Target population: Patients with diabetes who receive primary care services at the Maxine S. Postal Tri-Community Health Center in Amityville, New York, which is administered through the Suffolk County Department of Health Services (SCDHS), Division of Patient Care Services. Most of the patients who receive care at this health center are from ethnic groups at high risk for diabetes and its complications. Of the nearly 6,000 patients who received care at this health center in 2004, 31% were African American and 38% were Hispanic. Thirty-nine percent of the approximately 340 patients diagnosed with non-gestational diabetes who were seen in 2004 were uninsured; 25% were Medicaid recipients and 21% were Medicare beneficiaries.
Goals and objectives: The goal of this project was to develop, implement and evaluate a collaborative system/chronic care model approach and offer shared medical appointments, or group visits, in a primary care setting to improve the management of diabetes. Objectives included demonstration of improvement in provider compliance with American Diabetes Association (ADA) clinical practice recommendations and patient achievement of ADA goals, and demonstration of increase in patients’ sharing of personal experiences and coping techniques with other patients who have diabetes. Increase in patient time spent with a primary care provider and enhanced patient satisfaction were additional objectives.
Diabetes, a serious and growing public health problem, is the sixth leading cause of death in the United States. It is the primary cause of blindness, non-traumatic lower limb amputations, and renal failure among adults. Cardiovascular disease causes approximately 65% of deaths among people with diabetes. People from minority populations, such as those who receive care at Suffolk County health centers, are at higher risk for the development of diabetes as well as its complications. The CDC reports that the number of people with diabetes in the United States more than doubled during 1980-2002.
The American Diabetes Association (ADA) maintains that people with diabetes should receive their care from a physician-coordinated team, and that it is essential that those with diabetes assume an active role in their care. The ADA publishes clinical practice recommendations, including goals of care that can be challenging to achieve in a primary care setting, especially for those who lack health insurance and financial resources.
Shared medical appointments or “group visits” are voluntary, interactive care delivery systems that have been found to be efficient, effective and offer unique benefits to patients. These benefits include a reduced sense of isolation, the provision of help from other patients and support staff, an opportunity to share personal experiences and successful coping techniques, more time with a provider at a more relaxed pace, enhanced quality of care, and increased patient satisfaction.
A review of the literature demonstrated that various models of shared medical appointments have been or currently are being implemented in the United States. These models include Drop-in Group Medical Appointments, Cooperative Health Care Clinic Appointments, Specialty Cooperative Health Care Appointments (Chronic Care Model) and Physicals Shared Medical Appointments. Team representatives visited a non-county agency that utilizes group visits for patients with diabetes, although a different model from our intended project. Based on information that we gathered, our team chose to implement a collaborative system/chronic care model approach, and develop tools and strategies that would be unique and appropriate for our patient population and clinical setting.
Agency Community RolesThe Suffolk County Department of Health Services (SCDHS) administers the clinical site that implemented this project. During planning and implementation, there was much collaboration within the SCDHS as well as with an outside agency, Cornell Cooperative Extension of Suffolk County. Internally, Information Systems (IS) provided patient data, the Revenue Unit advised the team on appropriate billing procedures, and the Compliance Unit participated in the development of a consent form that addressed confidentiality. Health Center providers, including primary care practitioners and podiatrists, and support staff, such as intake workers, nurses, laboratory staff, the social worker, and coders participated and consulted throughout the project.
SCDHS contracts with an outside agency, Cornell Cooperative Extension, to provide diabetes self-management education at the County health centers. A diabetes nurse educator and dietitian employed by this agency work at this health center and were key participants in this project, assisting in the planning, implementation and project evaluation. Through the collaborative agreement between the County and the outside agency, self-management education, including Medical Nutrition Therapy, is provided to health center patients and classes are offered free of charge to community residents. This multidisciplinary team approach is consistent with the ADA clinical practice recommendations.
ImplementationPreparation for the DSMAPP began with a literature review and a visit to a non-county agency that had implemented a group visit model. A “team” consisting of administrative and clinical staff was formed and health center providers were asked to recommend patients with diabetes whom they felt would be able to participate in a daytime group visit experience. As the care team spoke English, it was specified that patients should be English speaking. Although 18 patients initially responded to forty individualized invitations sent to their homes, 15 patients participated.
Other SCDHS Divisions were consulted as needed. The Revenue Unit advised the team on appropriate billing procedures. The Compliance Unit participated in the development of a consent form that addressed confidentiality. Tools were developed and utilized to facilitate patient flow and paperwork. These included a patient navigation sheet, template Progress Notes, and encounter forms for billing and coding.
Group visits were implemented every month for six months; each visit lasted slightly more than two hours. The visits included group discussions, individual time with a provider, and interaction with nurses and a dietitian. A physician and physician’s assistant served as the primary care providers. Patients were examined and treated by a podiatrist, and received immunizations and consulted a social worker, as needed. A “Patient Navigator” directed each patient to specific stations. The physician opened the discussions at each visit and remained with the group when other team members focused on a topic (e.g., nutrition, monitoring, etc.). The discussions promoted a philosophy of patient empowerment, versus one of patient compliance, and served to engage patients as active participants in their care. A “Suggestion Box” was available for patients to propose topics for discussion. Patient incentives included raffles of donated gifts, pedometers, weekly pill containers and reusable divided plates to promote the “Plate Method” for portion control. A light snack was provided at each visit.
Goal: The goal of this project was to develop, implement and evaluate a collaborative system/chronic care model approach and offer shared medical appointments, or group visits, in a primary care setting to improve the management of diabetes.
Objective: Demonstration of improvement in provider compliance with ADA clinical practice recommendations:
Performance measures: 1) to have 100% of recommended tests and smoking status &/or advice to stop smoking documented on all participants, and at least 70% of recommended vaccines and at least 90% ASA prophylaxis administered &/or documented.
Data collection: 1) documented performance of: A1C, urine for microalbumin, lipid levels, smoking status &/or advice to stop smoking , flu and pneumonia vaccine status; 2) Diabetes Program Coordinator (NP, CDE) collected the data; 3) chart review (N=15 pre and post intervention).
Outcomes (short-term): Percent of patients who had documentation: 1) recommended A1C, urine for microalbumin and lipid levels performed went from 87, 80, and 80 to 93, 100, and 100, respectively; 2) smoking status addressed or with advice to discontinue smoking went from 80 to 100; 3) Flu and pneumonia vaccine went from 60 to 73 and 67 to 100, respectively.
Objective: Demonstration of improvement in patient achievement of ADA goals:
Performance measures: To increase percentage of patients who achieve ADA recommended A1C and HDL, and LDL cholesterol goals by at least 5%.
Data collection: 1) patients' A1C, HDL, and LDL cholesterol levels; 2) Diabetes Program Coordinator collected the data; and 3) chart review.
Outcomes (short-term): Percent of patients who achieved ADA recommended goal for; A1C went from 46 to 60, HDL went from 50 to 80, and LDL went from 75 to 80.
Objective: Demonstration of increase of patients' sharing of personal experiences and coping techniques with other patients who have diabetes:
Performance measures: To increase by at least 30% the percentage of patients who report sharing personal experiences and coping techniques with other diabetic patients and to decrease the percentage of patients who feel alone in managing their diabetes by at least 10%.
Data collection:1) Confidential patient surveys that included the questions:“At this time, do you share personal experiences and coping techniques with other diabetic patients?” and “At this time, do you feel you have to manage your diabetes alone?”; 2) Clinical team collected the data; and 3) Participants completed confidential patient surveys/questionnaires
Outcomes (short-term): The percent of patients who reported sharing personal experiences and coping techniques with other diabetic patients increased by 46%. The % of patients who reported feeling less alone in managing their diabetes decreased by 12%.
Aside from the dedication of staff time and the nominal expenses previously described, no additional funding was allocated for this project. Although the pilot project was labor-intensive, staff involved felt future applications of this visit type would be easier to implement, as the initial groundwork was completed. It was generally felt that the results of the Diabetes Shared Medical Appointment Pilot Project (DSMAPP) support the probability that it could be made available for patients with other chronic illnesses (e.g., asthma), for different groups of patients from similar cultural backgrounds, and for those who receive care at other Suffolk County Department of Health Services (SCDHS) sites.
The Chronic Care Committee is comprised of clinical and administrative personnel. The Committee is currently developing strategies to expand upon the use of the chronic care model at additional clinical sites. The tools that were developed for this project are being re-evaluated and revised, as needed. The SCDHS has committed to the development or possible purchase of a disease registry, which will greatly assist providers in expanding on this project to manage patients with chronic illness, and improve clinical outcomes and patient satisfaction. The disease registry process is currently underway.