In a verdant river town in rural New Hampshire, people are gathering for dinner at the community center. The cooks are a group of locals who have made big strides in managing their type 2 diabetes—despite obstacles such as low incomes. The guests also have type 2 diabetes, and they’ve come to glean insights from the cooks on managing their illness.
During the meal, people swap stories and the cooks share the health-boosting strategies that have worked for them: Skip the supermarket aisles that stock unhealthy foods and beverages. And if you can’t afford a glucometer and test strips, local resources can help you pay for them.
Thanks to a new project blending public health, data and primary care, this scene is slated to take place in Epsom, New Hampshire, this summer. The initiative involves partnering with “bright spotter” patients who’ve managed to make sustained improvements to their health, despite having a severe medical condition and risk factors associated with poor outcomes. “If these patients can do it, then anyone in their community can do it,” explains family physician Cole Zanetti, DO, who drew on his experience with the Positive Deviance Initiative to develop the Bright Spotter project at the Epsom Family Medicine clinic.
The positive deviance paradigm centers on finding people who’ve devised ingenious solutions to tricky problems—solutions other locals could use, too. In Dr. Zanetti’s project, the bright spotters’ proposed dinner series will help educate uncontrolled type 2 diabetes patients from the community. Ultimately, Dr. Zanetti’s primary care team hopes to use these perspectives to reimagine health care delivery for similar patients. Following is an edited interview with Dr. Zanetti.
How did you determine the focus of the Bright Spotter project?
I asked the team at the Epsom clinic which patient population they were having the hardest time treating effectively, and they said the complex diabetic population. We defined that as patients with uncontrolled type 2 diabetes who have multiple additional medical conditions such as depression, anxiety, heart disease or chronic obstructive pulmonary disease. The patients also had life circumstances linked with poor health outcomes, such as lack of income and low levels of education.
How did you find the bright spotters?
We wanted to find patients with type 2 diabetes who had a very high hemoglobin A1C level—9 percent or higher—and managed to get it under control and sustain it. We were also looking for type 2 patients who were complex, which we defined based on clinical literature as well as what we knew about our uncontrolled patient population.
Using the clinical data from our practice, we were able to identify 12 patients with the profile we were looking for. We brought that list of 12 patients to the primary care team and asked, “Are these patients doing it on their own, or are there other things that are contributing?” With their input, we refined our list to seven patients.
Out of our final list of seven patients, four were in the area and willing to participate in our research. We went to their homes and conducted some semi-structured qualitative research to find the patterns that allowed them to be successful in managing all their conditions. Six areas stood out: medication management, dietary habits, motivation, purpose, healthy coping mechanisms and the support of a partner.
How did the dinner club idea take shape?
We presented the research results to our bright spotter patients, and we asked them, “Could you design an action-based learning environment for your peers that you would have been interested in attending when you were struggling?” And they developed this beautiful intervention called the Diabetes Dinner Club and Discussion, which they proposed holding twice a month. The bright spotters told us they wanted to go to the local grocery store and purchase the foods that they’ve figured out taste good and are healthy and cost-effective. They’ll prepare the meal and serve it buffet-style, and they’ll talk about their struggles and provide their story of hope. We hope to deploy the dinner club by summer.
How will you measure the project’s success?
We’re using the approach of the clinical value compass, which includes clinical measures, cost measures, a satisfaction measure, and the functional area, which is unique to each patient and is based on their goals. This time next year, we expect to have preliminary results on the impact of the initiative.
How might the project change clinical care for these patients?
For the patients who are part of this program, we’ve proposed changing the blue banner at the top of their electronic medical record to green, so physicians can see that and think, “Oh, they’re part of that group—I’m going to ask them how that’s going.” If we accomplish that, we’ve created a different way for our clinical team to reinforce those goal-setting issues by just having a conversation.
We’re also very fortunate to have a nurse navigator as part of our team. The bright spotters proposed that she attend the dinner club to answer questions and document the obstacles that come up and the solutions that will be suggested. Then she’ll bring that information back to the clinic. So when a health care professional encounters a patient that fits the population-based profile, he or she will know to ask about the common obstacles and what to do if those obstacles are present.
Do you see this model of care being used more in the future?
The Bright Spotters project is still a work in progress. If the impact turns out to be beneficial for patients and primary care teams, I could see the idea spreading. Everybody can acknowledge that with EMRs and big data, we’ll be able to garner great insights. But the Bright Spotters project creates an opportunity to investigate our own population through this data, and then find these people and ask important questions to help clarify their behaviors to a specific, actionable level.
We’re having a conversation with people who are managing their health effectively despite all the obstacles they face—they’ve figured out the things we haven’t been able to figure out for years. Using the bright spotters’ expertise, we can design new strategies for caring for these patients. When you’re able to bring back this kind of local, grassroots effort in a primary care setting, you bring back the heart of what primary care’s about.