Shared Medical Appointments to Improve Diabetes Care within a Federally Qualified Health Center

Research Article

Shared Medical Appointments to Improve Diabetes Care within a Federally Qualified Health Center

*Corresponding author: Harry S. Saag  M.D., Medical Director, Greater New York City Practice Transformation Network, Medical Director, Network Integration and Ambulatory Quality, NYU School of Medicine, Department of General Internal Medicine and Clinical Innovation, 1 Park Avenue, Office 10-103, New York, New York  10016, Tel: 212-404-4043, Fax: 877-992-9416, Email: Harry.Saag@nyumc.org

Abstract

Purpose: Over 15% of patients with type 2 diabetes have uncontrolled disease (hemoglobin A1c > 9%); low-income patients are disproportionately likely to have uncontrolled disease and complications. Shared medical appointments have been used effectively to control diabetes by combining clinical care, patient education, and peer support during clinic visits.

Methods: A Practice Transformation Network practice facilitator assisted a federally qualified health center clinic to create a shared medical appointment program for patients with type 2 diabetes consisting of monthly group visits led by a primary care physician and certified diabetes educator followed by brief individual physician appointments. The primary outcome was reduction in hemoglobin A1c (A1c) with a secondary outcome of patients converting from uncontrolled to controlled disease.

Results: In the pilot intervention, 11 patients participated in at least 1 shared medical appointment, of whom 8 had uncontrolled disease at baseline. The primary outcome of a reduction in A1c was seen in 9/11 (82%) patients. All 8 patients with uncontrolled disease experienced at least a 10% reduction in A1c, with 5 of the 8 patients achieving disease control by the end of the program.

Conclusions: Shared medical appointments represent an effective and efficient way to improve care for patients with diabetes in a federally qualified health center.

Keywords

shared medical appointments; federally qualified health center; diabetes; nutrition education

Abbreviations
Alc: hemoglobin A1c; FQHC: Federally Qualified Health Center

Introduction

Over 30 million Americans suffer from type 2 diabetes mellitus, of whom 15.6% have uncontrolled disease, defined as a hemoglobin A1c (A1c) >9.0%.[1]  Uncontrolled diabetes can lead to serious health consequences such as limb amputation, which has been shown to disproportionately affect patients living in low-income zip codes.[2] Shared medical appointments are patient encounters where patients receive education, counseling, and peer support in a group setting in addition to usual clinical care at the time of the visit.[3,4]  Prior studies have shown the effectiveness of shared medical appointments in treating patients with diabetes in a variety of settings including large primary care clinics, Veterans Affairs clinics, and family medicine practices.[5-9] Our study examines the feasibility of implementing shared medical appointments within an urban federally qualified health center (FQHC).

Methods

The study took place at Park Slope Family Health Center at NYU Langone. A practice facilitator from the Centers for Medicare and Medicaid Services-funded Greater New York City Practice Transformation Network met with site leaders to review quality performance data on diabetes care. With the assistance of the practice facilitator, a plan was designed to begin shared medical appointments for diabetic patients. A total of 20 patients with a diagnosis of diabetes who were already being cared for by the lead physician of the shared medical appointment pilot were invited to participate in monthly shared medical appointments, of whom 11 agreed and participated in at least 1 shared medical appointment. Prior to the intervention, patients were receiving usual care, defined as 20 minute office-based ambulatory encounters solely with the physician once every 3-6 months. Shared medical appointments were held monthly for 6 months between December 2017 through May 2018. Baseline A1c’s and demographic data were collected at the initial visit.

Measures

The primary outcome was reduction in A1c using the A1c obtained at the first shared medical appointment visit as the baseline and the last available A1c as the post-intervention result. The secondary outcome was the number of patients with uncontrolled diabetes who achieved disease control by the end of the pilot, defined as A1c < 9.0%.

Intervention

Shared medical appointments consisted of a multi-disciplinary effort between the physician, certified diabetes nurse educator, nursing, and clerical staff at the site. Clerical staff reminded patients of their appointments 3 days in advance of their visit. Visits started at 9:00am and began with a 10-minute introduction from the lead physician giving a broad overview of the educational content planned for the visit. Following the introduction, a certified diabetes educator and a registered nurse led the remaining 2 hours of the group visit, focusing on the educational content of that particular session. Each shared medical appointment focused on a different core aspect of comprehensive diabetes care discussed as a group with an emphasis on group participation and peer learning. Session topics included nutrition, physical exercise, medication adherence, and strategies to reduce diabetic complications. Shared medical appointments also addressed accessing social support and behavioral health. See Table 3 for further detail of focused content for each visit. Shared medical appointments also included a one-on-one follow-up visit with the physician to address individual clinical care. Shared medical appointments generally lasted three hours, including one-on-one time with the physician.

Statistical analysis

We described demographic characteristics of participating patients using standard descriptive statistics. We assessed change in hemoglobin A1c for each patient using the Wilcoxon Signed Rank Test to assess for statistical significance to account for the paired nature of the measures. We considered a two-tailed p value of <0.05 to be statistically significant. This work met NYU Institutional Review Board criteria for quality improvement work, not human subjects research, and did not require approval.

Results

                11 patients participated in at least 1 shared medical appointment, of whom 8 had uncontrolled diabetes at the first visit. The 11 patients included in the analysis had an average age of 53.3 years, and 6 were female. The mean A1c at the first shared medical appointment was 10.3%. Further baseline demographic data can be found in Table 1.

The primary outcome of a reduction in A1c was seen in 9/11 (82%) patients. 8 of the patients (73%) experienced a reduction of at least 10% in A1c, while 5 (45%) saw a reduction of at least 25% (Table 2).

A1c levels decreased significantly over the course of shared medical appointment participation from the first visit (Mean = 10.3, SD = 2.44) to the most recent visit (Mean = 8.11, SD = 1.38) (P < .005, z = -2.70).

Among the 8 patients with uncontrolled diabetes at baseline, all 8 saw at least a 10% reduction in A1c, with 5 of the 8 (62.5%) achieving the secondary outcome of moving from uncontrolled to controlled diabetes.

Discussion

We found that shared medical appointments were feasible and effective in improving glucose control for underserved patients with diabetes who had previously not achieved optimal outcomes through usual care at a federally qualified health center. These results are consistent with prior studies that found a similar benefit to shared medical appointments in A1c reduction in other care settings.[5-9]

Shared medical appointments are a powerful tool for managing patients with diabetes given the importance of self-management such as nutrition, exercise, and lifestyle modifications. Discussing all aspects of comprehensive diabetes care can be challenging in a traditional 20 minute office visit with a physician; thus, there is benefit for this population to spend additional time discussing self-management. Further, the opportunity to learn from peers in the same community who are suffering from the same illness likely contributed to the overall value of the shared medical appointment for patients. This may be particularly important for patients in an underserved setting, who may need information about community resources, and suggestions for low-income appropriate and culturally-competent self-management strategies that a physician alone might not be able to provide. As demonstrated in Table 2, it is notable that the most profound impact was seen in patients with the most uncontrolled disease at baseline, signifying the value of shared medical appointments for patients with severely uncontrolled disease. Lastly, shared medical appointments highlight the importance of a team-based approach to caring for these patients well beyond the physician by involving ancillary support staff and peers as critical influencers in helping patients manage this disease.

Limitations to the results include a small patient population and potential selection bias, as patients were not randomly selected and may have had an above-average level of health activation or engagement that partly contributed to their success. However, these patients had previously been receiving usual care from the same physician prior to the intervention, making it unlikely that other factors besides participating in the shared medical appointment contributed to the dramatic improvement in their disease control. Our study also saw a significant drop out rate. Of the 20 patients contacted to participate, only 8 participated in at least 2 visits. The preliminary results were, however, sufficiently encouraging that the family health center has now opted to continue and expand the program.

In summary, this study demonstrates the potential benefits of shared medical appointments for diabetics in an underserved setting. This model serves as an example for how other FQHC’s and safety net care centers may be able to provide more effective diabetes care in the future.

Support

The Greater New York City Practice Transformation Network is funded by a grant from the Center for Medicare and Medicaid Innovation (L1 CMS331468). CMMI reviewed and approved this manuscript for submission.

Acknowledgements

We thank Michael Chapman, Site Director, Park Slope Family Health Center at NYU Langone and Dr. Ekatrina Olkhina, MD, Medical Director, Park Slope Family Health Center at NYU Langone for their enthusiastic support of this program. The Greater New York City Practice Transformation Network is funded by a grant from the Center for Medicare and Medicaid Innovation (L1 CMS331468). CMMI reviewed and approved this manuscript for submission.

Conflict of Interest Statement

All authors declare no potential, perceived, or real conflicts of interest.

References

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