Starting the conversation to improve diabetes care

Anna Kahkoska and Nick Brazeau, students in UNC’s MD-PhD program, have developed an innovative approach to patient care at the Open Door Clinic, a free clinic in Burlington staffed by students from the UNC School of Medicine, Elon University, and Alamance Community College that treats a large number of patients with diabetes.

In North Carolina, 1 in 10 people have diabetes. That includes a large number of patients at the Open Door Clinic, a free, student-run clinic in Burlington staffed by volunteers from Elon University, Alamance Community College, and the UNC School of Medicine. Two years ago, Anna Kahkoska and Nick Brazeau took a direct leadership role in the Diabetes Maintenance and Prevention Program, where they were responsible for coordinating a monthly Endocrinology clinic for patients with diabetes referred from the general clinic for specialized care.

What started as a way to do some good in the community while also gaining valuable clinical skills quickly morphed into something much larger. When they began working at Open Door, Brazeau said the continuity of care was lacking. Patients would come to clinic one month, and then miss several subsequent visits due to changes in work hours, childcare responsibilities or other issues. When they did come back, they were frustrated with long waits.

"The reality is that patient visits were really complicated, providers were trying to offer advice and counsel on social concerns, as well as the multiple clinical issues. The visits just took a really long time, and we weren't able to see as many patients in a given night as was needed," Brazeau said.

The two decided a change was needed. They wanted to develop a model that would help address the patients' clinical and social needs, but also give them an incentive to return to clinic each month.

With the help of faculty mentor, John Buse, MD, PhD, Chief, Division of Endocrinology, Executive Associate Dean for Clinical Research, as well as Laura Young, MD, PhD, and Joe Largay, PA from UNC Endocrinology, they developed a plan for introducing group visits for diabetes patients at the clinic. The shared medical appointments would allow patients to have more direct interaction with clinicians and each other. Through the conversations, patients share information about their experiences relevant to the group, and clinicians can use the conversations to identify themes worthy of further discussion.

"Our faculty mentors, Dr. Buse, Dr. Young, and Mr. Largay, have been incredibly supportive," Kahkoska said. "Offering diabetes care in a free clinic is challenging, especially given the flux of students, rotating staff, and variability in attendance. Completely changing the model of care in such a way that takes all of those factors into account is very challenging, and there has been a lot of brainstorming, trouble shooting, and discussion involved. Our mentors have given a lot of their time to help us work through the challenges and find the best way to make the shared medical appointments happen."

Introducing a radical change like this bred some apprehension among clinic staff, and even Brazeau and Kahkoska say they weren't sure how it would go.

"These are patients from all walks of life with very different life experiences," Brazeau said. "Our biggest fear was that we would put 10 people in the room for the first visit and we would just hear crickets."

The opposite happened.

"It's been incredible to see how much the patients have given of themselves," Kahkoska said. "We do the leg work required to get the patients in the room together, but once they are there, there's not a whole lot we have to do to facilitate discussion. I've been surprised and moved by how generous the people in our shared medical appointments are in sharing their stories and how focused they are on really listening and helping each other. It's inspiring."

The nature of the group visits provides a forum for shared experiences and support, but also a high level of accountability.

"If you have a group of patients, and one of them is having success meeting his or her goals and has found some strategies that really work, modeling that for the other patients can be really effective," Kahkoska said. "But the biggest shift that we've seen is that patients come back to shared medical appointments. I think that for many of the patients we see, the group visit model is more engaging and enjoyable than an individual appointment, and as a result, we have fewer 'no-shows' at the clinic."

In addition to the social support, the group appointments have provided clear clinical benefits. Since beginning the group appointments, many of the patients have experienced reductions in HbA1c levels. HbA1c measures the average level of glucose in the blood over the previous three months. Sharing strategies and discussing common barriers – combined with the accountability of the group – has helped motivate patients to take the steps needed to monitor and manage their glucose levels, begin exercising, or take a close look at their diet.

Kahkoska and Brazeau are also working on their PhDs at the UNC Gillings School of Global Public Health; Kahkoska is a second-year doctoral student in the Nutrition program and Brazeau is a first-year doctoral student in the Epidemiology program. They say this project has allowed them to weave together both sides of their training.

"We can combine the tenets of public health best practices with the clinical skills that we are learning in medical school," Kahkoska said. "This project has helped me to understand both my research and my clinical goals in a deeper way."

In the future, they would like to see this model expanded to other community clinics, and augmented to include students from other health disciplines like nursing, dentistry, nutrition, and allied health sciences.

"As a future provider, I have become more empathetic to the broad range of issues our patients face," Brazeau said. "This experience has also been a crash course in everything that goes into providing holistic patient care – especially in an underserved environment. We hope that through expanding this program, more patients can benefit from this model, and more students can have the same transformative experience that we've had."

Funding support for the implementation of medical group appointments was provided through the Albert Schweitzer fellowship.