Work Smarter, Not Harder Shared Medical Appointments

1
Work Smarter, Not HarderShared Medical
Appointments

• Sylvia Fletcher, MS, FNP, CS
• Terry Wilk, MS, FNP, CS

2
Objectives

• Discuss use of Shared Medical Appointment (SMA)
  as an alternative approach in providing high
  quality , cost effective patient care
• Describe the different types of SMA and
  appropriate patient population
• Illustrate SMA currently used at a large urban
  homeless program

3
What is a Shared medical Appointment? (SMA)

• SMA simply defined as delivery of care in a group
  setting with other patients. Models include
• Cooperative Health Care Clinic Model (CHCC)
• Specialty CHCC
• Drop In Group Medical Appointments (DIGMA)
• Edward B. Noffsinger, Ph.D

4
Are all SMA created equal?

• Cooperative health care clinic (CHHC)
• Disease Specific exclusive groups that aids
  patients with common chronic disease management
• Older patients requiring frequent, broad spectrum
  care

• Drop in group medical appointment (DIGMA)
• Established patient needing follow-up or
  episodic care

5
Advantages of SMAWork Smarter Not Harder

• Each patient's unique medical needs are
  individually addressed
• 1 on 1 encounter with provider, with observers
• Improves communication, patients with provider
  for 90 minutes
• Group support and encouragement, gives patients
  balanced perspective on illness.

6
Advantages of SMA Work Smarter Not Harder

• Increases access to care, especially when
  provided as adjunct to individual office visits
• Increases efficiency, time saved minimizing
  patient movement from station to station
• Participation of a Behaviorist, usually a Medical
  Social Worker (MSW), to facilitate group process
  and to address psychosocial issues
• Billed as an individual episodic visit.

7
Who should attend an SMA?

• Routine follow-up care
• Relatively stable chronically ill patients
• High or low utilizers
• Compliant or non-compliant patients
• Extensive information/psychosocial issues
• Difficult problematic patients
• Patients needing more time and support
• Patients willing to attend (voluntary)

8
Who should NOT attend a SMA?

• Initial evaluations/one-time consults
• Severe psychological issues
• Serious acute infectious illnesses
• Medical emergencies
• Complex medical procedures
• Patients refusing to attend

9
HOMES Patient Population

• Homeless children and adults residing in various
  shelters and on the streets in Dallas County.
• Medical care provided at 23 sites utilizing 3
  mobile units and a fixed site clinic in downtown
  Dallas
• Appointments are all open access. Patient seen
  as they present, time, staff and space allowing

10
SMA at HOMES

• Diabetes SMA
• Disease Specific CHCC Model
• Tuesdays 900 a.m. to 1030 a.m.
• Team Members FNP, MSW, LVN, Clerk
• Group size varies 8-12 patients
• Visits open to established patients with diabetes
  , however they may have any problems addressed in
  this visit

• HOMES SMA
• DIGMA model
• Tuesday 600 p.m.-730 p.m.
• Team Members FNP, MSW, RN, clerk
• Group size varies 8-12 patients
• Visit open
• Established patient for follow-up.
• New and established patients with 1-2 routine
  problems

11
Registration

• Patients not scheduled, there is open access.
• Patient are registered by clerk and given
  confidentiality agreements
• Patient are directed to be seated in group circle

12
Intake

• Patient are escorted by nurse out of circle to
  adjacent area for vital signs and chief
  complaint.
• DM SMA random BG are obtained.
• Patient return to circle and are seated.

13
Facilitation

• Behaviorist addresses group reviewing how visit
  is conducted
• Behaviorist review confidentiality agreement
• Behaviorist manages group process, when provider
  is not addressing patients
• Behaviorist may discuss common social problems as
  well as prevention issues

14
Visit

• Provider addresses each patients problem and
  where possible educates on condition for the
  benefit of the group e.g. Flu, Hepatitis C,
  diabetic foot care
• Patient visit is conducted as an episodic visit
  in office, including exam within the group or at
  an adjacent site if privacy is an issue

15
Group Process

• Patient encouraged to stay for the duration of
  the SMA.
• Patient may be called upon to share their
  experiences with same problems.
• While provider is charting and writing Rx and lab
  request, the MSW introduces life skills topics to
  occupy the group until provider is ready to
  address next patient
• Patients may be escorted by nurse for additional
  lab work
• Patients complete Evaluation Form at completion
  of visit
• Patients are discharged

16
Team Debriefing

• Group Health Care Team completes Census and
  Debriefing Surveys
• Provider completes charting

17
Alternative Clinical Team Members

• For practices with scheduled appointments
• Scheduler (appointment clerk) is an additional
  member of the clinical team.
• Ensure census at least 10-12 patients
• Market SMA as patients register

18
Alternative Clinical Team Members

• HOMES SMA employ FNP providers, however other
  PHHS COPC SMA employ Physicians providers
• Alternative to MSW can be NP/PA

19
Is SMA Right for Your Practice?

• Not always, with the following circumstances
• Providers lacking adequate resources (time,
  staff, funding, space, etc.) needed to run the
  program
• Providers with small practices
• Providers with few or no access problems

20
Questions