Health

Group Visits: Best Practices in Team-Based Care at MGH Back Bay

In April of this year, MGH Back Bay began trying out a new model for delivering care and education for their diabetes community: shared group medical visits. Led by a nurse practitioner, a diabetes nurse educator and a registered dietitian, these shared visits are offered to people with prediabetes or Type 2 Diabetes (newly diagnosed or anyone needing a little extra help bringing blood sugars under control). Visits are divided into two sessions, two weeks apart. The first session focuses on diabetes basics and nutrition; the second covers nutrition in more detail and reviews complications.

At the beginning of each session, the nurse practitioner meets with each participant for a short individual visit. A larger group discussion takes place afterwards. Although there is a curriculum with prepared material about A1C, blood pressure and cholesterol (LDL), the discussion is allowed to grow organically. Questions are encouraged and participants are welcome to share personal stories if they wish. Opportunities for hands-on learning are woven into the session, such as exercises on reading food labels or using rice in a shoe to illustrate symptoms of neuropathy. At the end of the second session, participants are asked to identify and write down one or two goals to work on. The diabetes nurse educator mails these goals two months after the group as a reminder of what was motivating them during the visit.

Response to the shared group visits has been very positive. The opportunity to talk about living with diabetes and learn tips from peers for overcoming every day challenges is a highlight for many. Much of the success of this visit model is the emphasis on team-based care. One of the reasons for offering shared visits was providing better access to nutrition education. Since a registered dietitian is there for the visit, participants do not need to schedule a separate appointment. The group setting also helps reduce anxiety some feel about seeing a dietitian. In addition to clinical outcomes (improved A1C, reduced weight), scheduling a follow up visit with a dietitian is considered a mark of success for this visit model.

More shared group medical visits have been planned for the fall. Given how well visits have gone so far, the practice is considering offering shared group visits for other chronic conditions such as hypertension

Uncategorized

Standards of Medical Care in Diabetes 2015

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

The American Diabetes Association (ADA) publishes guidelines each January to educate professionals about the best clinical practice for people with diabetes. They were formally called Clinical Practice Recommendations but are now referred to as Standards of Medical Care in Diabetes. I would like to acknowledge that Dr. Deborah Wexler from the Diabetes Center at MGH is a member of the Professional Practice Group of the ADA, Glycemic Group Subchair. This group edits the Standards of Care and reviews ADA Position Statements.

These standards are meant to provide general treatment goals for patients with diabetes. They are not meant to replace clinical judgment. I am going to briefly review some of the changes this year; visit the American Diabetes Association website for a more detailed explanation of the standards. Please remember, that these are in no way meant to replace the individual care that you are participating in with your health care team.

The ADA determined that the following themes were to be considered by clinicians, policymakers, and patient advocates at all times:

  1. Patient-Centeredness – These recommendations are a guide to care and must be adapted to each patient’s individual needs. There is no “one size fits all” in the care of diabetes.
  2. Diabetes Across the Life Span – People with Type 1 and Type 2 Diabetes are not only increasing in number, but are also living longer. There are few clinical trials that address the needs of this population, so it’s important that all health care team members communicate well to be sure the best care is provided.
  3. Advocacy for People with Diabetes – Living with diabetes is challenging. It’s important for all of us in this field to act as educators for our patients and the community. This is the best way to avoid issues of discrimination. The ADA has published position papers on diabetes and employment, diabetes and driving, and diabetes and correctional institutions, to name a few.

Standards Review of Changes

S2: Classification and Diagnosis of Diabetes – Screening of overweight Asian adults with another risk factor should be considered at a BMI of 23 or greater. All other overweight patients with another risk factor should be screened at a BMI of 25 or greater.

S4: Foundations of Care/Education – The ADA supports diabetes self-management education (DSME) for all patients with pre-diabetes and diabetes. This model has better health outcomes as well as possibly resulting in cost savings.

S4: Foundations of Care/Physical Activity – It’s important to be as active as possible. Sitting for more than 90 minutes at a time should be avoided.

S4: Foundations of Care/Smoking Cessation – E-cigarettes are not supported by evidence based research as a good alternative to tobacco products.

S4: Foundation of Care/Immunizations – All patients with diabetes need to be vaccinated annually for influenza. Hepatitis B immunizations should be provided for people ages 19-59 and there is consideration of this being done across the lifespan. Pneumococcal vaccination is also important. These recommendations are based upon the Centers of Disease Control (CDC) recommendations:

  • People over the age of 2 should receive the PPSV23 vaccine.
  • Adults who are 65 or older and HAVE NOT been vaccinated should receive the PCV13 vaccine and the PPSV23 vaccine 6-12 months after the initial vaccine.
  • Adults who are 65 or older and HAVE received PPSV23 should receive a follow up within 12 months of the PCV13 vaccine.

S6: Glycemic Targets – Pre-meal targets have been changed from 70-130 mg/dL to 80-130 mg/dL to better avoid episodes of hypoglycemia.

S7: Approaches to Glycemic Treatment – The algorithm for medication management of diabetes has been updated to include the newest medications available for the treatment of diabetes. Lifestyle changes including healthy eating, weight control, activity, and education are still extremely important in all management strategies for diabetes.

S8: Cardiovascular Disease and Risk Management – The goal for patients with hypertension is now <140/<90. It is also perfectly acceptable for this goal to be changed to meet individual needs. The goals for lipid management have also been changed to focus more on each person’s individual risk and to keep the LDL <100. Again, this goal may be altered to meet the need of each individual.

S9: Microvascular Complications and Foot Care – Feet should be examined at each office visit if there is a history of deformity, ulcer, or decreased sensation.

S11: Children and Adolescents – An A1c level of 7.5% or lower are acceptable.

S12: Management of Diabetes in Pregnancy – This is a new chapter that provides guidance for the care during pregnancy from pre-conception across the lifespan.

It is important to remember that these standards are not the final say in how to care for people with diabetes. Always talk with your health care team about what is the best treatment for YOU.

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Announcements

GRADE Study at Mass General

Do you have type 2 diabetes?

Have you had it for less than 5 years?

Do you take only metformin for your diabetes?

You may be able to join GRADE, a clinical research study being conducted at Massachusetts General Hospital. GRADE seeks to identify the best combination of commonly used medications to treat type 2 diabetes for long-term health.

Participants receive, at no cost to them:
• Diabetes treatment, tests, medicines and supplies
• $100/year and free parking at Mass General parking garages
• Regular, coordinated care from a diabetes medical team at the Mass General Diabetes Center. Visits are four times a year for four to seven years, depending on date of enrollment.

The diabetes medicines, and medication combinations studied in GRADE are regularly prescribed by doctors, and are approved by the U.S. Food and Drug Administration and the American Diabetes Association to treat type 2 diabetes.

To learn more, call 617-643-7737
GRADE@partners.org
https://grade.bsc.gwu.edu

GRADE: Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study: A nationwide clinical research study sponsored by the National Institutes of Health.

Announcements

Help Save a Life: Donate Blood

Did you know that you can donate blood at the MGH Blood Donor Center if you have Diabetes?

As long as your Diabetes Mellitus is under control with diet, oral medication, or insulin and you meet the other donation requirements you should be eligible to donate. There is a deferal for individuals who received bovine insulin from the UK since 1980

The need for blood affects us all, and the demand for vital blood donations remains constant. Each and every day, blood donations are needed to sustain Mass General patients. Treatment of cancer, organ transplantation, and surgery all depend on the availability of a safe and adequate blood supply. The MGH Blood Donor Center collection efforts support patients at MGH, Shriners Burn Institute, Spaulding Rehabilitation Hospital, the Massachusetts Eye & Ear Infirmary, and theMassachusetts General Hospital for Children. The largest transfuser of blood in the region, MGH transfuses approximately 70,000 blood components each year to patients at Mass General and its affiliates. 

For more information on eligibility requirements, visit the Blood Donor Center’s website or   e-mail Melissa at mmacphee@partners.org.  To schedule an appointment to donate, call    617-726-8177.