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A Guide to Virtual Shared Medical Appointments

Virtual SMAs are a virtual space where one-to-one consultations take place as part of a group. The format of a virtual SMA and an in-person SMA are similar.

What are virtual shared medical appointments?

 

Shared medical appointments (SMAs) are an evolving way of managing long-term conditions in primary care. Virtual SMAs are a newer kind of SMA developed mainly in response to the impact of COVID-19 on continuity of care. They are proving to be a valuable adjunct to service delivery.


Virtual SMAs are a virtual space where one-to-one consultations take place as part of a group. The format of a virtual SMA and an in-person SMA are similar.


View more here: www.smstoolkit.nz/group-visits


The participants in a virtual SMA often share a similar set of conditions. A typical virtual SMA lasts about 60–90 minutes, has 6–12 patients and includes a doctor and a trained facilitator who manages group dynamics and directs the sessions. It may be helpful to have an additional person who has responsibility for the technical aspects of running the session.
Before the virtual SMA, it is important to decide on workflow and clearly define roles of the clinician, facilitator and IT support person (if using one).


With virtual SMAs, it is not possible to do a physical examination at the time of the SMA – separate arrangements need to be made. In addition, an offline facility will need to be made available for personal discussions where needed. 
Virtual SMAs provide a supportive virtual group setting, where all can listen, interact and learn. Virtual SMAs are different to, and should not be confused with, group education sessions.

 
The virtual SMA may include patient education and counselling, as well as clinical support. 


Most often, patient groups are established around a common health condition or illness stage, e.g., about to start insulin, or stage 2 chronic kidney disease.

Virtual Shared Medical Appointments webinar

This Healthcare Home ‘Virtual Shared Medical Appointments’ webinar discusses recent experiences of virtual SMAs in 
New Zealand.

Roles for virtual SMAs

A GP is usually the clinical lead for a virtual SMA, and they are supported by a group facilitator and others who might include a practice nurse and note taker, as well as clinical support services such as pharmacy or physiotherapy where relevant to the health condition being discussed. A technical expert/support person may also be included.


Virtual SMAs have become much more prevalent since the COVID-19 pandemic.

Regularly scheduled SMAs are an alternative to individual visits for some patients.


The SMA can be thought of as an extended doctor’s office visit where not only physical and medical needs are met, but educational, social and psychological concerns can be dealt with effectively.

Virtual Shared Medical Appointments in the UK – Library of resources

The British Society of Lifestyle Medicine have a large collection of videos from webinars about virtual group visits. These range from primary care to secondary care settings. 
 
This video describes a suggested process and set up of virtual group SMAs.

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What are the benefits of virtual SMAs?

Patients, clinicians and practices have all found benefits in SMAs, particularly for the management of long-term conditions (LTCs) and lifestyle change.


SMAs have been identified as an effective alternative to short (10–20 minute) consultations and sporadic clinic visits where health professionals felt limited in their ability to meet the large number of preventive and LTC goals.


The potential advantages of SMAs were identified by Egger et al., 2018:

For patients

  • Extra time with their own doctor and a more relaxed pace of care.

  • Emotional support and understanding from peers.

  • Answers to questions they might not have thought to ask.

  • More extensive medical and educational inputs.

  • Greater education of self-management and attention to psycho-social matters.

Bottom line: Improved patient health and wellbeing, and enjoyment of the experience

For clinicians

  • Reduced repetition of information, plus a more fun and relaxing interaction.

  • Better support for GP (from patients and facilitator).

  • Better management of waiting lists and demanding patients.

  • Reduced individual GP or specialist visits.

  • Time to address educative questions more comprehensively.

Bottom line: Improved efficiency and work satisfaction

 

For practices

  • Containment of costs while increasing efficiencies.

  • ‘Frequent flyers’ can be treated more attentively.

  • Improved quality of care and efficiency in care provision.

  • Being innovative in their practice makes the practice more of a ‘patient-centred medical home’.

Bottom line: Improved outcomes and efficiencies

Similarly, a literature review by Kirsh et al (2017) identified the following benefits:

  • Being part of a group combats isolation, helping reduce doubts about one’s ability to manage illness.

  • Patients learn about disease self-management by hearing others’ experiences and seeing their progress over time.

  • Patients feel inspired by seeing others who are coping well.

  • Spending more time in a health care discussion results in patients feeling more supported.

  • The combination of professional expertise and hearing from peers leads to increased health knowledge and retention of key information.

  • Group dynamics lead patients and providers to develop more equitable relationships.

  • Providers learn from the patient experiences and learn how to better meet their patients’ needs.

  • Providers feel increased rapport with colleagues and achieve efficiencies.

  • Patients have the opportunity to see how the physicians interact with other patients, which allows them to get to know the physician and better determine their progress.

Additional benefits of virtual SMAs

  • Enables people who live in rural and remote areas to participate.

  • Facilitates continuation of care for people who may have mobility issues or who have challenges in attending person face to face appointments.

  • Virtual sessions can be run at any time. Providers can select a time that works for participants, and often evening sessions are popular.

  • Ongoing peer support following the SMA can be facilitated via a private Facebook group or similar online solution.

A summary of further literature on group visits and SMAs can be found in the references section.

Types of virtual SMAs

 

A typical virtual SMA lasts around 60–90 minutes, has 6–12 patients and includes a doctor and a facilitator who manages group dynamics and directs the sessions. The facilitator should have been trained in the use of facilitation skills. It may be helpful to have an additional person who has responsibility for the technical aspects of running the session.

There are two main types of virtual SMAs:

1. Programmed shared medical appointments (PSMAs)​

PSMAs are a series of individual medical consultations, in a supportive group setting, that also provide educational input on a specific topic. A good example is a diabetes or gout focused group, which allows people with the same condition to come together regularly to listen, interact and learn from each other, and which provides a good opportunity for a facilitator with extra training in the topic to educate the group using a lecture or discussion format.


Programmed SMAs can also give the wider multidisciplinary team the opportunity to have an individual consultation in a group setting. Such groups can respond to the needs of the participants by agreeing on what areas people would like to cover in upcoming sessions and inviting relevant allied health professionals such as dietitians, pharmacists, physiotherapists or nurse specialists to come and answer questions.


Some programmed SMAs are quite structured and focus on a specific outcome. Examples include smoking cessation and weight management groups being run in Australia. For these groups, participants attend a series of sessions with specific topics covered at each session. Sessions are scheduled to suit the purpose or goal of the group, for example smoking cessation groups may meet weekly for 6 weeks, whereas a weight management group might meet monthly for 6 months.

​2. Individual or one-off SMAs
 

Patients are invited to a one-off session that is either topic based or set up as part of a rolling programme for annual or quarterly reviews.

Equity and health literacy in the virtual environment

 

COVID-19 has had a huge impact on the way people use technology. Zoom sessions and virtual activities have become much more a normal way of doing things. However, not everyone has access to the devices and technology needed for an effective virtual consultation, or they may not be confident using them.

Additionally, many people live in areas where the broadband width is insufficient for videoconferencing. Helping participants and whānau work through these issues by discussing the choice of venue, talking to whānau who have and know how to use suitable devices, etc will enable improved participation in the SMA.

Communication and relationships are at the heart of any consultation, be it virtual or in-person. Many people will feel uncomfortable with sharing personal medical information in a virtual environment with people they have not met in person. Setting up an in-person group session prior to the virtual SMA, for participants who are able to travel, can allow people to meet and can help build confidence.

You will find more information about equity, health literacy and using telehealth on our website.

Facilitator Training

The success of any group session relies on effective group dynamics and the participation of all members of the group. The skills required to facilitate this effectively are specific and not necessarily held by clinicians who are involved in running SMAs.

A facilitator who is trained in these skills is an important and necessary member of the team. A facilitator can have any background – some are doctors, nurses or allied health professionals – a clinical background is not required. A lay leader or peer support worker can be a highly effective facilitator and bring knowledge and attributes with them that improve cultural safety and enhance participants’ experience.


The role of the facilitator must be clearly defined and understood by all members of the SMA leadership team. SMA facilitator training is therefore important. The Australasian Society of Lifestyle Medicine runs both in-person and online training programmes. Find out more about this training programme on their website.

Getting started – Planning virtual shared medical appointments

 

Planning a virtual SMA

All of the things that need to be done for in-person SMAs are also needed for virtual ones.


See our Guide to Shared Medical Appointments: www.smstoolkit.nz/guide-to-group-visits


The difference is that the room has become virtual. Most virtual SMAs undertaken to date have used the Zoom platform to create a virtual room.


There are a few things you can do to help your virtual SMA run smoothly:


Purchase the Pro Zoom licence, which allows you to have up to 100 participants and unlimited meeting length. It also offers admin features and meeting ID and passwords for greater security compared to the free licence, which has limitations in some of these areas. Zoom has a number of online training resources that will show you how to invite participants, schedule meetings, tips for managing meetings etc.


These videos can be accessed here: https://support.zoom.us/hc/en-us/categories/201146643


Once you have invited people to the virtual SMA, either by Zoom email, phone call, letter etc, always follow up with information about confidentiality, payment expectations and other important information such as the need for blood tests or other clinical data. Encourage the use of patient portal, this will help with administering and accessing appointments, test results etc.


Some people have found Facebook to be a helpful resource. The private group function can be used to organise the virtual SMA, invite people and enable ongoing peer support.


Virtual SMAs held in the evening have been found to be more popular for patients than sessions held during business hours. 


PowerPoint slides or resources can be shared with the group via the screen share function. 


Remind everyone at the start of the virtual SMA Zoom session about normal Zoom housekeeping: everyone should be on mute unless they are speaking, should respect people who are speaking, and can also raise questions using the Zoom chat function.


Any clinical follow-up can be followed up with the patient directly following the meeting, including sending out prescriptions, etc. Patients may need to make a follow-up in-person consultation if required.


Additional international guides and resources for group visits and shared medical appointments are available on https://www.smstoolkit.nz/group-visits

Information for patients

 

Here is an example of an explanation you could use with patients when inviting them to an SMA. This could be turned into talking points for doctors who invite patients in person, a script for phone invites, and as the basis for a letter sent out in follow-up to an invite.

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Privacy and confidentiality

 

In preparation for a virtual SMA, short privacy/confidentiality agreements need to be printed for participants to sign. Your PHO should be able to supply these or provide guidance about what these should contain. At the first (in-person) SMA, the agreement should be explained to participants and two copies signed by each person (including support people who are present). One copy is kept by the practice and the other is kept by the patient.


The agreement should be mailed to people who cannot attend the first (in-person) SMA. Someone should then contact these individuals to explain the agreement and ask them to return the signed agreement to the practice in the most convenient way possible.


Managing group behaviour


Working with a group of people is different to managing one-to-one interactions. The facilitator’s role is to manage the group’s discussion so that everyone has an opportunity to participate and feels welcome and safe to do so. The facilitator also enables the medical team to focus on individual patients when needed.


While most groups will run smoothly, in preparation for a virtual SMA it will be helpful for the team to discuss how unwanted behaviour will be managed if needed and by whom. 


To find some great ideas for managing difficult situations and individuals, check out the end of this guide from the Institute for Healthcare Improvement at www.ihi.org/resources/Pages/Tools/GroupVisitStartKit.aspx


Online Zoom tutorials also offer guidance on virtual meeting etiquette and technical tips for managing unwanted behaviour such as how to temporarily mute a participant if needed.


It is also helpful to agree to some group rules with participants at the beginning of each virtual SMA. These could initially be attached to the privacy agreements people sign. Prepare a PowerPoint slide with this information and briefly refer to it at the beginning of each session. Here is an example you can use or adapt.

 

During the shared medical appointment I agree to:
1. Talk and encourage others to talk.
2. Treat others with respect.
3. Listen carefully to others.
4. Ask questions if I don’t understand something.
5. Not interrupt others.
6. Take turns at speaking to make sure everyone gets a chance to talk.
7. Respect other people’s privacy.
8. Never share information about group members outside of the group.
9. Be kind to others.

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Running a virtual shared medical appointment

 

For all SMA sessions

 

 

 

 

 

 

 

 

 

 


Example programme for first SMA session (likely to be in-person)

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Virtual sessions should be run using the same format, with a few adjustments:

  • Participants are sent lab requests etc and test results before the meeting and the team will collate them on a PowerPoint slide to be shared during the SMA. This is most efficiently done by using the patient portal.

  • During the welcome part of the SMA, the facilitator and/or technical support person ensures that all participants are connected to the Zoom link and can see all of the participants on their screen.

  • The facilitator will also remind participants about the purpose of the session and that it will run in the same format as the first in-person session.

  • The facilitator will also remind participants about Zoom etiquette – for example, staying on mute while others are talking.

Supplies

Depending on the type and purpose of the group, the following are some of the supplies you may need:

For the first in-person session

  • White board, markers, chart or large sticky poster sheets

  • Name badges

  • Group behaviour poster/sheets

  • Privacy agreements

  • Clipboard for each patient with pens (depending on style of group)

  • Patient summaries (key diagnoses, medications, test results etc)

For the follow-up virtual sessions

  • Group behaviour poster as PowerPoint slide

  • Patient summaries (key diagnoses, medications, test results etc) as PowerPoint slides

  • Presentation slides from all of the presenters as PowerPoint

For more information about virtual SMAs visit www.smstoolkit.nz/group-visits

Feedback from attendees and clinical teams

As well as asking participants whether they found the virtual SMA useful, and how the visit could be improved, you may want to give people an evaluation form to complete. You could use or adapt this form.

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References

Hayhoe, Benedict, Verma, Anju, & Kumar, Sonia. (2017). Shared medical appointments
BMJ, 358, j4034. doi: 10.1136/bmj.j4034


Shared Medical Appointments - A quantum leap forward in chronic disease management and treatment Australasian 
Society of Lifestyle Medicine


Kirsh, Susan R., Aron, David C., Johnson, Kimberly D., Santurri, Laura E., Stevenson, Lauren D., Jones, Katherine R., & Jagosh, Justin. (2017). A realist review of shared medical appointments: How, for whom, and under what circumstances do they work? BMC Health Services Research, 17(1), 113. doi:10.1186/s12913-017-2064-z


Egger, G., Stevens, J., Ganora, C., & Morgan, B. (2018). Programmed shared medical appointments.


Australian Journal for General Practitioners, 47, 70-75.


Noffsinger E. The ABCs of group visits: An implementation manual for your practice. New York: Springer, 2013.


Egger G, Binns A, Cole MA, et al. Shared medical appointments – An adjunct for chronic disease management in the 
Australia?
Aust Fam Physician 2014;43(3):151–54.


Stevens J, Cole MA, Binns A, Dixon J, Egger G. A user assessment of the potential for shared medical appointments in Australia. Aust Fam Physician 2014;43(11):804–07.


Egger G, Dixon J, Meldrum H, et al. Patients’ and providers’ satisfaction with shared medical appointments. Aust Fam 
Physician 2015;44(9):674–79.


Stevens JA, Dixon J, Binns A, Morgan B, Richardson J, Egger G. Shared medical appointments for Aboriginal and Torres 
Strait Islander men
. Aust Fam Physician 2016;45(6):425–29.


Mejino, A., Noordman, J., & van Dulmen, S. (2012). Shared medical appointments for children and adolescents with type 1 diabetes: perspectives and experiences of patients, parents, and health care providers. Adolescent health, medicine and therapeutics, 3, 75–83. doi:10.2147/AHMT.S32417 Kahkoska, A. R., Brazeau, N. F., Lynch, K. A., Kirkman, M. S., Largay, J., Young, L. A., & Buse,

 

J. B. (2018). Implementation and Evaluation of Shared Medical Appointments for Type 2 Diabetes at a Free, Student-Run Clinic in Alamance County, North Carolina. Journal of medical education and training, 2(1), 032.


Braun, Tara L., Kaufman, Matthew G., Hernandez, Cristina, & Monson, Laura A. (2017). Shared Medical Appointments for Adolescent Breast Reduction. Annals of Plastic Surgery, 79(3), 253-258. doi: 10.1097/sap.0000000000001118

 

Doorley, S. L., Ho, C. J., Echeverria, E., Preston,0 C., Ngo, H., Kamal, A., & Cunningham, C. O. (2016). Buprenorphine shared medical appointments for the treatment of opioid dependence in a homeless clinic. Substance abuse, 38(1), 26–30. doi:10.1080/08897077.2016.1264535


Pascual, AB, Pyle, L, Nieto, J, Klingensmith, GJ, Gonzalez, AG. Novel, culturally sensitive, shared medical appointment model for Hispanic pediatric type 1 diabetes patients. Pediatr Diabetes. 2019; 1– 6. https://doi.org/10.1111/pedi.12852


Tkachenko, Elizabeth, Refat, Maggi Ahmed, Balzano, Terry, Maloney, Mary E., & Harris, John E. Patient satisfaction and physician productivity in shared medical appointments for vitiligo. Journal of the American Academy of Dermatology. doi: 10.1016/j.jaad.2019.03.044


Dana, Schneeberger, Mladen, Golubíc, C.F., Moore Halle, Kenneth, Weiss, Jame, Abraham, Alberto, Montero, Michael, Roizen. (2019). Lifestyle Medicine-Focused Shared Medical Appointments to Improve Risk Factors for Chronic Diseases and Quality of Life in Breast Cancer Survivors. The Journal of Alternative and Complementary Medicine, 25(1), 40-47. doi: 10.1089/acm.2018.0154


Jackson, Margaret, Jones, Daniel, Dyson, Judith, & Macleod, Una. (2019). Facilitated group work for people with long-term conditions: a systematic review of benefits from studies of group-work interventions. British Journal of General Practice, bjgp19X702233. doi: 10.3399/bjgp19X702233