Shared Medical Appointments

Tell any provider they need to see 12 patients in one hour, and the reaction will likely be a cringe, a shudder or even a chuckle. Most providers already operate at warp speed, so working faster is simply not an option.

But if providers could see those 12 patients simultaneously, they might react differently.

PA Teresa D’Alessandro hosts an SMA at the Cleveland Clinic Respiratory Institute.

Shared medical appointments (SMAs), also known as group visits, are a growing topic of discussion among providers looking for ways to increase access to care and improve efficiency. The group visit format has been used sporadically since the 1990s, but it’s been getting more attention in recent years as a strategy to add more value for the patient.

Providers know that simply telling patients what to do often does not improve their health. The basic premise of SMAs is to build more patient engagement and inspire lasting behavior change by offering patients the opportunity to share their personal experiences not only with their provider but also with other patients dealing with similar issues.

“The beauty of having multiple people in the same visit is that it benefits both the patient and the provider,” says Edward Shahady, MD, who began holding SMAs at his practice in Miami, Fla., more than a decade ago and is considered one of the leaders in this field.

“It’s highly likely that people with the same condition have the same questions, allowing the provider to address the concerns of multiple patients at the same time,” says Shahady, now medical director of the Diabetes Master Clinician Program Inc., and a clinical professor of family medicine at the University of Florida and the University of Miami.

Before Shahady implemented SMAs, he says, he was not seeing enough improvement in the health of many of his patients. He felt the individual visits were often too short to be of real value, especially for those with diabetes.

Many providers might agree that individual visits are not long enough, and for some, the visits are getting even shorter. Faced with an aging population and evolving reimbursement models, many providers are feeling increased pressure to see more patients in less time.

This can be especially troubling for patients with chronic diseases such as diabetes. For them, a standard doctor’s visit is already crammed with conversation about blood sugar control, nutrition, physical activity, foot care, hypertension and medications. That leaves very little time, if any, to address the personal obstacles that can often derail patient health.

SMAs, on the other hand, can be more conducive to uncovering the patients’ underlying concerns as they talk with and listen to others who are dealing with similar challenges.


Driving the Conversation

               SMA with a group of COPD patients.

Though the patients do most of the talking, Shahady says the provider must artfully guide the discussion to meet the objectives of the visit. When he first began holding SMAs, Shahady says, he struggled to generate enough group discussion, which made the visits feel more like lectures.

“One of the most critical skills to have during a group visit is the ability to facilitate the discussion,” Shahady says. “For me, it took some time, but through experience I learned to restrain many of my own comments and instead, continually ask follow-up questions. Inevitably, the patients begin voicing their shared concerns, and the discussion gets more involved.”

Shahady has become a strong supporter of group visits, and the evidence, he says, is in the numbers. More than 200 of his patients with diabetes have attended group visits and nearly all have improved their blood pressure, cholesterol and low-density lipoprotein (LDL) numbers. And roughly half of them bring their numbers to near normal within three to six months.


One Size Does Not Fit All

There is no universal format or agenda for SMAs. However, most are intended to last between one and two hours and include two components: a session during which brief, individualized visits may be conducted to assess each patient’s condition, and a group discussion facilitated by the provider.

Individual visits may not be required, but the provider should develop ways to address each patient’s concerns, according to PAs who do SMAs.

Don Duger, MEd, MHP, PA-C, director of PAs at Harvard Vanguard Medical Associates, says the multispecialty medical group began offering SMAs more than five years ago. They tried many different formats in the beginning, but quickly developed a model that providers in multiple specialties could follow and customize.

“Our model incorporates a clinician, a medical assistant, a documenter and a behaviorist, each of whom has specific roles to help keep the appointment moving along efficiently,” Duger says. “The behaviorist is specially trained in group facilitation and has the ability to guide the group through conversation and toward those learning moments.”

Duger says it is quite common for patients to experience some level of nervousness or hesitation in the beginning. For that reason, patients are encouraged to stand up and move around the room as much as they please. This promotes a more casual atmosphere to help patients feel more at ease.

“Amazing things start to happen where patients can convince other patients to overcome their fears, whether it be starting a medication, changes to diet or what to do for exercise,” Duger says. “We’ve found that hearing from other patients can be so much more effective than only hearing from the clinician.”


No Panacea

Increased efficiency. Reduced costs. Improved patient health. SMAs might seem like an obvious solution for all providers, especially those caring for patients with chronic conditions.

So why isn’t everyone offering SMAs? One reason is discomfort—provider discomfort.

“For many, being a facilitator is not intuitive,” Shahady says. “This can be challenging because, in a sense, the provider is giving control of the visit over to the patient, and many simply can’t give that up.”

Shahady says several providers have told him they are uncomfortable in that setting and eventually stop holding their group visits.  However, he believes most providers have the ability to learn the necessary skills to do well—particularly PAs.

“In many ways, PAs can be better at this than the physician,” Shahady says. “PAs often have a mindset that is more focused on disease prevention, whereas physicians are trained more for acute disease.

“More importantly,” he says, “most of the PAs I’ve worked with have the ability to be great facilitators and are willing to try new approaches.”


Time Management

Time is a precious commodity for healthcare providers. While the notion of serving more patients in less time is appealing, getting to that point can be difficult with certain patient populations.

Teresa D’Alessandro, PA-C, recently began hosting SMAs for her patients at the Cleveland Clinic Respiratory Institute.  She held her first SMA in early 2015 and immediately realized how challenging time management can be during a group visit.

“The patients really start to get into the discussions, which is great,” D’Alessandro says. “But it also presents a challenge, especially when you first start, to stay on schedule and not go overtime.”

During her SMAs, D’Alessandro enlists the help of a pharmacist and a registered nurse to address prescription concerns and disease management. To maximize her schedule, she has the nurse and the pharmacist begin the appointment without her, and then call her in when they have concluded their portions of the visit.

Many of the patients she sees are dealing with chronic obstructive pulmonary disease (COPD), while also struggling with addictions to such illegal drugs as heroin and cocaine.

“When a patient is sitting there listening to someone who is on oxygen talk about their struggles to quit smoking, that carries with it much more meaning than any anecdotes from the provider,” D’Alessandro says. “There’s definitely a camaraderie among these patients that would be difficult to replicate in any other setting.”

D’Alessandro says the group dynamic fosters a unique level of trust among the participants and eventually leads many patients to be more open. She notes that on several occasions, some of her patients who had previously denied their substance abuse during a one-one-one visit with her, have freely admitted it to their fellow patients during a group visit.


Making It Your Own

D’Alessandro knew there was no such thing as a step-by-step guide on how to lead an SMA. So before she held her first group visit, she determined the best way to learn good technique was by observing others. She soon found other providers in her area who were conducting group visits, so she sat in on several of them to see first-hand how it is done.

“Everyone has their own approach, but I learned that it’s critical to determine a clear goal from the start in order to measure progress and determine what’s working and what isn’t,” D’Alessandro says. “Our goal was to reduce readmissions, and even though it’s still very early, we’ve already made progress.”

Working the appointments into her already busy schedule was a challenge, and developing the format that works best for her and her patients took time. However, D’Alessandro says she has truly come to enjoy the group visits.

“I love it because it’s a great opportunity to be autonomous; I’m the only provider there, leading the discussion and making the decisions,” she says. “It involves a lot of problem solving and it forces me to perform at a higher level. It’s all on me, and that’s pretty cool. “

Dave Andrews is a communications and public relations professional specializing in the improvement of healthcare delivery. Contact him at [email protected]