diabetes group visits: an alternative to managing chronic disease outcomes

www.npjournal.org The Journal for Nurse Practitioners - JNP 671

Type 2 diabetes mellitus (T2DM) is a costly dis-ease associated with multiple comorbidities thatcan be dramatically reduced through appropri-

ate management of blood glucose. Delayed diagnosiscan further increase complications, creating additionalstresses on patients’ well-being and increasing the finan-cial burden for the patient, the health care system, andthe community as a whole.

An estimated 23.6 million people in the UnitedStates have diabetes, accounting for approximately 8% ofthe population and costing in excess of $174 billion ayear in expenditures.1,2 Diabetes was the seventh leadingcause of death in 2006, as documented on 72,507 deathcertificates.3 Many experts view this to be a gross under-estimation since it is often the complications of diabetesthat are recorded as the cause of death. Common com-

plications of diabetes that compound costs include dia-betic retinopathy and blindness, nephropathy, heart dis-ease, and stroke. Diabetes is the leading cause of bothblindness and kidney failure in the US.1,3

Good glycemic control of diabetes, defined by theAmerican Diabetes Association (ADA) as maintenance ofa glycosylated hemoglobin A1c (HbgA1c) less than 7%,has been shown to reduce micro- and macrovascularcomplications.4,5 According to the United KingdomProspective Diabetes Study (UKPDS), patients withT2DM can reduce their risk for serious microvascularcomplications by 35%, myocardial infarction risk by 14%,and any diabetes-related end point by 21% for every 1percentage point decrease in HbgA1c.5,6

It is clear that diabetes represents one of the nation’slargest health care concerns, but less than 10% of patients

ABSTRACTDiabetes mellitus is a chronic disease with an ever-expanding prevalence and finan-cial burden for our health care system. Because patients with diabetes often requiresimilar education and disease management, group visits or shared medical appoint-ments have been piloted as an alternative to standard office visits. This article reviewsthe evidence from clinical trials involving the group visit model. Specific outcomesmeasured include the evaluation of diabetes care standards, associated costs, overallblood glucose and glycosylated hemoglobin levels, and patient satisfaction scores.Implications for nurse practitioners are highlighted, with emphasis on best practicesin the era of health care reform.

Keywords: American Diabetes Association, chronic care, diabetes group visit,patient self-management, shared medical appointment© 2011 American College of Nurse Practitioners

Diabetes Group Visits: An Alternative to Managing Chronic Disease OutcomesChris Simmons, FNP-BC, and Jane Faith Kapustin, CRNP

672 The Journal for Nurse Practitioners - JNP Volume 7, Issue 8, September 2011

with diabetes meet recommended treatment goals formaintenance of glucose levels.4 Alternative methods tomeet the needs of patients with chronic disease areneeded because traditional outpatient visits do not seemto be sufficient.6

Diabetes has a high morbidity and mortality rate, butwith improvement in management strategies, evidencesuggests that many co morbidities can be reduced oravoided.1 As diabetes persists as a public health threat,and with ever-increasing numbers of people affected byT2DM, the US health care system needs to exploremore cost-effective and efficient alternatives for provid-ing comprehensive care.6-8 The reality of providing ade-quate care for all patients is becoming compromised,especially given the relative shortage of primary careproviders. Because patients with T2DM frequently haveother comorbidities, such as hypertension and hyperlipi-demia, they need additional time than is allowed in thetypical office visit in primary care. Diabetes group visits(DGVs), originally developed in managed care arenas,are growing in popularity and provides an alternative toroutine 1-on-1 office visits while addressing treatmenteffectiveness and efficiency.7,8

In DGVs, a group of patients “share” a medicalappointment where education is provided, but individualconcerns are still addressed and patient confidentiality isstill maintained. It has been suggested that peer supportand group dynamics are driving factors in the success.5,6,8

Instead of the typical 15-minute office visit, the DGV canbe arranged as a shared appointment among up to 20patients in which education and other concerns areaddressed for up to 2 hours.8 Group visits (GVs) can beheld annually or more frequently as needed, and a varietyof chronic illnesses can be addressed, such as asthma, heartfailure, or obesity.9 The curriculum can be developed inadvance and can include such topics as diabetes self-man-agement, pharmaceutical/insulin management, foot care,nutrition management, exercise, and social concerns.8,9

If documented appropriately with individualized flowcharts or other standardized materials, the GV can be abillable visit. Adequate support staff need to be present tomanage the GV, and the physician or nurse practitioner(NP) must be present to discuss the plan of care, makechanges in therapy, sign charts, and complete encounterforms. Time should also be allowed at the end of the GVfor 1 or 2 patients to discuss urgent or unrelated matterswith personnel.8,9

METHODSDGVs have been shown to improve patient satisfaction,increase quality of care indicators, decrease emergencydepartment (ED) visits and specialty care utilization, andimprove control in disease specific outcomes. Becausethey are focused on chronic disease management, GVsreinforce information received in individual sessions andallow for more group interactions, problem solving, andself-efficacy.9

In addition, costs related to typical visits can bereduced, and higher routine standards of care can beachieved. A clear advantage of GVs is that patients benefitfrom discussions with peers and can learn successful cop-ing strategies from their interactions. The longer time-frames can also facilitate the overall learning process.6,10

For this synthesis, the MEDLINE, CochraneSystematic Reviews, PubMed, and CINAHL databaseswere searched for studies on GVs. Studies that assessedthe effectiveness of GVs had to meet acceptable criteriafor search terms (“diabetes,” “group visits,” and “sharedmedical appointments”) and include a health careprovider in the GV. Review articles were excluded.

A total of 18 studies were reviewed, and 9 studiesmet acceptable criteria of group education and elementsof an individual office visit (Table 1). Of the studies thatmet the inclusion criteria, there were inconsistencies inthe size and structure of the GVs, and the populationsvaried in terms of insurance and access to care. In gen-eral, the size of the group ranged from 8-20 patients,and visits typically lasted for 2 hours. Criteria ratingscores per the Agency for Healthcare Research andQuality (AHRQ)11 were applied and are summarized inTable 2, along with the study location, patient/groupdemographics, and GV structure.

REVIEW OF EVIDENCEPatient Satisfaction/Patient EducationImproved patient satisfaction and enhanced overallpatient knowledge were demonstrated in studies byClancy et al,7 Trento et al,18 and Wagner et al.19 Clancyand colleagues7 were able to show significant improve-ments in patients’ perception of continuity of care, cul-tural competency, and provider trust. Trento et al16

showed increased patient satisfaction and statistically sig-nificant improvements in diabetes knowledge andimprovements in health care behaviors from a modifiedversion of Diabetes Quality of Life Survey. Overall


quality of life was reported as significantly improved inthis study as well. Wagner and colleagues19 also demon-strated that patients were very satisfied with diabetes spe-

cific care in the GV format compared to routine care,documenting improvements from 50% to 61% of patientssatisfied in GV cohort before and after, prospectively,

Bray et al,200512

North Carolina

5 ruraloutpatient

clinics; FQHCs

Non-experimental

N � 314Mean age: 61 years

72% AA54% female

Primarilyunderinsured

4 GVs over 1year

10 patients pergroup

Nurse casemanagement

Unclear lengthof visits

NP conductedvisits

Improveddocumentation of footexams, lipid testing;

improved aspirin use;improved provider

productivity. Clinicaland patients embracedconcept; better billable

visits and increasedproductivity

III/BLack of patient-

orientedevidence/focusedon feasibility only

Clancy etal, 200313

South Carolina Randomized clinicaltrial (80% follow up)

N � 120

Type 2 diabetes

2 hour GVs

Held everymonth for 6

months

Improved adherenceto ADA standards;improved sense of

trust in providers (A1c,lipids, and other

patient perceptions ofcare not significant)

I/BLack of patient

outcomesOnly focused on

patient acceptance

Clancy etal, 200814

South Carolina

Adult primarycare center

Randomized clinicaltrial

N � 186

Control n � 90Intervention n � 96

72% women

82% AAMean A1c 9.1%

2-hour visits 14-17 patients

per groupMonthly x12

months

Physician- andRN-led groups

15-minute warmup/socialization

30-45 minuteinteractivediscussion

60-minute 1-on-1sessions

GV patients hadhigher outpatient

expenditures (by $699per year), 49% lower

ED costs, 30.2% lowertotal expenditures

compared to controls.

Improved trust inphysician and

improved patientperception of care

Improved adherenceto ADA standards of

care

I/BFocused on

managed careperspective, not onpatient outcomes

Edelman etal, 201015

North Carolinaand Virginia

2 VA medicalcenters

Randomized controltrial

N � 239 with poorlycontrolled diabetesand blood pressure

Intervention � groupvisit

Control � usual care

7-8 patients pergroup

12.8 months

Team: internist,pharmacist,

nurse, or CDE

Structured GVsled by educator

Pharmacist andphysician adjusted

medication atvisits

Mean A1C improvedby 0.8% in treatment

group and 0.5% inusual care (not

significant); baselinesystolic BP improved13.7 mmHg and 6.4mmHg in treatmentgroup (statistically

significant)

I/BMeasurements

blinded to researchpersonnel

Table 1. Diabetes Group Visits Summary Table

Study Design, Number of Subjects, GV AHRQ Rating11

Authors Location Groups Studied Structure Outcomes and Limitations


while the control group satisfaction decreased from 57%to 53%. Also, the study subjects had significantly fewerspecialists and emergency department visits.

Clancy’s7 study also showed a decrease in patients’locus of control by the Diabetes-Specific Locus ofControl Survey (DCL). This survey measures 5 domains

Kirsh et al,200716

Cleveland, OH

VA medicalcenter

Mixed method quasi-experimental design

N � 44

8 patients pergroup

1-7 visits over 5months for 1-2

hours

Interprofessionalteam: internist,

NP, PharmD,psychologist

Statistically significantreduction in A1C and

BP control inintervention group

II/BLow sample size

Loney-Hutchinsonet al, 20096

Kings CountyHospital Center


Compared usual careand GVs

N � 66 HgA1c � 10%

No care in clinic for atleast 1 year

Average 6 visitsper patient

Followed for 18months

73% patientssignificantly lowered

A1C (average decreasedfrom 12.1% to 8.3%)Adequate BP control

rose from 15% to 38% ofcases; LDL levels

decreased in � 60%cases

I/BStatistics andanalyses not

included in study

Sadur etal, 199917

KaiserPermanente,

California

HMO


N � 185

Cluster visitsMean age 56 years

41% women71% CaucasianMean A1c 9.5%

Type 2 DM patientsHgA1C �8.5%

10-18 patientsper month

2-hour clustervisits

6 months

Team led bydiabetes nurse

educators,psychologist,

dietitian,pharmacist

Decreased HgA1C by1.3%, increased

medicationcompliance, increasedglucose monitoring,

increased satisfactionwith diabetes control,lowered frequency ofhospital visits, overall

decreased use ofmedical care

I/B

Trento etal, 200218

Turin, Italy Randomized clinicaltrial

T2DMMean age 62 years

46% womenMean A1c 7.4%

Compared usual carewith GVs

N � 112 56 GVs

56 Routine care

9-10 patients2 hours every 3

months for 4years

Systematic groupeducation

Physician andclinical educator

4 parts to visit:1. Intro/social2. Interactive

learning3. Patient

experiences4. Directions for

f/u -homework

Increased problem-solving skills,

increased healthbehaviors, lessprogression to

retinopathy, stable A1ccompared to controls,increased quality of

life and diabetesknowledge, decreasedhypoglycemic events

I/B

Table 1. Diabetes Group Visits Summary Table (continued)




and revealed a statistically significant number of patientswho viewed their health care provider to be a powerfullocus of control over their health care. High scores in thisdomain have been associated with poor knowledge ofdiabetes and decreased willingness to take control ofcare.20 Clancy and colleagues did acknowledge this find-ing, suggesting that the underserved/underinsured popu-lation being evaluated typically lacked continuity, andthat increased perception of locus of control may actuallyindicate increased provider confidence, rather than anunwillingness to participate in self-management.7

Bray et al12 were able to demonstrate increasedpatient knowledge by improvements in self-managementstrategies on before and after surveys, which improvedfrom 0% to 42% on willingness to monitor blood sugar,to keep appointments, and to participate in self-care.

Financial OutcomesFour studies were able to demonstrate positive financialimpact of GVs by showing a decrease in both ED visitsand hospital admissions, as well as improved clinic pro-ductivity. Wagner and colleagues in 200119 demonstratedthat, on a large-scale managed care model, DGVs resultedin cost savings. In this study of 714 patients, over 14practices were randomized. It was noted in the interven-tion groups that there were statistically fewer specialtyvisits, ER visits, and hospital admissions. Clancy andcolleagues14 also demonstrated a decrease in total healthcare costs that were accomplished by reduced number ofER visits and specialty care utilization. Sadur and col-

leagues17 demonstrated reduced utilization of hospital vis-its and overall use of medical care.

In 2008, Bray and colleagues,12 with a 12-monthfeasibility study, demonstrated that providers’ productiv-ity increased from an average of 20.17 visits to 31.55visits on the days the DGVs were conducted. Usingstandard evaluation and management codes (EM) at thelevel of a 99214 outpatient visit at Medicare reimburse-ment rate of $73.72 yield, an additional $737.20 of serv-ices per day during GVs were conducted according toMedicare standards.

Patient OutcomesTrento et al18 and Kirsh et al16 reported disease-specificoutcomes, such as A1c, systolic blood pressure, high densitylipoprotein (HDL), triglycerides, and low density lipopro-tein (LDL), which either improved or maintained stabilitycompared with control patients. Trento did not showimprovements in A1c, but rather was able to maintain lev-els over 2 years at 7.4%, while mean A1c in the controlpatients increased from 7.4% to 8.3%. Slight improvementswere noted in HDL and triglyceride levels.16

Kirsh and colleagues16 demonstrated a significantreduction in A1c (-1.4, p � 0.05) and modest improve-ments in systolic blood pressure (-16.7, p � 0.001) andLDL (-4.8, p � 0.02) among subjects at a VA medical cen-ter in Ohio. Bray and colleagues12 showed improvementsin the ADA quality indicators by improving documenta-tion of a lipid panel from 55% at baseline to 76% and doc-umentation of foot exams from 15% to 54%, despite a

FQHC � federally qualified health center; GV � group visit; ED � emergency department; AA � African American; VA � Veterans Affairs; CDE � certified diabeteseducator; HMO � health maintenance organization.

Wagner etal, 200119

Seattle,Washington

HMO14 primary care

clinics

Randomized trialcompared GV with

usual care

N � 707

14 practices24 months

Mean age 61 years 44% women

30% nonCaucasian T1DM, T2DM

Mean A1c 7.5%

6-10 patients pergroup

1-2 hour visitsEvery 3-6

months x2 years

GV led byphysician: nurse,

pharmacistinvolved

Increased quality ofcare (number of

preventive proceduresordered, more patient

education), fewerdisability days,

lowered specialtyvisits, lower ED visits,

improved generalhealth status (self-rated), improved

patient satisfaction

I/BMultiple providersacross 14 centers

Difficult to maintainconsistent

intervention

Table 1. Diabetes Group Visits Summary Table (continued)




large number of uninsured patients. Edelman et al15 alsostudied specific disease outcomes at several VA medicalcenters, and Loney-Hutchinson et al6 obtained improve-ments in A1c levels and LDL levels in their GV model.

OVERALL SYNTHESISResults from these studies indicate that the DGV concept is a viable alternative to standard primarycare; however, the data are heterogenous and limited.

More studies are needed to replicate the findings, andthere is a lack of standardization in what the “GV”consists of and what level of interprofessional collabo-ration is needed to obtain the results reported. Medicalprofessionals participating in these GVs included physi-cians, NPs, pharmacists, psychologists, and registerednurses. The studies differed in the type of GV used andthe overal structure, curriculum style, presentationmethods, and populations studied. In addition, the

A. High Research Consistent results with sufficient sample size, adequate control, and definitiveconclusions; consistent recommendations based on extensive literature review that

includes thoughtful reference to scientific evidence

Summativereviews

Well-defined, reproducible search strategies; consistent results with sufficient numbersof well-defined studies; criteria-based evaluation of overall scientific strength and quality

of included studies; definitive conclusions

Organizational Well-defined methods using a rigorous approach; consistent results with sufficientsample size; use of reliable and valid measures

Expert opinion Expertise is clearly evident

B. Good Research Reasonably consistent results, sufficient sample size, some control, with fairly definitiveconclusions; reasonably consistent recommendations based on fairly comprehensive

literature review that includes some reference to scientific evidence

Summativereviews

Reasonably thorough and appropriate search; reasonably consistent results withsufficient numbers of well-defined studies; evaluation of strengths and limitations of

included studies; fairly definitive conclusions

Organizational Well-defined methods; reasonably consistent results with sufficient numbers; use ofreliable and valid measures; reasonably consistent recommendations

Expert opinion Expertise appears to be credible

C. Low-

quality or

major

flaws

Research Little evidence with inconsistent results; insufficient sample size; conclusions cannot bedrawn

Summativereviews

Undefined, poorly defined, or limited search strategies; insufficient evidence withinconsistent results; conclusions cannot be drawn

Organizational Undefined or poorly defined methods; insufficient sample size; inconsistent results;undefined, poorly defined, or measures that lack adequate reliability or validity

Expert opinion Expertise is not discernable or is dubious

Table 2. Agency for Healthcare Research and Quality Scale11

Strength of the EvidenceLevel I Experimental study/randomized controlled trial or meta-analysis of randomized controlled trial

Level II Quasi-experimental study

Level III Non-experimental study, qualitative study, or meta synthesis

Level IV Opinion of nationally recognized experts based on research evidence or expert consensus panel (systematicreview, clinical practice guidelines)

Level V Opinion of individual expert based on non-research evidence (includes case studies, literature review, organizationalexperience [eg, quality improvement and financial data], clinical expertise, or personal experience)

Quality of the Evidence

*A study rated an A would be of high quality, whereas a study rated a C would have major flaws that raise serious questions about the believability of the findings andshould be automatically eliminated from consideration.


research methodology, measurement tools, and analysesvaried. The financial impact of GVs was not a primaryoutcome for most of the studies, so fiscal outcomeswere not sufficiently demonstrated in this summary.Further research in the area offinancial considerations isindicated.

In general, the studies alldemonstrated overall patientsatisfaction with GV formats.It is unclear if the findingswere a result of the groupdynamics or the team thatdelivered the visit; however, itis speculated that GVs allowfor more patient-providercontact. Also, some of the providers may have had moretime to apply motivational interviewing techniques,futher increasing patient satisfaction.

Although the exact factors that led to positive per-ception are unclear, GVs produce some promising dataand outcomes appear to be at least as good as routinecare, if not better. In all studies, patients were acceptingand most authors commented in their discusions thatthey would continue conducting GVs in their practice.

IMPLEMENTATION MODELSBased on the review of the evidence, it appears that theGV structure for diabetes care is a viable option toroutine, 1-on-1 care. In a time of increased budgetaryconstraints, where expectations of doing more for lessis common, the GV model should be considered forimplementation, particularly as more people are diag-nosed with diabetes. Diabetes is a common major pub-lic health concern, and new strategies for care need tobe considered. GVs have been shown to be well-received by both patients and providers and producedesirable outcomes, such as decreased emergencydepartment visits, improved productivity, and improvedoverall diabetes outcomes.

A model receiving attention is the chronic caremodel (CCM). Originally developed by Wagner andcolleagues21 at the Group Health Cooperative of PugetSound, the CCM combines the concepts of chroniccare management, such as using registered nurses tosupport patient self-management skills, tracking corecomponents of care, and offering telephone follow up.

There are data to suggest that incorporating CCMaspects of care into primary care practices will improvepatient care outcomes,21-23 and it is reasonable to spec-ulate that using elements from each model will assist

with enhancing diabetes out-comes as well as provideviable alternatives for seeingthe increasing number ofpatients burdened withthe disease.

In the literature, the DGVfollows one of several modelsof delivery. In 1 model, theGV is managed by individualprimary care practices and thestaff is provided by the prac-

tices. In another model, groups of practices in the samegeneral location offered DGVs and refer eligiblepatients to the DGV. The staff can be sponsored by thegroup of practices, and often, the GV addresses theneeds of patients with other chronic disease conditionssuch as chronic obstructive pulmonary disease, heartdisease, and gastrointestinal reflux disease.8

The GV concept offers alternatives to the typical15-minute office visit by offering medical care andadvice/education for several or up to 20 patients. Timeis allowed for education and group discussion whereinthe dynamics of the group are monitored and moder-ated by a trained healthcare professional, such as aphysician, NP, dietitian, or nurse educator.6,9,25

GVs have been highly successful with enhancingmany aspects of patient self-care, such as dietary com-pliance, self-glucose monitoring, and understanding themedication regimen; however, the meetings and cur-riculum must be planned in advance to be successful.The goals of care and targets must be discussed withparticipants in advance so they understand the basicpremise of the visit. Patients need to be identifiedwho would benefit from the GV, and a registry can becreated. Typically, about two thirds of invited patientswill actually participate. Scheduling needs to be con-ducted carefully so that patients with similar needs willbe grouped together and appointment intervals arespaced as appropriately as insurers will permit.6,9,25

Evaluation of the GV projects consists of carefuldata collection. Patient self-monitoring of glucose levels, engagement in exercise, biophysical markers of

GVs produce somepromising data and

outcomes appear to be atleast as good as routine

care, if not better.


each patient (blood pressure, A1c, lipids, weight), anduse of specialists and visits to the emergency depart-ment should be noted. These indicators can be used forcomparison to routine care.

DIABETES GROUP VISIT CASE Consider the case of a GV model as established in afamily practice setting on the East Coast, where NPsconducted visits for patients with combined problemssuch as T2DM. At the time, GV was developed as aresponse to a very high patient load coupled with areduction in provider resources. In a short period, 1physician had became ill and a Reserve Army nurse wasrecalled to active duty. In order to accommodate theshift in patient load and to continue to provide highquality care, the GV concept was introduced and pilotedas a short-term solution.

The GV pilot was led by an experienced family NP,and patients were recruited and placed in groups of 8 to10 after the concept was explained and consent wasobtained. One evening per week, a 2-hour block was setaside for GVs. In collaboration with pharmaceutical andproduct representatives, dietitians and chefs served light,healthy snacks along with cooking tips, and sometimesfood-preparation demonstrations were offered.

Before the start of the GV, all the participants’charts were made available, and lab forms along withprescription refills were prepared in advance. Uponarrival, patients were triaged by medical assistants whochecked vital signs and blood sugar and recorded anyspecific individual concerns. Approximately 20 min-utes was spent on diabetes education, followed by agroup discussion. Questions and comments from thegroup stimulated other ideas and perhaps more ques-tions from other members that otherwise would nothave been addressed. About 45 minutes into the ses-sion, the dietitian or chef made a presentation as indi-vidual patients were systematically placed intoexamination rooms.

Very brief (5- to 10-minute) individual exams wereconducted, and then each patient subsequently returnedto the group. While this was not a part of a researchstudy and data were not collected, it was reviewed anec-dotally as a well-received process. Of note, a large per-centage of the patients who participated returned to aGV forum for the follow up. This pattern was continuedfor almost a full year until new providers were hired. In

all, the GV concept was found to be viable and well-received by patients as an acceptable alternative to tradi-tional 1-on-1 visits.

CARE INNOVATIONS AND CONSIDERATIONSThe future of chronic disease management has opportu-nity in innovative care models supported by social net-works and virtual worlds. Diabetes care and educationcan be delivered by cell phones, the Internet, and smartglucose meters. These devices or technological systemscan be supported with algorithms of diabetes care thatprompt patients for appropriate actions, depending onglucose levels.26 The important feature is that demonstra-tion projects using these modes highlight the willingnessof patients to participate and experiment with nontradi-tional delivery platforms.

Second Life, a 3D world created by its residents andmanaged with the use of avatars, can support diabeteseducation. Patients can attend GVs designed to deliverspecific information on topics such as hypoglycemia man-agement, self-care skills, insulin injection, and dietarychoices. Through the use of their Second Life avatars,patients can experience firsthand the effects of low glu-cose levels or poor sight from damage related to retinopa-thy. The “lived” experience may provide patients withadditional motivation to avoid diabetes complications.

Second Life offers great promise for DGV education;however, there are disadvantages to consider. As with anyvirtual or Internet experience, authentication of who isactually leading the session can be problematic. Patientswill need to be directed to choose expert sources such asthe ADA or hospitals to ensure safety and accuracy.26

RECOMMENDATIONS FOR PRACTICEThe practice problem of limited resources for a growingburden of chronic disease and increasing demand foradequate health care is highlighted in the case of T2DM.Despite attempts to effectively manage this chronic ill-ness, its prevalence is predicted to grow exponentiallyover the next several years, given the rise in obesityrates.3 With recent economic challenges and strains onstate budgets, community and public health groups areexpected to do more with fewer resources. The risingprevalence of comorbidities associated with T2DMdemands innovations for strategies that deliver qualityhealth care and provide cost savings. New approaches,such as shared medical appointments for patients with


T2DM, can maximize impact and meet growing demandfor services but need to be refined.9

The DGV shows great potential for managing patientcare. Many important patient outcomes demonstratedimprovement in most of the studies reviewed, and GVsmay represent an innovative care model to meet the needsof patients with chronic illnesses. NPs are well-positionedto participate in and lead GV pilot projects since chronicdisease management and patient teaching are essential ele-ments of the patient care in which NPs excel.

Establishing more effective modes of care for allchronic illnesses is an urgent problem facing the healthcare system. This is especially vital as more residentssecure health insurance and health care reform initiativesevolve. Innovative techniques such as GVs, virtual worldencounters, and social media sessions hold great promiseas the search continues to create patient-centered learn-ing environments.26,27

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27. Watson AJ, Grant RW, Bello HB, Hoch DB. Brave new worlds: how virtualenvironments can augment traditional care in the management of diabetes.J Diabetes Sci Tech. 2008;2(4):697-702.

Chris Simmons, MS, FNP-BC, is a staff nurse practitioner atFamily Medical Centers in Middleberg, FL. Jane Faith Kapustin,PhD, CRNP, BC-ADM, FAANP, is an associate professor andthe assistant dean for the Master's and DNP programs at theUniversity of Maryland School of Nursing in Baltimore. She canbe reached at [email protected]. In compliancewith national ethical guidelines, the authors report no relationshipswith business or industry that would pose a conflict of interest.

1555-4155/11/$ see front matter© 2011 American College of Nurse Practitionersdoi: 10.1016/j.nurpra.2010.12.002

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diabetes group visits: an alternative to managing chronic disease outcomes

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