The Diabetes Shared Medical Appointments (SMA) Program was developed in conjunction with the University Health Network Sun Life Financial Banting & Best Diabetes Clinics. This initiative brings a group of people living with diabetes together to jointly meet with a variety of healthcare professionals and engage in group education sessions. Trialed at the Toronto General Hospital and Toronto Western Hospital, the SMA program has helped to streamline the diabetes care system and has proven to be a big hit with participants.

What is a Shared Medical Appointment?

A Shared Medical Appointment (SMA) consists of a group of patients living with diabetes working together with their healthcare team during a 90 to 120 minute session. A physician sees each patient individually over the course of the session or as a group in conjunction with other healthcare providers to better streamline the healthcare process. Shared Medical Appointments for those living with diabetes often incorporate group education focusing on diabetes self-management and behavioural interventions.¹

It is important to note that an SMA is not a traditional “diabetes class”; rather, all aspects of physician, nurse and dietitian appointments are provided in a group setting. A wide range of diabetes specific interventions such as foot exams, blood pressure measurement, self-monitoring blood glucose logbook review, nutrition education, and even blood test reviews are undertaken in a collaborative manner.

The Canadian Diabetes Association Clinical Practice Guidelines Expert Committee recommends a system of diabetes care that is organized around a person living with diabetes who is practicing self-management and is supported by a proactive, interprofessional team with specific training in diabetes.² In keeping with this patient-centred philosophy, SMAs break down silos of care better equipping interprofessional teams to manage the various components of patient care in a collaborative group environment. Furthermore, SMAs expand team member roles to include blood pressure monitoring, medication reconciliation, injection site assessment, foot screening, ophthalmology and chiropody referrals, as well as insulin dose adjustment. SMAs have been shown to improve clinical outcomes including HbA1C levels and blood pressure, as well as to improve self-care, access to care, and efficiency. SMAs encourage cooperative team based decision-making that includes patients.  They have also been shown to reduce Emergency Department visits and inpatient admissions.^3.4

Quality Improvement, Experienced-based Co-design Process:

The University Health Network Endocrinology program recently established a Shared Medical Appointment model at the Toronto Western and Toronto General Hospital diabetes clinics.  The team used a model of quality improvement, applying several Plan-Do-Study-Act cycles to identify ways to enhance the patient experience and improve efficiencies. Throughout the development and implementation of the SMAs, direct observation, patient focus groups, team debriefs, and staff surveys were used to enable an experience-based co-design method of quality improvement.   This approach allowed the team and patients to be active participants in the innovation of SMAs specifically tailored to a tertiary specialty clinic setting.

SMA Innovation Team

Margaret De Melo, RD, CDE
Dr. Phillip Segal, MD FRCPC
Elaine Wylie, RN (CNS) , CDE
Anne Murphy , RD, CDE
Lynne Barone, Patient Champion

The SMA Structure:

We structured each of our Shared Medical Appointments (SMA) as a 90-minute group session offered to people living with either Type 1 or Type 2 diabetes. A registered nurse (RN), a registered dietitian (RD), and an endocrinologist comprised the interprofessional team tasked with facilitating the SMA. Only participants who had been previously assessed by an RN, RD and endocrinologist in individual sessions were selected for inclusion in the program.

Two weeks prior to the first Shared Medical Appointment (SMA) we asked all participants to complete routine lab tests. On the day of the SMA, participants were required to check-in at the front desk, be weighed, and were immediately taken to the SMA classroom, effectively eliminating unnecessary clinic wait times.

The SMA is very much a trans-professional, shared-care model whereby roles overlap throughout a series of concurrent components of diabetes management wherein the healthcare team works in collaboration and in seamless manner. Once in the classroom, participants were presented with an SMA package and asked to complete a series of diabetes-related forms. Forms included a consent and confidentiality form, a DSM Diabetes Self-Assessment, the Stanford Diabetes Self-efficacy Scale, and a 1-minute distress scale: Problem Areas in Diabetes (PAID-5) scale.^{5, 6} Our intention was to better our understanding of patient diabetes self-management competency and any challenges therein. In the meantime, the nurse and dietitian addressed each patient individually for about 10-15 minutes each.  They measured vitals, reviewed self-assessment survey responses, food records, blood work and self-blood glucose monitoring results with each patient, and completed a medication reconciliation. Any necessary insulin dose adjustments and recommendations were made following their assessment and discussion. On average we found it took a group of 8 participants roughly 60 minutes to complete the appropriate paperwork and be seen individually by an RN and RD.

In the interim, as the nurse and dietitian completed 2 or 3 patients’ individual assessments, the endocrinologist would begin one-on-one consultations, pulling individual participants out of the group for 10 minutes medical appointments wherein the physician reviewed the nurse and dietitian’s completed flowsheets, progress notes, made other necessary medication adjustments, and ordered any necessary lab work.

Once the paperwork and one-on-one meetings with RN, RD and endocrinologist were completed, all of the attendees participated in a discussion-style education session with the care team. Discussion focused on any diabetesself-care challenges, sources of diabetes distress, and questions that arose from the one-on-one discussions with the healthcare team.  These sessions were not structured as lectures but were participatory in nature allowing participants to dictate the agenda, engage in conversation with the healthcare team,  and to learn with and from each other, as people living with diabetes. We found that this was an extremely effective way to engage patients as true partners in their care, facilitate mutual understanding between those living with diabetes and all members of the healthcare team in a relaxed, supportive setting.

Shared medical appointment process map. The green squares highlight the value-added activities from the participant perspective.

From the participant perspective the key value added activities to come out of the SMA were the elimination of wait times, the ability to engage with a multi-disciplinary care team and other people living with diabetes, and the flexibility to structure the SMA in accordance with their specific needs. This care model empowers people living with diabetes to structure their interactions with healthcare professionals based on their individual needs while enabling the healthcare team to provide more efficient and effective care.

Evaluating the SMA:

The efficiency of the Shared Medical Appointment program was measured by comparing the time invested per SMA participant  to standard care protocols. It was found that for healthcare providers, the average monthly time spent with patients was reduced by 64% for RDs (72 minutes per individual per month in a one on one setting down to 26 minutes a month during an SMA), 75% for RNs (83 minutes down to 21 minutes), and 33% for physicians (15 minutes down to 10 minutes). While the data set is small, it suggests a significant decrease in time spent per patient for all members of the care team.

Importantly, this reduction in time is the product of the concurrent activities done during the SMA which eliminates duplication of work for all members of the team.  Moreover, the enhanced scope of practice allows both nurse and dietitian to complete the same tasks per patient.  Instead of each individual member of the team reviewing the same information with patients, the communication between team members and their collaborative approach enables the information to be presented to patients once, and reviewed as needed.

To test whether this model was effective for those living with diabetes, a focus group was assembled to ensure that the quality of care was sustained or improved. The patient focus group was facilitated by a peer volunteer and it found that participants were in favour of having the SMA model as an alternative option to one on one care. Furthermore, participants valued having peer support at the SMA and felt they spent more time with their healthcare team than usual. Participants also appreciated the lighthearted environment created by the healthcare practitioners through the injection of humour into the classes and the instillation of hope among patients.

NEXT STEPS

The project aims to expand across the entire diabetes program at Toronto Western Hospital. It currently supports six cohorts of patients, representing roughly 10% total active diabetes patients at Toronto Western Hospital. The aim of the program is to scale up the program in order to meet the needs of a higher proportion of  patients. As well, the team is also considering stratification of patients with similar diabetes management needs such as young adults with type 1 diabetes.

The Shared Medical Appointment program can be adapted to other clinic types and should be more formally evaluated as a model of care that supports patient education and collaborative care.

LEARN MORE

Interested in learning more about the UHN Shared Medical Appointment program or starting your own SMA clinic? Contact Margaret De Melo at [email protected]

Pictured left-to-right: Emma McGrory, Student Volunteer; Margaret De Melo, RD, CDE, QI Lead; Lucia Chan, RN, CDE; Robert Silver, Endocrinologist, MD Lead; Christine MacGibbon, Peer Volunteer; Michelle DeFreitas, Administrative Assistant

References:

[1] Noffsinger, E.B. (2012). The ABCs of group visits: An implementation manual for your practice. Springer Science & Business Media.[2] Canadian Diabetes Association. (2013). Canadian diabetes association 2013 clinical practice guidelines for the prevention and management of diabetes in canada.  Organization of Diabetes Care. 37(Supplement 1), S20-S25. [2] Canadian Diabetes Association. (2013). Canadian diabetes association 2013 clinical practice guidelines for the prevention and management of diabetes in canada.  Organization of Diabetes Care. 37(Supplement 1), S20-S25. [3] Housden. L., Wong, S.T., & Dawes, M. (2013). Effectiveness of group medial visits for improving diabetes care: A systematic review and meta-analysis. CMAJ, 185(13), E635-44. [4] Edelman, D., et al. (2013). Shared medical appointments for patients with diabetes mellitus: A systematic review. J Gen Intern Med, DOI 10.1007/s11606-014-2978-7. [5] Lorig K, Ritter PL, Villa FJ, Armas J. (2009) Community-Based Peer-Led Diabetes Self-Management: A Randomized Trial. The Diabetes Educator; Jul-Aug; 35(4):641-51. [6] McGuire BE, Morrison TG,Hermanns N, Skovlund S, Eldrup E, Gagliardino J,  Kokoszka A, Matthews D, Pibernik-Okanovic M, Rodríguez-Saldaña, de Wit M, Snoek FJ.  (2010). Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia 53:66–69. DOI 10.1007/s00125-009-1559-5.