shared medical

Healthcare Reform

Better Than One-On-One? An Introduction to Shared Medical Appointments

, , , ,

shared medical

Grouping patients by chronic conditions might be the next leap forward to improve patient care and maximize doctors’ time management.

“Shared Medical Appointments” (SMA), in which patients gather for doctor’s appointments in a group, with up to a dozen who usually share a chronic condition or some other common medical concern, have been popping up in media outlets like Time Magazine and in scientific journals lately.

To learn more, we spoke to Dr. Marianne Sumego, Director of the SMA program at the Cleveland Clinic, one of the first practices to embrace the model. There, groups meet with two providers – a physician or nurse practitioner, and a second person called a ”facilitator” who brings an extra dimension of expertise. For diabetes groups, the facilitator is often a nutritionist.

The 90-minute meetings include the usual exams and medication and symptom updates, as in a regular appointment, plus a group discussion of progress, management, and answers to any questions the group might have. The appointments can be weekly, monthly, or less often depending on the highlighted medical condition.

It’s really about being efficient with the patients who have common needs and common ground, and by doing that you’re opening up access for new patients to get in. 

We asked Sumego about the role technology plays in the appointments, how the trend is spreading and how she responds to privacy concerns.

Q: This is a relatively new model; Cleveland Clinic started its program 10 years ago. How did you become involved?

I am an internal medicine pediatric physician and I joined the Clinic in 1996. In 1999 my direcor heard an expert speak about alternative care models and he was really intrigued by the whole concept, so he started getting us up and running. My director at the time and I were the first two that helped get SMAs up and running in Cleveland.

Over the last 10 years we have been lucky and gotten great feedback from our patients, so in 2010, under (Cleveland Clinic CEO) Dr. Cosgrove, we really decided to commit to this model and expand the offerings and diseases we cover. We’ve reached out to a number of disease groups and created shared medical appointments around them based on the benefits we thought patients would see.

Q: What are those benefits?

If you’re seeing 10 patients over 90 minutes, that’s not something I would do effectively one-on-one. Take something like asthma. Not having to talk about something like asthma control ten times but to say it once so it applies to five or six people, it really creates efficiency within the model.

It’s really about being efficient with the patients who have common needs and common ground, and by doing that you’re opening up access for new patients to get in.

When it’s 90 minutes of full medical information about your asthma or diabetes, and your typical visit might be 15 minutes, patients are really getting more out of it. That’s what’s really attractive about the concept.

Q: So it functions like a seminar conversation?

It’s a medical visit. If I were to see you for a regular visit, we go through your labs, your refills, see if you are having any side effects. We do the exact same thing, so you’re getting your entire visit and then some, because someone else might ask a question you hadn’t even thought of. There’s all kinds of added benefits from the patients who are also participating.

Q: How do patients get involved with SMA at Cleveland Clinic?

We have several SMAs, like with asthma, where anybody that’s interested in their asthma management, self-management and better understanding, they are welcome to come to the SMA. We’re not going to turn anyone away. We have wellness SMAs, which teaches them what prevention looks like and what they need to do to be healthier.

A few patients are not selected for shared medical. Those are patients who do not speak English very well or are hard of hearing. In a group setting, they need to understand what everyone in the room is saying, including the physician and facilitator.

Q: Does SMA align with healthcare reform, since the Affordable Care Act encourages more collaborative care models?

Healthcare reform is about putting all the resources on the same page and letting the patient have access to all of them. This person may have had an endocrinologist and a primary care physician, now they’ve also had a diabetes focused visit with access to a nutritionist.

By the third or fourth time, they’re really starting to hear the same information over and over about what good diabetes care is, and we’re closing the loop. Here we’re on electronic medical records, so we send those charts back to the primary care doctors. That way everyone knows the patient was seen, what transpired, if there was a change in plan.

It’s collaborative for patients and providers.

Q: Providers often tell us about the challenges of time-consuming data entry. Do you encounter those challenges using EHRs, especially when you see more than one patient at once?

You do, but I have to tell you, we encountered more challenges on paper, and we sort of forget that.

We do this as a process. We walk through what data that doc is going to need, what is the pertinent medical information, and we decide together whether that should go in the questionnaire or in the body of the note. You just have to work with your own documentation and embed that in, so that some information in the EHR can pull out automatically. If you’re designing your templates to do that, it’s actually easier.

It’s a challenge, but you just have to think through it. Adding your team to that discussion really helps. There are so many medical assistants and RNs that are looking for ways to be incorporated into the practice, and some of this information can be gained and entered by the staff.

Q: How else do you use technology in your SMAs?

A lot of it is focused on data sharing, so we will put up on a monitor our patients’ numbers, where their cholesterol and glucose are, where their blood pressure is. We put those numbers up in a way that our patients can easily see them and compare them to one another.

I do think there’s a lot of opportunity to send chart messages, reaching out proactively and gathering information ahead of time. That’s one of the directions we are going to alleviate some of the challenges. Certainly using our charting to proactively reach out to patients so they return some of these questionnaires ahead of time.

Q: Are there privacy concerns, when displaying medical information to everyone in the room?

We’re not actually sharing the chart. Because of HIPAA, we don’t share last names, only first names. We display first names in columns alongside their numbers. It really puts things in perspective to look at your glucose level and see if yours is borderline.

The physician or facilitator makes clear that this is a medical appointment, a place that is safe and secure to share information. Then, as we go through, we are very sensitive to the information we put up. We have weight management SMAs, and we’ve experimented and gotten feedback from the patients to see what it felt like to see their BMI weight up there on the screen. Did percent change numbers feel better because at least your absolute number wasn’t up there but you could share successes with each other?

There’s some sensitivity, but it’s the same sensitivity that we have when we’re in the office talking to the patient.

Q: Have you seen an increase in interest in SMA lately?

We are getting so many inquiries about how our program runs, what have been our challenges, successes, tidbits, because providers don’t want to reinvent the wheel. In an institution our size with the variety of programs we have, we reach out every day to providers in other settings to give them feedback or advice on things we have tried.

If you Google it, you start seeing a lot more about SMA. We’ve got a website, patients look at it, they get information, and often times they will call saying they saw it.

Q: How do providers go about making SMA part of their practices, if they are interested?

There’s a whole process. For a provider who’s really busy, has high demand and high volume, sees a lot of common patients, we walk through what we call our fundamental elements: How are you scheduling? What are your goals for SMA? What are you resources?

My advice is, if you are really engaged or interested, reach out to someone who has done it. It cuts the learning curve down, you can share experiences, and get advice. That’s what I did.

Q: What do you say to physicians who are still wary of trying SMA?

The key to SMAs spreading is making sure they are done right and benefits are maximized.

Some providers might be unsure or hesitant. Physicians all take care of patients differently and have different styles. Medical care should be about more than one option for the patient.

We went in to medicine because we wanted to give more information for our patients and give them all the resources they need. If that’s still your goal, this is a great tool. Try it.