Influence of shared medical appointments on patient satisfaction: a retrospective 3-year study

Characterizing primary care patient referrals and attendance patterns for virtual lifestyle medicine shared medical appointments

Objective

To better understand patient engagement in a Lifestyle Medicine Shared Medical Appointment.(LMSMA) program with Health and Wellness Coaching (HWC).

Methods

From July 2022 to June 2023, adult patients were referred to the Massachusetts General Hospital Healthy Lifestyle Program by primary care providers or self-referred in LMSMAs and HWC, both virtual programs supporting lifestyle behavior change. Demographic and clinical data extracted from electronic medical records were analyzed to assess associations with engagement using independent samples t-test, Chi-squared, Fisher exact-test, and odds ratios.

Results

In total, 1315 patients enrolled in LMSMAs and 947 (72.0 %) attended at least one session. Also, 151 patients (15.9 %) attended at least one HWC session. For LMSMAs, age was associated with higher enrollment (OR = 1.02, CI = 1.01-1.03) and attendance (OR = 1.02, CI = 1.01-1.02), male sex was associated with lower enrollment (OR = 0.64, CI = 0.48-0.87) but higher attendance (OR = 1.46, CI = 1.04-2.06). Lower education was associated with lower attendance (OR = 0.42, CI = 0.21-0.83). For HWC enrollment, male sex was associated with higher enrollment (OR = 1.96, CI = 1.19-3.41). Black race (OR = 2.90, CI = 1.36-7.60), Hispanic ethnicity (OR = 2.05, CI = 1.07-4.44), and lower education (OR = 1.71, CI = 1.20-2.46) were associated with higher HWC enrollment.

Conclusions

Primary care provider- and self-referred patients both attend LMSMAs and HWC. Both LMSMAs and HWC may reach a racially and educationally diverse subset of patients. Research is needed to better understand the role that age, sex, race, and ethnicity play in LMSMA and HWC participation.

Training providers to implement heart failure shared medical appointments: A qualitative evaluation

Shared medical appointments (SMA) help patients learn skills to self-manage chronic medical conditions. While this model of care delivery is thought to improve access to care with an efficient use of healthcare providers' time, many healthcare teams struggle to implement this healthcare model. Guidance and training resources on the implementation of SMAs is expected to improve adoption, implementation and sustainability of SMAs. Our evaluation team collaborated with the HF SMA trainer to complete a developmental formative evaluation of a two-day training program with a goal of adapting the training program and to better suit the needs and resources of healthcare teams interested in implementing HF-SMAs. Our evaluation team interviewed members of healthcare teams participating during each stage of training: pre-training, post-training, and post-implementation. The evaluation team also observed training sessions and reviewed minutes from debrief and training team meetings. Qualitative data collected from interviews, observations and document reviews were analyzed using matrix analysis with a focus on identifying potential adaptations to improve the HF-SMA training program. Data summaries were presented by the evaluation team to the training team for consideration. Training program participants found the training comprehensive, useful, and helpful; they highlighted how the trainers were experienced SMA providers who shared lessons learned. While participants found the training to be useful, opportunities for improvement, success of the virtual format and identified six adaptations: 1) the two-day training was reduced to short online modules, 2) curriculum was adapted to fit local site's needs, 3) added periodic one-on-one coaching, 4) shifted training to focus on skills and knowledge needed for each team member requirements, 5) adapted curriculum provides for more team building during premeeting assignments, and 6) training had more information included. We offer/present an improved model for a HF-SMA training program. Future studies, potentially using comparative designs to measure success and sustainability are needed.

Using the Socioecological Model to Understand Medical Staff and Older Adult Patients' Experience with Chronic Pain: A Qualitative Study in an Underserved Community Setting

Purpose

Chronic pain is highly prevalent and disabling for older adults, particularly those from underserved communities. However, there is an absence of research on how contextual (eg, community/societal) factors interact with pain for these patients. Informed by the socio-ecological model, this study aimed to elucidate the individual, interpersonal, community, and societal factors associated with chronic pain from the perceptions of older adult patients and medical staff in a community clinic.

Patients and Methods

In this qualitative study, we conducted four focus groups and two interviews with medical staff (n=25) and three focus groups and seven individual interviews with older adult patients with chronic pain (n=18). Participants were recruited using purposive sampling from an ethnically and economically diverse primary care clinic in the greater Boston community. We transcribed assessments and thematically analyzed data using a hybrid deductive-inductive approach.

Results

At the individual level, we identified three themes: (1) older adults with complex care needs, (2) impact of pain (including on physical, emotional, work, and identity functioning), and (3) coping with pain. At the interpersonal level, complex relationships with (1) social supports and (2) medical staff emerged as themes. The need for (1) resources and (2) culturally informed care was identified at the community level, and socioeconomic status impacting the availability of resources for managing chronic pain emerged for the societal domain.

Conclusion

Findings underscore the intersection of factors contributing to the experience of pain among older adults from underserved communities. Our findings highlight the need to develop and implement treatments that fully address the experience of older adults with chronic pain at the individual, interpersonal, community, and societal levels.

Insights from Team Clinic: A Person-Centered Virtual Peer Group Care Model Adapted for Marginalized and Historically Excluded Youth with Type 1 Diabetes (T1D)

BACKGROUND

Despite advancements in T1D care regimens, racially and ethnically diverse youth with low income continue to experience worse health outcomes, more psychosocial challenges, and higher barriers to care. Alternative care models are needed to address the needs of this population.

METHODS

Team Clinic is a person-centered virtual peer group (VPG) care model that was assessed in a 15-month, pragmatic randomized controlled trial. Youth (ages 10-17) and their families were assigned to study arms based on their clinician's group (standard care or person-centered care, PCC) and then randomized to VPGs or no groups.

RESULTS

Data from 79 youth and their families were examined. While positive outcomes were seen across all study groups, youth that participated in Team Clinic (PCC + VPG) reported the largest increases in resilience at the end of the study (+7.42, to 51.63, p = 0.009). These participants also reported the lowest levels of depressive symptoms as assessed by PHQ-8 scores (-5.07, p = 0.002) at the end of the study.

CONCLUSION

Team Clinic can serve as an alternative care model for racially and ethnically diverse youth with T1D and their families. VPGs can provide unique benefits, including an increase in resilience, a decrease in depressive symptoms, and a safe space for families to connect, learn, and receive support.

Testing the Feasibility of a Newly Developed Lifestyle Practice Targeting Social Connections: Narrative Healing Circle Shared Medical Appointments

The aim of this pilot was to assess the feasibility and acceptability of virtual Narrative Healing Circles (NHC), a new form of Shared Medical Appointments (SMA) among mixed diagnosis population within an urban tertiary academic medical center.

METHODS

Multi-method, voluntary recruitment of eligible patients, included referrals, flyers, hospital events page, and patients who participated in an ongoing 7-week integrative oncology SMA series. Two physicians (lifestyle medicine and chaplaincy specialists), both trained in narrative medicine, co-led one-hour long virtual NHC SMAs held every other week for a total of either 4 or 8 sessions. Sessions included a centering meditation, brief check-in, topic introduction, short writing exercise initiated with a written, musical, or visual prompt, followed by time of sharing and listening. Optional electronic pre and post participant surveys were emailed at enrollment (7-questions, response rate 29%) and after 4-8 NHC SMA sessions (12-questions, RR 34%).

RESULTS

Virtual NHC SMA were offered from 2/23/22-8/30/23 with 62 unique participants, 266 total visits. Average age: 57 years (range: 27-84 years). Gender: 85% Female, 15% Male; Ethnicity: 73% White, 16% African American, 6% Asian, 5 % Hispanic. About half lived in underserved areas (Harlem, Bronx, Queens, Brooklyn). Payor mix included 40% Medicare, 60% Commercial insurance. Session attendance: 6 participants (mean); 1-13 (range). The number of sessions attended ranged between 1-28 sessions. Anxiety or fear (89%), depression (61%) and pain (67%) were the top 3 symptoms reported in the pre-survey. After 4-8 sessions, participants reported improvements in anxiety/fear (43%), sadness/depression/hopelessness (33%), irritability/stress (33%), isolation/loneliness (33%). They reported several positive changes: restarting yoga or meditation practice, greater focus on awe, journaling, increased mindfulness, and feeling better equipped to manage stress. 94% reported goals met, 95% would recommend the series to others. The 2 clinician leaders reported increased empathy, personal well-being, and work satisfaction.

CONCLUSION

Virtual NHC SMA series among mixed diagnosis population is feasible, positively affects patients' agency and well-being, and acceptable to patients and providers. A more formal study design with broader representation of diverse population and assessment of causality such as an RCT with longer follow-up is recommended.

Patient Perspectives on Lifestyle Medicine Virtual Group Visits

Lifestyle Medicine Virtual Group Visits (LMVGVs) have potential for providing effective lifestyle education and counseling to patients who have or are at risk for chronic disease. The purpose of this study was to assess primary care patients' motivations for participation in and preferences for future engagement with LMVGVs. This was a cross-sectional survey conducted in an academic community-based clinic. A total of 111 patients who signed up for LMVGVs between September 2020 and August 2021 completed the survey between February and April 2022. Patient demographics and LMVGV attendance data were collected from the medical record. The most common reported reasons for signing up for LMVGVs were to focus on lifestyle changes and to lower chronic disease risk. The most common reasons for attending subsequent LMVGVs were the focus on healthy lifestyle changes and the positive focus of the groups. Almost all (98%) respondents who attended ≥5 LMVGVs indicated they would recommend LMVGVs to family or friends. Most respondents preferred monthly LMVGVs, including 71% of those who attended ≥5 LMVGVs. These findings inform efforts to develop LMVGVs that are feasible and acceptable to patients, contributing to the promotion of lifestyle behaviors that aid in the prevention and treatment of chronic disease.

Exploring the Feasibility and Acceptability of Telehealth Qi Gong Shared Medical Appointments: A Novel Approach to Expand Access

Background

Research on Qi Gong (QG) supports promising health benefits. Both interest and use of QG in U.S. adults has increased over the past decade. Shared Medical Appointments (SMAs) are a novel, cost-effective, and time efficient health care delivery approach associated with patient and clinician satisfaction.

Objectives

A telehealth delivered QG SMA was pilot tested among a diverse demographic population within an integrative medicine practice at an academic medical center to assess feasibility and acceptability.

Methods

This was a feasibility/acceptability pilot study conducted at a large New York City academic medical center's Integrative Health and Wellness center from January to July 2023. A QG instructor-acupuncturist and an integrative medicine physician-acupuncturist co-led 3 separate series (5 Element QG, Eight-Section Brocade, and Joint-Mobilizing/Sinew Strengthening exercises) of weekly 30-45-minute sessions of QG SMA on a weekday afternoon via telemedicine. The first session included an overview of QG and Traditional Chinese Medicine (TCM) research while follow-up sessions included a check-in, didactic demonstration followed by QG practice, and a debrief to answer questions. Video links were provided for home practice. Surveys assessing satisfaction were sent pre/post series.

Results

18 sessions of QG SMA were offered over a 6-month period. A total of 40 unique participants from diverse demographics (gender, race/ethnicity, primary residence) attended, for a total of 197 virtual visits. A total of 20 participants enrolled in Series 1 (8 weeks), 23 enrolled in Series 2 (7 weeks), and 16 enrolled in Series 3 (3cweeks). For each session, group attendance ranged from 8-16 with an average of 11 participants. Attendance was high with participants attending an average of 72% of the sessions. Participants attended 88% of the first 8-week series, 54% of the second 7-week series, and 60% of the third series. Participant interest persisted over time with 35% of the 40 participants attending more than 1 series, and 12.5% attending all 3 series. Participants' diagnoses and health symptoms included pain (62.5%), cancer (45%) anxiety/depression (40%), cardiovascular disease (CVD) or metabolic conditions (32.5%), gastrointestinal (GI) symptoms/diagnoses (27.5%), stress (22.5%), osteopenia/osteoporosis (17.5%), and insomnia (17.5%). Pre-series [n = 27] participants endorsed symptoms including sleep disturbances, fatigue, pain, stress, weakness, GI symptoms, psychological symptoms, hot flashes, and brain fog. Post-program survey results [n = 11] suggested QG program addressed common symptoms including fatigue, insomnia, anxiety, stress, pain, weakness, and gastrointestinal symptoms. Participants reported incorporating QG, breathing techniques, and meditation into their daily routine. All participants reported their goals were met and that they would recommend the program to others. Regarding delivery preferences, 73% preferred telehealth, 27% hybrid, and none preferred in-person. Participants appreciated the format, new skills, community, and instructors.

Conclusion

While the Virtual QG SMA series provided to diverse demographic population with mixed diagnoses is feasible, acceptable, and shows promising positive impact in this pilot, caution in interpreting the data is advised due to the low response rate of the post-program survey. Robust studies with longer follow-ups are recommended.

Group medicare wellness visits: A pilot exploration of an approach to wellness and preventive medicine for older adults

Introduction

The Medicare annual wellness visit was designed to address health risks and encourage evidence-based preventive care in aging. However, it can be challenging for providers to dedicate time for comprehensive attention to wellness during these visits. Our project implements a group setting for Medicare wellness visits (GMWV) as an efficient method for delivering high value preventive care.

Methods

Three hundred patients from two primary care ambulatory clinics in Detroit, MI in need of their annual Medicare visit were invited to participate in the pilot GMWV. Fifty-eight patients agreed and completed their GMWV. The visit included collection of vitals, vision screening, and risk assessment during check-in, followed by educational wellness presentations led by an interdisciplinary team of six healthcare professionals. Patients completed a post visit-satisfaction survey and researchers calculated rates of completion of health maintenance gaps (HMG), i.e. immunizations and cancer screenings, among participants.

Results

The average age of participants (N female = 48) was 74 years old. Thirty-four participants had more than one HMG at baseline. On average, 8 % of immunization gaps and 12 % of screening gaps were completed at or within one-year post GMWV. Participant feedback reported that 82 % of patients felt that they learned something new from the presentation and 81 % of patients felt satisfied with the amount of time they spent with their physician.

Discussion

GMWV is a feasible approach to promoting wellness and healthy aging that patients find satisfying although, additional study is needed to compare the effectiveness of this model to standard care.

Applying the use of shared medical appointments (SMAs) to improve continuous glucose monitor (CGM) use, glycemic control, and quality of life in marginalized youth with type 1 diabetes: Study protocol for a pilot prospective cohort study

Background

Continuous glucose monitors (CGMs) have been associated with improved glycemic control and diabetes-related quality of life in youth with type 1 diabetes (T1D), however use is lowest among youth from low-income households and racial/ethnic minorities. Shared medical appointments (SMAs) have been shown to improve glycemic control and reduce diabetes distress in adolescents with T1D, but a focus on marginalized youth has been lacking. This prospective cohort pilot study will assess feasibility and acceptability of the SMA intervention and impact on CGM uptake and sustained use, glycemic control, and diabetes distress in marginalized youth with elevated hemoglobin A1c (HbA1C).

Methods

The pilot study will recruit 20 publicly insured youth with T1D aged 8-12 years who identify as non-Hispanic Black or Latinx and have had at least one HbA1C value > 8% in the past year and their primary caretaker. The trial will employ an enrollment visit, SMA visits every 3 months over a 12-month study period, and a 6-month follow-up observational period. Feasibility measures include proportion of eligible youth successfully recruited for participation, proportion initiating CGM, SMA attendance, and retention through study completion. Acceptability will be assessed using satisfaction surveys. Changes in glycemic control will be assessed using CGM metrics and A1c from baseline to completion of the 12-month SMA intervention, as well as 3 and 6-months after completion of the SMA intervention.

Conclusion

Implementing SMAs for marginalized youth has the potential to address diabetes disparities by optimizing clinical and psychosocial outcomes for the most vulnerable youth living with T1D.Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05431686.

Primary Care Patient Social Networks and Tobacco Use: An Observational Study

IMPORTANCE

Tobacco use remains the leading cause of preventable deaths and is susceptible to social influence. Yet, we know little about the characteristics of primary care social networks and how they influence tobacco use.

OBJECTIVE

To determine what primary care patient social network characteristics are associated with individual smoking behavior.

DESIGN

Cross-sectional.

SETTING

Two primary care practices in West Philadelphia, Pennsylvania (PA), USA.

PARTICIPANTS

A random sample of 53 primary care patients and 155 of their nominated social ties.

MAIN OUTCOME AND MEASURES

We examined the association between social network characteristics (degree, communicated weighted social ties, and presence of social reinforcement) and tobacco use history (never smoker, successful quitter, or current smoker). Other covariates included age, race/ethnicity, sex, education, income, and employment status, self-efficacy, depression status, provider-patient relationship.

RESULTS

Of those enrolled in our study (n = 208), 101 identified as never smokers, 59 as successfully quitters, and 48 as current smokers. Social reinforcements from connected alter pairs that never-smoked (OR = 1.20, 95% CI: 1.08, 1.34) was significantly associated with a participant being a never smoker. Participants with stronger ties with successful quitters were significantly more likely to identify as successfully quitting (OR = 1.37, 95% CI: 1.11, 1.69) and conversely had a negative association with stronger ties to unsuccessful quitters (OR = 0.59, 95% CI: 0.44, 0.80) or current smokers who had not tried to quit in the last year (OR = 0.82, 95% CI: 0.68, 0.98). Social reinforcement from connected pairs of alters that were unsuccessful quitters was significantly associated with the participant being a current smoker (OR = 1.26, 95% CI: 1.10, 1.45).

CONCLUSIONS

Our study suggests that smoking behaviors do not occur in isolation, nor because of 1 or 2 prominent social network members. Rather, our findings suggest that both strong ties and social reinforcement from clusters of similarly-behaving persons influence smoking behavior. Primary care practices have an opportunity to leverage these insights on patient networks to improve cancer prevention.

Optimizing Care Delivery by Applying an Innovative Shared Medical Appointment Model for Determination of Cochlear Implant Candidacy

OBJECTIVE

To develop and implement an innovative group appointment with the potential to improve access to cochlear implantation (CI) while maintaining patient satisfaction and experience.

PATIENTS

Adult patients with advanced sensorineural hearing loss.

INTERVENTIONS

Implementation of novel shared medical appointment (SMA) model.

MAIN OUTCOME MEASURES

Patient satisfaction with group visit; anecdotal description of provider efficiency and experience.

RESULTS

Survey data were collected from 166 adults who participated in a group CI candidacy appointment from September 2017 to February 2020 as part of a quality improvement initiative. Provider time is anecdotally optimized by accommodating more patients in a shorter timeframe while effectively triaging those candidates most likely to meet candidacy criteria for a full CI evaluation. Most importantly, patient feedback has been positive which suggests that patients find value in this novel format.

CONCLUSIONS

The current climate of healthcare demands that providers maximize the efficacy and efficiency of patient care. Our large CI program has determined that using an SMA format as an entry point for CI candidacy evaluation offers many benefits. The group appointment improves patient throughput and also provides a positive patient experience. Group visits offer a viable solution for increasing patient access to CI while maintaining quality in a busy academic medical center setting.

Patient and Clinician Satisfaction With Shared Medical Appointments for Glaucoma

Shared Medical Appointments (SMAs) are patient-centered care tools designed to administer patient counseling and education, typically delivered individually, in a group setting. SMAs are effective in facilitating peer-learning, resulting in improvement in knowledge and health behavior. This study aimed to implement what we know of as the first ophthalmology SMA done in the United States. We evaluated the implementation feasibility, patient and provider experience, changes in patient knowledge, and provider stress. Five glaucoma patients who expressed issues with adherence during their clinic visit at Boston Medical Center (BMC) who were interested in the SMA were recruited. Patients and staff had a positive experience with the SMA. There was a marked increase in patient glaucoma knowledge and a decrease in average staff member stress level score during the SMA. From all standpoints, including billing and management, we conclude that SMA implementation is feasible in ophthalmology departments in academic settings.

Shared medical appointments: Translating research into practice for patients treated with ablation therapy for atrial fibrillation

BACKGROUND

People with atrial fibrillation (AF) have lower reported quality of life and increased risk of heart attack, death, and stroke. Lifestyle modifications can improve arrhythmia-free survival/symptom severity. Shared medical appointments (SMAs) have been effective at targeting lifestyle change in other chronic diseases and may be beneficial for patients with AF.

OBJECTIVE

To determine if perceived self-management and satisfaction with provider communication differed between patients who participated in SMAs compared to patients in standard care. Secondary objectives were to examine differences between groups for knowledge about AF, symptom severity, and healthcare utilization.

METHODS

We conducted a retrospective analysis of data collected where patients were assigned to either standard care (n = 62) or a SMA (n = 59). Surveys were administered at pre-procedure, 3, and 6 months.

RESULTS

Perceived self-management was not significantly different at baseline (p = 0.95) or 6 months (p = 0.21). Patients in SMAs reported more knowledge gain at baseline (p = 0.01), and higher goal setting at 6 months (p = 0.0045). Symptom severity for both groups followed similar trends.

CONCLUSION

Patients with AF who participated in SMAs had similar perceived self-management, patient satisfaction with provider communication, symptom severity, and healthcare utilization with their counterparts, but had a statistically significant improvement in knowledge about their disease.

Impact of a Multidisciplinary, Endocrinologist-Led Shared Medical Appointment Model on Diabetes-Related Outcomes in an Underserved Population

A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.

Mixed methods study of a new model of care for chronic disease: co-design and sustainable implementation of group consultations into clinical practice

Objectives

Group consultations are used for chronic conditions, such as inflammatory arthritis, but evidence of efficacy for treatment to target or achieving tight control is lacking. Our aim was to establish whether group consultation is a sustainable, co-designed routine care option and to explore factors supporting spread.

Methods

The study used mixed methods, observational process/outcome data, plus qualitative exploration of enabling themes. It was set in two community hospitals, in 2008–19, with a third hospital from 2016, and was triangulated with primary care qualitative data. There was a total of 3363 arthritis patient attendances at 183 clinics during 2008–19. The early arthritis cohort comprised 46 patients, followed monthly until the treatment target was achieved, during 2016–19. Focus groups included 15 arthritis and 11 osteoporosis group attendees. Intervention was a 2 h group consultation, attended monthly for early/active disease and annually for stable disease. Measurements included attendance, DAS, satisfaction and enabling themes.

Results

There was a mean number of 18.4 patients per clinic (n = 16, 2010–15; n = 18, 2016; n = 20, 2017; n = 23, 2018–19). Forty per cent (1161/2874) of patients with DAS data reached low disease activity (DAS < 3.2) or remission (DAS < 2.6). Forty-six early arthritis patients followed monthly until they achieved remission responded even better: 50% remission; and 89% low disease activity/remission by 6 months. Qualitative analysis derived five main enabling themes (efficiency, empathy, education, engagement and empowerment) and five promotors to translate these themes into practice (prioritization, personalization, participation, personality and pedagogy). Limitations included the prospectively collected observational data and pragmatic design susceptible to bias.

Conclusion

Co-designed group consultations can be sustainable, clinically effective and efficient for monthly review of early active disease and annual review of stable disease. Promoting factors may support effective training for chronic disease group consultations.

Characteristics and Components of Medical Group Visits for Chronic Health Conditions: A Systematic Scoping Review

Objectives: Chronic health conditions are a major challenge to the health care system. Medical Group Visits (MGVs) are a valuable health care delivery model used in a variety of medical settings and patient populations. We conducted a systematic scoping review of MGV research literature for chronic health conditions to summarize the characteristics and individual components of MGVs in the United States of America and Canada. Design: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology and searched five databases using nine widely used MGV-related terms. Subjects: We included studies conducted in the United States and Canada, whose participants were >18 years old and attended an MGV conducted in a medical setting by a billable health care provider. We excluded groups related to diabetes, pregnancy, and cancer. Results: Of 3777 studies identified, we found 55 eligible studies of which 9 are randomized controlled trials and 46 are observational studies. The majority of studies were conducted in academic medical centers, were observational in design, and recruited patients using physician referrals. The three most frequently studied groups include a combination of several chronic conditions (n = 12), chronic pain conditions (n = 10), and cardiovascular disease (n = 9). Curriculum components included didactics (n = 55), experiential activities (n = 27), and socializing components (n = 12). Didactic areas include (1) medical topics such as symptoms management (n = 27) of which 14 included pain management, and (2) lifestyle/educational component (n = 33) that comprised of talks on nutrition (n = 29), exercise (n = 20), stress (n = 16), and sleep (n = 10). The top integrative medicine (IM) modalities (n = 13) included: mindfulness techniques (n = 8), meditation (n = 6), and yoga (n = 5). Substantial heterogeneity was observed in the recruitment, implementation, curriculum components, and outcomes reported. Conclusion: The MGV is a model of patient-centered care that has captured the attention of researchers. IM modalities are well represented in the curriculum components of MGVs. Further investigation into the components identified by this study, may help in better targeting of group interventions to patients and contexts, where it is most likely to be effective.

Shared Medical Appointments in Preoperative Joint Replacement: Assessing Patient and Healthcare Member Satisfaction

BACKGROUND

Shared medical appointments (SMAs) have proven to be effective in improving patient access and education while augmenting productivity. In shifting from a traditional visit model, patient and interdisciplinary healthcare team (IHCT) member satisfaction is imperative. Predominantly seen in primary care, SMA use in orthopedics is limited. After identification of access and productivity concerns, the SMA was implemented as a quality improvement project in a rural clinic. The lower extremity joint replacement (LEJR) population was chosen because of multiple preoperative appointments and costs on the healthcare system.

PURPOSE

To assess patients' and IHCT members' satisfaction levels in using an SMA for the preparation of LEJR.

RELEVANCE TO HEALTHCARE QUALITY

The SMA is an effective model offering an efficient, cost-effective methodology aligning with the Institute for Healthcare Improvement's Triple Aim.

RESULTS

Twenty SMAs were conducted. Sixty-three patients and 14 ICHT members participated. Mean (M) satisfaction rating for SMA patients (M = 4.90, SD 0.26) was significantly higher than mean for traditional patients (M = 4.03, SD 0.39). Interdisciplinary healthcare team members' attitudes toward SMAs revealed a mean score of 4.58. Incidentally, cycle times improved as did lengths of stay.

CONCLUSIONS

Lower extremity joint replacement patients and IHCT members reported high satisfaction with SMAs.

Preparation for and Implementation of Shared Medical Appointments to Improve Self-Management, Knowledge, and Care Quality Among Patients With Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and is associated with an increased risk of stroke, heart failure, and death. Therapy for this pervasive arrhythmia is complex, involving multiple options that chiefly manage symptoms and prevent stroke. Current therapeutic strategies are also of limited efficacy, and can present potentially life-threatening side effects and/or complications. Emerging research suggests that the burden of AF can be reduced by improving patient understanding of the arrhythmia and teaching patients to adopt and maintain lifestyle and behavior changes. Shared medical appointments (SMAs) have been successfully used to deliver education and develop patient coping and disease management skills for patients with complex needs, but there is a paucity of studies examining the use of SMAs for managing AF. Moreover, few studies have examined strategies for implementing SMAs into routine clinical care. We detail our approach for (1) adapting a patient-centered SMA curriculum; (2) designing an evaluation comparing SMAs to routine care on patient outcomes; and (3) implementing SMAs into routine clinical practice. We conclude that evaluation and implementation of SMAs into routine clinical practice requires considerable planning and continuous engagement from committed key stakeholders, including patients, family members, schedulers, clinical staff, nurse educators, administrators, and billing specialists.

Impact of Collaborative Shared Medical Appointments on Diabetes Outcomes in a Family Medicine Clinic

Purpose

The purpose of this study is to evaluate the impact of a collaborative diabetes shared medical appointment on patient outcomes in an urban family medicine practice.

Methods

Fifty-nine patients were enrolled to participate in multiple shared medical appointments (SMAs) over 12 months. Baseline data included hemoglobin (A1C), lipids, systolic blood pressure (SBP), weight, adherence to American Diabetes Association (ADA) guidelines, and surveys, including the Problem Areas in Diabetes (PAID-2) scale and the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD). A1C and SBP were evaluated at each visit. Lipid control was assessed at baseline and at 6 and 12 months. Adherence to ADA guidelines, SKILLD and PAID-2 survey scores, and number of antihyperglycemic and antihypertensive medications were also evaluated at 12 months.

Results

Thirty-eight patients completed the study. Compared with baseline, A1C and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly over 12 months ( P < .001 and P = .004, respectively). More patients became compliant with the ADA guidelines throughout the course of the study. Specifically, more patients achieved the LDL-C goal of ≤100 mg/dL (2.59 mmol/L; P < .001), were prescribed appropriate antihypertensive medications ( P < .001) and aspirin ( P < .001), and received the pneumonia vaccine ( P < .001). PAID-2 and SKILLD survey scores also significantly improved over the course of the study ( P ≤ .001 and P = .003, respectively).

Conclusion

Short-term interdisciplinary SMAs decreased A1C and LDL-C, improved patient adherence to ADA guidelines, improved emotional distress related to diabetes, and increased knowledge of diabetes.

CoYoT1 Clinic: Home Telemedicine Increases Young Adult Engagement in Diabetes Care

BACKGROUND

Young adults with type 1 diabetes (T1D) experience poor glycemic control, disengagement in care, and are often lost to the medical system well into their adult years. Diabetes providers need a new approach to working with the population. The goal of this study was to determine whether an innovative shared telemedicine appointment care model (CoYoT1 Clinic [pronounced as "coyote"; Colorado Young Adults with T1D]) for young adults with T1D improves care engagement, satisfaction, and adherence to American Diabetes Association (ADA) guidelines regarding appointment frequency.

SUBJECTS AND METHODS

CoYoT1 Clinic was designed to meet the diabetes care needs of young adults (18-25 years of age) with T1D through home telemedicine. Visits occurred every 3 months over the 1-year study (three times by home telemedicine and one time in-person). Outcomes were compared to patients receiving treatment as usual (control).

RESULTS

Compared with controls, CoYoT1 patients attended significantly more clinic visits (P < 0.0001) and increased their number of clinic visits from the year before the intervention. Seventy-four percent of CoYoT1 patients were seen four times over the 12-month study period, meeting ADA guidelines, but none in the control group met the ADA recommendation. CoYoT1 patients used diabetes technologies more frequently and reported greater satisfaction with care compared with controls.

CONCLUSIONS

Delivering diabetes care by home telemedicine increases young adults' adherence to ADA guidelines and usage of diabetes technologies, and improves retention in care when compared to controls. Home telemedicine may keep young adults engaged in their diabetes care during this challenging transition period.

Primary Care Group Visits for Childhood Obesity: Clinical Program Evaluation

We conducted 29 group visits targeting children with elevated body mass index (BMI) and their families. Visit activities focused on social support, mind-body techniques, exercise, and nutrition. Measures included attendance, family satisfaction scores, and per-patient change in BMI percentile. Ninety-six patients attended ≥1 group visit, mean 2.0 (SD ±1.8; range 1-14). Mean patient age was 9.6 years (SD ±2.4; range 4-15 years); 53.1% were female; 44.8% had a BMI 95th to 99th percentile for age/sex; 35.4% had a BMI >99th percentile. Mean attendance per group visit was 6.8 patients (SD ±3.8; range 1-16 patients). Mean family satisfaction scores were 9.8 (SD ±0.8) with 10/10 "would recommend to family or friends." Of 42 patients who attended ≥2 group visits, 5 (11.9%) experienced a ≥5 BMI percentile reduction between first and last visits; 3 (7.1%) maintained this reduction 2 years later. Group visits were associated with high family satisfaction scores, though few patients experienced a reduction in BMI percentile.

Early experience with shared medical appointments for penile problems

We examined the use of shared medical appointments (SMA) for educating and counseling children with penile problems. Forty-eight families were seen over 4 months with 21 participating in the SMA group and 27 in the traditional group. Using a questionnaire to assess adequacy of education, there was no difference in the overall scores between groups with a mean of 6.64/7 in the SMA and 6.56/7 in the traditional setting. With the increasing demands on providers, an SMA offers a solution to caring for more patients with penile problems in an efficient manner without impacting family education and satisfaction.

Acceptability of Group Visits for Attention-Deficit Hyperactivity Disorder in Pediatric Clinics

OBJECTIVE

Children with attention-deficit hyperactivity disorder (ADHD) have ongoing needs that impair home and school functioning. Group visit models are a promising way to deliver timely parenting support but family and provider acceptance has not previously been examined. The objective was to describe the acceptability of ADHD group visits in busy pediatric clinics based on caregivers, child participants and facilitators.

METHODS

Data were analyzed from school-age children and caregivers who participated in one of two 12-month long randomized controlled studies of the ADHD group visit model from 2012 to 2013 or 2014 to 2015. Feedback was obtained using semi-structured questions at each study end, by telephone or at the last group visit. Sessions were audio-recorded, transcribed and themes were extracted by participant type.

RESULTS

A total of 34 caregivers, 41 children and 9 facilitators offered feedback. Caregivers enjoyed the "support group" aspect and learning new things from others. Caregivers reported improved understanding of ADHD and positive changes in the relationship with their child. Children were able to recall specific skills learned including how skills helped at home or school. Facilitators acknowledged systems-level challenges to offering group visits but felt the group format helped increase understanding of families' needs, improved overall care, and provided innovative ways to engage with families.

CONCLUSION

The majority of comments from families and facilitators highlighted a variety of benefits of the use of a group visit model for ADHD chronic care. Despite systems-level barriers to implementation, families and facilitators felt the benefits outweighed the challenges.

Effectiveness of Shared Medical Appointments Targeting the Triple Aim Among Patients With Overweight, Obesity, or Diabetes

BACKGROUND

Obesity and diabetes are epidemic in the United States, with many treatment options having limited long-term efficacy. A possible effective medical management tool is the shared medical appointment (SMA), which offers an efficient and cost-effective approach to behavior change and aligns with the Triple Aim (reduce costs, improve population health, and improve patient care experience) set forth by the Institute for Healthcare Improvement.

OBJECTIVES

To assess the effectiveness of SMAs to achieve the Triple Aim and to improve the management of overweight/obesity or diabetes.

METHODS

Peer-reviewed literature from PubMed was searched by the keywords shared medical appointments, group medical appointment, and group medical visit, with no date restrictions and limited to English publications with sample sizes greater than or equal to 20.

RESULTS

Eight articles met inclusion criteria. The Triple Aim was not referenced in the studies, but most reported some combination of reduced costs, improved care, and improved outcomes or patient satisfaction.

CONCLUSIONS

Potential benefits of SMAs include improved patient outcomes and satisfaction. Osteopathic and, in particular, primary care medicine could likely benefit from moving toward greater adoption of SMAs; however, more randomized controlled trials are needed to assess their effectiveness with regard to the Triple Aim.

A new marker of primary care utilization - annual accumulated duration of time of visits

BACKGROUND

Most of the research on primary care workload has focused on the number of visits or the average duration of visits to a primary care physician (PCP) and their effect on the quality of medical care. However, the accumulated annual visit duration has yet to be examined. This measure could also have implications for the allocation of resources among health plans and across regions. In this study we aimed to define and characterize the concept of "Accumulated Annual Duration of Time" (AADT) spent with a PCP.  METHOD: A cross-sectional study based on a national random sample of 77,247 adults aged 20 and over. The study's variables included annual number of visits and AADT with a PCP, demographic characteristics and chronic diseases. The time period was the entire year of 2012.

RESULTS

For patients older than 20 years, the average annual number of visits to a PCP was 8.8 ± 9.1, and the median 6 ± 10 IQR (Interquartile Range). The mean AADT was 65.8 ± 75.7 min, and the median AADT was 43 ± 75 IQR minutes. The main characteristics of patients with a higher annual number of visits and a higher AADT with a PCP were: female, older in age, a higher Charlson index and a low socio-economic status. Chronic diseases were also found to increase the number of annual visits to a PCP as well as the AADT, patients with chronic heart failure had highest AADT in comparison to others (23.1 ± 15.5 vs. 8.6 ± 8.9 visits; and 165.3 ± 128.8 vs. 64.5 ± 74 min). It was also found that the relationship between AADT and age was very similar to the relationship between visits and age.

CONCLUSION

While facing the ongoing increase in a PCP's work load and shortening of visit length, the concept of AADT provides a new measure to compare between different healthcare systems that allocate different time frames for a single primary care visit. For Israel, the analysis of the AADT data provides support for continued use of the number of visits in the capitation formula, as a reliable and readily-accessible indicator of primary care usage.

Models of Care for Adolescents and Young Adults with Type 1 Diabetes in Transition: Shared Medical Appointments and Telemedicine

Transitioning through adolescence and young adulthood is challenging, and even more so for patients living with a chronic disease such as type 1 diabetes. Patients in this age group encounter multiple obstacles to effectively managing their diabetes, experience suboptimal glycemic control, face higher rates of acute complications, and are often lost to medical follow-up. Comprehensive strategies and innovative clinical models are needed to engage this population in diabetes medical care, address barriers to ideal management, and improve outcomes. Telemedicine, shared medical appointments (SMA), or a combination of telemedicine and SMA are potential models to more successfully, efficiently, and satisfactorily address the urgent need for improved care in this high-risk population. This article reviews various clinical care models within these categories of telemedicine and SMA. [Pediatr Ann. 2017;46(5):e193-e197.].

Team Clinic: An Innovative Group Care Model for Youth with Type 1 Diabetes-Engaging Patients and Meeting Educational Needs

The purpose of this pilot was to implement an innovative group care model, "Team Clinic", for adolescents with type 1 diabetes and assess patient and provider perspectives. Ninety-one intervention patients and 87 controls were enrolled. Ninety-six percent of intervention adolescents endorsed increased support and perceived connecting with peers as important. The medical providers and staff also provided positive feedback stating Team Clinic allowed more creativity in education and higher quality of care. Team Clinic may be a promising model to engage adolescents and incorporate education and support into clinic visits in a format valued by patients and providers.

Use of a Wearable Activity Device in Rural Older Obese Adults: A Pilot Study

Objective: Assess the feasibility and acceptability of Fitbit for supporting behavioral change in rural, older adults with obesity. Method: Eight adults aged ≥65 with a body mass index (BMI) ≥30kg/m² were recruited from a rural practice and provided a Fitbit Zip device for 30 days. Participants completed validated questionnaires/interviews. Results: Mean age was 73.4 ± 4.0 years (50% female) with a mean BMI of 34.5 ± 4.5kg/m². We observed reductions in exercise confidence (sticking to it: 34.5 ± 3.3 to 30.9 ± 4.3, p = .04; making time: 18.9 ± 1.3 to 17.0 ± 2.6, p = .03) but no changes in patient activation (45.4 ± 4.3 vs. 45.0 ± 3.9). All reported high satisfaction, seven (87.5%) found Fitbit easy to use, and five (62.5%) found the feedback useful. The majority (n = 6 [75.0%]) were mostly/very satisfied with the intervention. Consistent themes emerged regarding the benefit of self-monitoring and participant motivation. Common concerns included finding time to exercise and lack of a peer group. Conclusion: Use of Fitbit is feasible/acceptable for use among older rural obese adults but may lead to reduced confidence.

Social and Support Services Offered by Cleft and Craniofacial Teams: A National Survey and Institutional Experience

BACKGROUND

A multidisciplinary approach to patients with craniofacial abnormalities is the standard of care by the American Cleft Palate-Craniofacial Association (ACPA). The standards of team care, however, do not require provision of social support services beyond access to a social worker. The purpose of this investigation is to study social support services provided by ACPA teams, funding sources for services, and family interest in services.

METHODS

A survey was submitted to ACPA cleft and craniofacial team leaders (N = 161), which evaluated the provision of potentially beneficial social support services, and their funding sources. A second survey administered to patient families at our institution gauged their level of interest in these services. Statistical analysis evaluated the level of interest among services.

RESULTS

Seventy-five of 161 (47%) teams and 39 of 54 (72%) families responded to the surveys. Services provided included scholarships (4%), summer camp (25%), social media (32%), patient support groups (36%), parties (42%), parent support groups (46%), other opportunities (56%), and social workers (90%). The majority of funding for social workers was by the institution (61%) whereas funding for ancillary services varied (institution, team, fundraisers, grants, and other sources). Families indicated an average interest of 2.4 ± 1.41 for support groups, 2.5 ± 1.63 for summer camps, 2.92 ± 1.66 for parties, 3.16 ± 1.65 for social media, and 3.95 ± 1.60 for scholarships (P value <0.05).

CONCLUSIONS

The ACPA standards of team care do not require teams to provide social support services beyond access to a social worker. Among our survey respondents, the authors found that in addition to a social worker, teams offered social support services, which were not required. The social worker position is usually institutionally funded, whereas funding sources for additional services varied. Respondents at our center desired additional social support services. The authors recommend a hybrid model of hospital and nonhospital funding to provide social and support services to patients with craniofacial deformities.

Experience of hypertensive patients with self-management of health care

AIMS

The aim of this study was to interpret how hypertensive patients experience health care self-management.

BACKGROUND

Hypertension is one of the most prevalent chronic diseases worldwide. The involvement of individuals in the management of their health care to treat this disease is fundamental, with aid and advice from healthcare professionals, especially nurses, so that hypertensive patients can effectively self-manage their health care.

DESIGN

Qualitative study.

METHODS

Hypertensive patients were recruited using theoretical sampling. The study sample consisted of 28 hypertensive patients aged 18-59 years who were registered in the e-Health programme of the Ministry of Health. Data were collected and analyzed between September 2012-October 2014 using a semi-structured interview based on the methodological framework of the constructivist grounded theory.

FINDINGS

The participants' statements depicted an outline of their experience with the disease: the beginning of the illness; understanding the disease process; incorporating behaviour for self-management of the disease; experiencing attitudes and actions in the control and treatment of the disease; and being treated in the public healthcare system. A central phenomenon emerged, namely hypertensive patients' experience of self-management of health care.

CONCLUSION

This phenomenon has paths, actions and interactions. When patients discover that they have the disease and become aware of the disease process, they assume the identity of being hypertensive and become proactive in their health care and in living with their families and in communities.

CoYoT1 Clinic: Innovative Telemedicine Care Model for Young Adults with Type 1 Diabetes

BACKGROUND

Young adults with type 1 diabetes (T1D) face many challenges in managing their diabetes, resulting in suboptimal glycemic control and often loss to follow-up. Comprehensive strategies are needed to engage this population in diabetes care and improve outcomes. This pilot study investigated the feasibility and acceptability of the Colorado Young Adults with Type 1 Diabetes (CoYoT1) Clinic-an innovative clinical care model for young adults with T1D, incorporating telemedicine and peer interactions.

SUBJECTS AND METHODS

Forty-five patients with T1D, 18-25 years of age, participated in this study. Patients completed one routine, diabetes clinic appointment, using Health Insurance Portability and Accountability-approved, Web-based videoconferencing from a location of their choosing. The clinic visit consisted of an individual appointment with a diabetes provider and a group appointment with other young adults, facilitated by a certified diabetes educator. Patients completed a satisfaction survey and reported the time lost from school or work to complete the virtual appointment compared with time typically lost to complete a traditional, in-person, visit.

RESULTS

Patients reported high levels of satisfaction with the virtual clinic and high levels of perceived support from the peer interaction. Additionally, patients reported saving over 6 h from their work or school day when completing their diabetes clinic visit virtually instead of in-person.

CONCLUSIONS

In this cross-sectional pilot study, the CoYoT1 Clinic, incorporating Web-based videoconferencing and peer interactions, was feasible and acceptable for young adults with T1D. This model may potentially increase engagement with diabetes care in the young adult population. However, further research is needed to fully evaluate the intervention.