Elizabeth I. Molina Ortiz, MD MPH

ObjectivesPresent an update on the progress of DM group

visits at the Institute for Family Health

Reflect on our pilot group, which continues at Phillips Family Practice

Addition of group visits at Mt Hope Family PracticeStep by step approach at organizing these visits

Highlight successes

Spring 2007Started group visits at Phillips Family

Practice with support from Dr. Andreas Cohrssen, residency director

Began by inviting patients from panel of two physicians, focusing on:

Spanish speaking patientsThose needing further intense educationUncontrolled DM markers (A1c, LDL, BP, etc)

Spring 2007Created list of patientsCalled patients to introduce idea of group

visits one month prior to starting visitsReminder phone calls one week and one day

prior to monthly visitCreated monthly calendar of topics which

would be addressed throughout the yearGroup continues to this date, led by Dr.

Venkataraman and Dr. Borrero, with additional support from psychologist

Mt Hope Family PracticeAugust 2007– February 2008

Established patient panel and developed physician-patient relationships

Worked with AmeriCorps volunteer developing curriculum for monthly group visits

Identified Spanish speaking patients in need of intense education and improved DM control

After five months at Mt Hope Family Practice, started to introduce the idea of group visits to our patients

February 2008Held our first

monthly meeting

Reminder phone calls, letters and flyers were sent

Core group of 8 patients with diabetes attend

Samples

LetterPhysician ScheduleWorkflow Physician Chart ReviewEducational HandoutPhysician NoteImprovements and successes

Sample Letter

Chart Review

Workflow1. Clinical triage (weight, BP, fingerstick check)2. Informal social time with healthy snacks in

conference room as all patients get triaged3. Interactive educational session lasting approx 45

minutes 4. A prize is awarded to participant with most

improved measure based on theme for the month (i.e.: most improved A1c, LDL, Blood pressure, etc.)

Workflow5. Participants and facilitators share goals with the

group for the following month

6. Each patient spends 5 minutes individually with the provider to review their goals and individual needs

7. If need is identified, separate follow up appointments two weeks after group visit are made. Otherwise, patient follows up in one month for next group visit.

Educational Handout

Educational tool

MOLINA-ORTIZ,MD Fri May 9, 2008 2:29 PM Signed

ZG is a 58 year old femaleSUBJECTIVE:Patient presents for f/u visit and diabetic group education.Zoila Gil is feeling well. Has no complaints

No polyuria, no polydipsia, no Chest pain, nor shortness of breath

Patient Active Problem List:DIABETES UNCOMPL ADULT-TYPE II [250.00]BENIGN HYPERTENSION [401.1]LIPIDOSES [272.7]MITRAL VALVE DIS NEC/NOS [394.9]SCREENING MAL NEOP-BREAST NOS [V76.10]MORBID OBESITY [278.01]DYSTHYMIC DISORDER [300.4]ANXIETY STATE NOS [300.00]ROUTINE MEDICAL EXAM-ADULT [V70.0]

Tobacco Use:Never

DM Chart review:Opthalmology visit in last 12 months: yesPodiatry visit in last 12 months: yesOn ASA: yesOn ACE if appropriate: yesFlu/PNA vaccine up to date: yes

Sample Note

OBJECTIVE:Filed Vitals:|----------------------|| | 05/01/2008 || | 12:48 PM ||----------------------|| BP: | 110/80 | Pulse: | 73 | Temp: | 96.8 °F (* | TempSrc:| Oral | Weight: | 250 lbs (* || SpO2: | 98% ||----------------------|

Results for orders placed on 05/01/2008

-RANDOM GLUCOSE INHOUSEGLUCOSE, FINGERSTICK 149 (*) Low: 70 High: 110

ZG appears well, in no apparent distress. Alert and oriented times three, pleasant and cooperative. Vital signs are as documented in vital signs section.Rrr, no murmurclear to auscultation bilaterally no wheezing or cracklesno pedal edema, no lesions or ulcers, good peripheral pulses.

HGBA1C 6.5 02/14/2008HGBA1C 10.8 09/04/2007HGBA1C 7.3 11/13/2006LDL 53 02/14/2008

ASSESSMENT/PLAN:58 yo here for DM f/u and educational group

Group Educational Topics Discussed: 1. Discussed long term effects of elevated glucose.2. Reviewed normal blood pressure levels, at group members' request 3. Shared each member's blood pressure and their progress in management of their 4. Discussed nutritional interventions and other lifestyle modifications to high LDL levels5. Reviewed goals set from previous meeting and set new goals.6. Reviewed appropriate amount of fruits and vegetable intake per day

250.00 DIABETES MELLITUS TYPE II-UNCOMPL (primary encounter diagnosis)Note: well controlled. Much improved a1cPlan: RANDOM GLUCOSE INHOUSEcontinue current management

-need for individual appointment did not become apparent during our group visit. Therefore, individual appointment was not scheduled in two weeks.-follow up in one month for next group visit.

Successes

5th group sessionFeeling of camaraderie AccountabilityResponsibilityGreater confidence in self managementTwo members started insulinPositive peer pressure

Successes 100% of group members on ASA, ACE/ARB,

have podiatry referrals (or monofilament documentation), ophthalmology referral, PNA, flu vaccines

100% have decreasing A1c levels:Patient Pre-Group A1c Latest A1c Change

SE 7.9 7.8 -0.1

B,Z 15.2 9.9 -5.3

G,Z 10.8 6.5 -4.3

H,D 8.6 8.2 -0.4

P,V 12.6 11.5 -1.1

D,F 11.9 -

C,M 10.3 -

C,M 12.5 10.8 -1.7

Successes Improvements in LDL, systolic and diastolic

blood pressureGreat improvement in weight

(group has lost net 16lbs)

Patient Pre-Group Wt Recent Wt Change

SE 186 189 3

B,Z 196 195 -1

G,Z 268 257 -11

H,D 193 189 -4

P,V 208 224 16

D,F 263 252 -11

C,M 131 126 -5

C,M 174 171 -3

More information…

http://diabetesgroupvisits.wikispaces.com/