Cost-effective chronic disease management is a challenge everywhere, but especially in remote areas like the one served by Calais Regional Hospital, on Maine's eastern border with New Brunswick. Calais sees one of the highest chronic disease rates in a state that opted out of Medicaid expansion. Diabetes is the most common diagnosis in its patient panel, but the nearest endocrinologist could be a two-hour drive away.
Despite these challenges, Calais manages to outperform 90 percent of similarly sized organizations on the athenahealth network in control of hemoglobin A1c, and is a high performer on the network in other key quality metrics.
For that, the quality management team points to a community-centric focus on patient education — anchored by a monthly community support group for diabetes that extends beyond lectures to include games, field trips, and family bonding to encourage healthy lifestyle changes.
“It's a really social-style gathering where patients discuss issues they're dealing with in the management of their diabetes," says Mona Van Wart, a registered dietitian and nutritionist who ran the group for many years. “It has a stickiness factor too, because it's a terrific community bonding opportunity."
And hospital staff say the investment has been worthwhile, even though the payment structure hasn't caught up.
"Even though it's not reimbursable, it does help because ultimately the patients are getting better. So it's paying back in other ways," says Eleonore Sullivan, the quality manager at Calais Regional Medical Services. "It's all intended to make patients more engaged and to be better stewards of their own health."
The power of peer groups
In regions with limited access to healthcare, support groups can be essential to filling in care gaps. That's the case in Calais, where the regional hospital treats about half of Washington County's 33,000 residents, including the occasional Canadian or member of the neighboring Passamaquoddy tribe. The majority of patients are on Medicaid or Medicare.
“They don't have access to care like somebody who lives in Bangor does, where the large hospitals and specialists are," says Van Wart.
But even outside rural areas, support groups are increasingly seen as a vital tool for patient engagement. In an athenahealth survey of 1,029 physicians, conducted in April 2017, physicians ranked peer groups for patients with chronic disease as one of the top 10 most important services to help patients improve their health. But only 11 percent of survey respondents said they worked in an organization that offers these services.
So, it's striking that a community on the edge of the United States, in a town with two traffic lights, has long been on the cutting edge of this strategy. Calais' program began in 1995 as part of the Maine Regional Diabetes Collaborative. Some of the same patients have continued to attend the free events since then, and providers continually refer new patients. While many attendees are local residents, some travel 30 to 40 minutes for the groups.
The gatherings cover a range of formats and topics, says Karen Thomas, a registered nurse who now runs the program and has been with Calais since 1983. During one meeting, a podiatrist might give a presentation. The next month, clinicians might review exercise alternatives or how to manage blood sugar issues and exercise.
Meetings have even taken place at the local grocery store, where patients walk through the aisles and discuss how to make healthy choices, read labels, and understand when packaging can be deceptive.
“Many of our patients simply don't have a good foundation for how to eat well," says Van Wart, with portion control as a constant focus.
So is the participation of relatives. Thomas and Van Wart say it's almost as important to educate the family as it is the patient; often the entire family needs to change eating habits to help a patient be successful. It's also likely that family members could be suffering from pre-diabetes or other comorbidities.
To encourage patients to bring their families along, Thomas sometimes "gamifies" the sessions with such features as a diabetes Bingo night.
The result, staff says, is a culture around patient education that spills over into daily life.
"I've had many approach me in the grocery store, even some I didn't know well, but they knew I was a dietitian, and they would ask if what they were buying was okay," Van Wart says, laughing.
Because the diabetes support group has been so helpful to patients, Calais is in the beginning phases of launching peer groups for other conditions, such as hypertension and smoking.
And Sullivan says the community interactions keep clinicians engaged, as well.
“We're remote. We are rural. We don't have access to every single thing in the world, but we do have quite a bit," she says. “There's something really special about being neighbors and knowing your patients."
Chelsea Rice is a senior writer for athenaInsight. Data analysis and qualitative research by analysts David Clain, Erica Granor, and Stewart Richardson.