Dimension of SMA Innovation – Basic guidelines that needed to be translated | Starting Point: Initial Decisions | Promoting Factor | Hindering Factor |
---|---|---|---|
Shared Medical Appointment Initiation | Core team with strengths related to diabetes were open to change and working together | Mandate from Central Office; Training provided; no specific guidelines; local facility has long history of supporting novel methods of care delivery | No specific guidelines; limited resources |
Focus: disease-specific or non-specific | Diabetes (reduce cardiovascular risk) | Provided focus consistent with strong core team | Â |
Drop-in or Schedule Patients | Scheduled | Able to call and remind; able to plan | Limits number and requires more coordination |
Multi-disciplinary Professional Team | Collaboration with key disciplines present | Strong, committed core team, including one member representing key leadership within primary care clinic | Difficulty coordinating, and finding and freeing up time to participate |
1 or more with prescribing Authority | Physician (Medical Director of Clinic); Endocrine nurse practitioner; Clinical pharmacist | Built-in redundancy of prescribers assisted with efficiency | Team members had different supervisors; Workload credit and credit for SMAs |
1 or more variety of Disciplines | Health Psychologist; Registered nurse | Â | Different supervisors; Workload credit |
Group of patients (8–20) | 4–8 patients (8 invited) | Flexibility to pilot test with small numbers of patients | Questions raised about inefficiency |
Target population | Local registry to identify patients | Sufficient numbers who would benefit | Â |
Primary care provider pool (pull from one or more) | All Primary care providers' patients eligible | Able to include all high- risk patients | Threatened provider-patient relationship |
Patient pool | A1c > 9%; systolic blood pressure > 130 mmHg; LDL-cholesterol > 100 mg/dL | Â | Getting several patients there; Viewed as difficult and non-compliant; concern about no-show rates |
Time and Frequency: Meet for 90–120 minutes and variable regarding frequency | 90 minutes and to meet weekly (Friday afternoons) |  |  |
Techniques and Processes for conducting SMA | Modification of chronic care model as a guide | Â | Â |
Didactics | Keep at a minimum | Â | Many team members most comfortable with 'teaching' rather than facilitating group discussion |
Information display and Sharing | Large board with patient lab values and other outcomes (e.g., A1c, systolic blood pressure and LDL-cholesterol); prepared by Clinical pharmacists | Summarized key points and helped solidify take home messages despite concern about non-lecture format | Â |
Group discussion | Peer support Motivational interviewing by Health Psychologist | Learning by all is possible even if not sharing; Simplified and focused individual session that followed group encounter | Some patients uncomfortable in groups |
Clinical component | Group chart display | Â | Â |
Forms: General information | ABCs of diabetes care (A1c, blood pressure, cholesterol, etc), foot care, etc. | Able to help meet performance measures; document patients educated | Hard to clarify for others what exactly was covered |
Forms: Patient-specific | Patient completed form with current values (copied from board), goals, med changes, plan of care outlined | Felt patients were getting individual information and tailoring | Preparation time |
Space | Remote training rooms not available and negotiated clinic space | Able to secure some space | Limited options especially given construction |
Location | Primary Care Clinic Conference Room | Familiar | Displaced providers who use the room and limited access to computers available in the primary care clinic conference room |
Size and arrangement | Small conference room with computers and crowded | Table seating conducive to group sharing | Limited in size and mobility; configuration not ideal |
Mechanics | Â | Â | Â |
Documentation (suggest/identify individual to take responsibility) | Initially used a group note field in electronic record system, but recognized that modifications would need to be made.1 | User friendly, consistent with usual methods of documenting | Â |