In this second interview of a three-part series on medication adherence, Arshiya A. Baig, MD, MPH, elaborates on a previous Diabetes Discoveries & Practice blog about group visits for patients with diabetes. She explains how offering them concurrently with individual appointments can enable patients to learn—from health care professionals and each other—how to improve their diabetes self-management, including their medication-taking practices. 

Q: How do you define medication adherence?

A: Medication adherence is when patients take their medicines at the frequency and the dose that’s been prescribed, and they take it more than 80% of the time as prescribed, with maybe some skipped doses here and there.

Q: You’ve explored group activities to help patients improve their medication adherence. What have you learned?

A: We’ve done multiple studies now on shared medical appointments, or group visits, for adults with type 2 diabetes. Eight to 12 patients would come together in a group with a facilitator, where they received diabetes education, social support, and the goal setting that happens within group education. They would get their vitals checked and there might be medication reconciliation, which is when you compare a list of the medicines the patient is prescribed to the medicines the patient is taking. They would also have an individual medical visit focused on their diabetes. As the group is going on, patients are pulled out one by one to be seen by a provider, where they can focus on patient-specific issues like lab tests, immunizations, referrals, refills, or medication titration as needed.

When that short visit is over, the patient goes back to the group. It’s an opportunity for patients to get targeted care and, also within the group, to learn from peers about successes and struggles: “I had that side effect with that medication too, but I’ve overcome it.” “I’ve been taking this medication and I’ve been fine.” “This is how I build exercise into my busy schedule.” The peer support helps normalize the experience of living with diabetes.

For our shared medical visits, there was an opportunity for patients to bring in a family member, a loved one, or a support person. I do think it can be a benefit to have a second person hearing all that information, so they can support the person with diabetes. Maybe they didn’t know that the patient needs to take a medicine twice a day or check their blood sugar before meals or have their eyes examined once a year.

Q: What is involved with setting up these group visits concurrent with individual medical visits? 

A: We’ve developed a toolkit on all the aspects that you need to think through for group appointments—who needs to be a part of the team, logistics, education, recruitment, and retention. The key factors are having the support of the clinic administration and having a team of staff and providers, even having a champion who leads the development of group visits. You need engagement with primary care providers, who understand that their patients might be seen in this group visit by another provider in the group. There are other considerations too, such as, when you have 8 to 10 patients checking in at the same time, how do you manage that? 

We have found that staff and providers really like working as a team on something as innovative as group visits. They’re not just providing one-on-one care but are working with their colleagues and doing something different, creative, and unique. And then also, they get to know their patients a little bit more, because they’re spending a couple of hours with them in this group. It builds that patient-provider relationship.

Q: Do group visits help with medication adherence?

A: In the group, we emphasized that patients should set goals. If they’re having some challenges in taking their medicines or even affording their medicines, they can brainstorm with their peers on ways to get around that: “Do you have time to take it? Do you remember to take it? Can you afford it? Did you have a side effect? Do you know why you’re taking it?” All those questions can be answered either by the person leading the group, by the health care professional in attendance, or by peers. And the group session also provides an opportunity for the health care professional to follow up within the one-on-one provider visit to figure out solutions.  

Q: Are there any patients who are not suitable for group appointments? 

A: There are some folks who don’t want to share their experience with diabetes or their clinical information within a group setting, even though there are confidentiality forms that patients and accompanying family members sign so that they do not share whatever they hear in the group with others outside of the group. Also, for people who have a really busy work life or family life, it may be challenging for them to take 2 hours out in the middle of the day. 

Q: How is reimbursement handled?

A: Group education is typically billable but has a low reimbursement rate. However, the one-on-one provider visit that occurs at this time can be billed as a clinical encounter.

Q: What else besides group visits can individual health care professionals do to improve medication adherence by their patients with diabetes?

A: A patient-centered approach is the most important. Each patient is going to have their barriers, their challenges, and their successes. Have an open and nonjudgmental conversation by, for example, just asking, “Have you been able to take the medicines? What challenges have you had? How can I help you? What questions can I answer? Is cost an issue?” It’s well established that health care professionals need to participate in shared decision-making with their patients and use patient-centered approaches.

Q: What research topics need to be explored so that medication adherence is better understood and addressed?

A: We need to understand how to approach the conversation around cost with patients. How do providers destigmatize cost, so that patients feel this is a conversation they can have with them?

We also need research on how to advance price transparency. Often, I prescribe medicines and I don’t know what the out-of-pocket cost is going to be for the patient. It would be great if I could type in a prescription and a window pops up that says, “This patient’s copay is going to be $1,000 a month.” At that moment, I could then say, “This may not be the right medication for you. Let’s find something else that’s similar.” Why does the patient have to go to the pharmacy to figure out that they can’t afford it and then call me, or bring it up at the next visit after they haven’t been taking the medicine for those intervening months?