1. Nora Gimpel M.D., Florence J Dallo PhD, MPH, Barbara Foster PhD, Natalia Gutierrez-Chefchis M.D. University of Texas, Southwestern Medical Center Parkland Health and Hospital System, Dallas, Texas Establish and Evaluate the Effectiveness of Group Visits for Hispanic Diabetic Patients in a Residency Clinic Establish and Evaluate the Effectiveness of Group Visits for Hispanic Diabetic Patients in a Residency Clinic

2.  Provide skills to Family Medicine residents, faculty members and private practitioners on how to implement Shared Medical Appointments (SMA)  Discuss effectiveness of SMA vs. standard of care from our ongoing study Objectives

3. Definition Implementation Research Outline

4. Definition

5.  Interactive quality care to a group of patients in an environment in which each patient’s unique medical needs are individually addressed  1:1 encounter with providers in the company of other patients and members of the health care team SMA

6.  Same goals, different populations and different approach  Drop in Group Medical Appointment (DIGMA)  Cooperative Health Care Clinic (CHCC)  Disease Specific CHCC SMA

7.  Why should you do a SMA?  Encounter 10-15 minutes  Four times a year  One hour of interaction annually  Patient lives with diabetes 8,760 hours a year (Peeples, 2007) SMA

8.  What is in it for Patient?  90 minutes with their provider  Team of professionals  Learn from other patients  Support  Quicker access  More information  Increased adherence to practice guidelines  Increased satisfaction  Improved care SMA

9.  What is in it for the health care team?  Improved access  Improved patient satisfaction  Innovative approach  The other members of the health care team can participate actively in patient care  Improved revenue SMA

10. Prior Studies Trento et al. University Of Turin, Italy RCT 2 yr follow up, group n=56, control n=56 Each group consisting of 9-10 patients HbA1c stable in group subjects but worsened in control p <0.002 Diabetes Quality of Life and Diabetes Knowledge was higher in group than control patients p<0.001

11. Prior Studies Barud et al University of Oklahoma Health Sciences Center 8 months, n=50 4-12 per group Patient satisfaction surveys with positive results

12. Prior Studies Erikson et al. Christus Medical Group, Houston,TX 6 months 2003, n=15 Hispanic, no control Fasting blood glucose 244  126mg/dl HbA1c 10.2%  7.6% Significance not published

13. Prior Studies Brooks et al. Medical Group in Suburban Chicago Retrospective, n=707 Patients seen by pharmacist with option of individual vs. group intervention HbA1c improved in intervention group (p <0.001) Increased adherence to preventive care measures (p<0.05) Increase in patients with LDL <100mg/dl (p<0.001)

14. Prior Studies Clancy et al. Adult Primary Care Center, Medical University of South Carolina RCT 6 months, n=120 with HbA1c >8.5% 19-20 patients per group and control groups Improved sense of trust in group vs. control (p=0.02) Better care coordination (p=0.076) Better community orientation and more culturally competent care (p=0.96) Increased adherence to ADA process of care (p<0.001) HbA1c and Lipid levels were not statistically different after intervention between control and group

15. Prior Studies Clancy et al. Medical University of South Carolina RCT, n=186, HbA1c >8% Group had higher ongoing care (p=0.001), community orientation (p<0.0001) and cultural competence ( p=0.022)

16. Prior Studies Bray et al. University Health Systems of Eastern Carolina 5 rural clinics, n=312, 72% African American Increase in DM self management goals, documented lipid panels, aspirin use and foot exam No significance published Bray et al 160 Diabetics, intervention n=112 & Control n=48 with HbA1c >7%, BP >135/85 or evidence of high risk of end organ disease HbA1c decreased in intervention group p <0.05

17. Evidence Summary SMA improve Quality of life Diabetes knowledge Patient satisfaction Adherence to preventive measures In some cases HbA1c

18. Implementation

19. Our Sma Every other Tuesday 2 hours Attendance Process Curriculum Normal Values, living with diabetes, nutrition, foot care, exercise, stress, depression Team Healthy snacks Pill boxes

20.  Establish feasibility of group visits in your setting  Tour  Institutional Support  Community vs. University based programs  Motivation  Research Initial Considerations

21.  Decide which type of group visits and population Getting Started

22.   Meet with head of Department, Clinic and Billing  Meet with Clinic Staff, Faculty and Residents Getting Started

23.  No coding for group visits  99213  99214  CDE Billing

24.   Designate a room for the visits  Space  Furniture  Flow  Phlebotomy services  Comfort  Temperature Establishing SMA

25.   Define roles and responsibilities for the staff  Form a strong team Establishing SMA

26.  Define needed paperwork  Confidentiality form  Patient satisfaction survey Establishing SMA

27.   Communicate with other departments in your institution, address their concerns  Disseminate your guidelines  GROUP NOT CLASS  Voluntary  Copay  Invitation letter  Referrals Recruitment

28.   Start SMA  Extra forms in folder  Plan ahead, review charts, prefill progress notes, billing sheets, order labs  Rolling cart Starting the SMA

29.   Mock SMA  Progress Report  Strong Team Pearls for Success

30. Entrance Exam Rooms HEALTH CARE TEAM RN, PHARM-D, ATTENDING, RESIDENT Social Worker DOOR Front desk clerk, MA, med student/observers REGISTRATIONREGISTRATION REGISTRATIONREGISTRATION ☺ ☺ ☺ ☺

31. Research

32.  Objective  Establish Group visits for Hispanic diabetic patients in a residency program and compare them with standard office visits  Clinical outcomes  HbA1c, Lipid panel  Adherence to guidelines from the American Diabetes Association standards of medical care.  Non Clinical outcomes  Diabetes knowledge, quality of life and patient satisfaction Research

33. Inclusion criteria: Consistent attendance to clinic (not be planning to move out of the area in the next year) Hispanic, spanish speaker, older than 18 Uncontrolled type 2 diabetes as evident by HbA1c ≥ 7% Sample Informed consent Randomization Coin Flipping Table Intervention SMA Control Regular office visit Follow-ups; Data collection/measurements Clinical test & survey Final Data collection & Analysis Exclusion criteria: Inability to consistently attend meetings or planning to move out Dallas County Dementia Age younger than 18 Pregnancy

34.  Every other week since January 2008  SMA n=50 & Control n=50  Group  Females 83%, Males 17%  Control  Females 67 %, Males 33% Research

35. Preliminary Results

36. Descriptive Characteristics At Baseline (mean values)

37. Hemoglobin A1c baseline and follow up (5.5months)

38. Variable Comparisons, Baseline and Follow-up P 0.004 P 0.822 P 0.002 P 0.129 P 0.855 P 0.784 P 0.000 P 0.684 P 0.640 P 0.096

39. Most Important Results Patient’s comments “Very informative, enjoy having other perspective” “I love this group visit” “Thank you very much for doing this program, all the people and the doctors are very nice, sweet and patient” “Was really good, it help me understand that there are more people like me” “Thank you for the service, is better in a group, thanks for giving us your time and care, I am very happy”

40.  Approximate 1 unit decrease in HbA1c for the SMA (p=0.000) and 0.5 unit decrease in the Control group(p=0.003)  The DQL rose on average about 2.5 points (P 0.057) which for our small sample size could be considered significant  The Knowledge score rose on average slightly over 1 point (P 0.006) Preliminary Results

41. Summary

42.  Implementing new disease management models in residency programs will help new family practitioners develop an effective approach to improve chronic disease management  SMA was effective in improving HbA1c  SMA may be more effective in improving outcomes than regular visits  This study indicates that SMAs are an effective an innovative way of improving quality of life and knowledge Conclusions

43. Future Improve Recruitment Change Rooms 1 and 2 yr follow up

44.  Tiffany Barr, Margaret Shin, Enrique Montero, Ana Ortiz, Aime Barahona  Our patients  TAFP Foundation grant  Jay Ohagi MPH  Madelyn Pollock M.D.  Alison Dobbie M.D.  Amer Shakil M.D.  Kay Lynn Currin Acknowledgments

45. Contact Information Nora.gimpel@utsouthwestern.edu Flora.dallo@utsouthwestern.edu Natalia.gutierrez-chefchis@utsouthwestern.edu

46. References Group Visits Improve Metabolic Control in Type 2 Diabetes. Diabetes Care. 2001;24:995- 1000 Further Evaluating the Acceptability of Group Visits in an Underinsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetics. The Diabetes Educator 2007;33:309-314 Feasibility and Effectiveness of System Redesign for Diabetes Care Management in Rural Areas. The Diabetes Educator 2005;31:712-718 Evaluating Group Visits in an Uninsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetes. The Diabetes Educator. 2003;29:292-302 Evaluating Concordance to American Diabetes Association Standards of Care for Type 2 Diabetes Through Group Visits in an Uninsured or Inadequately Insured Patient Population. Diabetes Care. 2003;26:2032-2036 Confronting Disparities in Diabetes Care: The Clinical Effectiveness of Redesigning Care Management for Minority Patients in Rural Primary Care Practices. The Journal of Rural Health. 2005;21:317-321 Models for Patient-Centered Health Care Delivery. Group Practice Journal. 2003;52:1-6 Pharmacist membership in a medical group's diabetes health management program. Am J Health-Syst Pharm. 2007;64:617-621