VCOM Carolinas Research Day 2023

Clinical Studies

A Multidisciplinary Patient Empowerment Program to Improve Diabetes Care at a Free Clinic Wade Hopper , OMS-IV 1 , Patrick Ruane , OMS-III 1 , Adrienne Z Ables , PharmD, MS 2 , JuliSu DiMucci-Ward , PhD, MPH, RDN, CDCES, LD 1,2 1. VCOM-CC, Department of Preventative Medicine and Public Health, Spartanburg, SC 2. St. Luke’s Free Medical Clinic, Spartanburg, SC

Abstract # CLIN-17




Mean A1c improvement of -3.4% (P<.0001) at 3 months of enrollment even though all patients started with an A1c ≥ 9.0% and the average hemoglobin A1c at baseline was 11.5%. • This indicates the benefit of treatment was rather immediate • We attribute the immediacy of results to the intensive multidisciplinary nature of the methodology rather than to any specific medications, exercise programs, or dietary strategies. Overall reductions were achieved in SBP, DBP, total cholesterol, and LDL-C. Mean SBP was reduced -17 mmHg and mean DBP by -9 mmHg at 12 months. Medication adherence improved. Surveys showed the program was liked. Strengths: Robust variety of outcomes; unique patient population; novel involvement of a nutritionist in the free clinic setting. Limitations: Small sample size; unable to establish causality of outcomes; challenging patient retention; some results subject to self-reporting bias.

Table 1. Schedule of Encounters and Procedures

Table 2. Baseline Patient Characteristics

In 2018, type 2 diabetes affected an estimated 10.2% the of United States adult population, and total direct and indirect costs of diabetes were $327 billion dollars. Diabetes disproportionately affects racial minorities and those of low socioeconomic status. Free clinics provide primary care and specialized medical services to underserved patient populations for little or no cost. There is a great need for quality outcomes reporting in order to characterize and improve the care provided at free clinics. We evaluated outcomes from a quality improvement (QI) program at St. Luke’s Free Medical Clinic (SLFMC) in Spartanburg, SC. Study Design: Data was collected via retrospective chart review of a QI program performed at SLFMC from May 2021 to October 2022. Inclusion Criteria: Patients aged 18 to 65 who had: 1. A diagnosis of type 2 diabetes with a documented hemoglobin A1c ≥ 9% 2. A diagnosis of hypertension treated with ≥ 1 antihypertensive medication Clinical Setting: SLFMC is a nonprofit free clinic that cared for over 1,600 patients in 2021. To qualify for enrollment, patients must live in Spartanburg County, have a household income at or below 150% of the federal poverty level, have no access to health insurance, and not qualify for Medicaid or Medicare. QI Program: Multidisciplinary care team including a pharmacist and a nutritionist with several patient encounters over a 1-year period (Table 1). Patient empowerment with personalized goal-setting was emphasized. Patients continued regular visits with their primary care provider as needed. The pharmacist made medication changes, encouraged lifestyle reflections, and helped patients create and track self-management goals. The nutritionist helped patients plan diet and exercise strategies. Outcomes: Primary clinical outcomes were changes in hemoglobin A1c and blood pressure at follow-up intervals compared to baseline. Secondary outcomes included changes in body mass index (BMI), serum lipid levels, cigarette smoking status, and patient satisfaction. Medication adherence was assessed with the four-point Morisky Medication Adherence Scale (MMAS-4). Statistical Analysis: The paired t-test was used to calculate significant differences in group means at intervals of 3 months and 12 months compared to baseline. Objective: To evaluate the effectiveness of an intensive multidisciplinary patient-centered approach involving a pharmacist and a nutritionist in a population of uninsured free clinic patients with diabetes and hypertension. Methods: A retrospective chart review of a patient empowerment program consisting of multiple visits over the course of 12 months in which patients met individually with a pharmacist and a nutritionist. Results: Seventeen patients completed 3 months of treatment, and 7 patients completed 12 months of treatment. Significant reductions in mean hemoglobin A1c values were observed at 3 months (-3.4%, P<.0001) and at 12 months (-4.0%, P=.0156). Improvements in outcomes related to blood pressure and lipids were also observed. Conclusions: The program was well-liked by patients and yielded meaningful improvements in chronic disease outcomes among the group. This collaborative, multidisciplinary model can be implemented by other free clinics that have access to similar personnel. Introduction & Methods


Patient characteristics present upon enrollment are presented for the groups of patients who reached 3 months and 12 months of enrollment. Values are represented as means or as n= (%) as appropriate.

1 . Large and significant A1c reductions were observed in patients with diabetes refractory to traditional medical management. 2. Goal-oriented patient empowerment is effective in improving many outcomes of care in the free clinic setting. 3. Dedicated attention to diet, exercise, and medications provided by ancillary specialists can redistribute the burden of teaching traditionally placed on a patient’s primary care provider.

Figure 1. Patient Retention

All clinic visits involved one-on-one meetings with both a pharmacist and a nutritionist lasting 30 to 60 minutes each. BMI – Body mass index; MAP – Medication action plan; PML – Personal medication list.

Table 3. Outcomes at 3 Months (n=17)


Reasons for program noncompletion included failure to keep appointments (n=11), voluntary withdrawal (n=5), conclusion of program timeframe (n=4), and loss of clinical eligibility (n=3). Factors influencing voluntary withdrawal included Medicaid eligibility, depression, and caregiver responsibility.

Patient outcomes at 3 months are compared to mean baseline measures (n=17). Values are represented as mean ± standard deviation or as proportion (%) as appropriate. One patient did not have blood lipid data available at 3 months and was excluded from relevant calculations. TC – Total Cholesterol; TG – Triglycerides.

Table 5. Patient Survey Results

Table 4. Outcomes at 12 Months (n=7)



Petra Warren, MD Japonica Owens, MSN, FNP-C

Patsy Whitney, SLFMC Executive Director Patient photo reproduced with permission. This research was reviewed and approved by Edward Via College of Osteopathic Medicine IRB (R#2022-075) on 11/07/2022.

Patient outcomes at 12 months are compared to mean baseline measures (n=17). Values are represented as mean ± standard deviation or as proportion (%) as appropriate. TC – Total cholesterol; TG – Triglycerides.

Patient satisfaction surveys utilized a 5-point Likert-type scale, with a response of 5 indicating highly satisfied. Mean responses are presented in each cell.


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