Group Diabetes Visits to Support Self-Management Goals: A Model for Care in an Urban, Resource-Poor Community

Camden Coalition of Healthcare Providers (CCHP), Cooper Medical School of Rowan University

Francine Grabowski, MS RD CDE; Nadia Ali, MPA; Andrew Katz; Steven Kaufman, MD

INTRODUCTION

DSME

Patients with diabetes are referred to the DSME class community outreach coordinator. The class runs for four consecutive weeks covering the AADE curriculum. Upon completion of all four classes patients receive a certi�cate of achievement. Eligible and interested patients are referred to quar-terly SMART (Speci�c, Measureable, Achievable, Relevant, and Time-Speci�c) group visits with their primary care provider.

CAMDEN: DEMOGRAPHICS, DIABETES, AND DISPARITY

SMART GROUP VISITS

Diabetes group visits provide routine diabetes follow up visits, continuing DSME, and o�ers pa-tients a community setting for education and peer support.

SMART Prep Work

Sta� mails reminderletters and schedules

patients for bloodwork

Sta� veri�es if patientslabwork is currentand calls patients

to remind them to work on BG logs

Sta� pulls and prepsprogrss note and

makes reminder callsto patients

Patients called andreminded to bring

binder, BG logs,and co-pay(if needed)

3 Weeks Before Class 2 Weeks Before Class Friday Before Class Day Before Class

Labworkcurrent

Labworknot current

Sta� schedules patient for blood

draw

Figure 2

Figure 3. The highlighted areas are �lled out by non-physician sta� prior to visit.

The SMART program is broken into three components: DSME, clinical care, and an interactive Q&A. The �rst part of the visit is highly structured. Providers are stationed at di�erent tables and patients cycle through as they arrive.

SMART Sta�ng

Primary Care Provider- The provider meets individually with all of the patients to review their charts and make medical decisions on medication management. The provider facilitates the Q&A with patients by eliciting responses from members of the group and ensuring that the information shared is accurate.

Certi�ed Diabetes Educator- Patients meet with CDE to develop and work on behavior change goals and problem solve issues common in a poor urban community. The CDE also facilitates the DSME component of the GDV.

Endocrinologist- For the �rst 6 months of the GDV an endocrinologist was on sta� to model diabetes related clinical decision making for the PCP. After which, the endocrinologist moved to a support role for the PCP.

CDE: Interim History, Medication Review, and Goal Planning

MA: BP, Weight, and Glucose

PCP: Blood Pressure, Lipid, and Glucose Management

Community Health Worker: Records Patient Questions for Group Discussion

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4

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

A1cPre

A1c3mo

HbA1c at �rst GDV and 3 months post visit

Unique Patients

HbA

1c

“I’ve been a nurse RN for 50 years and when I became diabetic 20+ years ago, there were classes but the knowledge was scant. Classes are a good thing for me at 70 years old and trying to ‘keep truckin’ because socialization is so important. I feel that the sta� are REAL People interested in me. The people that attend have become part of my life and I think about my life and I think about my class as I prepare food and I hear Fran, Rosa and Jackie ‘whisper’ in my ear as I read labels while shopping. They’re tough!”

RESULTS

Medical Assistant- The MA is responsible for pre-visit work: chart preparation, reminder calls, and scheduling of bloodwork. During the visit the MA is involved in taking vitals, reviewing medical history, and helping participants record questions for the Q&A session.

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Barriers to care become an accumulated and compounding burden for the pa-tients in poor communities. Such health disparities, operating across many di-mensions including geography, race, class, and gender add to the burden of dia-betes appreciated in resource poor communities. Camden, NJ is one such com-munity.

Group diabetes visits (GDVs) were initiated to provide a team approach to ongo-ing patient-centered diabetes (DM) care and o�er a model for sustaining behav-ioral change after diabetes self managemnt education (DSME).

DM Group Visit Structure

CONCLUSIONS

• Poverty, in addition to racial and ethnic disparities in DM care, is associated with decreased access to healthcare and worse clinical outcomes.• GDVs were investigated as a novel method for delivering DM care in an urban, resource- poor community. • GDV allow for physician directed, team based medical care, peer-to-peer support and continued emphasis on behavior change. • GDV were associated with a trend in HbA1c reduction.• Combining education and medical components of a visit improves glycemic control in an underserved patient population.

Attendance 2+ visits 63% 3+ visits 36%

Thirty Patients with previous DSME participated in the GDV

Race • African American • Hispanic • White

72% 11% 17%

Sex • Male • Female

50% 50%

Age 56.6 +/- 12.4 years

Patient HbA1c over time HbA1c (Pre-visit) 9.1 +/- 2.17 HbA1c (Post 3 months) 7.98 +/- 1.78 p-value .085

Over the course of the program there were 16 patients that HbA1c’s were collected for pre-class and 3 months post class.

Over the two year time period 14 group DM visits were held. The majority of the population was African Ameri-can with an even male to female ratio. Attendnace varied by individual but over half of all participants participated in at least two classes and a third participated in three or more.

MA contacts patients in advance of the appointment for reminders of insurance refer-rals, labwork, current BG logs, and reminders for specialty appointments. (Fig. 2).

Pre-work:

First 45 minutes: The health care team: MA, CDE and physician meet with the patient sequen-tially at individual stations with warm hando�s.

Second 45 minutes: CDE and PCP facilitate a group discussion and question and answer session. This work is completed by non-physician sta� and is logged in a special SMART visit progress note (Fig. 3).

CAMDEN, NJ is a city of nine square miles lo-cated along the Delaware River, directly across from Philadelphia. According to the 2010 Census:

• Population: 77,346 residents - 48% African American - 47% Hispanic/Latino

• Median Household income (2007-2011): Camden- $26,347 New Jersey- $71,180

• Persons below poverty level (2007-2011): Camden- 38.4% New Jersey- 9.4%

According to the Camden Health Database:

• Number of Diabetic Patients who visited the hospital (2010): -3,117 individuals

• Total Charges/Receipts for those visits (2010): -$200,828,878/$24,954,213