For doctors, they can be an efficient way to deliver diabetes care She knew her diabetes patients could benefit from shared medical appointments, but what surprised Maureen Mavrinac, MD, who worked in a remote California Central Valley clinic, was that shared appointments made her clinical team happy. "Not only did our patients feel better, but we did, too," she said. "We were actually reaching people." Mavrinac has offered shared medical appointments since 2011. "I saw the frustration my medical students and residents felt at a Los Angeles county clinic when they were trying to take care of people with chronic diseases in a short 15- to 20-minute time slot," she said. "I knew there had to be a better way." What Shared Appointments Accomplish Shared medical appointments -- clinical sessions that treat a group of patients with similar diagnoses at one time -- are successful at the Cleveland Clinic, Kaiser Permanente, and other health care systems throughout the U.S. For clinicians, shared medical appointments can be an efficient way to deliver care. Doctors avoid repeating common advice, improving their productivity and allowing them to engage in higher-quality patient interactions. For patients, shared appointments can improve health. Patients benefit from interacting with peers and hearing answers to questions that may be relevant to them. Studies show that shared appointments can lead to better clinical outcomes. When David Edelman, MD, of the Duke University School of Medicine analyzed 17 different studies, he found that shared medical appointments gave patients better improvements in HbA1c scores and blood pressure readings than traditional diabetes care. A Stanford University study found that among adolescents with type 1 diabetes, shared appointments helped with glycemic control to keep it from worsening, which it tends to do in teen years. Patients who participate in shared appointments may adhere to guidelines better and be more satisfied with care, too. Edelman, who also has investigated shared appointments in clinical trials, said, "Patients are uniformly enthusiastic not just about the hard outcomes, but about the opportunity to get together and talk about diabetes every few months with experts and peers. They certainly get a lot of benefit out of it." But shared appointments can be complicated. "Organizing shared medical appointments can be disruptive, and while some health care systems are willing to work with them, others aren't," Edelman observed. "Smaller practices may have a hard time trying to incorporate something that is a very different practice model. And while reimbursement is getting better, we still hear complaints about it in the private sector." In second year of a clinical trial Edelman was involved with, diabetes patients who had been treated with shared appointments had fewer hospitalizations and lower health care costs than those with usual care. "However, cost savings to a system are not the same thing as cost savings to a practice," he noted. "There's no doubt that if the payer is the provider, shared medical appointments are much easier to do." What's Holding Shared Appointments Back Given their effectiveness, why aren't more physicians using shared medical appointments? A recent editorial in the New England Journal of Medicine noted that shared appointments still lack four critical components: rigorous scientific evidence showing their value, easy ways to pilot them, regulations and incentives supporting them, and education for both patients and clinicians. Shared medical appointments are not one-size-fits-all, Mavrinac said: they require different skills, like group management and motivational interviewing techniques. And shared appointments in poor, inner-city clinics are not the same as ones in wealthier, suburban settings: they may have different no-show rates, require different communication approaches, and need to address different patient lifestyles. Marianne Sumego, MD, has been offering shared medical appointments since 1999 and, since 2010, has been the Cleveland Clinic's director of shared medical appointments, overseeing them for diabetes care and other conditions. At the Cleveland Clinic, a shared medical appointment lasts about 90 minutes and serves 10-15 patients at a time. "When shared medical appointment patients check in with my medical assistant, we do their vitals and see if they need refills; we address the appointment as we would traditionally," Sumego said. "It is a standard [evaluation and management] E&M appointment and billed that way," she explained. When patients go into the shared appointment room, Sumego's facilitator coordinates their information and sees what questions they have. "Then when I enter the room, I start talking with each patient one-on-one, with everyone observing," Sumego said. "Maybe we talk about how patients should inject insulin appropriately and share stories if patients are hesitant to start an injectable. The education builds off of the sequence of events as we go around the room." In one appointment, the group helped a man who worked third shift who wasn't getting breaks to eat properly. "Patients chimed with ideas about what he could say to his boss and how they approached their work -- what they packed, how they used their medications. It was a dynamic interaction. He walked out of the appointment with a better, clearer way to manage his work and diabetes than he would have had just relying on a physician giving some information about the right way to do it." How can a practice start offering shared medical appointments? "Pilot it first to do it right," Sumego advised. "And reach out to someone who has done this successfully. It helps to know whether you're on the right track." The learning curve to set up a shared medical appointment program can be 6 months, she noted. "Take time and realize it's a fluid process," she said. "My appointments now are not the same as they were when I started in 1999. They've grown better as I've incorporated feedback from patients and my team." Source
