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Customized Diabetes Self-Management Through Primary Care Helps a Rural, Vulnerable Community

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Publication Date: June 2008

Publisher(s): Robert Wood Johnson Foundation

Topic: Health (Health services for the chronically ill)


The St. Peter Family Medicine (SPFM) residency is one of 14 family medicine residency programs affiliated with the University of Washington. The hospital serves 300,000 residents in Thurston County and four adjacent counties in western Washington. The residency program emphasizes physician training for small-town and rural practices, with special attention to poor and vulnerable populations.

The Advancing Diabetes Self-Management project at SPFM is centered on enhancing the training of the provider-medical assistant (MA) team and engaging patients in their care. The goal of the project is to create a primary care system that supports healthy self-management for people with chronic conditions. SPFM uses a Self-Management Goal Cycle model to redefine interaction between the medical team and the patient. The model expands the role of the MA, allowing the primary care provider (PCP) to spend more quality time with each patient.

Prior to a PCP visit, the MA holds a planned visit with each patient in which vital signs, lab tests, referrals and immunizations are completed under standing physician orders. The concepts of patient self-management goal-setting are introduced, and, if appropriate, the patient sets a goal. The MA follows up with a phone call to the patient two weeks later to offer support and reinforcement and review and update goals. The MA repeats the process three to four months later.

Following the planned visit, a patient can choose between two options:

1. a one-on-one PCP visit that includes medical management and self-management goal-coaching, or
2. a mini-group medical visit in which two or three patients meet with their PCP-MA team for a one-hour group goal-setting session.

During mini-group visits, patients receive the same medical care they would with an individual, 15-minute traditional visit, but also benefit from meeting others with diabetes. The patients explore barriers and successes with lifestyle change and review self-management goals. After each visit, the same patients are offered scheduled mini-group medical visits every three to four months.

Open office visits are also available to supplement traditional individual or mini-group medical visits. These offer an open forum for further discussion between the provider team and patients. Seven to 12 patients attend each session, which is staffed by a faculty preceptor and a provider. Patients support and encourage each other while the providers facilitate discussion of stress management and healthy coping strategies.

Key Lessons:

* Medical assistants play a critical role in providing comprehensive diabetes self-management services in a family medicine practice.
* Collaborative goal-setting in a primary care setting improves diabetes self-management.
* Group and mini-group medical visits are promising alternatives for delivering quality diabetes care in primary care settings.


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