The nationwide diabetes epidemic continues in an environment of escalating health care costs and declining reimbursement. As a result, it is our challenge as health care professionals to find effective models of care to improve the quality of life and reduce the disease burden of our patients with diabetes.
Three key recommended components for effective disease management planning include regular medical care, self-management education, and ongoing patient support.1,2 Shared medical appointments (SMAs), also called group visits, are one option that allows the integration of all three of these recommended components. As a clinician providing diabetes care in primary care group practice for the past 15 years, I believe SMAs can meet the various medical and education needs of multiple patients in one appointment while also providing the peer support and motivation necessary to help individuals with diabetes cope and effectively manage their disease.
SMAs started as a solution to overcome the challenges of the traditional 15-minute visit with a primary care provider (PCP), with the goal of increasing both efficiency and revenue. However, SMAs have also become opportunities for patients to benefit from additional visits, group interaction, and support and to get more time with their PCP.
This Diabetes Spectrum From Research to Practice section examines the group care model to improve diabetes care and self-management education. The section begins with a review I conducted (p. 72) to assess the evidence in support of SMAs and to determine the gaps in the literature. In clinical trials, SMAs have been effective in improving knowledge, quality of life, and problem-solving skills related to diabetes care compared to usual care. Improved adherence to the American Diabetes Association (ADA) standards of medical care for diabetes management has also been demonstrated in some studies. Additionally, some clinical trials using SMAs have demonstrated improvement in glycemic control and in patients' perceptions of their health care providers.
However, there are still gaps in the literature. Additional research is needed to study the cost-effectiveness of delivering SMAs and to determine the optimal group size, format, and curriculum for group visits.
The second article in this issue, by Sharon A. Watts, DNP, RN-C, CDE, and colleagues (p. 75), discusses a model that uses a multidisciplinary team and has been effectively implemented for more than 6 years at a large Veterans Affairs Medical Center. The authors share lessons they have learned from this model, with an emphasis on the unique role of diabetes educators in delivering SMAs. It takes a team of people from various disciplines to provide care for individuals with diabetes. By working together as a team, both patients' and providers' are more successful and satisfied with the outcomes achieved.
The next article (p. 79) is from Valerio Miselli, MD, and his colleagues, who share the Group Care model developed for and evaluated with patients with type 2 diabetes during the past 16 years at the University of Turin in Italy. This model, which includes a repeating series of seven sessions, also uses a multidisciplinary approach (i.e., nurse, dietitian, and pedagogist) to deliver care, with the end goal of transforming individuals with diabetes into “self-educators.” Miselli and his team have tested the Group Care model in a randomized, controlled trial and a multicenter trial and have demonstrated that it improves clinical outcomes, health behaviors, and quality of life and is replicable in other settings.
SMAs are reimbursable by health insurance carriers. Our last article, by Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC (p. 84), outlines reimbursement issues in SMAs, including reimbursement related to diabetes self-management education/training. As she points out, providing SMAs in primary care may potentially increase revenue by maximizing providers' time and streamlining care. On the other hand, it is more valuable to patients with diabetes, who receive more time in front of their health care providers without paying higher costs.
Overall, SMAs in primary care practices provide an organized approach to delivering diabetes care while focusing on meeting ADA standards of medical care. Although PCPs are busy caring for many different disease states each day, SMAs create a focus that can be used to organize care for a complex disease and to assist patients in meeting target outcome measures. The SMA model of care is a rational approach, but more randomized trials are necessary to show that it is superior to, or at a minimum as effective as, usual care and to determine in which health care settings SMAs are optimal.
