Original Research

Experiences of Veterans With Diabetes From Shared Medical Appointments

Fed Pract. 2015 May;32(5):40-45

References

1. Vouri SM, Shaw RF, Waterbury NV, Egge A, Alexander B. Prevalence of achievement of A_1c, blood pressure, and cholesterol (ABC) goal in veterans with diabetes. J Manag Care Pharm. 2011;17(4):304-312.

2. Kupersmith J, Francis J, Kerr E, et al. Advancing evidence-based care for diabetes: lessons from the Veterans Health Administration. Health Aff (Millwood). 2007;26(2):156-168.

3. Mulcahy K, Maryniuk M, Peeple M, et al. AADE Position Statement: standards for outcomes measurement of diabetes self-management education. Diabetes Educ. 2003;29(5):804-816.

4. Fitzpatrick SL, Schumann KP, Hill-Briggs F. Problem solving interventions for diabetes self-management and control: a systemic review of the literature. Diabetes Res Clin Pract. 2013;100(2):145-161.

5. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:120180.

6. Heisler M, Resnicow K. Helping patients make and sustain healthy changes: a brief introduction to motivational interviewing in clinical diabetes care. Clin Diabetes. 2008;26(4):161-165.

7. Williams GC, Rodin GC, Ryan RM, Grolnick WS, Deci EL. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998;17(3):269-276.

8. Rosland AM, Piette JD, Choi HJ, Heisler M. Family and friend participation in primary care visits of patients with diabetes or heart failure: patient and physician determinants and experiences. Med Care. 2011;49(1):37-45.

9. Lafata JE, Morris HL, Dobie E, Heisler M, Werner RM, Dumenci L. Patient-reported use of collaborative goal setting and glycemic control among patients with diabetes. Patient Educ Couns. 2013;92(1):94-99.

10. Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Ann Intern Med. 2010;153(8):507-515.

11. Collier IA, Baker DM. Implementation of a pharmacist-supervised outpatient diabetes treatment clinic. Am J Health Syst Pharm. 2014;71(1):27-36.

12. Kirsch S, Watts S, Pascuzzi K, et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care. 2007;16(5):349-353.

13. Moen J, Antonov K, Nilsson JLF. Interaction between participants in focus groups with older patients and general practitioners. Qual Health Res. 2010;20(5):607-616.

14. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.

15. Aujoulat I, Marcolongo R, Bonadiman L, Deccache A. Reconsidering patient empowerment in chronic illness: a critique of models of self-efficacy and bodily control. Soc Sci Med. 2008;66(5):1228-1239.

16. Olshansky E, Sacco D, Fitzgerald K, et al. Living with diabetes: normalizing the process of managing diabetes. Diabetes Educ. 2008;34(6):1004-1012.

17. Goldman JB, Maclean HM. The significance of identity in the adjustment to diabetes among insulin users. Diabetes Educ. 1998;24(6):741-748.

18. Long JA, Jahnle EC, Richardson DM, Lowenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans. Ann Intern Med. 2012;156(6):416-424.

19. Kirsch SR, Schaub K, Aron DC. Shared medical appointments: a potential venue for education in interprofessional care. Qual Manag Health Care. 2009;18(3)217-224.

20. Kirsch SR, Lawrence RH, Aron DC. Tailoring an intervention to the context and system redesign related to the intervention: a case study of implementing shared medical appointments for diabetes. Implement Sci. 2008;3(suppl 1):34.

21. Heisler M, Piette JD, Spencer M, Kiefer E, Vijan S. The relationship between knowledge of recent HbA_1c values and diabetes care understanding and self-management. Diabetes Care. 2005;28(4):816-822.

Limitations

One of the strengths of this study is that to the authors’ knowledge, this is the first report of findings from a focus group on motivating factors and barriers for veterans with diabetes who had attended an SMA in a primary care setting. Although the study was small, the participation rate was high.

The study had a few limitations. The results might not be applicable to other populations, because all participants were veterans, predominantly male with T2DM. Selection bias is possible, because participants had already attended SMA classes. Participants may have been biased in their providing positive feedback of the SMA classes, since SMA facilitators held this focus group.

Conclusions

The study findings have several implications. Weight gain was ranked as the greatest barrier to self-managing diabetes in this focus group. Veterans stated they had limited resources, which could impact their AADE 7 self-care activities of being active and healthy eating. As resources allow, cooking classes, gym memberships, and VA-affiliated exercise facilities may be beneficial. Since there was heterogeneity in veteran experiences during diabetes diagnosis, consistent information should be provided upfront, including general concepts of diabetes and available resources.

This diabetes focus group highlighted the challenges of having a double identity, of being both a veteran and having diabetes. Shared medical appointments with veteran cohorts were identified as a promising intervention that allows for camaraderie and shared narratives to be enhanced by clinical guidance and education. By providing social support, SMAs may nudge fellow veterans to act on barriers that have them “stuck” in certain behaviors or situations. Many veterans view A_1c as an important motivator, and this should be considered as a general educational tool.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.