Intentional Centering Through Nurse Practitioner-Led Diabetic Group Visits at a Free Clinic

Group diabetic education and education sessions exist to promote self-management by directly targeting improvement in knowledge, skills, and attitudes of people with diabetes. This innovation capitalizes on existing diabetic group sessions, but intentionally integrates these sessions with the traditional provider-based office visit. This change in the healthcare delivery model, which integrates these previously separate resources, provides the patient increased face-time with the nurse practitioner, eases the burdens on the patient associated with travel and other resources, and facilitates in-the-moment intervention by the provider that addresses needs identified by the group or individual participants. Prior to this program change, the education and exercise sessions were facilitated by a lay person who did not directly interface with the providers. Although there was antidotal support for these sessions, there was a clear disconnect between the depth and breadth of education provided and the provider’s plan of care. Furthermore, there were missed opportunities when relevant medical concerns were shared that were not communicated to the healthcare team. For this semi-rural, poor, underserved population, any access to education is valuable; however, their ability and willingness to travel, their engagement in self-care, and their access to resources often negatively impact their ability to interface with the provider. The new group sessions associated with this project, changed in structure, delivery, and focus. Originally based on the concept of centering from women’s health, the diabetic group visits foster relationship-building between the participants, and support collaboration between the patient and provider. Over the course of the two-hour sessions, the nurse practitioner engages in much of the education, but will occasionally defer to a co-facilitator and briefly meet with individual participants. By engaging in-the-moment, when something mentioned by the patient requires intervention, the provider can immediately address a concern or issue and provide appropriate management or guidance. The education provided by the nurse practitioner addresses current standards of care and is tailored for each group as needed. By taking time to be present and engage with the groups, that range in size from 5 to 15 participants, the provider gains insight into the personal, individual experiences of the patients. This format also positively impacts on the patient experience, providing them the opportunity to see different perspectives, to gain a better understanding of normal versus abnormal in their disease presentation and management, and to discuss barriers, challenges, and successes. By listening to each other, patients are better able to articulate their concerns and their shared experience of the disease. This provides the provider the opportunity to address topics with the group as a whole or with the individual in the moment. This model works well with adult learners who benefit from seeing the relevance of the teaching and immediately linking it to their personal experience. In lieu of formal individualize visits, which were separate stand-alone events, the group sessions provide the impetus for individualized provider-based interventions. In the current version of the session, the provider serves as the educator, group facilitator, coach, manager of care, and prescriber, thus maintaining intimate involvement in the medical management of the patient in a more focused, but somewhat informal setting. In the first two iterations of this new program, participants demonstrated statistically significant decreases in hemoglobin A1C, blood pressure, and LDL. This replicable, cost-effective, efficacious healthcare delivery model maximizes provider impact, while fostering mutually-beneficial relationships in underserved populations.