• Shared Medical Appointments Improve Access, Quality, and Efficiency

    Daniel Bouland and Richard Siegrist Apr 25, 2013

    By delivering a high level of patient education and instilling a sense of community among group members, shared medical appointments at UC San Diego Health System are helping patients learn new ways of taking control of their health conditions. 

    UC San Diego Health System staffA woman broke down after she recognized her poor laboratory results among the set of eight numbers that a physician specialist wrote on a large whiteboard. She expressed concerns about how she would take care of her family during her medical treatment and how to cope with such overwhelming circumstances. The other seven patients in the room instantly chimed in, saying that they had been in the woman’s shoes and offered words of empathy and encouragement. 

    This isn’t a support group, although a casual observer might think so. It’s a shared medical appointment at the UC San Diego Health System, which treats multiple patients at the same time in a supportive group setting. When properly conceived and executed, shared medical appointments have the potential to better leverage existing resources, improve access to medical care, increase capacity and quality, enhance productivity, and strengthen a healthcare organization’s bottom line.

    The approach may also ease the looming primary care physician shortage. The United States will need approximately 52,000 more primary care physicians by 2025 to accommodate population growth, an increase in the number of senior patients, and newly insured patients as a result of coverage expansion through the Affordable Care Act, according to data reported in “Projecting U.S. Primary Care Physician Workforce Needs: 2010-2025,” Annals of Family Medicine.

    A Sense of Community Is Created

    Three active shared medical appointment programs are in place at UC San Diego for diabetes, liver disease, and HIV/AIDS, with other specialized groups planned for the future. In a group setting of eight to 14 patients, the physician tends to the medical needs of each patient one at a time. This is done in front of the entire group, with the support of a team of healthcare providers. Often, a portion of the exam involves the need for privacy, in which case the doctor and patient repair to an adjacent room.

    Patients are checked in by a medical assistant and sign a confidentiality agreement. The 90-minute session formally begins when the physician arrives. A facilitator—often a behaviorist, social worker, or nurse—helps lead the session and encourages discussion. A nurse takes medical notes and assists the physician. A scheduler is also available as needed.

    “The result is that patients are no longer isolated by their chronic diseases,” says John Fontanesi, PhD, director of UC San Diego’s Center for Management Science in Health. It’s common for patients in shared medical appointments to report problems, such as tracking medications or controlling blood sugars, and for other patients to share how they also struggle with those issues and what they are doing to cope, he says.

    Nina Krishun, RN, who spent eight years in human resources before switching to nursing, was chosen to be the facilitator for UC San Diego liver disease shared medical appointments, which include patients who are about to have a transplant or are recovering from one. “When the physician is done examining patients and is working on notes, I lead a group discussion. Most of the time, we talk about tips and tricks patients use related to lifestyle, exercise, diet, and goal-setting. Patients are so excited by the end of a session that they are exchanging phone numbers. That is what is so unique about the model; it creates a sense of community.”  

    Patient Makeup Varies

    Each shared medical appointment at UC San Diego differs based on the nature of the patient population and physician preferences. For example, the HIV/AIDS sessions have multiple races, ethnicities, genders, sexual orientations, and age ranges in the room. “The diversity of the group represents my real-life practice,” says Amy Sitapati, MD, who is nationally recognized for her work to improve the quality of life for people living with HIV.

    The diabetes appointments, led by Steven V. Edelman, MD, an expert on diabetes education and founder of the not-for-profit organization Taking Control of Your Diabetes, have taken the opposite approach. “In choosing people for the shared medical appointments, I looked at all my patients and I separated out those with Type 1 diabetics from those with Type 2 and separated men from women. I also tried to pick people from the same age groups. The more homogenous the group, the more people are going to feel comfortable talking about sensitive issues,” he says.

    Sitapati says the biggest challenge for her has been the complexity of her patients’ care. Her practice delivers primary care plus chronic disease management for conditions such as congestive heart failure, plus the HIV component. “The average patient is on at least seven medications, and we have at least 22 prevention activities we have to run through. So how do you get all those drugs and tests ordered and reconciled in 90 minutes with that many patients?”

    Having said that, Sitapati says she “loves shared medical appointments” and believes the team approach in a group setting helps physicians efficiently deliver primary care. 

    Outcomes Improve

    Shared medical appointments may also deliver a higher quality of care than solo appointments. A 2001 study found that group visits reduced emergency department (ED) visits among seniors with chronic illness. Only 34.9 percent of group visit participants visited the ED at least once over a two-year period, compared to 52.4 percent of controls (Coleman E.A., et al, “Reducing Emergency Visits in Older Adults with Chronic Illness. A Randomized, Controlled Trial of Group Visits,” Effective Clinical Practice, March-April 2001, vol. 4. no. 2, pp. 49-57).

    In another 2007 study, expectant mothers assigned to group care were 33 percent less likely to have preterm births compared with those in standard care: 9.8 percent compared with 13.8 percent, with no differences in age, parity, education, or income (Ickovics, J.R., et al, “Group Prenatal Care and Perinatal Outcomes: A Randomized Controlled Trial,” Obstetrics and Gynecology, August 2007, vol. 110, no. 2, part 1, pp. 330–39).

    And a five-year study in Italy found diabetic patients in group-visit programs had better control of their disease and took less medicine than those who had private appointments (Trento M., et al, “A 5-Year Randomized Controlled Study of Learning, Problem Solving Ability, and Quality of Life Modifications in People with Type 2 Diabetes Managed by Group Care,” Diabetes Care 2004; 27: 670–5).

    One reason for these successful results is the high level of education patients receive, Edelman says. Patients share their experiences with their continuous glucose monitors, the features of their insulin pumps, and how they manage their exercise regimens.

    Many patients also prefer shared medical appointments. Approximately 85 percent of Cleveland Clinic patients participating in the shared appointments canceled their future solo appointments in favor of shared visits. In addition, the percentage of patients rating their overall satisfaction with their physician visits as excellent was much higher for shared visits (75 percent) than for individual office visits with the same providers (63 percent).  

    Capacity Frees Up

    The business case for shared medical appointments is one of capacity, says Zeev Neuwirth, MD, chief medical officer and senior vice president, Physician Services Group, Carolinas Healthcare System, which has also adopted shared medical appointments. “Your physicians are a limited resource. If they are able to see 12 patients in a shared appointment, and hold two shared appointments in a half-day session, they can literally double the number of patients they can see. This increases capacity, which allows for the ability to grow market share.”

    Greater access to care is another competitive advantage, he says. Instead of a patient calling in for follow-up care and being told that the wait is eight weeks, the patient might be able to find a drop-in appointment that same afternoon. 

    Success Depends on the Right Process

    The number of physicians conducting shared medical appointments more than doubled between 2005 and 2010, according to the American Academy of Family Physicians. In 2005, approximately 5.7 percent of family physicians implemented shared medical appointments, compared to 12.7 percent in 2010. Health systems that now offer group visits include Carolinas Healthcare System, Harvard Vanguard Medical Associates, Cleveland Clinic, Kaiser Permanente, Sutter Health, and the Veterans Health Administration.

    Despite this growth, shared medical appointments remain a challenge to implement. Healthcare providers can establish their own programs, but most will fail, Neuwirth says. “They are hard to put together and even harder to sustain, unless you know what you are doing. You need rigor in the process.” The following assessment tool is designed to assist providers in deciding whether shared medical appointments are a viable option for their facilities.

    UC San Diego began by reaching out to physician leaders of every clinical area to identify physician champions for shared medical appointments. Without engaged physicians, no program can succeed.

    A consulting firm that specializes in developing shared medical appointment programs helped UC San Diego apply an assessment tool with 16 weighted criteria in three major domains, including patient factors (e.g., a chronically ill population), staff factors (e.g., an enthusiastic physician sponsor) and organizational factors (e.g., strong administration support). Ten clinical areas were scored, and three priorities emerged—AIDS/HIV, diabetes, and liver disease. After the teams were assembled, the firm provided training and conducted mock shared appointments, with role-playing and practice for live sessions.

    The following is an example of an assessment tool designed to assist providers in deciding whether shared medical appointments are a viable option for their facilities. 

    Exhibit 1 SMA Assessment Tool

    The program at UC San Diego has been a resounding success. However, shared medical appointments aren’t for everyone. Younger, healthy people may not find shared appointments beneficial. In addition, some medical conditions don’t require repeated follow-up appointments that are the basis for the shared medical appointment model. But for those with chronic conditions who can benefit from group education and interaction with others in a similar situation, shared appointments present golden opportunities.

    Daniel Bouland, MD, MS, is vice chair for clinical operations, Department of Medicine, UC San Diego Health System.
    Richard Siegrist, MBA, MS, CPA, is president & CEO, Cambria Health, Concord, Mass.