A FEDERALLY QUALIFIED health center (FQHC) in the Detroit metropolitan area recently conducted a 7-week shared medical appointment (SMA) program for patients with diabetes. Each SMA focused on self-care behaviors, including nurse-led group education and one-on-one mini-visits with an NP. Diabetes empowerment results improved significantly. Hemoglobin A1C (A1C) rates also improved in this patient population, but the change was not statistically significant.
Using an interactive group and elements of an office visit to address the disease burden, SMAs harness the advantages of group education for patients with diabetes, such as improved A1C levels and increased diabetes knowledge.1,2 This article examines the impact of an SMA program in improving diabetes empowerment and glycemic stability in patients with type 2 diabetes mellitus (T2DM).
The burden of T2DM is markedly high in local low-income residents. Compared with a national median prevalence of 9.6%, the Michigan prevalence of T2DM is 10.4% and more than twice as high for low-income Michigan residents compared with those with higher incomes.3 Limited diabetes education may contribute to poor glycemic stability and self-care, which increases the disease burden in this population.4
The American Academy of Family Physicians recognizes the value of SMAs in providing cost-effective, high-quality management of chronic diseases.5 A 2010 systematic review of SMAs related to diabetes demonstrated cost-effectiveness, decreased ED and inpatient visits, psychological benefits, and improved patient and clinician satisfaction. Although A1C was not consistently improved in SMA groups compared with patients receiving traditional care, a more recent study of SMAs demonstrated A1C improvement in a low-income population.1,6
This quality improvement project was conducted after the need for an SMA program became apparent at an FQHC in the Detroit metropolitan area. Patients and staff had experienced a lack of time and peer support from the traditional office visit model. The goal was to improve diabetes empowerment and glycemic stability in patients with T2DM through a 7-week program of SMAs called “Take 7.”
Diabetes empowerment embraces the belief that patients with diabetes are the experts on their lives and ultimately manage their disease.7 It has been associated with glycemic stability and improvements in self-care, diet, knowledge, medication regularity, exercise, blood glucose levels, and foot care.8 Take 7 was designed according to seven self-care behaviors defined by the American Association of Diabetes Educators (AADE7): healthy eating, being active, self-monitoring of blood glucose levels, taking medications, problem solving, reducing risks, and healthy coping.6,9
The SMA program was exempted by the FQHC's collaborating institutional review board. Patients with T2DM over age 18 were recruited for the program until 10 patients committed to both the spring and fall cohorts. Recruitment was based on the patient's need, desire, and ability to complete the 7-week program. All participants signed a confidentiality agreement before group participation. Inclusion criteria did not include A1C values.
SMAs were conducted for 2 hours weekly over 7 weeks at the same time each week, focusing on one AADE7 self-care behavior each week. For 6 weeks, the RN led group education, while the NP pulled each participant out one by one for a visit in an exam room. Additional support staff included a minimum of one medical assistant and one community health worker. All clinical resources available during a routine office visit were available during these visits.
Group education followed an AADE7 handout corresponding to that week's self-care focus and included a related activity (see Group activities). Participants were encouraged to engage in peer support during group sessions to reach their goals.
Each NP visit included an interview regarding the week's self-care behavior and a focused physical assessment to refine the patient's plan of care. This included adjusting medications, ordering lab studies, and addressing diabetes health maintenance. Each visit also included the documentation of measurable goals, barriers, and a plan to overcome those barriers. Participants were encouraged to schedule additional appointments with their primary care provider for concerns not related to T2DM, but time-sensitive issues were accommodated.
The seventh and last session focused on healthy coping. An RN was present during this session for continuity and to answer any follow-up questions from previous weeks.
In the summer cohort's last session, a social worker counseled the participants individually during a behavioral health visit that focused on coping with T2DM using AADE7 handouts, and a community worker led group relaxation exercises. In the fall cohort, on the other hand, no one-on-one counseling was provided. Instead, a social worker led the group in a behavioral health visit, which included group relaxation activities, discussion of a coping plan using AADE7 handouts, and a brief overview of the cognitive-behavioral therapy model. The change from a one-on-one visit to a group visit was based on feedback from the social worker that time did not allow for a meaningful behavioral health one-on-one session.
Both cohorts had a 3-month follow-up SMA that consisted of a 2-hour group diabetes education session led by an RN and a one-on-one follow-up with an NP.
Analysis and results
Data were collected from diabetes empowerment scale-short forms (DES-SFs) and patient electronic health records (EHRs) to determine empowerment and glycemic stability, respectively.10 All statistics were analyzed using statistical software. Data were collected only for participants who attended four or more sessions (n = 15); the average attendance was 5.5 sessions. Out of the seven participants from the summer cohort, three came to the 3-month follow-up SMA; out of the eight participants from the fall cohort, four came to the 3-month follow-up SMA.
Participants included in the final analysis were 73% female and 27% male, with an age range of 33 to 64 and a mean age of 56. Twenty percent of participants (n = 3) were uninsured. The other participants were insured mainly through government programs, such as Medicaid (n = 6) and Medicare (n = 4), but two had commercial insurance as well. Most participants were on insulin with or without other oral or injectable therapies (n = 9), and 40% were on noninsulin medication therapy only (n = 6).
The DES-SF scores were documented in the EHR following the participants' first SMA and after 3 months.11 No additional A1C measurements were taken beyond routine diabetes care. Each patient's A1C measurements before or during the SMA program were compared with their A1C measurements afterward. Two participants did not return for their A1C follow-up, and four did not complete the DES-SF follow-up.
Due to a low sample size and a nonnormal distribution of data, pre- and post-SMA A1C and DES-SF measurements were evaluated with the Wilcoxon signed-rank test, a nonparametric statistical assessment to compare scores from two groups of the same participants.12 Average A1C levels improved from 7.9 pre-SMA to 7.7 post-SMA, but these figures were not significant (P = .456). A1C values for the summer cohort improved from 9.0 to 8.7 (P = .345). Participants in the fall cohort had started with a superior baseline of 6.9 that did not change at follow-up (P = .917).
Comparatively, the average DES-SF scores showed statistically significant improvement, increasing from 30.00 pre-SMA to 33.27 post-SMA (P < .05). The summer cohort's DES-SF scores improved from 28.7 to 33.4 (P = .078), which, due to low sample size, is not statistically significant. Scores for the fall cohort, which had a superior baseline at 33.0, improved minimally to 33.2 (P = .752).
Empowerment was significantly improved with the Take 7 SMA quality improvement project.
A1C measurements also improved following the SMA program, but these figures were not statistically significant. Notably, five participants started the program at their individualized goal A1C level, which may have made significant improvements difficult. Previous studies have demonstrated conflicting evidence comparing SMAs to traditional care in improved A1C measurements.1,6
Comparative improvement in the summer cohort was likely due to the fall cohort's superior baseline data and cannot be contributed to the change in delivery of the coping session. The group behavioral health visit with the fall cohort was more satisfying for the social worker and more engaging for participants. The staff noted peer-education and encouragement among participants in the group discussion.
Although both participants and staff expressed satisfaction in the program, satisfaction was not measured in the project; however, these observations are consistent with well-established evidence related to SMAs.1
Challenges and limitations
The Take 7 SMA program was limited by a small sample size and the loss of data in follow-up, as the 3-month visit saw a decrease in attendance. Despite this, staff members were optimistic overall regarding program attendance. Missed appointments are prevalent at this FQHC due to barriers such as lack of transportation, childcare, and telephone access.
The commitment required for the Take 7 project also lent itself to the enrollment of participants who were already engaged in their diabetes care, often with superior baseline stability, empowerment, and attendance. More significant improvements may be seen in less engaged patients, but they may struggle to maintain participation in the SMA program.
Implications for future practice
This was a quality improvement project, not research. As such, it is unlikely to be generalized for the greater population and more research is required to determine best practices for SMAs.
The foundational knowledge and group cohesiveness established in the Take 7 program can serve as a template for ongoing SMAs in routine diabetes care. To improve retention at 3 months, participants recommended more frequent contact after the program to sustain engagement. The staff recommended scheduling participants for their follow-up SMA before leaving the final session.
The Take 7 SMA program demonstrated a new method for diabetes care at an FQHC in the Detroit metropolitan area. Although the improved A1C measurements were not significant, the DES-SF scores did improve significantly. Implementation has encouraged future growth in the use of SMAs in caring for patients with diabetes at the facility.