It is 9 AM on Thursday morning. A patient with systolic heart failure dejectedly hangs up his telephone. He wonders how he is supposed to take care of himself and manage his heart failure if he can never get into the doctor's office. His weight is starting to increase, he is running out of pills, and he received laboratory results from the office but does not know what they mean. He questions whether he needs to find a different doctor, one who has time for him. At the same time, an internal medicine nurse practitioner (NP) looked over her schedule and noted that today, like most days, she was heavily booked. In addition, she heard the secretary inform a patient that he would have to wait 2 months for a follow-up appointment.
Since practicing independently in a NP role, the amount of time allotted per patient decreased from 30 to 15 minutes because of an increased number of patients with chronic disease who require frequent monitoring and administrative duties that compete with patient appointments. Like the patient example above, the NP is frustrated with the limited time per visit and less visits overall, because the patient's care plan and opportunities for education that promote heart failure self-care may not be optimized. The patient and NP in this fictional case study might experience less frustration and better outcomes by using a shared medical appointment (SMA) model.
In today's evolving healthcare environment, there is a rapidly increasing number of individuals living with multisystem dysfunction and complications of advanced cardiac conditions. The traditional 15-minute visit format once every few months designed to treat acute illnesses (ie, episodic approach) is unrealistic. The SMA is gaining popularity because it may improve patient access and knowledge as well as increase provider productivity and efficiency.
The purposes of this article were to define an SMA, describe components of an SMA, and demonstrate how this innovative practice can effectively be used to improve physiological, psychological, and social outcomes of people with chronic cardiac disease. This article will outline patient selection for group membership, describe how SMAs are conducted, and demonstrate how an SMA model successfully increases patient health and caregiver productivity in terms of access, outcomes, and satisfaction.
Although the concept of a group appointment has been used for many years, the terminology shared medical appointment was originally developed in 1996 by Dr Edward Noffsinger, a psychologist at Kaiser Permanente of Northern California, to improve quality of care and access for patients. First attempts used a "drop-in" format; however, now most appointments are scheduled. To date, an SMA model is promoted by many large practices, hospital systems, and teaching facilities to manage a wide range of chronic conditions including diabetes, hypertension, chronic obstructive pulmonary disease, asthma, hyperlipidemia, obesity, and pain.1
By definition, an SMA is a series of one-on-one patient encounters conducted simultaneously in a group setting. There are multiple formats (1) disease-specific groups focusing on follow-up care designed to aid chronic disease management, (2) annual physical examinations, or (3) drop-in format for follow-up care without an intended focus on a particular disease.2 In each, 6 to 12 established patients meet for 90 to 120 minutes with a multidisciplinary team that generally includes the patients' healthcare provider (physician or NP), a registered nurse (RN), a medical assistant, and a behavioral health specialist. Although all group participants are listening, the physician speaks with each patient individually about their health issues, diagnostic results, and prescription needs. Patients may be examined privately or in the presence of the group. Whereas the provider is documenting assessment findings, the nurse or behaviorist creates an interactive setting with open discussion focusing on disease education, problem solving, self-management, and patient concerns. In reality, although 7 to 10 minutes are spent with each patient, there is an added benefit because each member hears the questions, advice, and management for the rest of the group. Although the SMA model has its roots in primary care, similar appointments can be offered in the milieu of specialty care for patients sharing similar medical conditions.
Rationale for Success of SMAs
The success of SMAs may be explained by the principles of group psychotherapy completed by Irvin Yalom in 1995.3 In groups, a sense of community is fostered, and the community offers support and acceptance to one another. Members can express feelings and challenges, observe others' responses to situations, and give/receive constructive feedback. Yalom described 11 "curative factors" or interpersonal experiences that promoted well-being, competence, and productivity of participants in a group. Many of these factors can be directly and indirectly applied to an SMA involving patients with a chronic cardiac disease (Figure 1).3,4
Outcomes of an SMA Model
Chronic cardiovascular diseases, such as hypertension, coronary artery disease, dysrhythmias, heart failure, stroke, and valvular disease, are the leading cause of morbidity and mortality in the United States. Affecting more than 90 million individuals, chronic diseases account for 70% of all deaths in the United States each year and consume 75% of the nation's medical care costs.5 By definition, a chronic disease has an insidious onset, multiple risk factors, and a long latency period. The threat of exacerbations, functional decline, higher healthcare costs, and increased morbidity and mortality is far greater than that of acute illnesses.6 Complexities of chronic cardiac diseases are difficult to address at individual appointments because of access constraints. Psychological burdens and self-management are important reasons for treatment failure reported by patients and providers.7 Those who may benefit most from an SMA format are patients with chronic cardiac diseases requiring frequent follow-up, education, and encouragement to remain healthy and decrease morbidity. The SMA model provides potential benefits for both patients and healthcare providers (Figure 2).8-10 In addition, benefits to patients and providers with respect to access, outcomes, and satisfaction have been described in the literature.
Improved Patient Access
Researchers demonstrated that 33% of Medicare beneficiaries perceived that the barrier to healthcare was not financial but rather lack of provider responsiveness to concerns. Positive correlations were found between provider accessibility and patient satisfaction and between patient satisfaction and improved health outcomes.11 Researchers explored the wait time for a physician with a significantly backlogged schedule and found an improvement from 57.7 days for new patients and 50 days for former patients to 25 days for new patients (P =.0046) and 20.3 days for former patients (P =.06).7 In low-income women, researchers revealed that 69% stated that they had greater access to medication refills and examinations with an SMA format. Furthermore, group visits represented a cost-effective alternative to traditional visits or more costly urgent care.12 Improved access was also demonstrated in patients treated for erectile dysfunction at a Veterans Affairs medical center who were referred to a pharmacist-led group meeting focusing on adverse effects of the drug, sildenafil. In 264 patients seen over 1 year, wait times decreased from 3 months to 3 weeks.13
Enhanced outcomes of SMAs include increased knowledge and self-management, decreased symptoms, and an overall better quality of life. When group visits were provided to patients with inadequate insurance and type 2 diabetes, emergency room visits were significantly reduced.14 Other researchers also found a reduction in emergency care services after implementation of an SMA15,16; however, it was unclear if improvements were due to increased access or improved patient knowledge, adherence to the plan of care, physician attention to meeting patient needs related to symptoms, or some other aspect of care. In a 24-month trial of patients with type 2 diabetes, those in a group model had less disability days and better general health status.15 In 112 patients with type 2 diabetes randomly assigned to traditional appointments or group visits, those selected for group visits had greater improvement in mean hemoglobin A1C than those who secured traditional appointments (hemoglobin A1C 7% vs 8.6%, respectively).17 Subjects in the group visit also decreased body weight by an average 2.6 kg compared with control patients who had a 0.9-kg weight loss. In addition, patients in the group model decreased use of hypoglycemic agents and had marked increases in problem-solving ability, quality of life, and diabetes knowledge.18 When researchers compared the effectiveness of an SMA model for chronically ill health maintenance organization patients with traditional care, group participants with monthly meetings had fewer hospital admissions, used fewer professional services, and accrued less costs per month over 2 years than those receiving traditional care.16 In patients with heart failure, an SMA significantly improved postintervention knowledge scores (P = .038) and improved self-care (P = .042) compared with patients who received one-on-one care.8 In patients with chronic obstructive pulmonary disease, researchers found significantly increased exercise tolerance after SMAs compared with patients managed by traditional office visits. Researchers concluded that improved exercise tolerance decreased symptoms and promoted a better quality of life in patients with chronic disease.3
Improved Patient Satisfaction
Patient satisfaction may be associated with SMAs because patients are able to spend more time with providers in an interactive, supportive environment on a voluntary basis. A group format may provide comfort and encouragement in frustrating situations. Patients seem willing, even excited, to participate in the SMA format. Researchers found that although patients received 7 to 8 minutes of individual attention on average, most felt that their questions were answered and fears were eased after listening and learning from other patients' examinations and treatments. Patients reported they felt more relaxed and were more willing to share personal information because others had the same issues.9 Of patients seen in group visits, there was a trend toward improved satisfaction as evidenced by 85% choosing another group meeting in lieu of a private appointment and 79% remarking that the group format was excellent.1 Patients participating in a group outpatient model reported greater satisfaction with their primary care physician, better quality of life, increased knowledge, and greater self-efficacy than those receiving usual one-on-one care.16 Similarly, patients with chronic obstructive pulmonary disease in the group model established a sense of belonging and cohesiveness, demonstrating support for the success of their peers and aspiration to accomplish their own goals.3 When investigators explored willingness of underserved patients to attend group visits for hypertension treatment, 80% of patients surveyed were willing to attend a group medical visit.19 Patients who participated in an SMA scheduled a subsequent SMA (91%) and indicated they would recommend SMAs (96%).7
Finally, Jaber et al20 published a qualitative review of evaluative research on group visits between 1974 and 2004. Although researchers found multiplicity of outcomes and suboutcomes (different aspects of access, enhanced services, and patient satisfaction), heterogeneity between studies made it difficult to evaluate the strength of the evidence. Based on a review of 17 reports, researchers found sufficient data to support the following benefits of SMAs: improved patient and physician satisfaction, improved quality of care, improved patient quality of life, decreased specialist visits, and decreased emergency care.20
Of note, not all outcomes studied by researchers were realized in a group visit format. In chronically ill older patients, health status and activities of daily living did not differ over a 2-year period of study between groups.16 In patient with type 2 diabetes, there was a nonsignificant trend of better coordination of care, better community orientation, and more culturally competent care in patients randomly assigned to receive group visits.21 In patients with coronary artery disease, group sessions focusing on a dietary intervention had clinical benefits, but there were no differences in costs between the control and intervention groups.22
The "How" of the SMA
In addition to patient characteristics previously discussed, patients most appropriate for an SMA should have a strong interest in participating in a group setting. Enrollment is conducted during a personal invitation by the provider during a traditional one-on-one visit, by mailed descriptive brochure, or by office staff trained in the recruitment process. Participants may be of either sex and of any age or race or have any disease severity, as long as they share a chronic illness, for example, heart failure.
In most literature on SMAs, the history and examination portion of the meeting are completed by a physician, with the NP as the "behaviorist" or educator.1,7,9 Although a multidisciplinary healthcare approach is one option, an SMA model provides a remarkable clinical opportunity for NPs to continue changing and advancing their roles as primary care providers. Thus, appointments can be executed exclusively by NPs. For example, an NP might perform the history taking and examination, alongside an RN who records findings, or a team of NPs may work together, performing assessments and leading groups in educational discussions. Because NPs are independent, cost-effective, and competent managers of chronic diseases,23 they carry out valuable roles in the SMA by providing education, addressing psychosocial and lifestyle issues, and autonomously coordinating plans of care.24 A clinical team might consist of a physician/NP to collect data on medical background and history of present illness, physical examination, treatment, and documentation. An RN would educate patients and maintain flow of meetings. A medical assistant would collect vital signs and prepare charts. A secretary would enroll and check in patients, and a billing specialist would oversee insurance and payment issues.
To maximize efficiency, healthcare team members conduct a previsit chart review for each patient. A thorough evaluation of pertinent laboratory work or testing can be identified and obtained prior to the meeting to facilitate the flow of the visit. Patients and guests must respect the confidentiality of healthcare information shared by others participating in the group. A Health Insurance Portability and Accountability Act statement of confidentiality must be signed by all group members prior to the first visit. Patients are also expected to prepare for each meeting by formulating a list of questions and concerns to be addressed by staff and other participants. Figure 3 describes in detail the time line of the preparation process.
Facilitating the Group Meeting
Each meeting is conducted on the same day every month (eg, second Monday) during a regular clinic day for a 2-hour period. Shared medical appointments are open discussion formats focusing only on matters concerning the medical condition itself or other related matters that reflect topics that are truly shared by most group members. Table 1 describes a 2-hour meeting agenda. Figure 4 describes pertinent educational content with an example of themes specific to heart failure.
An SMA is not a class or seminar, but an actual office visit. Many insurance companies do not reimburse for group visits. Because the same documentation for individual appointments is required for group visits (ie, history, physical examination, vitals signs, laboratory testing, plan), it is possible to bill each patient according to the Current Procedural Terminology code based on the level of care provided. It is not advisable to bill according to time spent with patients.25
Although the majority of the literature provides advantages of SMAs, challenges may arise for patients or healthcare providers. It may be difficult for patients to understand this modern style of visit (versus a traditional appointment), and initially, patients may feel discouraged from participating. If nonparticipation persists, patient volume may decrease, which may jeopardize cost-effectiveness and group benefits. Patients may have varying levels of comfort regarding sharing personal information with a group of strangers. Learning to effectively deal with sharing confidential and personal health information can be tricky in the initial phases of appointments. Reassuring patients about confidentiality can build participation. Healthcare providers may need to develop creative ways to encourage patients that an SMA is worth trying at least once.
Future Directions for SMA
In the future, it may be beneficial to design research that examines predictors of continued participation in an SMA over time or predictors of trying an SMA approach over traditional care for the first time. Results would help healthcare providers determine the best candidates for this model and facilitate new research on how to expand attendance. Learning the rationale for dropout over time would provide valuable information to providers about the natural course for group visits and if there should be a planned number of sessions from the outset. If patients knew that each SMA would build on the last in terms of knowledge about their condition and self-care expectations, they may be more likely to continue the course of sessions.
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In summary, this article provides healthcare providers and patients with the background and rationale for successful implementation and participation in SMAs. Benefits of an SMA model such as improved patient access and satisfaction, enhanced health outcomes, and increased provider productivity are described. We provide practical examples for preparing an SMA including patient and team member selection, necessary components, agenda, time line, educational content themes, and billing. Possible challenges and ideas for future directions for SMAs were highlighted.
The authors thank Jackie Owens, MSN; Susan Busch, MSN, CNP; and Nancy Albert, PhD, CCNS, CCRN.
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