For our SMA, patients are
identified by a clinical registry as having high-risk status
based on A1c, blood pressure, and lipids (Kern et al.,
2008). In addition, patients may be referred by their primary
care providers or RN care managers. The 90-min
session starts with a discussion section facilitated by the
health psychologist and dietician. Patients are given their
own laboratory/blood pressure results and encouraged to
examine barriers (and facilitators) of self-management.
This occurs in the context of group support. After 60,
patients are pulled out individually for medication adjustment
(Kirsh et al., 2009). We now describe our results
in routine practice in >1000 patients over a 4.5-year
period.