Integration of Personalized Health Planning and Shared Medical Appointments for Patients With Type 2 Diabetes Mellitus

Connor Drake, MPA; Caroline Meade, BS; Sharon K. Hull, MD, MPH; Ashley Price, PhD, MPH; Ralph Snyderman, MD

Disclosures

South Med J. 2018;111(11):674-682. 

In This Article

Abstract and Introduction

Abstract

Objectives: This study describes the feasibility of implementing personalized health planning (PHP) within shared medical appointments (SMAs) for patients with type 2 diabetes mellitus. The PHP-SMA approach was designed to synergize the benefits of SMAs with those of PHP, enabling greater patient engagement focused on meeting individualized therapeutic goals in a group setting.

Methods: Patients were assigned randomly to a PHP-SMA or a standard eight-session SMA series. Standard SMAs included an interactive educational curriculum delivered in group medical encounters. The PHP-SMA included the addition of a patient self-assessment, health risk assessment, shared patient-provider goal setting, creation of a personal health plan, and follow-up on clinical progress. Clinical and patient-reported outcomes and qualitative data from focus groups with patients, providers, and administrative staff were used for evaluation. Qualitative data explored facilitators and barriers to implementation of the PHP-SMA. The Consolidated Framework for Implementation Research was used to provide insight into implementation factors.

Results: PHP was successfully integrated into SMAs in a primary care setting. Patients in the PHP-SMA (n = 12) were more likely to attend ≥5 sessions than patients assigned to the standard SMA (n = 7; 58% PHP, 28.5% control). Qualitative data evaluation described the advantages and barriers to PHP, the team-based approach to care, and patient participation. The PHP-SMA group experienced reductions in hemoglobin A1c, low-density lipoprotein, blood pressure, and body mass index, as well as successful attainment of health goals.

Conclusions: The PHP-SMA is a proactive and participatory approach to chronic care delivery that synergizes the benefits of PHP within SMAs. This study describes the components of this intervention; collects evidence on feasibility, acceptability, and clinical outcomes; and identifies implementation barriers and facilitators. The PHP-SMA warrants further evaluation as an approach to improve health outcomes in patients with common chronic conditions.

Introduction

More effectively preventing and managing chronic diseases are among the greatest challenges to our nation's health and economy. The burden of chronic diseases continues to grow and falls disproportionately on vulnerable populations.[1] The chronic care model recognizes that effective management of a chronic disease requires patients to be engaged in their health self-management and decision making.[2,3] Achieving this is a challenge in primary care, where clinicians must balance the goal of quality improvement with the financial constraints of the fee-for-service reimbursement system. Type 2 diabetes mellitus, like many chronic conditions, requires self-management,[4] patient activation,[5,6] peer support,[7,8] and care coordination[9] to achieve the best outcomes, yet this type of care can be difficult to provide within a conventional, time-constrained visit. The patient-centered medical home (PCMH) is a validated organizational structure based on chronic care model elements, with an emphasis on supporting self-care efforts of patients in care plans.[10] To fully realize the potential of the PCMH, proactive, personalized, and participatory care delivery models must be developed to provide a coherent approach to improve the prevention and management of chronic diseases.

This study adapted personalized health planning (PHP), an evidence-based intervention designed to engage patients in creating and achieving meaningful personal health-related goals, to be delivered within shared medical appointments (SMAs). The primary objective of this study was to determine the feasibility of integrating PHP into SMAs while simultaneously evaluating implementation factors. PHP is an approach to care that focuses on primary and secondary prevention of common chronic diseases through the identification of each patient's health risks, desired health goals, strategies to enhance their engagement, development of a plan to achieve therapeutic goals, and coordination of care.[11,12] The effectiveness of PHP has been studied in diverse populations and settings. PHP was compared with usual care in a randomized controlled trial to reduce the cardiovascular risk factors of patients.[13] The research team used an integrative approach that emphasized self-care, mindfulness stress reduction practices, psychosocial well-being, and health coaching. The success of PHP in reducing cardiovascular risk factors in this trial provided a rationale and guidance as a model for how to integrate PHP into SMAs to improve chronic disease management. The PHP framework also has been applied to multimorbid, homebound Medicare patients,[14] a primary care provider (PCP) network to reduce emergency department visits and inpatient admissions,[15] and diverse Veterans Administration clinical settings.[16]

SMAs bring together patients with a shared chronic condition for longer billable visits in a group setting, and they show promise for the management of type 2 diabetes mellitus.[17,18] A meta-analysis of 17 studies that compared diabetes mellitus SMAs with usual care shows an association between participation in a diabetes mellitus SMA and a reduction in hemoglobin A1c (HbA1c) levels (mean −0.55 percentage points) and lower systolic blood pressure (mean −5.22). The meta-analysis indicated that there is heterogeneity among components of diabetes mellitus SMA interventions and that the intervention components often are poorly defined, leading to varying effect sizes.[17] SMAs have had only modest uptake[19] in part because of the heterogeneity and ambiguity of their characteristics and the strategies used to implement them.

To address SMA adoption challenges associated with intervention heterogeneity and ambiguity, PHP provides a detailed and structured approach that could make SMA interventions more effective and acceptable to patients. The structure of the PHP approach also may simpify future replication and dissemination efforts because the intervention components are clearly defined. There also was reason to believe that because PHP is a patient-centered and personalized goal-oriented process, it could synergize well with the additional time and peer support offered through an SMA. This study explores the feasibility of integrating PHP into a diabetes mellitus SMA series and implementing the series to leverage the complementary advantages of PHP and SMAs.

The intent of this work was to develop a replicable approach to facilitate uptake in diverse clinical settings and to provide practitioners with insights into how to offer an SMA intervention that is responsive to the clinical needs, personal values, and preferences of patients through a collaborative PHP process.

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