health beliefs. Multiple linear regression analysis was applied to determine possible associations between dementia prevention behaviors and health belief perceptions. A high level of preventive behavior was associated with high perceptions of the benefits of, and barriers to, dementia prevention and longer duration of patients' diabetes. Findings indicate the predictive role of the two factors in the perception of health beliefs about dementia prevention behaviors among the participants. Although further testing with different samples and in different locations is warranted, education programs for health practitioners that integrate the findings of this study would be beneficial to improvement of dementia prevention behaviors in people with diabetes.

Patient and Clinician Satisfaction With Diabetes Group Visits in Community Health Centers

Diabetes group visits (GVs) have been shown to improve glycemic control and quality of care. However, little is known about the patient and clinician experience. We trained staff to conduct a 6-month GV intervention at six community health centers (CHCs) for adults with uncontrolled diabetes. Patient satisfaction was analyzed using postintervention surveys. Clinician satisfaction was analyzed through pre and posttraining surveys and 1:1 semistructured interviews. Twenty-seven staff and clinicians were trained. Fifty-one adult patients were enrolled and 90% reported high satisfaction with the program. Patients enjoyed longer visits with peer support and felt better equipped to manage barriers to diabetes control. 88% of staff reported that they enjoyed taking part in the program and noted improved team morale, professional development, and increased interdisciplinary collaboration. Perceived challenges of GVs included time investment for a new program, integration into workflow, and staff turnover. Patient and staff satisfaction was high across multiple domains. Staff noted many benefits but reported challenges with patient recruitment and retention as well as the time needed to implement GVs.

Group Prenatal Care and Emergency Room Utilization

Pregnancy-related complaints are a significant driver of emergency room (ER) utilization among women. Because of additional time for patient education and provider relationships, group prenatal care may reduce ER visits among pregnant women by helping them identify appropriate care settings, improving understanding of common pregnancy discomforts, and reducing risky health behaviors. We conducted a retrospective cohort study, utilizing Medicaid claims and birth certificate data from a statewide expansion of group care, to compare ER utilization between pregnant women participating in group prenatal care and individual prenatal care. Using propensity score matching methods, we found that group care was associated with a significant reduction in the likelihood of having any ER utilization (-5.9% among women receiving any group care and -6.0% among women attending at least five group care sessions). These findings suggest that group care may reduce ER utilization among pregnant women and encourage appropriate health care utilization during pregnancy.

Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes

To translate improvements in diabetes management into improved outcomes, it is essential to improve care delivery. To help guide clinicians and health organizations in their efforts to achieve these improvements, this article briefly describes key components underpinning effective diabetes care and six categories of innovations in approaches to improve diabetes care delivery: (1) team-based clinical care; (2) cross-specialty collaboration/integration; (3) virtual clinical care/telehealth; (4) use of community health workers (CHWs) and trained peers to provide pro-active self-management support; (5) incorporating screening for and addressing social determinants of health into clinical practice; and (6) cross-sectoral clinic/community partnerships.

Mentored implementation to initiate a diabetes program in an underserved community: a pilot study

INTRODUCTION

Community clinics often face pragmatic barriers, hindering program initiation and replication of controlled research trial results. Mentoring is a potential strategy to overcome these barriers. We piloted an in-person and telehealth mentoring strategy to implement the Telehealth-supported, Integrated Community Health Workers (CHWs), Medication-access, group visit Education (TIME) program in a community clinic.

RESEARCH DESIGN AND METHODS

Participants (n=55) were low-income Latino(a)s with type 2 diabetes. The study occurred in two, 6-month phases. Phase I provided proof-of-concept and an observational experience for the clinic team; participants (n=37) were randomized to the intervention (TIME) or control (usual care), and the research team conducted TIME while the clinic team observed. Phase II provided mentorship to implement TIME, and the research team mentored the clinic team as they conducted TIME for a new single-arm cohort of participants (n=18) with no previous exposure to the program. Analyses included baseline to 6-month comparisons of diabetes outcomes (primary outcome: hemoglobin A1c (HbA1c)): phase I intervention versus control, phase II (within group), and research-run (phase I intervention) versus clinic-run (phase II) arms. We also evaluated baseline to 6-month CHW knowledge changes.

RESULTS

Phase I: compared with the control, intervention participants had superior baseline to 6-month improvements for HbA1c (mean change: intervention: -0.73% vs control: 0.08%, p=0.016), weight (p=0.044), target HbA1c (p=0.035), hypoglycemia (p=0.021), medication non-adherence (p=0.0003), and five of six American Diabetes Association (ADA) measures (p<0.001-0.002). Phase II: participants had significant reductions in HbA1c (mean change: -0.78%, p=0.006), diastolic blood pressure (p=0.004), body mass index (0.012), weight (p=0.010), medication non-adherence (p<0.001), and six ADA measures (p=0.007-0.005). Phase I intervention versus phase II outcomes were comparable. CHWs improved knowledge from pre-test to post-tests (p<0.001).

CONCLUSIONS

A novel, mentored approach to implement TIME into a community clinic resulted in improved diabetes outcomes. Larger studies of longer duration are needed to fully evaluate the potential of mentoring community clinics.

Evaluating the Effectiveness of Diabetes Shared Medical Appointments (SMAs) as Implemented in Five Veterans Affairs Health Systems: a Multi-site Cluster Randomized Pragmatic Trial

OBJECTIVE

To examine whether diabetes shared medical appointments (SMAs) implemented as part of usual clinical practice in diverse health systems are more effective than usual care in improving and sustaining A1c improvements.

RESEARCH DESIGN AND METHODS

A multi-site cluster randomized pragmatic trial examining implementation in clinical practice of diabetes SMAs in five Veterans Affairs (VA) health systems was conducted from 2016 to 2020 among 1537 adults with type 2 diabetes and elevated A1cs. Eligible patients were randomly assigned to either: (1) invitation to participate in a series of SMAs totaling 8-9 h; or (2) continuation of usual care. Relative change in A1c (primary outcome) and in systolic blood pressure, insulin starts, statin starts, and anti-hypertensive medication classes (secondary outcomes) were measured as part of usual clinical care at baseline, at 6 months and at 12 months (~7 months after conclusion of the final SMA in four of five sites). We examined outcomes in three samples of SMA participants: all those scheduled for a SMA, those attending at least one SMA, and those attending at least half of SMAs.

RESULTS

Baseline mean A1c was 9.0%. Participants scheduled for an SMA achieved A1c reductions 0.35% points greater than the control group between baseline and 6-months follow up (p = .001). Those who attended at least one SMA achieved reductions 0.42 % points greater (p < .001), and those who attended at least half of scheduled SMAs achieved reductions 0.53 % points greater (p < .001) than the control group. At 12-month follow-up, the three SMA analysis samples achieved reductions from baseline ranging from 0.16 % points (p = 0.12) to 0.29 % points (p = .06) greater than the control group.

CONCLUSIONS

Diabetes SMAs as implemented in real-life diverse clinical practices improve glycemic control more than usual care immediately after the SMAs, but relative gains are not maintained. Our findings suggest the need for further study of whether a longer term SMA model or other follow-up strategies would sustain relative clinical improvements associated with this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT02132676.

Group Prenatal Care as a Strategy to Address Diabesity

Group prenatal care is a health care delivery model that utilizes shared medical appointments to place greater focus on patient education, mutual support, and increased time with the clinician to promote a healthy pregnancy. Several studies suggest that medically low-risk women participating in group prenatal care have improved pregnancy outcomes, but the same tenants can likely be used to help women with diabetes and obesity achieve healthy outcomes during pregnancy and throughout their life course. This chapter will review the background, care model, and evidence regarding group medical visits for pregnant women with diabetes and obesity.

A Telehealth-supported, Integrated care with CHWs, and MEdication-access (TIME) Program for Diabetes Improves HbA1c: a Randomized Clinical Trial

BACKGROUND

Many individuals with diabetes live in low- or middle-income settings. Glycemic control is challenging, particularly in resource-limited areas that face numerous healthcare barriers.

OBJECTIVE

To compare HbA1c outcomes for individuals randomized to TIME, a Telehealth-supported, Integrated care with CHWs (Community Health Workers), and MEdication-access program (intervention) versus usual care (wait-list control).

DESIGN

Randomized clinical trial.

PARTICIPANTS

Low-income Latino(a) adults with type 2 diabetes.

INTERVENTIONS

TIME consisted of (1) CHW-participant telehealth communication via mobile health (mHealth) for 12 months, (2) CHW-led monthly group visits for 6 months, and (3) weekly CHW-physician diabetes training and support via telehealth (video conferencing).

MAIN MEASURES

Investigators compared TIME versus control participant baseline to month 6 changes of HbA1c (primary outcome), blood pressure, body mass index (BMI), weight, and adherence to seven American Diabetes Association (ADA) standards of care. CHW assistance in identifying barriers to healthcare in the intervention group were measured at the end of mHealth communication (12 months).

KEY RESULTS

A total of 89 individuals participated. TIME individuals compared to control participants had significant HbA1c decreases (9.02 to 7.59% (- 1.43%) vs. 8.71 to 8.26% (- 0.45%), respectively, p = 0.002), blood pressure changes (systolic: - 6.89 mmHg vs. 0.03 mmHg, p = 0.023; diastolic: - 3.36 mmHg vs. 0.2 mmHg, respectively, p = 0.046), and ADA guideline adherence (p < 0.001) from baseline to month 6. At month 6, more TIME than control participants achieved > 0.50% HbA1c reductions (88.57% vs. 43.75%, p < 0.001). BMI and weight changes were not significant between groups. Many (54.6%) TIME participants experienced > 1 barrier to care, of whom 91.7% had medication issues. CHWs identified the majority (87.5%) of barriers.

CONCLUSIONS

TIME participants resulted in improved outcomes including HbA1c. CHWs are uniquely positioned to identify barriers to care particularly related to medications that may have gone unrecognized otherwise. Larger trials are needed to determine the scalability and sustainability of the intervention.

CLINICAL TRIAL

NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.

Functional gastrointestinal disorders: real-life results of a multidisciplinary non-pharmacological approach based on group-consultations

INTRODUCTION

functional gastrointestinal disorders are prevalent and resource consuming. The use of group-consultations in these diseases is limited and no specific multidisciplinary programs have been developed.

METHODS

a multidisciplinary approach was used in patients with diverse functional gastrointestinal disorders attending group-consultations (group A). Five two-hour sessions were scheduled over a four-month period. Sessions consisted of a theoretical introduction (Pathophysiology, Low fodmap diet, Over the counter medications, Mediterranean diet, and Laughter therapy workshop) followed by relaxation techniques. This group was compared to a similar group of patients who received written information covering the topics discussed during the group-consultations (group B). Severity of digestive and psychological symptoms, use of drugs and adherence to the diet were the main outcomes measured.

RESULTS

the mean age of participants was 43 (± 1.38) years, 78 % were female and 73 % had at least two functional gastrointestinal disorders. Sixty-two patients were included in group A and 17 in group B. The severity of gastrointestinal and psychological symptoms at baseline was similar in both groups. Globally, there was an improvement in all symptoms in both groups. The proportion of participants with severe baseline gastrointestinal symptoms or pathologic anxiety scores that showed improvement was significantly higher in group A (74 % vs 23 %, p = 0.005; 47 % vs 8 %, p = 0.02, respectively). Symptoms were reassessed at six and 12 months after the intervention in participants from group A who attended ≥ 80 % sessions and a sustained response was observed.

CONCLUSIONS

group-consultations are useful and efficient to alleviate gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders.

A Qualitative Evaluation of Patient Experiences With Group Medical and Individual Education Appointments for Type 2 Diabetes Management in Saskatchewan, Canada

PURPOSE

The purpose of this study was to capture information on patient experiences and perspectives of group medical appointments (GMAs) and compare them to those attending individual appointments (IAs) with the diabetes education team (usual care) for managing type 2 diabetes.

METHODS

Adults (N = 18; 61% male; 83% 50-70 years old ) with type 2 diabetes (or prediabetes) living in rural Saskatchewan were recruited to complete a semistructured interview on their experiences with GMAs or IAs. To be eligible to participate, individuals must have attended at least 2 GMAs or 2 IAs. Transcripts were coded and analyzed using content analysis.

RESULTS

Overall, participants spoke highly of their respective appointment type. Results indicated that both appointment types positively influenced understanding of diabetes management, with the most notable difference being greater understanding of stress management in the GMAs. Participants identified several positive aspects of each appointment type, which included convenience, supportive and enjoyable, and informative for GMAs and time and tailored information for IAs. Participants provided some suggestions to improve diabetes related-care for their respective appointment type.

CONCLUSIONS

Participants of GMAs and IAs for type 2 diabetes each reported unique strengths to their respective care plan and reported benefiting from their care.

Group Medical Visits: experiences with patient and resident implementation

Objective: Patients with diabetes must navigate multiple components of care to self-manage their disease. Group Medical Visits (GMVs) are a forum for patients to see a provider as well as actively participate in education and care management with other patients with diabetes. The objective is to describe GMV implementation and resident involvement in a primary care setting.Methods: We adapted and implemented a GMV model into a primary care practice with a residency program. Residents attend GMV sessions that provide a continuity experience in addition to their regular clinic schedules. A cohort of patients enroll in a series of eight GMVs occurring over of 4 months. Each patient and resident complete surveys evaluating the visits.Results: There have been 14 GMV groups totaling 70 participants. GMV groups (N = 67) mean A1C for reduction was 0.53 ± 1.60 from baseline to 3- to 6-month post-GMV follow-up. Resident and patient feedback show an overall positive experience.Conclusion: The GMV model offers patients the setting to interact and exchange experiences with each other as well as to receive feedback from providers and the health-care team.  The incorporation of the GMV program into residency training provides a continuity group care experience and an alternative practice model.

Characteristics and Delivery of Diabetes Shared Medical Appointments in North Carolina

BACKGROUND Successful diabetes care requires patient engagement and health self-management. Diabetes shared medical appointments (SMAs) are an evidence-based approach that enables peer support, diabetes group education, and medication management to improve outcomes. The purpose of this study is to learn how diabetes SMAs are being delivered in North Carolina, including the characteristics of diabetes SMAs across the state.METHOD Twelve health systems in the state of North Carolina were contacted to explore clinical workflow and intervention characteristics with a member of the SMA care delivery team. Surveys were used to assess intervention characteristics and delivery.RESULTS Diabetes SMAs were offered in 10 clinics in 5 of the 12 health systems contacted with considerable heterogeneity across sites. The majority of SMAs were open cohorts (80%), offered monthly (60%) for 1.5 hours (60%). SMAs included a mean of 7.5 ± 3.4 patients with a maximum of 11.2 ± 2.7 patients. Survey data revealed barriers (cost-sharing and provider buy-in) to, and facilitators (leadership support and clinical champions) of, clinical adoption and sustained implementation.LIMITATIONS External validity is limited due to the small sample size and geographic clustering.CONCLUSION There is significant heterogeneity in the delivery and characteristics of diabetes SMAs in North Carolina with only modest uptake across the health systems. Further research to determine best practices and effectiveness in diverse, real-world clinical settings is required to inform implementation and dissemination efforts.

Integrative Group Medical Visits: A National Scoping Survey of Safety-Net Clinics

Purpose: Integrative group medical visits (IGMVs) aim to increase access to complementary and integrative health care, which is particularly relevant for low-income people. We sought to describe IGMV programs in US safety-net clinics through a survey of providers. Methods: An online and paper survey was conducted to collect data on the use of complementary health approaches and characteristics of IGMV programs. We recruited a purposive sample of safety-net clinicians via national meetings and listservs. Results: Fifty-seven clinicians reported on group medical visits. Forty percent worked in federally qualified health centers, 57% in safety-net or teaching hospitals, 23% in other settings such as free clinics. Thirty-seven respondents in 11 states provided care in IGMVs, most commonly for chronic pain and diabetes. Nutrition (70%), mindfulness/meditation/breathing (59%), and tai chi/yoga/other movement practices (51%) were the most common treatment approaches in IGMVs. Conclusion: Safety-net institutions in 11 states offered IGMVs to treat a range of chronic conditions. IGMVs are an innovative model to improve access to non-pharmacologic approaches to chronic illness care and health promotion. They may advance health equity by serving patients negatively impacted by health and health care disparities.

Integration of Personalized Health Planning and Shared Medical Appointments for Patients with Type 2 Diabetes Mellitus

OBJECTIVES

This study describes the feasibility of implementing personalized health planning (PHP) within shared medical appointments (SMAs) for patients with type 2 diabetes mellitus. The PHP-SMA approach was designed to synergize the benefits of SMAs with those of PHP, enabling greater patient engagement focused on meeting individualized therapeutic goals in a group setting.

METHODS

Patients were assigned randomly to a PHP-SMA or a standard eight-session SMA series. Standard SMAs included an interactive educational curriculum delivered in group medical encounters. The PHP-SMA included the addition of a patient self-assessment, health risk assessment, shared patient-provider goal setting, creation of a personal health plan, and follow-up on clinical progress. Clinical and patient-reported outcomes and qualitative data from focus groups with patients, providers, and administrative staff were used for evaluation. Qualitative data explored facilitators and barriers to implementation of the PHP-SMA. The Consolidated Framework for Implementation Research was used to provide insight into implementation factors.

RESULTS

PHP was successfully integrated into SMAs in a primary care setting. Patients in the PHP-SMA (n = 12) were more likely to attend ≥5 sessions than patients assigned to the standard SMA (n = 7; 58% PHP, 28.5% control). Qualitative data evaluation described the advantages and barriers to PHP, the team-based approach to care, and patient participation. The PHP-SMA group experienced reductions in hemoglobin A1c, low-density lipoprotein, blood pressure, and body mass index, as well as successful attainment of health goals.

CONCLUSIONS

The PHP-SMA is a proactive and participatory approach to chronic care delivery that synergizes the benefits of PHP within SMAs. This study describes the components of this intervention; collects evidence on feasibility, acceptability, and clinical outcomes; and identifies implementation barriers and facilitators. The PHP-SMA warrants further evaluation as an approach to improve health outcomes in patients with common chronic conditions.

Implementation and Evaluation of Shared Medical Appointments in Veterans With Diabetes: A Quality Improvement Study

OBJECTIVE

The aim of this study is to implement and evaluate shared medical appointments (SMA) in veterans with diabetes.

BACKGROUND

Health systems are challenged to meet the complex care needs of veterans with diabetes. Use of SMA has resulted in significant improvements in A1c, blood pressure, and self-management skills in this population.

METHODS

Shared medical appointments were implemented in a Veterans Administration Health System. A1c, blood pressure, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, weight, and height were collected at baseline, 3 months, and 6 months; hospitalization anytime; and veteran satisfaction at baseline and 6 months.

RESULTS

From October 15, 2015, to March 15, 2016, 30 male veterans with diabetes participated in monthly SMA. Outcome measures except for high-density lipoprotein improved significantly (P < .02) from baseline to 6 months. No veterans were hospitalized. Veteran satisfaction increased significantly (P < .001).

CONCLUSION

Shared medical appointment can be a highly effective intervention for veterans with diabetes. Nursing leaders need to be at the forefront of implementing SMA for populations with chronic conditions.

Attending to power differentials: How NP-led group medical visits can influence the management of chronic conditions

Objective

In Canada, primary care reform has encouraged innovations, including nurse practitioners (NPs) and group medical visits (GMVs). NP‐led GMVs provide an opportunity to examine barriers and enablers to implementing this innovation in primary care.

Design

An instrumental case study design (n=3): two cases where NPs were using GMVs and one case where NPs were not using GMVs, was completed. In‐depth interviews with patients and providers (N=24) and 10 hours of direct observation were completed. Interpretive descriptive methods were used to analyse data.

Results/Findings

Two main themes were identified: (i) acquisition of knowledge and (ii) GMVs help shift relationships between patients and health‐care providers. Participants discussed how patients and providers learn from one another to facilitate self‐management of chronic conditions. They also discussed how the GMV shifts inherent power differentials between providers and between patients and providers.

Discussion

NP‐led GMVs are a method of care delivery that harness NPs’ professional agency through increased leadership and interprofessional collaboration. GMVs also facilitate an environment that is patient‐centred and interprofessional, providing patients with increased confidence to manage their chronic conditions. The GMV provides the opportunity to meet both team‐based and patient‐centred health‐care objectives and may disrupt inherent power differentials that exist in primary care.