Advancing Diabetes Self Management: St. Peter Family Medicine Residency Program

The goal of Advancing Diabetes Self Management at the St. Peter Family Medicine Residency Program was to support healthy self management among people with chronic conditions.

A "Self Management Goal Cycle" model was used. This model increased the role of the medical assistant (MA) and allowed the primary care provider (PCP) to spend more quality time with each patient. Prior to a PCP visit, the MA met with each patient and collected vital signs and labs and completed referrals and immunizations. The MA also introduced patient self management and goal setting and the patient often set a goal. Two weeks and again three months after this visit, the MA followed up with a phone call to the patient to offer support and review goals.

After the MA visit, patients would choose from two types of appointments. The first option was a one-on-one PCP visit that included medical management and self management goal coaching. The second option was a mini-group medical visit with two or three other patients for a one-hour medical/self management goal setting session. Open office visits were also provided as a supplement to the individual or mini-group sessions. During the open office visits, seven to 12 patients attended each session that was staffed by a faculty preceptor and a physician. Medical expertise was provided and the stress of suffering from a chronic illness was often discussed.

The goal of Advancing Diabetes Self Management at the St. Peter Family Medicine Residency Program was to support healthy self management among people with chronic conditions.

Patients that participated in planned or group medical visits and set goals had lower HbA1c's than the clinic average over a three year period. In addition, the clinic LDL cholesterol average decreased from 116 to 101.6 from the first to the last measure.