Santa Cruz Community Health Centers (SCCHC) Diabetes Group
Carolina Espinosa Noya, FNP-BC, RN, MS, is a PhD student in the UCSF School of Nursing and Assistant Clinical Professor in the FHCN department. She graduated in 2000 from our MEPN program with an MSN as a Family Nurse Practitioner. Nearly the last two decades of her work have been spent in family practice at Community Health Clinics in Sonoma and the Santa Cruz counties in California. In 2011, when Carolina received a Minority Nurse Faculty Scholars award from the American Association of Colleges of Nursing (AACN) she aspired “to develop culturally specific interventions to improve health outcomes for people with diabetes, specifically to enhance the health of minority and underserved populations through research, teaching, mentoring, and practice.” We caught up with Carolina recently and discovered her incredible progress toward this objective.
Two years ago, Carolina began teaching in the School’s FNP program while concurrently pursuing her doctoral studies. Though she was concerned about taking on this responsibility in addition to her doctoral studies, her mentors and fellow faculty encouraged her to consider this opportunity and help lead the diabetes minor. Carolina rose to the task, co-developing some of the courses in the diabetes minor curriculum and teaching full time in the program until recently when she decided to focus her attention on completing her doctorate.
The Santa Cruz Community Health Centers (SCCHC) includes the Santa Cruz Women’s Health Center—founded in part by UCSF School of Nursing’s own Erica Monasterio, RN, MN, FNP, and the East Cliff Family Health Center—a Federally Qualified Health Center (FQHC). Carolina’s doctoral inspiration came from her extensive experience working in community clinics and witnessing first hand all the barriers experienced by uninsured Latinos living with diabetes.
Shared Medical Appointment Program
The concept and practice of shared medical appointments (SMA) originated 20 years ago and has been implemented primarily at Health Maintenance Organizations and in the Veteran Affairs clinic practices. The SMA program offers a two-hour visit to a group of eight-to-twelve patients instead of several twenty-minute visits to individual patients. The SMA format creates a space where clinicians can incorporate diabetes self-management education, medical management and peer support. In the SMA program patients share their individual diabetes care struggles and successes, and support each other. This social component to care has proven to be very effective, enhancing the humanness of both the health care providers as well as the patients receiving care in the group setting.
Carolina pitched the SMA idea to the East Cliff Family Health Center and started a trial of the SMA program in January of 2015 with a target patient population of people with Type 2 Diabetes who were monolingual Spanish speaking, uninsured, or under-insured. Her SMA program also targeted the highest risk population, those with extreme cases of disengagement with health care. The program created a video, which allows the patient perspective to come through directly—watch here.
Results of the SMA Program
As a model of care, the SMA program provides Carolina with the luxury to integrate, peer support, diabetes education and support, and medical management. SMA’s resounding success is evidenced by the program’s latest challenge—accommodating the consistent and growing demand. Patients exhibit stalwart commitment to participation in the SMA. Group participants continuously return while new patients are being enrolled.
As Carolina explains, “The space created is the greatest success. Rather than having a defined curriculum, the patients themselves have ownership over the agenda for care.” In each meeting the patient group decides what it is they are going to do in the following meeting. Whether it’s a walk on the beach, Zumba class, or education-focused meeting, the patients determine what and how it is that they will engage. Carolina also credits the culturally specific nature of the SMA model as a key factor in its success. In one SMA the group addressed nutrition through the specific example of licuados or smoothies—a popular refreshment for the Latin American community in California. The group brought typical licuado ingredients and through demonstrations making various licuados learned about fruits and carb counting. They also had a collective discussion about the nutrition education and substitution suggestions received. This type of hands-on approach also allows those with low-literacy an interactive venue for health care learning.
Patients in the group setting are doing so well it’s astounding! Preliminary data shows that while only 25% of patients enrolled had achieved their hemoglobin A1C goal, 50% had achieved it at six months and 67% at 6 months follow-up.
The SMA program is also innovative for nursing in particular. Historically, while SMA’s have been multi-disciplinary, nurses have had supportive roles and advanced practice nurses have been excluded. Typically, it’s medical doctors or pharmacists in command of the medial management and health education components of the patients’ health care experience. Carolina ‘s SMA model is one that puts advanced practice nurses in the leadership position. Moreover, for the UCSF School of Nursing, the model provides a holistic training ground for faculty and students alike while also delivering cost-effective health care to a high-risk patient population. Carolina’s SMA program team consists of a group health education coordinator who provides administrative support, a medical assistant from the clinic, Carolina herself, a nurse volunteer from Mexico who is preparing for certification, and one-two UCSF School of Nursing advance practice students who are either interested in diabetes or formally part of the diabetes minor.
Future plans
The overwhelming success of the initial SMA cohort dictates that future plans include the obvious—expansion. Carolina will start a second SMA group that will meet in the evening early next year. Her doctoral dissertation will explore the effectiveness of the SMA program on improving biophysical and economic outcomes for Latinos living with diabetes. Patient empowerment, a natural by product of the SMA program, affords for the exploration of otherwise costly and inaccessible areas of health care such as mental health support. First person testimonials shared in the SMA resonate for those more hesitant in the group. As one participant said, “Being part of the group has made me realize that I matter. I am now taking care of my diabetes and also taking care of myself at home. I don’t put up with abusive behavior from my husband anymore.” Carolina asserts that a large percentage of Latinos served at the clinic have historically not accessed mental health help. However, with the SMA program Carolina has seen significant increase in engagement and willingness to explore mental health support. Carolina will be focusing this year on her dissertation and contributions to the Department of Family Health Care Nursing’s Health Resources and Services Administration (HRSA) grant, specifically being involved in planning and implementation of a diabetes SMA in the central valley.