Original Research

Experiences of Veterans With Diabetes From Shared Medical Appointments

Camaraderie and shared narratives, coupled with clinical guidance, may help motivate veterans to better manage their diabetes.

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

Author(s):

Jolene Siple, PharmD, BCPS, CDE

Elizabeth A. Harris, RD, CDE

Jessica M. Morey, BCACP

Eleni Skaperdas, BS

Kathy L. Weinberg, RN

Anais Tuepker, PhD, Mph

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References

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Treatment of diabetes can be difficult and challenging. Information to improve the self-management behavior of patients with diabetes is important, because the prevalence of diabetes is expected to increase as the population ages, along with rising medical costs, premature death, and morbidity due to complications. Veterans, as a group, present unique challenges in health care. A recent analysis at a VA setting found only 17.3% of veterans were meeting all 3 of their “ABC” goals—A_1c, blood pressure, and cholesterol.¹

Within the VA, diabetes is the third most common diagnosis, with a higher prevalence among veterans (25%) than among the general U.S. population (8.3%).² However, little information exists about the barriers and motivations of the veterans who have completed a diabetes shared medical appointment (SMA) series.

The VA promotes SMAs as an effective alternative to one-on-one encounters for a cohort of patients with similar health conditions. In these SMAs, a multidisciplinary team meets with a group of patients for about 2 hours. These SMAs can be especially important for patients who need frequent encounters for care management, such as diabetes. Shared medical appointments focus on the American Association of Diabetes Educators 7 (AADE 7) self-care behaviors and provide a medium to foster improved self-management and healthy coping.³

Several systematic reviews of qualitative studies have identified and summarized factors that impact diabetes self-management.^4,5 Behavioral science and social psychology provide rich examples of theories to influence and understand behaviors, including motivational interviewing and self-determinism.^6,7 Other recent innovative approaches in primary care settings and diabetes self-management at the VA include companion (family or friend) participation in primary care visits, collaborative goal setting with patient and providers, age-matched patient pairing, and using a clinical pharmacist clinic as a midlevel provider to help meet VA national diabetes performance standards.^8-11

In accordance with the Patient Aligned Care Team (PACT) focus on the delivery of patient care, the goal of this study was to understand the experiences of veterans and to learn about the tools and methods they perceive to be most useful in improving patient education and motivation for self-management of diabetes. A onetime diabetes focus group was held to inquire about these specific issues.

Methods

The focus group took place at the Vancouver, Washington, campus of VA Portland Health Care System (VAPHCS). All veteran participants and their family members who had completed at least 3 of a 4-session SMA series were invited. Out of 29 invited veterans, 18 participated in the discussion along with 3 family members (all wives), for a total of 21 participants. The SMAs focused on meeting primary care performance standards on A_1c, blood pressure, and hyperlipidemia, in accordance with the new PACT model. The VA education division approved the use of the Conversation Map for SMAs, created by Merck (Whitehouse Station, NJ) in collaboration with the American Diabetes Association. Using the Conversation Map format in a VA setting has been shown to reduce mean A_1c levels by -0.9 (± 1.9%; P < .001).¹² The SMA team made lifestyle and medication changes weekly (under a scope of practice for the pharmacist).

Data Gathering and Analysis

Participants attended a 2-hour focus group facilitated by the same 4 clinic care providers (2 pharmacists, 1 clinical nurse, 1 dietician) who had led the SMAs. The decision to have the discussion led by these same providers was grounded in the belief that this format would be familiar to the participants, and the rapport already established between providers and participants would encourage greater participation than if the meeting were led by unfamiliar VA employees. Two trained VAPHCS qualitative researchers attended the focus group and took extensive verbatim notes.

During the first 45 minutes, participants used a dot-voting technique to provide general demographic and background information in response to questions posted on boards around the room. Participants then were asked to choose their top 3 answers in response to each of a series of questions about barriers, resources, and motivators in self-management. The group was divided into 2 smaller groups of 10 or 11 participants, each facilitated by 2 researchers and assisted by a note-taker trained to capture the verbatim discussion. Session audio was not recorded, because VA policy requires signed consent, and this requirement might have discouraged participation.

The following questions guided the discussion: (1) Thinking back to when you were diagnosed with diabetes, what could you have done then that would have made a difference? (2) Thinking about all your experiences with diabetes, what was most helpful in motivating you to take control? (3) What one thing helped education or information “stick” with you? (4) What additional resources that are not currently available at the VA would help you? and (5) Tell us about your diabetes management plan.