By Kara Jablonski, PharmD, BCPS, Naval Hospital Camp Pendleton
Focusing on our patients as a whole person, as more than just the sum of their disease is what the patient-centered medical home, known throughout Navy Medicine as Medical Home Port, is all about.
This model is also about forming relationships between patients and their care team and getting patients to become active partners in managing not only their disease, but also their overall health. Due to the high number of diabetic patients enrolled to the family medicine clinic, we initiated shared medical appointments in 2012 to target this patient population.
Unlike a routine individual appointment that lasts about 20 minutes with a primary care provider, these shared appointments last two hours and patients spend time as a group with a medical provider or medical resident and a clinical pharmacist (like me!). Other specialists, such as behavioral health consultants and dietitians, rotate through our monthly appointments.
To make the most of our group appointments, we’ve structured them to address any medical concerns, provide patient education, and allow time for patients to share ideas with each other. At the start of each appointment, support staff check-in patients and collect vital signs. The first hour is the “medical” portion and includes talking with our patients about goals they’ve achieved since their last visit, new labs or their logbooks with their blood glucose values, and any questions or concerns they may have.
That first hour is also when we can change medications and order any additional labs if needed. For example, many patients have a gastrointestinal intolerance to metformin, and often stop their medication, even though evidence shows this medication has great outcomes for diabetics. By having an open dialogue with our patients, they can let us know they’re having problems and we can help them stay on this medication by switching them to an extended release version, which patients tolerate much better because of fewer side effects. Patients will also tell us about their episodes of hypoglycemia or hyperglycemia and we can adjust their insulin regimens accordingly. This also provides us an opportunity to help them understand that hypoglycemia can be much more dangerous than hyperglycemia and educate patients on appropriate methods to correct a low blood glucose event.
The next 30 minutes is spent on patient education with lectures from guest speakers. Topics include nutrition, exercise, medications, foot care and neuropathy, heart disease, understanding diabetic labs, and the importance of vaccinations. We’re not only helping our patients understand how to better manage their diabetes and overall health, we’re also fostering relationships between them and Naval Hospital Camp Pendleton staff, which is every bit as important as providing medical information.
The last 30 minutes is for a Q&A session and wrapping things up. We want to encourage our diabetic patients to get moving and incorporate fitness into their daily lives, so we finish each appointment with a 15-20 brisk walk around the hospital. I really enjoy this because it not only gets our patients moving but it gets me moving too!
However, the best part about these shared appointments is that patients get to spend time with others who are living with diabetes and they can share their ups and downs. In a sense, our shared appointments are very much like a support group and many of our patients even exchange phone numbers to support each other outside of “class.”
We have one patient who really motivates everyone else in the group. She has lost 150 pounds in the past year and has gone from an A1C of >12% to an A1C of 6.7% within a four month period. As a clinician, I can “tell” patients how they can improve their health all day long, but when they can learn from others with diabetes and “see” for themselves that they can take charge of their health, it’s so much more inspirational.
Patients aren’t the only ones who benefit from the shared appointments, though. I’ve learned to be less “heads down” with medications and more focused on the patient’s well-being and their medical care as a whole – mental, spiritual, and physical. It’s also been a great opportunity to push less medication use through supporting lifestyle changes as opposed to more medications.
Being a clinical pharmacist embedded in Medical Home Port has been a wonderful experience. The medical home model makes care more streamlined for patients and I’m happy to be a part of that. The typical consult process to pharmacy is as easy as a provider walking next door and introducing their patient to me.
I’m able to use my expertise to provide medication education and answer drug information questions for patients and staff. I am also able to co-manage patients with specific disease states, such as diabetes, which helps out patients and providers due to the limited time allotted for provider visits. I also impact patient safety, because medications can be confusing and I have the time and the flexibility to help patients understand their medications and prevent medication-related errors.
Most importantly, I get to be part of a professional and compassionate team that is dedicated to improving the patient’s health care experience and their overall well-being.