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Optimising Practice Efficiency to Promote Team Effectiveness. DEVELOPED BY: Rob Wedel, MD, CCFP, FCFP Family Physician, Associate Medical Centre, Taber Palliative Care Physician, South Zone, Alberta Health Services Medical Director, Chinook Primary Care Network Co-Chair, Alberta AIM

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Shared medical appointments

DEVELOPED BY:

Rob Wedel, MD, CCFP, FCFP

Family Physician, Associate Medical Centre, Taber

Palliative Care Physician, South Zone, Alberta Health Services

Medical Director, Chinook Primary Care Network

Co-Chair, Alberta AIM

Chair, Advisory Committee on Primary Care, College of Family Physicians of Canada

FACULTY:

Kenneth Bayly, MD, CCFP, Physician General Practice, Saskatoon District Health, Saskatoon, SK

Mel Cescon, MD, MCFP, Family Physician, Kitchener , ON , Quality Improvement and Innovation Partnership, ON

Brian Craig, MD, MCFP, Family Physician, St. John, NB

Lorraine Tessier, MD, MCFP, Family Physician, Hôpital du Sacré-Coeur de Montréal , Montréal, QC

CONTRIBUTOR:

Maureen Clement, MD, CCFP,

Medical Director, Diabetes Education Centre, Vernon Jubilee Hospital, Vernon , BC

This program was supported in part by an educational grant from AstraZeneca Canada.

Shared Medical Appointments


Disclosure of potential for conflict of interest
Disclosure of Potential for Conflict of Interest

Dr.

Financial Disclosures:

  • Grants/Research Support:XYZ Pharma Co

  • Speakers Bureau/Honoraria:

  • Consulting Fees: XYZ Company

  • Other: Employee of XXY Hospital Group



Objectives
Objectives Appointments

  • After completing this session, attendees will be able to:

    • Understand the concepts surrounding a shared medical appointment model of care:

      • What a shared medical appointment is

      • The benefits to patients, physicians and teams for a shared medical appointment

      • The evidence for the use of a shared medical appointment

      • Guiding principles for planning, conducting and evaluating a shared medical appointment


Overview
Overview Appointments

  • Shared Medical Appointments fall under a general category of Group Visits. Group Visits also include Group Medical Appointments, and Group Patient Visits. Sometimes the terms are used interchangeably but all have some similar principles.


Agenda
Agenda Appointments

Shared Medical Appointments Presentation (60 minutes)

  •  What are Shared Medical Appointments?

  •  Step 1: Planning Shared Medical Appointments

  •  Step 2: Conducting Shared Medical Appointments

  • Step 3: Measuring Effectiveness

  •  Step 4: Refining and Repeating

    Group Discussion and General Feedback (30 minutes)

    • Group Discussion

    • Q and A


Shared medical appointments vs group medical appointments vs group patient visits
Shared Medical Appointments vs Group Medical Appointments vs Group Patient Visits…

  • All share the same principles of personal exam, group interaction and education with patient self management at the core

  • Common elements are:

    • Medical care

    • Education

    • Questions/answers

    • Socializing

    • Participant feedback about future educational sessions

  • Different models exist

  • Terms are usually used interchangeably but some differentiate based on model used


Shared medical appointments1
Shared Medical Appointments Group Patient Visits…

  • Developed in the 1990s by Drs. John Scott and Ed Noffsinger

  • Motivated to deliver patient-centered care with improved quality and outcomes despite:

    • An aging population with complex medical needs1

    • Deteriorating access2

    • Substantially increased physician workloads2

    • Growing patient demands and expectations2

    • Rapidly expanding patient panels2

FHT. Guide to Chronic Disease management and Prevention, September 2005.

Noffsinger EB. The Permanente Journal. Fall 1999; 3(3): 58-67.


What are shared medical appointments
What are Shared Medical Appointments? Group Patient Visits…

  • An effective means to deliver integrated healthcare

  • An expanded medical appointment delivering most elements of an individual visit including:

    • Personal examinations (e.g., collection of vital signs, history taking, physical exam)

    • Formal and informal education

    • Social and psychological support

Patient Self-mgmt


Why would we want to conduct shared medical appointments benefits 1
Why Would We Want to Conduct Shared Medical Appointments: Benefits1

General Practice Services Committee (GPSC) Shared Medical Appointments (http://www.gpscbc.ca/psp-learning/group-medical-visits/tools-resources)


Why would we want to conduct shared medical appointments cont d
Why Would We Want to Conduct Shared Medical Appointments (cont’d)?

Better ‘Comprehensive Care Plan’(CCP) *Patient Management

  • An opportunity to follow your patients with CCPs

    • Monitor and support patient adherence

    • Update CCPs as required

    • Provide necessary education

  • Demonstrate practice team support for the CCP

    • Regular scheduled follow-ups

  • Recognize patient success in following CCP

    * Plans in various provinces for dealing with chronic disease may have other names



Optimising practice efficiency to promote team effectiveness
Medical Clinics Versus Usual Care for Patients with Both Diabetes and Hypertension: A Randomized Trial1

  • 239 patients with poorly controlled hypertension and diabetes were randomized to either GMCs or usual care

  • Poorly controlled hypertension and diabetes:

    • Systolic BP >140 mm Hg or Diastolic BP >90 mm Hg,

      and HbA1c level >7.5%

  • Patients in each group were similar1

  • Data collection at baseline, midpoint (~6 mos) and study end (~12 mos)

Aim: Assess the effectiveness of Group Medical Clinics (GMCs)

for the management of diabetes and hypertension

Edelman D, et al. Ann Int Med 2010;152:689-96.


Reductions in sbp and dbp were associated with group medical clinic attendance
Reductions in SBP and DBP were Associated with Group Medical Clinic Attendance

Better Systolic and Diastolic BP measurements seen with diabetic

GMC patients may contribute to reduced CV morbidity and mortality.1

Edelman D, et al. Ann Int Med 2010;152:689-96.


Further benefits observed with gmc attendance
Further Benefits Observed with GMC Attendance Clinic Attendance

  • Fewer ER visits (p<0.001)

  • Fewer Primary Care visits (p=0.010)

  • Enhanced perceived competence for engaging in healthier behaviour (p<0.001)

Patients attending GMCs benefited from CV risk reduction and an enhanced sense of empowerment.

Edelman D, et al. Ann Int Med 2010;152:689-96.


Primary care practices are the cornerstone of effective chronic disease management
Primary Care Practices are the Cornerstone of Effective Chronic Disease Management

  • Health outcomes are a function of continuity of care by the same family physician1

  • Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1

  • Shared Medical Appointments may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided2

Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44.

Steering Group Communication.



Implementation process
Implementation Process Practice?

identify and plan ahead for change, analyze and predict the results

PLAN:

DO:

STUDY:

ACT:

execute the plan, taking small steps in controlled circumstances

check and study the results

take action to improve the process

The process is flexible…….Engage in continual planning, studying and refining at all stages


Model for improvement three important questions
Model for Improvement: Three Important Questions Practice?

Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?


Implementing shared medical appointments
Implementing Shared Medical Appointments Practice?

Step 1: Planning Shared Medical Appointments (PLAN)

  • Conduct Needs Assessment to identify gaps and patient groups

  • Select shared medical appointment model

  • Create Plan of Action

    Step 2: Conducting Shared Medical Appointments (DO)

  • Identify specific patients

  • Organize resources and conduct Shared Medical Appointments

    Step 3: Measurement and Evaluation (STUDY)

  • Evaluate results and make adjustments

  • Identify methods to sustain change

    Step 4: Refine and Repeat (ACT)

  • Plan more Shared Medical Appointments


Planning shared medical appointments
Planning Shared Medical Appointments Practice?

  • Know your Practice and Your Patients

  • Select the Appropriate Shared Medical Appointment Model

  • Create an Action Plan


Select appropriate shared medical appointment model
Select Appropriate Shared Medical Practice? Appointment Model




Conducting shared medical appointments
Conducting Shared Medical Appointments Practice?

  • Patients

    • Identify specific patients within your “priority patient group”

  • Invitations

  • Resources

    • Identify and organize resources

  • The Visit


Conducting shared medical appointments1
Conducting Shared Medical Appointments Practice?

Identify specific patients to participate

  • Relatively stable and will benefit from education

  • Function well in a group setting

  • Good cognitive, sight and hearing function

    Patient Invitations

  • Explains the SMA and the patient’s role as a participant

  • Multi-pronged approach may be needed/effective


Conducting shared medical appointments cont d
Conducting Shared Medical Appointments (cont Practice? ’d)

Identify and Organize Resources

  • Team member roles and responsibilities

  • Patient charts and medical equipment

  • Patient information binder

  • Educational materials

  • Forms (e.g., attendance sheets, confidentiality agreements, evaluations, etc.)


Conducting shared medical appointments cont d1
Conducting Shared Medical Appointments (cont Practice? ’d)

The Visit

  • Success is dependent on:

    • Productive interactions

    • Physical involvement and /or endorsement

  • Time management is critical

    • Agenda and expectations

    • Group Norms

  • Confidentiality

Ensure that confidentiality is addressed early on in every meeting – this helps establish trust among the group


Measurement and evaluation
Measurement and Evaluation Practice?

What to measure to assess benefit of SMAs?

  • Practice Utilization:

    • Demand for one-on-one appointments

    • Reduced waiting times

    • Medical team satisfaction

  • Clinical Outcomes:

    • % patients meeting clinical guidelines

    • Increased patient self-management and satisfaction

    • Patients’ commitment to Complex Care or other similar plan

    • Pre/post medical tests (e.g.: HbA1c, BP, Lipids etc.)

    • Reduced utilization of ER/hospital admissions

Don’t try to measure everything…..start with small steps such as vital signs and key lab work.


Practice resource use and satisfaction
Practice Resource Use and Satisfaction Practice?

All identified topics for education. staff

Very informative and happy time. These meetings are very helpful! patient

Hopefully it will provide help and interest as it continues. patient

Great way to learn what is needed to teach self-management. medical student

All voiced they would like to come again. staff

This meeting was very good because we could see how other people did under similar conditions. It also gave answers to so many questions I wasn’t sure of.

patient

Very important team-based experience. medical student


Refine and repeat
Refine and Repeat Practice?

  • Planning more Shared Medical Appointments

Did the chosen model work?

YES

NO

Expand SMAs to other patients, perhaps with more complex conditions and comorbidities

  • Revise the model

  • Work with the same patient group before expanding


Sustaining shared medical appointments in your practice
Sustaining Shared Medical Appointments Practice? in Your Practice

  • PATIENTS

  • Know your panel

  • Appropriate clinical information

  • MEDICAL TEAM

  • Support

  • Appropriate resourcing

  • Role alignment

  • Action plan

  • Refinement

  • Repetition

Shared

Medical

Appointments

  • INTERACTIONS

  • Effective facilitator

  • Targeted education

  • Self-management support

Informed, Engaged Patients

Productive Interactions

Prepared, Proactive Medical Team

Productive, Group Interactions

ENHANCED OUTCOMES, EFFICIENCY, AND SATISFACTION

Adapted from Kirsh s, et al. Qual Saf Health Care 2007;16:349-353.


Module 2 interactive workshop building a clinic shared medical appointments action plan
Module 2 – Interactive Workshop: Practice? Building a Clinic Shared Medical Appointments Action Plan


Objectives1
Objectives Practice?

  • After completing this session, attendees will be able to:

    • Identify clinical gaps to address within their clinical practice and resultant desired outcomes

    • Identify the appropriate shared medical appointment model to use

    • Develop a Clinic Action Plan to:

      • Plan a group visit

      • Conduct a group visit

      • Evaluate a group visit


Overview1
Overview Practice?

  • Shared Medical Appointments fall under a general category of Group Visits:

    • Group Visits also include Group Medical Appointments, and Group Patient Visits. Sometimes the terms are used interchangeably; all have some similar principles


Agenda1
Agenda Practice?

Shared Medical Appointments Presentation

  • Brief introduction to Shared Medical Appointments (recap of Module 1) (15 minutes)

    Workshop- Building a Clinic SMA Action Plan

  • Step 1: Assessing Needs – Clinic and Patients (10 minutes)

  • Step 2: Creating a Plan of Action

    • Patient Group Needs (10 minutes)

    • Identifying YOUR clinic purpose or improvement goals? (5 minutes)

    • Building your FIRST SMA agenda (15 minutes)

    • How will you determine success? (10 minutes)

    • Team Roles & Responsibilities in Planning your SMA (10 minutes)

      Group Discussion and General Feedback

    • Group Discussion (10 minutes)

    • Summary and measure effectiveness (5 minutes)


Implementation process1
Implementation Process Practice?

identify and plan ahead for change, analyze and predict the results

PLAN:

DO:

STUDY:

ACT:

execute the plan, taking small steps in controlled circumstances

check and study the results

take action to improve the process

The process is flexible…….Engage in continual planning, studying and refining at all stages


Planning shared medical appointments1
Planning Shared Medical Appointments Practice?

  • Know your Practice and Your Patients

  • Select the Appropriate Shared Medical Appointment Model

  • Create an Action Plan


Know your practice and your patients
Know Your Practice and Your Patients Practice?

  • Does your clinic have a Patient Registry?

    • A registry is a very important step in patient management

    • EMR systems - registry is populated via data search

      • Clinical outcomes (e.g. HbA1c >7%; BP >130/80 etc.)

    • Manual registries - tracking patients via commercially available spreadsheets

      • Populated by chart review, when lab results are received, at diagnosis of a chronic disease (e.g. diabetes) etc.

      • For info: www.aafp.org/fpm/2006/0400/p47.html1

Oritz, p. 51


Conduct a clinic needs assessment know your practice and your patients
Conduct a Clinic Needs Assessment Practice? Know Your Practice and Your Patients

  • Know the patients in your practice and their care needs

  • Identify your Priority Population

    • Define characteristics of your unique patient list

    • Determine patients with chronic conditions

    • Identify priority target populations


Conduct a clinic needs assessment know your practice and your patients1
Conduct a Clinic Needs Assessment Practice? Know Your Practice and Your Patients

  • Identify need for improved practice efficiency

    • Are there gaps in care you would like to address?

    • What specific goals could be addressed or accomplished through Shared Medical Appointments?

  • Identify your priority patient groups

    • What are the Top 10 Conditions patients visited your clinic for in the past year?

    • What was the frequency of those visits?

    • Are you successful with Comprehensive Care or other similar plan implementation and follow up?





Create an action plan
Create an Action Plan Practice?

  • Action Plan is a detailed summary of steps to be accomplished and allows you to analyze and predict results

  • Plan Includes:

    • Shared Medical Appointment details:

      • Goals and objectives

      • Identification of specific patient group

      • Frequency

    • Specific Action Plan:

      • Tasks

      • Resources and roles

      • Determine what to measure



Conducting shared medical appointments2
Conducting Shared Medical Appointments Practice?

  • Patients

    • Identify specific patients within your “priority patient group”

  • Invitations

  • Resources

    • Identify and organize resources

  • The Visit


Measurement and evaluation1
Measurement and Evaluation Practice?

What to measure to assess benefit of SMAs?

  • Practice Utilization:

    • Demand for one-on-one appointments

    • Reduced waiting times

    • Medical team satisfaction

  • Clinical Outcomes:

    • % patients meeting clinical guidelines

    • Increased patient self-management and satisfaction

    • Patients’ commitment to Complex Care or other similar plan

    • Pre/post medical tests (e.g.: HbA1c, BP, Lipids etc.)

    • Reduced utilization of ER/hospital admissions

Don’t try to measure everything…..start with small steps such as vital signs and key lab work.


Refine and repeat1
Refine and Repeat Practice?

  • Planning More Shared Medical Appointments

Did the chosen model work?

YES

NO

Expand SMAs to other patients, perhaps with more complex conditions and comorbidities

  • Revise the model

  • Work with the same patient group before expanding


Shared medical appointment workshop
Shared Medical Appointment Workshop Practice?

  • Divide into groups, preferably with your clinic team

  • You will have 60 minutes to discuss/prepare an action plan as a group

  • You may want to designate a ‘note-taker’


Shared medical appointments workshop your task
Shared Medical Appointments Workshop – Your Task Practice?

  • Step 1: Assessing Needs - Clinic and Patients:

    • Review the two assessment forms provided to reflect on YOUR clinic’s needs and gaps (10 minutes)

    • You will use these forms when you return to your clinic

  • Step 2- Creating a Plan of Action for sample data

    • Patient Group Needs (10 minutes)

    • Identifying YOUR clinic purpose or improvement goals? (5 minutes)

    • Building your SMA agenda (using one of the provided case examples) (15 minutes)

    • How will you determine success? (10 minutes)

    • Team Roles & Responsibilities in Planning your SMA (10 minutes)

  • Reconvene with the entire group to share outcomes

    • Group discussion (10 minutes)

    • Summary and measure effectiveness (5 minutes)

  • The Resource and Reference Guide includes all key information and the appropriate pages are referenced for each step




    Group discussion
    Group Discussion Practice?


    Summary
    Summary Practice?


    Shared medical appointments2
    Shared Medical Appointments Practice?

    • Evidence supports enhanced clinical and practice-related outcomes

    • Structured approach

    • Productive group interactions are the key to success

    • Win-win for patients and practices


    Further references and resources
    Further References and Resources Practice?

    • The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. The PDCA was modified by Edwards Deming to become the PDSA. Deming WE. The New Economics for Industry, Government and Education. Cambridge, MA: the MIT Press. 2000.

    • The Institute for Health Improvementwww.ihi.org/IHI/Topics/chronicConditions/all conditions/tools/groupVisitStartKit.htm

    • BC Medical Association. Introducing group visits information support packagewww.practicesupport.bc.ca