Implementing Shared Diabetes Medical Appointments Within the Latino Patient Population
By Diana Shaghayegh Sepehri
This is the second place winner of the 2009 Namey/Burnett Writing Award, implemented by the ACOFP Public Health and Wellness Committee to honor the best preventive medicine papers submitted by osteopathic family practice residents and medical students.
Abstract: According to a 2007 Centers for Disease Control and Prevention (CDC) report, 24 million people in the United States have diabetes. Among them, Latinos experience disproportionately high rates of type-2 diabetes. This trend increases over time, with the rates of severe diabetic complications being up to six times higher among Latinos. Compelling scientific evidence indicates that life-style changes can prevent or delay the occurrence of type-2 diabetes in high-risk groups.
This paper proposes specific steps to be taken by any primary care clinic in adopting the Shared Medical Appointment (SMA) model of patient education for their Latino diabetic population. This includes: 1) Selection of diabetes educational material and assessment tools in Spanish, 2) Validation of all survey tools in a Spanish-speaking low-literacy Latino immigrant population, and 3) The training of interested medical students and providers in the health education components of diabetes care.
Background & Introduction
Based on the most recent statistics from the CDC, 24 million people in the United States, approximately 7.8 percent of the population, have diabetes and these numbers are expected to more than double by 2050.1 In California alone, an estimated 10 percent of the population suffers from diabetes, not including the potentially large group of people that remain undiagnosed. Underserved minority populations are more likely to be affected by diabetes and its related complications.1 Specifically, based on 1999–2008 National Health and Nutrition Examination Survey (NHANES) estimates of total prevalence, it is projected that approximately 13 percent of Latinos in the United States today suffers from diabetes, approximately two to three times the rate among the White/non-Hispanic population. Due to lack of available and affordable routine care, many Latinos remain undiagnosed and untreated until they are facing catastrophic deterioration in health status, at which point interventions are costly and outcomes are poor.
Once Latinos are diagnosed with type 2 diabetes, their experience with this devastating chronic illness is distinct from non-Latino groups. National longitudinal data suggest that rates of severe diabetic complications, such as chronic kidney failure, lower limb amputations, and blindness, are up to six times higher among Latinos.2 Rates of severe retinopathy as a complication of diabetes are significantly higher among Latinos.3 The incidence of end-stage renal disease is reported to be four to six times higher among diabetics.3 Higher rates of lower extremity amputation peripheral vascular disease (80 percent) is more common in Mexican-Americans compared to non-Latino Whites with diabetes.4 And since more than half of the immigrant minority population is uninsured, financial burden of prevention and chronic disease management falls on local and county clinics.4 Thus the message is clear: there is a tremendous need for interventions that reduce diabetes-related complications and their associated high costs, by improving early-stage disease management that is both culturally and linguistically validated for a diverse patient population.
Compelling scientific evidence indicates that lifestyle change prevents or delays the occurrence of Type 2 diabetes in high-risk groups.5 Latinos, who constitute the fastest growing ethnically distinct U.S. group, experience disproportionately high rates of Type 2 diabetes. At the same time, linguistic and economic barriers, differing cultural expectations between patients and physicians, provider reactions based on stereotypes, and managed healthcare shortfalls limit diabetes care. Such trends highlight physicians’ need to consider the role of culture in the delivery of effective services.6
Role of Culture and Language in Project Design
When designing an intervention for any patient population, it is imperative to consider linguistic and cultural components that are particular to that population. The majority of Latinos living in the United States is composed of monolingual Spanish speakers or those who prefer to speak Spanish despite varying degrees of English-language skills.7 This trend makes translation of instruments an essential part of the intervention design process for this specific patient population. Also, cultural factors such as the role of interpersonal trust (confianza), social support, and recognition of family roles have been identified as crucial when working with Latino/Hispanic populations.7,8
The Centers for Disease Control and Prevention’s Racial and Ethnic Approaches to Community Health (REACH 2010) program has supported various initiatives that aim to increase our understanding of the sociopolitical and historic context in which health disparities are created.9 For instance, a culturally-tailored diabetes lifestyle intervention delivered by trained community residents (promotoras) in Detroit has produced significant improvement in dietary and diabetes self-care related knowledge and behaviors of Latino patients.4
Evidence also suggests that community-based and family-oriented interventions can provide the social support necessary to promote and sustain healthy lifestyles among low-income, recently immigrated Latinos with diabetes.8,10 Specifically, results from a four-year randomized controlled clinical trial demonstrated improved quality of life, diabetes knowledge, and health problem identification for patients who attended the group visit (all P-values less than 0.001) compared to those who received regular health services.
Also, at the four-year follow-up, group intervention patients demonstrated less progression of retinopathy, lower blood sugars, and improved diabetes knowledge and quality of life compared to control patients.11 Another example of successful initiatives is Project Dulce, a comprehensive 12-week program that provides outreach, recruitment, screening, diagnosis, clinical care, and culturally sensitive educational services to low-income Latino diabetics in North San Diego County. Implemented in July of 1998, the program has demonstrated improvement in diabetes knowledge, cultural beliefs practices, treatment satisfaction, and health locus of control for its patients.12
Shared Medical Appointments Model of Care
An alternative to standard individual appointments, Shared Visits or Shared Medical Appointments (SMAs) were developed by Dr. Edward Noffsinger at Kaiser Permanente Medical Center in San Jose, California, in 1996. Recognizing the growing demand for innovative and cost-effective patient care, Dr. Noffsinger envisioned group visit models to be “a tool for leveraging physician time and for increasing both efficiency and production while improving service and quality of care”.13 When applied to a plastic surgical nursing unit, SMAs were found to be a great way to deliver comprehensive patient education and to improve patient access.
Rooted in social support behavioral theories, this initiative has been shown to be particularly effective for chronic illnesses where social support networks, self-care practices, notions of self-efficacy, and patient education are important determinants of health outcomes.13,14 SMAs have also been praised for creating an optimal learning environment through mutual and supportive exchange between the staff and patients.15
More recently, in her review of different group visit models conducted over the past decade, Weinger concluded that each of the models recognized that patient education is extremely important, identifying this as a significant key to their successes.14 Therefore, it can be hypothesized that a group-based model of education delivering linguistically concordant and culturally competent information has increased potential to positively impact health care delivery and outcomes for diabetes.
As a result of the aforementioned efforts by various non-governmental organizations as well as the CDC, NIH, and the American Diabetes Association, there is now a range of translated educational material available in Spanish. However, while there have been various initiatives with demonstrated success using support groups, there is a lack of clinic-based comprehensive diabetic care models that adopt the principles of SMA for the Latino patient population. In recognition of each community’s unique social, economic, and educational background, it is necessary to create a systematic approach for educational materials and methods to be reviewed, piloted and selected for this specific patient population. To do so, this paper proposes the use of a Continuous Quality Improvement (CQI) model - a system-based approach to the assessment of potential causes of less than optimal quality, which once identified, can be corrected or eliminated in order to achieve the desired improvement.
Implementing SMAs Within the Diabetic Latino Population
To effectively design and implement a new program for any setting, it is important to first understand the existing doctor-patient structure. Traditionally, diabetic patients have been managed within a chronic disease model utilizing a one-on-one visit with medical staff. This paper proposes a new diabetes program be modeled after the Shared Visits or Shared Medical
Appointments initiative, the design for which is based on social-support behavioral theory. Multiple versions for various populations (including the VA clinics) have been developed and pilot tested for efficacy using Hemoglobin A1c, LDL cholesterol, and Blood Pressure as the main outcome measures.16
Clinically, the SMA model includes a 90 minute weekly group session with a four to eight week return visit interval until goals are achieved. Each session is usually staffed by a medical provider (DO/MD, RN, or PharmD), a psychologist or diabetes educator, and a medical student or intern for a group of 10-15 patients. In each session group activities include: 1) review and discussion of lab results for all patients, 2) guided education about common concerns and complications, 3) progress tracking, and 4) setting up achievable individual goals along with a review of strategies to achieve those goals. Group activities are also supplemented by brief individual counseling (15-20min) directed at medication management and referrals.
This paper proposes specific steps to be taken by a primary care clinic in cultural and linguistic adaptation of the SMA model of patient education among Latino diabetic population. The first step requires that all educational material be selected and validated for the specific patient population using forward and backward translation methods as well as piloting trials in the target population.
In addition, a Spanish-speaking Certified Diabetes Nurse Educator should be engaged in order to ensure sustainability of the program and to provide culturally competent and linguistically concordant educational materials in the group visits. If implemented in a teaching medical facility, the time for individual counseling sessions can be extended to 30 minutes per patient, allowing for each patient to be first seen by a medical student or intern. The medical students and interns then present to the attending physician who would be responsible for approving the medical plan, ordering laboratory tests, initiating or altering medication, and organizing appropriate referrals.
Also, since provision of care for chronic illnesses is distinctly different from other aspects of primary care practice, it is important to continuously involve and educate the medical staff and physicians in the SMA model.
Specifically, interested providers will be given a packet of educational material along with an invitation to observe a session prior to their direct involvement in the program.
Determining the Efficacy of SMA for Specific Patient Populations
The process of evaluation for this project would include two components: 1) CQI methods for system-based assessment of potential causes of quality shortfalls and their correction or elimination for improvement, and 2) pre-test/post-test analysis for evaluation of the program’s impact on patients’ health outcomes.
A key principle of the CQI process is continuous involvement of all team members in data collection, monitoring, integration, and the decision making process. Accordingly, all patients are requested to complete a five-minute survey in Spanish at the end of each group session to provide feedback from the patient perspective. Also, all medical staff and team members are invited to an informal post-group session each week to provide feedback. This meeting includes the clinic management staff, medical student staff, the diabetic educator, translators, laboratory personnel, etc. Both sets of feedback are then considered in making modifications for the next week’s plans.
All modifications are also summarized in a weekly PDSA (Plan; Design; Study; Act) report and sent out to all involved team members in advance of the following week’s SMA. In addition, key team members (medical director, medical student, project manager, group assistant, diabetes educator, etc.) are invited to monthly strategy meetings to discuss the progress, the necessary changes, and future goals for the program. Furthermore, all research tools and materials (diabetes table, goal-sheet, minute surveys, etc.) are continuously examined and modified for better results as part of the CQI process.
Furthermore, patients would be provided a Self-Assessment Workbook. This workbook is designed according to CQI guidelines in order to provide patients with tools to better understand and control their condition. Contents include a daily log of blood sugar levels, root-cause diagrams, control charts, and goal-setting instructions which will be reviewed during every session. This workbook would also include a short description of the SMA model of patient care, and encourages patients to take control of their health and become an active contributor to the shared medical appointments and the quality improvement process. Ultimately, the hope is to move patient-care beyond earlier models of compliance and towards concurrence and collaboration with medical treatments.
Lastly, the program’s long-term impact may be assessed using pre-test/post-test analysis at 0, 3, 6 and 12 months. To collect the pre-test information, a chart extraction may be carried out on the baseline quality indicators such as hemoglobin A1c, blood pressure, and cholesterol levels for the entire eligible and consented patient population. Also, prior to the first group visit, a questionnaire is administered to obtain demographic data and baseline self-efficacy scores for all study participants. Self-efficacy is defined as an individual’s belief that she can formulate and execute a plan to accomplish a given task.
A subjective outcome measure, self-efficacy is influenced by personal, behavioral, and environmental factors and is measured by the Stanford Diabetes Self-Efficacy Scale. After gathering baseline data, the weekly SMA visits will run for one year, during which the post-test information will be gathered every three months. The questionnaire will be re-administered in order to obtain each group participant’s post-test self-efficacy score. The chart extraction will also be performed again in order determine the post-test quality indicators. The change in self-efficacy scores and quality indicators will then be analyzed.
HIPPA Compliance Issues
All patients who choose to participate in the SMA program will be signing a consent form that clearly explains the process and the extent of personal medical information that will be shared and discussed during each SMA visit. Also, patients are made aware that their participation in this program will be completely voluntary and that they may choose to opt out of this program and continue with the traditional one-on-one visit at any time. If patients decide to participate in this study, they will also be giving consent for the researchers or their assistants to review their medical record as a part of the evaluation of the program’s efficacy.
The evaluation data that will be gathered from patient participation will be made available only to the researchers, the Certified Diabetic Educator, and students involved in the analysis of data. All information will be kept in a secure location to protect patient privacy and may only be disclosed if required by law. While absolute confidentiality cannot be guaranteed since research documents are not protected from subpoena, all personal patient information will be identified only by a number and will only be used for evaluation of the program. Patient names will not appear on any of the questionnaires. Finally, while the results of the program’s implementation and its progress may be presented at meetings or in publications, patients’ personal identity will not be revealed.
Conclusion
In recognition of each community’s unique social, economic, and educational context, it is necessary to create a systematic approach where educational materials and methods are reviewed, piloted and selected for a specific patient population. As an example, this paper offers specific steps to be taken by a primary care clinic in cultural and linguistic adaptation of the SMA model of patient education among members of the Latino diabetic population.
Specifically, CQI evaluative methods should be used within an SMA model of patient education for weekly system-based assessment and improvement. Therefore, while the proposed intervention design begins with a modified SMA model of patient education, the CQI process helps create a linguistic and cultural adaptation of that model which would be specifically tailored to the site and its patient population. It is the hope that this combination strategy helps create a methodological template for an effective cross-cultural adaptation of health initiatives, which could have further potential for application among other immigrant and ethnic communities.
Diana Shaghayegh Sepehri is currently a third year medical student at Touro University College of Osteopathic Medicine, California. She received her Masters in Public Health and Medical Anthropology from Case Western Reserve University, Ohio. Her graduate education and the MPH thesis that led to the above paper were funded by the Paul and Daisy Soros Fellowship Program.
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