RESEARCH

Diabetes affects a large number of patients seen in a family medicine practice day to day. It is increasing in prevalence in the United States, and it affects more than the individual patient’s health. It places strain on quality of life, finances, and family dynamics and well-being. Disproportionately in America, more Hispanic and Black patients are diagnosed with diabetes than other groups. [1] Teaching self-management strategies help improve blood sugar control. Self-management items can include recording home glucose readings, adopting lifestyle measures and goals, and prevention of diabetic complications through foot care, weight control, and blood pressure readings. [3] Ideally these patient education topics should occur during individualized patient visits. Unfortunately, competing clinical demands limit the ability for residents and attendings to complete these goals. Extrinsic and intrinsic barriers include poor health literacy, language barriers, transportation difficulties, lack of adequate childcare, and financial difficulties. [7, 9, 12] It is challenging to address these barriers in a typical 20-minute patient visit. [4]

Group visits have been found to be an effective means to help patients learn the self-management items needed to gain control of their diabetes. Reported benefits include improved blood glucose and HbA1c levels, decreased weight, improved blood pressure readings, and decreased escalation of medications. Other benefits of group visits include improved HDL cholesterol and triglyceride levels, improved monitoring of parameters recommended by American Diabetes Association guidelines, increased knowledge and problem-solving ability of patients, increased access to care for patients, decreased costs, improved patient satisfaction, and increased patient trust in their physician. [5, 6, 8-13]

The Northwest Health Center (NW) serves as the patient continuity clinic for Baylor College of Medicine’s family medicine residents and well as serving as a patient-centered medical home for socioeconomically disadvantaged patients within Harris County. Greater than 60% of patients at NW are Hispanic, many of whom do not speak English. Amongst all the ambulatory Harris Health System clinics, NW has one of the highest concentration of patients with uncontrolled diabetes.

As recipients of a Texas Academy of Family Physicians Foundation grant, the investigating team sought to create a sustainable resident led patient self-management curriculum to better serve our patients with uncontrolled diabetes. In particular, the curriculum incorporates group visits where a patient may invite a family or support person to the group session. The patient curriculum is flexible and has adapted to the COVID pandemic by offering phone and video group visits in 2021. Between 2021 and 2022, resident physicians at NW completed the patient curriculum with a small cohort of patients with positive associations regarding patient knowledge and perceived self-management confidence.

In this pilot study, we planned to study the feasibility and outcomes of conducting group visits on patients in the Harris Health System and to further incorporate this resident-led patient curriculum as part of the residency continuity curriculum as possible. We used quasi-experimental format with one group, pre-test, post-test design. We used a closed cohort of patients and support persons — family members or other identified support persons. There was no randomization or use of control subjects. In the pilot patient curriculum, patients between the ages of 18 and 75 with a HbA1c ≥ 8% from Northwest Health Center and their respective family members were recruited to participate in five weekly group sessions held at a local library or telehealth platform. We chose a lower HbA1c criteria so that we could recruit more patients. Because many of the patients recruited to the pilot speak Spanish as their primary language, we offered the group visit sessions in both Spanish and English concurrently. Each group session was led by one of the co-investigators. If the co-investigator was not fluent in Spanish, one of the other co-investigators who was fluent in Spanish simultaneously interpreted the contents of the group session into Spanish for patients and their support persons.

Using materials from the National Diabetes Education Program, each group session was centered around a topic of the day, including the basics of diabetes, nutrition, exercise, and medication management. As much as possible, each group session included an interactive portion such as dancing for exercise. Patients are prompted to create individualized SMART goals at the end of each group visit to evaluate their progress throughout the curriculum.

A total of 19 patients were recruited from the residents’ continuity clinic panel in early October 2023. Of the 19 patients, 17 consented to participate in the study. The group sessions occurred from October 14, 2023, to November 18, 2023. Three patients reported transportation barriers. Due to difficulty with accessing the ClinCard system of reimbursement, which did not allow gift cards that would be familiar with the participants, these targeted patients were not able to attend the sessions.

There was good turnout to the first group session. Patients and their support person report being motivated and enthusiastic to participate in the group sessions. Participant turnout decreased significantly in the third session. This may be in part to an intercession in the schedule due to a lack of resident availability to lead the group session on a consecutive Saturday. At the end of the group sessions, only one participant was successful in completing the patient passport requirement to receive the $50 reimbursement. During the final session, this participant very sincerely thanked the residents for hosting the group sessions and told the residents that “their efforts and work can really touch patients.” This is similar to prior patient comments from previous iterations of the patient curriculum in 2021 and 2022. Patients reported positive feelings regarding increased time with the resident physicians and community amongst their peers. Overall, those prior patient participants in 2021 and 2022 experienced fluctuations between improvement and uncontrolled in their HbA1c in the months after the curriculum that on chart review seem to be related to loss of financial assistance plan from Harris Health or our financial and transportation hardships. Residents who participated as investigators for this project reported feeling more connection with their patient panel and increased altruism.

Of the patients that completed at least one session in 2023, three patients’ HbA1c values decreased approximately one point and are currently in the 7 to 8 range. Two patients did not have their HbAa1c rechecked as they were lost to follow up.

Given the lack of patient participation even with maximal support and incentives, the team will be looking at restructuring the project altogether. Although the project was not a success, we were able to test several hypotheses toward improving patient care and engagement including the use of incentives and transportation reimbursement in our specific patient population. A significant barrier to providing patient reimbursement for transportation was the Baylor College of Medicine reimbursement process. Currently the college does not allow direct reimbursement through gift cards such as the metro card and grocery card we had proposed. Reimbursement could only occur through the ClinCard system, which requires patient social security numbers. This is significant barrier as most of the participants were undocumented or have family that are undocumented.

A takeaway of this project is the need for more buy-in from Harris Health and the clinic in general. The work of recruiting patients, reminding patients, and coordinating the curriculum were done by family medicine clinicians, resident, and faculty alike. We realize that given our patient population’s low health literacy, communication, and socioeconomic barriers that a specific bilingual patient navigator is needed to more closely guide the patients through completion of the curriculum. In one specific instance, a patient went to the wrong location despite the paper schedule given and verbal reminders at the end of the previous session.

Despite the setbacks in the execution of the project, the investigating team is very thankful to the Foundation for the opportunity to pilot our patient curriculum with all the monetary support we could imagine. This was a valuable experience of the residents and faculty of Northwest Health Center. Residents left the project feeling more capable of completing IRBs and conceptualizing future QI projects.

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