Shared Dietetic Appointments Offer Value in Diabetes Care

Nutrition education is a key component of diabetes care. But covering every concern in a 15-minute session with a dietitian isn’t easy. And for dietitians, a day of seeing patients one-on-one can mean giving the same advice over and over.

For the right patients, shared dietetic appointments—which combine individual attention with the support of a group—can be an alternative that eases scheduling problems and offers patients greater value, according to a dietitian and an administrator who use the model. They shared their blueprint Saturday at the annual meeting of the American Association of Diabetes Educators (AADE) in San Diego, California.

Evelina Sands, administrative director of operations at the North Shore Physicians Group in Boston, Massachusetts, and Diane Dube, MEd, RDN, LDN, CDE, have brought shared dietetic appointments to the group’s 20 practices, with positive results. Patient surveys report a 98% satisfaction rate, and Dube said there’s rarely a no-show.

Shared appointments offered a solution to long wait times and provider shortages, they said. Dube remains the only dietitian for the entire group, so her schedule was always full. “Patients were feeling frustrated,” Sands said.

Yet, Sands said, it took some convincing to get the program off the ground. Getting the group’s physicians and leadership to buy-in took time, and there were administrative pieces that had to be in place:

· To comply with HIPAA, every participant—both patients and spouses or partners—must sign a confidentiality agreement.

· Marketing and referrals from physicians were needed to attract patients.

· Sands created a meeting space with whiteboards and equipment for teaching.

· Billing and IT systems had to be created. Dube sets aside 15 minutes for each patient, and only her time is billed even if other providers take part. She limits appointments to 4-8 patients, so the session never lasts more than 2 hours.

Dube describes her model as a “hybrid” of an individual nutrition session, and education session, and a support group. She carefully selects the participants; new patients are seen one-on-one first, and offers the shared only to those who will engage without trying to dominate the group.

During the session, she allots a block of time to address each patient’s concerns, but invites the others to comment. Patients learn from each other, and Dube doesn’t have to give the same advice multiple times. Each patients A1C, blood pressure, and weight change from the last session are recorded and shared. Both type 1 and type 2 diabetes patients can use the model, which can be tailored to address those with kidney disease or other conditions.

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For the right patients, shared appointments are “transformative,” Dube said. In the group setting, patients instantly relax, and they appreciate advice from fellow patients. “You’re not going to get that in a traditional office visit,” she said.

With Dube is a medical assistant who documents each session, so afterward Dube only has to finish the notes with recommendations. Sometimes, a behaviorist joins the session, which gives patients an added benefit.

Best of all, Dube said, the shared appointment gives patients more for their money. Because health plans consider her a specialist, “I have patients who have $60 co-pays. How would you feel checking in to be told you have to pay $60 to see the dietitian?”

“If I can bring that patient to a group, they feel they are getting much more value,” she said.

Sands said that building enthusiasm for the concept among referring physicians and others in the practice is essential. “We encourage the staff to be involved,” she said, “A lot of people don’t know what a shared appointment is, so marketing is important.”

There’s not much research on the effectiveness of shared medical appointments, Sands said. (A new study appeared in the July 2016 issue of The American Journal of Managed Care.) Dube hopes to do outcomes research on her experience, and Sands believes the shared medical appointment can work in other areas with physician shortages, such as rheumatology.

Dube sees success in the patient responses. When asked how many patients stop taking part in the group after trying it, she said. “I can tell you there are very few that do. Most say to me, ‘when in the next one?’ ”