Group visits are good for diabetes control
Shared experiences help to address problems
Knowing that other health care facilities had been successful with group visits, professionals from the Medical University of South Carolina in Charleston decided to conduct a six-month pilot group for patients with poorly controlled diabetes. To cover the costs, they applied for a grant.
Although not a factor in the selection process, this patient population with diabetes was not well educated, had difficulty with transportation, and for the most part were indigent. Therefore, the medical center gave patients participating in the pilot transportation vouchers and grocery coupons as an incentive.
"We got our participants from our clinics and screened them according to certain criteria. For example, their hemoglobin A1-C, which is a diabetes marker, had to be elevated," says Tamara Wolfman, MD, assistant professor of medicine and co-director of medicine/pediatrics residency at the Medical University of South Carolina in Charleston and one of the group visit leaders.
There were three groups of patients that met once a month for a two-hour period during the pilot study. The first hour was devoted to education and during the second hour a clinical intervention took place in a group setting. If a patient needed to be examined privately, they were taken upstairs to the clinic, says Wolfman.
At the beginning of the group visit, each patient was asked what he or she would like to learn about that day, and then the group decided the educational focus for that session. Some of the topics covered during the pilot study were complications of diabetes, how to control diabetes, diet and exercise, and how to deal with families and holidays when you have diabetes. "There were certain things we decided we had to teach them as part of the pilot, but it turned out that they wanted to learn about what we needed to teach them, anyway," she says.
As part of the education, patients were given notebooks and asked to track their blood glucose readings. Some patients recognized when the numbers were too high and suggested they increase their insulin. "We tried to let them take ownership of their whole medical regimen," says Wolfman.
Another group member answered most of the questions asked. Each time Wolfman began to answer a question, another patient would talk about his or her experiences, she says. Guest speakers also were brought in on occasion, including a dietitian and an exercise physiologist who addressed how to overcome barriers to physical activity, such as living in a neighborhood where it is not safe to leave the house.
"Very rarely did a group member have a problem that someone else in the group did not have. There was a lot of interaction and a lot of sharing," says Wolfman. People participating in the group visits either had answers for the question or the same concern.
For a physician, the group setting where patients addressed their problems for one hour provided an opportunity to learn more about them individually, says Wolfman. She discovered things about their home life, their personalities, and religion that affect their diabetes. She also learned about the difficulties they had getting to the clinic and that some could not read.
"The most important finding of the pilot study was that patients felt much more educated and in control of their diabetes than they previously had and they felt more connected with their doctor. The trust factor was increased," says Wolfman.
When the pilot study ended, patients were asked if they wanted to continue coming to a group visit once a month; about half said yes. However, before another group was scheduled, these people were screened to determine if they were appropriate for group visits.
During the pilot, the organizers had learned that some people were not appropriate for group visits. Those with profound depression tended to monopolize the discussion, and those who frequently accessed medical care obviously needed more attention than the once-a-month group visit.
There was a two-month lag time between the pilot study and the start of the new group. At the first scheduled group appointment, about 75% of the patients reported that their diabetes had gotten worse. "They basically said that being in the group made them feel like they wanted to take better care of their diabetes because other people were doing it with them and trying to help them, and they were trying to help other people. When they were out of that group, they lost that accountability," says Wolfman.
For more information about the pilot study on group visits for people with poorly controlled diabetes, contact:
- Tamara Wolfman, MD, Assistant Professor of Medicine and Co-Director of Medicine/Pediatrics Residency, Medical University of South Carolina, Ambulatory Care Services, 326 Calhoun St., P.O. Box 250105, Charles-ton, SC 29425. Telephone: (843) 876-0888. E-mail: firstname.lastname@example.org.