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ViewsImplementing the Shared Medical Appointment Model in Diabetes Care: An Overview
By Elaine Massaro
Introduction
The Shared Medical Appointment (S.M.A.) Model has been suggested as a strategy to improve patient self-management and clinical outcomes in chronic care. This model has been scientifically tested in various practice settings over the past 15 years. However, significant variability has been noted among these studies. Examples include intervention components, outcome measurements related to quality, costs and utilization. In addition there has a paucity of randomized studies examining the difference in group and individual settings.
Background
Although there are different formats available for conducting SMAs the defining feature is that multiple patients are seen together in the same clinical setting. These medical appointments are led by a physician or other health care professional. The appointment divided into two components: a group education experience and a one-on-one consultation with a physician or midlevel provider such as a nurse practitioner (NP) or physician assistant (PA). Typical components of the exam include vital signs, medical history, physical exam, diagnostic evaluation, and medication management. The class size includes 6 – 12 participants with duration of 90 – 120 minutes. The sessions are designed to create consistent, homogenous groups that meet regularly (usually monthly or quarterly). SMAs should not be mistaken for support groups or an optional educational activity but rather an alternative or supplement to the traditional office visit. Once enrolled, the patients are expected to attend the same as any other appointment.
Patient Identification
Patients with the greatest potential benefit include high risk individuals who failed to reach treatments goals and frequent users of medical care. These patients may benefit from the group experience sharing feelings about diabetes and multiple challenges that they may encounter in everyday life. During these sessions they will be able to observe how others respond to similar situations giving and receiving feedback. A patient registry is an excellent resource during the patient recruitment period. Key identifiers are easily accessed in the database or initially identified during the 1:1 clinic visits. A personal invitation from the clinician outside or during a routine follow up visit is most effective. It is recommended that the clinician clearly describes the SMA as a medical visit intended to replace or supplement usual care and that typical payment, including copays, will apply. An invitation may also be extended through a personalized letter and a descriptive brochure featuring clinicians who are familiar with the invitation recipient.
Timeline for Implementation
Pre-Planning Essentials (23 months prior)
● Meeting space selection
● Date and time convenient for target population
● Team member selection
● Role identification
● Inclusion criteria identification
● Recruitment plan development
One Month Prior
● Invite eligible patients
● Establish laboratory panel criteria and order supplies
● Create template for EMR
● Explore educational components
● Prepare patient handouts for all sessions
● Gather supplemental educational materials
● Suggested resources: American Diabetes Association, American Association of Diabetes Educators, American Association of Family Practioners, American Association of Clinical Endocrinologist ● Development of specific forms for documenting key aspects of the clinical exam
● Clinical forms should correspond to the E/M code requirements for private payors or Medicare plan(most common: CPT Code 99214)
● Outline DSME/T or MNT requirements
● Development of patient action plan
● Progress review form development (to be used for all visits)
● Current Coding instructions available in writing to serve as a source document
One Week Prior
● Record review charts pulled with key clinical elements extracted to prepare medical history, problem list and medication list
● Phone call reminder regarding appointment
● Refreshments ordered
● Name tags, signin sheet
● Review laboratory and test results for all confirmed patients
Day of Visit
● Set up meeting room
● Equipment assembled
● Staff (medical assistant) assigned to check in patient
● Collection of copay
● Distribute and collect HIPPA and general consent forms
● Review staff assignments/roles
● Conduct SMA with EMR template and respective forms in place
● Patient Notebook and handouts available for distribution
Implications for the Diabetes Educator
This model can be utilized effectively in the clinical management of patients with diabetes in many practice settings. It certainly opens up the door for future research opportunities, accreditation and quality improvement activities. The literature suggests that additional research is needed in order to explore differences between groups and individual sessions with the same number of visits, same providers and a standard education curriculum provided for both groups. However, although more research is needed to continue to test efficacy of this model, it has been concluded that SMAs are effective as evidenced by improvements in fasting blood glucose levels, A1C and improvement in problem solving skills and quality of life.
References
1. Clinical Endocrinologists: www.aace.org
1. Clancy DE, Huang P. et al. American Association of Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med 22:620 624, 2007.
1. Clancy DE, Brown SB., et al. Group Visits with type 2 diabetes:preposthoc analysis. J Health Care Poor Underserved 12:315327, 2005.
1. Miselli V., Trento M., Porta M. Group Care for Type 2 Diabetes: The Turin experience. Diabetes Spectrum Vol 25 (2) 2012.
1. Sadur CN, Moline N., et al. Diabetes management in a HMO efficacy of care management using cluster visits. Diabetes Care 22:20112017,1999.
1. Shahady, E (2010)
Podcast: http://www.consultantlive.com/diabetes/content/article/0162/1542902 1. Trento,M., Passera P. et al. 5 year randomized controlled study with type 2 diabetes managed by group care. Diabetes Care 27:670675, 2004. 1. Wagner E, Grothaus L., et al. Chronic care clinics for diabetes in primary care. Diabetes Care 24:695700, 2001.
1. Trento M., Gamba S. et al. Rethink Organization to Improve Education and Outcomes (ROMEO). Diabetes Care 33: 745747,201.
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Implementing the Shared Medical Appointment Model in Diabetes Care: An Overview
By Nurse Advisor Magazine (Official)
The Shared Medical Appointment (S.M.A.) Model has been suggested as a strategy to improve patient self-management and clinical outcomes in chronic care.
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