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Selma Medical Associates

Patient-Centered Care Patient-Centered Care

Sub-Domain: Practice-Focused


Improving Diabetes Self-Management Via Pharmacist-Run Diabetes Education Group Classes

Submitted by Nataliya Scheinberg, Pharm.D., BCPS, CDE

SelmaCase Overview

Clinical pharmacy services were established at Selma Medical Associates in the 1990s and include medication management and drug information services. The pharmacy team has an established collaborative practice agreement with providers and offers one-on-one patient-centered appointments for various disease states. Clinical areas of focus include diabetes education and medication management.

At Selma Medical Associates, pharmacy team one-on-one diabetes care visits have consistently identified patients with poor insight into diabetes self-management skills. Although one-on-one medication management visits with the pharmacist help patients achieve diabetes-related health goals, it seemed apparent that more needed to be done to capture a larger number of patients and provide them with essential tools to take care of their disease.

The pharmacy team led an initiative to develop and offer a Diabetes Education Group Class Program as an additional service at the primary care clinic. The program’s goal is to capture more patients and provide them with a structured plan in diabetes self-management education. The program consists of five 2-hour classes that meet every other week for approximately 10 weeks. Two class cohorts run simultaneously, meaning a diabetes education group class is offered at the practice every week.

The classes’ content varies depending on the respective focus of the class. Many of the classes include videos and animations that help support the discussion. Patients are provided with folders containing the PowerPoint slides and diabetes educational handouts that align with the content each class. A “Doc Talk” is incorporated into each class as well. This involves having a healthcare provider present on a topic related to the class session and answer patients’ questions. At the end of every class session, a professional health and fitness coach from Winchester Medical Center’s Wellness Center leads a 30-minute exercise session to teach patients safe and simple exercises they can perform at home and to emphasize the importance of exercise in the management of diabetes.

The pharmacy team set aside a 4-hour clinic session each week to design and implement the program. It took a total of approximately 6 months to develop the program, gain provider buy-in, recruit patients, submit and wait for acceptance of the grant, and order giveaways.

Key Elements

One of the key elements for success is provider buy-in. The providers need to be willing to volunteer their time to present a Doc Talk. Providers also need to be interested in referring patients to the program and/or willing to allow the pharmacy team to recruit their patients based on elevated hemoglobin A1c values.

Patient recruitment is another key element for success. It is essential to set aside time to call patients and enroll them in the program. This process often requires a large time commitment, approximately 15 hours, as only about 10% of patients who are contacted end up enrolling in the program, with approximately six to eight patients completing the full Program in each class.

Another element for success includes having a physical space to hold class sessions. Selma Medical Associates has a conference room with a projector screen, projector, and laptop for the PowerPoint presentations as well as a large table with chairs for participants. The resources to print patient handouts and supply them in a folder prior to the beginning of each class is also an important element for success. Selma Medical Associates provides the pharmacy team with access to the photocopy machine, staplers, paper, as well as manila folders. A separate budget for purchasing giveaways is also helpful.

Incorporating a “Doc-Talk” into every class keeps the service sustainable, as it allows the practice to utilize the evaluation and management 99213 billing code for each patient who is present for the class session.

Impact on Patient Outcomes

Data for the first 39 enrolled patients was analyzed. Patients were enrolled following provider referral, recent diabetes diagnosis, or (HbA1c) ≥8%, to meet for 5 classes, every-other week. DSME was provided in each class, vaccinations were offered at the commencement of the program, when indicated. Mean baseline HbA1c-level was 9.1%, and post-intervention HbA1c-levels was 7.7%. HbA1c-levels declined markedly, though the effect of the intervention was not significant, it is likely that the sample was too small to observe a significant effect.

Pharmacy and Pharmacist Roles

The pharmacy team developed and implemented the program and now manages the enrollment and scheduling of patients, recruitment of healthcare providers to present at each session, coordinates with the health fitness coach, and orders end-of-class giveaways. 

Lessons Learned

Patient recruitment has been the biggest challenge for the successful implementation of the program. After calling patients, including referrals and those identified as having elevated hemoglobin A1c levels, only 10% of patients enrolled in the program. A slightly lower percentage end up completing all five classes. Setting administrative time aside to call a large number of patients is very important to yield a reasonable class size.

Choosing the best time to offer the class sessions is also an important factor to consider. This may vary by practice site and the demographics of the patient populations in question. It is difficult to predict our patient population’s schedule, but generally, we have found that a late morning class time (10 a.m. to 12p.m.) has been favorable for our patients. Unfortunately for patients who have full-time jobs, this time of day presents a challenge. As a result, we find that many of the patients who enroll in the class are retired or have a flexible work schedule that allows them to plan and take time away from work to attend the classes. We considered offering class times at the end of the workday, but provider availability would have become an issue. We felt that this time of day would also be challenging for patients who need to be home after work due to family obligations.

It is possible to offer make-up sessions for patients who miss a class. At the beginning of the first class for each cohort, we provide patients with a printed class schedule and ask that they let us know in advance if they will be unable to attend any of the five sessions. We highly encourage patients to attend their scheduled sessions to become familiar and comfortable with their group but having the option to make up a class has been helpful when missing a session is unavoidable. 

Budget & Resource Allocation

As part of a research grant funded by Shenandoah University, the pharmacy team can purchase and distribute free giveaways at the end of each class that are related to the topics presented that day. The purpose of the giveaways is two-fold:

  1. Provide patients with examples of items that can help manage their diabetes; and
  2. Provide a feel-good experience to better enhance the patients’ perceptions of the classes and help support class retention.

Examples of giveaways include glucose tablets, pillboxes, slippers, diabetes supply organizers, pedometers, exercise resistance bands, plate-method plates, and lunch boxes. The pharmacy team also receives donations from various local and national vendors. These often include dental supplies, diabetes needles/syringes, glucometers, or diabetes-friendly snacks, and beverages. After the final class, patients are encouraged to bring diabetes-friendly snacks that they would like to share with their groups as part of the end-of-class group lunch.

Future Goals

At the end of the fifth class, the pharmacy team gathers patient feedback via surveys. One survey question showed a high level of patient interest in continuing the program through follow-up diabetes support group classes. At this time, the pharmacy team is working to develop an extension to the program, where alumni patients from the class are invited to attend new Diabetes Support Group Classes on a quarterly basis. Every quarter, patients will have the opportunity to contribute to more in-depth discussions related to diabetes management and discuss the challenges of staying on track during the respective time of year (e.g., summer BBQs, Halloween, Thanksgiving, holiday season, etc.).

An additional future goal is to develop a pre-diabetes education group class, which would involve meeting with patients at risk for developing type 2 diabetes. The class session’s goal would be to teach these individuals how to improve their lifestyle to help prevent the onset of diabetes.

The pharmacy team at Selma Medical Associates is affiliated with Shenandoah University’s School of Pharmacy. Another goal is to expand the offering of Selma’s Diabetes Education Group Class Program to other practice sites affiliated with the School of Pharmacy by having additional clinical faculty members lead similar programs at their practice sites.