Shared Medical Appointments and Their Effects on Achieving Diabetes Mellitus Goals in a Veteran Population
In 2012, 9.3% of the U.S. population had diabetes mellitus (DM).1 According to the American Diabetes Association, in 2012, the total cost of diagnosed DM in the U.S. was $245 billion.2 Diabetes mellitus is a leading cause of blindness, end-stage renal disease, and amputation in the U.S.3 Up to 80% of patients with DM will develop or die of macrovascular disease, such as heart attack or stroke.3
Diabetes mellitus is a chronic disease of epidemic proportion with management complexity that threatens to overwhelm providers in the acute care and primary care settings. Limited specialist availability and increased wait times continue to afflict the VA health care system, prompting efforts to increase health care provider (HCP) access and improve clinic efficiency.4 One of the methods proposed to increase HCP access and maximize clinic efficiency is the shared medical appointment (SMA).5,6
The SMA was designed to improve access and quality of care through enhanced education and support. With the number of people living with chronic diseases on the rise, the current patient-provider model is unrealistic in today’s health care environment. Shared medical appointments offer a unique format for providing evidence-based chronic disease management in which patients and a multidisciplinary team of providers collaborate toward education, discussion, and medication management in a supportive environment.7 Research has suggested that SMAs are a successful way to manage type 2 DM (T2DM).8,9 However, there is uncertainty regarding the optimal model design. The goals of this study were to evaluate whether the diabetes SMA at the Adam Benjamin, Jr. (ABJ) community-based outpatient clinic (CBOC) was an effective practice model for achieving improvements in glycemic control and to use subgroup analyses to elucidate unique characteristics about SMAs that may have been correlated with clinical success. This study may provide valuable information for other facilities considering SMAs.
Overview
The Jesse Brown VAMC (JBVAMC) and the ABJ CBOC implemented a T2DM-focused SMA in 2011. The ABJ CBOC multidisciplinary SMA team consisted of a medical administration service clerk, a registered dietician, a certified DM educator, a registered nurse, a nurse practitioner (NP), and a clinical pharmacy specialist (CPS). This team collaborated to deliver high-quality care to patients with poorly controlled T2DM to improve their glycemic control as well as clinical knowledge of their disease. A private conference room at the ABJ CBOC served as the location for the SMAs. This room was divided into 2 adjacent areas: One area with tables was organized in a semicircle to promote group discussion as well as minimize isolated conversations; the other area had computer terminals to facilitate individualized medication management. Other equipment included a scale for obtaining patient weights and various audio-visual devices.
The ABJ CBOC offered monthly SMAs. The team made several attempts to maximize SMA show rates, as previous studies indicated that low SMA show rates were a barrier to success.3,4,7-9 One review reported no-show rates as high as 70% in certain group visit models.4 About 2 weeks prior to a session, prospective SMA patients received automated and customized preappointment letters. Automated and customized phone call reminders were made to prospective SMA patients a few days before each session. As many as 18 patients participated in a single ABJ SMA.
The ABJ SMAs lasted from 60 to 90 minutes, depending on the level of patient participation and the size of the group. The first half of the SMA was dedicated to a group discussion, which involved the SMA team, the patient, and the patient’s family (if desired). The topic of conversation was typically guided by patient curiosity and knowledge deficits in a spontaneous and free-flowing manner; for this reason, these sessions were considered to be open.
The team also engaged in more structured focused sessions, which limited the spontaneous flow of conservation and narrowed the scope to provide targeted education about various aspects of T2DM care. During focused sessions, services such as dental, optometry, podiatry, MOVE! (a VA self-management weight reduction program), and nutrition also participated. Focused sessions addressed topics such as hypoglycemia management, eating around the holidays, sick-day management of T2DM, grocery shopping, exercise, oral health, eye care, and foot care. The specialty services were encouraged to be creative and interactive during the SMA. Many of these services used supportive literature, demonstrations, diagrams, and props to enrich the educational experience. Group discussion typically lasted 30 to 40 minutes; after which patients met individually with either a CPS or NP for medication management.
Medication management focused on optimizing T2DM therapy (both oral and injectable) to improve glycemic control. Interventions outside of T2DM therapy (eg, cholesterol, hypertension, and other risk reduction modalities) were not made, due to time constraints. Once a patient demonstrated improved working knowledge of T2DM and a clinically significant reduction in their glycosylated hemoglobin A1c (A1c) they were discharged from SMAs at the discretion of the SMA team. There was no set minimum or maximum duration for the SMAs.
