Group Lecture

Shared Medical Appointments

A series of consecutive individual clinical consultations delivered in a supportive group setting, where all can listen, interact, and learn.

What are shared medical appointments?

Shared medical appointments (SMAs) are a series of individual medical consultations in a supportive group setting, where all can listen, interact and learn. SMAs are an evolving way of managing long-term conditions in primary care. 

 

An SMA isboth an individual consultation and an opportunity for participants to share experiences and knowledge.

 

Shared medical appointments are different to, and should not be confused with, group education sessions.

 

An SMA may include patient education and counselling, as well as physical examinations and clinical support.


SMAs usually include 6–12 patients and their support people. 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. 


Who is involved?

  • A GP or nurse practitioner is usually the clinical lead for an SMA.

  • They are supported by a group facilitator.

  • Other roles might include a practice nurse and notetaker.

  • At times it can be useful to also include clinical support services such as pharmacy or physiotherapy where relevant to the health condition being discussed.


SMAs have been used overseas since the early 1990s. 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.

What are the benefits of SMAs?

 

​Patients, clinicians and practices have found multiple benefits in SMAs, particularly for managing 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.


A great 2018 webinar explaining SMAs and how they work, as well as describing the benefits of this approach can be found at: 
www.lifestylemedicine.org.au/content/introduction-to-shared-medicalappointments-webinar


Also this British Society of Lifestyle Medicine video describes ‘what is a group consultation’, also known as a group visit or SMA: 
https://bslm.org.uk/lifestylemedicine/group-consultations


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 reduced wait times.

  • 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 selfmanagement 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.

 

Appendix 1 provides a summary of further literature on group visits and SMAs.

Types of SMAs

A typical 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.
 

There are four main types of SMAs: programmed shared medical appointments, individual or one-off SMAs, drop-in group medical appointments and virtual shared medical appointments.

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 clinician with extra training in the topic to educate the group using a lecture or discussion format. Time is also provided for individual questions and group discussion.

 

Programmed SMAs can also give the wider multidisciplinary team the opportunity to provide individual consultations 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.

In this video, John Stevens describes how a PSMA runs in his practice

John Stevens.jpg

An example of a PSMA - Australian Lifestyle Medicine group weight loss for men:

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. 

3. Drop-in group medical appointments

Drop-in appointments involve an ever-changing group of patients with a range of standard medical problems. They are provided at a set time each week to reduce waiting times and enable acute care to be more accessible. People learn from hearing each other’s experiences, can start to see common risk factors, e.g., the effect of smoking, obesity etc. on health, and the value of healthier lifestyle choices such as keeping active and healthier eating for most health conditions. They can also pick up a range of self-care skills they can share with their whānau, e.g., how to manage skin infections, the treatment and prevention of gout or recognising that a chronic cough isn’t normal. This is the format being used by a Taupō practice that provides a regular drop-in group appointment at a local marae once a week.

4. 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. To find out more about virtual SMAs go to our Shared Medical Appointment web page and guide to virtual SMAs. www.smstoolkit.nz/group-visits

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:


www.lifestylemedicine.org.au/courses/shared-medical-appointments-onlineworkshop-for-practitioners-and-facilitators

Getting started – Planning shared medical appointments

Prepare the practice

1. Starting an SMA requires planning, both to introduce a new process to your practice, and to prepare for the SMA itself.

2. Talk with your PHO about the guidance and support they provide for SMAs and if there are any funding streams available. Some PHOs have very detailed written guides. This gives you an idea of costs and the business case needed 
to make the SMA cost effective.


3. Think about where and when an SMA could be run, and who would attend from your practice.


4. Identify the administrative support you will need to set up the SMAs.


5. The initial SMA will take longer to plan and administer as it will be introducing new processes to the practice and patients, however, the process will become more efficient over time.


6. Talk with the leaders in your practice and seek their support. Share the outcomes you think can be achieved from your SMAs for patients, staff and the practice, and identify the financial business case.


7. Identify the team you will work with, a doctor, a nurse and a person who can serve in the role of facilitator. This team needs to help plan the process and agree on the roles each member will play. There are videos and guides, along with PHO resources and training, you will be able to use to prepare the team.


8. At a team meeting, determine the population group you would like to invite for SMAs. Identify a condition where a significant number of patients need ongoing follow-up or improved management, or where significant inequities exist.

Prepare for the SMA

1. Prepare a process, scripts and letter/messages for inviting patients to an SMA.


2. To get a group of 6 –10 patients, you may need to invite up to 20 people. Initially, you may need three to four weeks of issuing invites to get enough people to run your first SMA and give people enough time to complete any tests required.

3. Agree on how patients will be identified as potential participants, and who will invite patients. Until patients become more familiar with the SMA format, it will be important to invite patients inperson, or ring to invite each person and answer their questions, as well as following up with a letter or message on their patient portal.


4. Identify the test results and other information you need about each patient to make the SMA effective. Encourage use of the patient portal for this.


5. Identify how SMAs will be funded and whether a payment is required. This must be made clear in the invite to patients.


6. You may decide to invite patients who have seen their doctor in the month prior to the SMA so you have recent  information on them. Selecting these patients means that people who attend the SMA are less likely to have unmet acute 
or unrelated medical needs when they attend the SMA.


7. Each doctor in the practice may be given the criteria for inviting patients and use the script to issue a personal invite to suitable patients at the end of their appointments. This could be followed up by a nurse or administrator over the phone and a letter or message.


8. Alternatively, suitable patients could be identified from their medical records, such as prediabetes and HbA1C levels or those not on uric acid lowering medicine who have a history of gout attacks. These patients could be contacted by phone by a nurse (using a script) to explain the SMA opportunity and answer any questions.


9. You may also extend the invite to interested family members or support people, but explain that personal medical history may be shared and individual consultations will take place for patients in the group setting.


10. As part of confirming patient attendance, it is important to organise relevant testing for patients, so their results can be used to inform the SMA discussion. This may require a patient to arrive early for the SMA for point-of-care testing, or for the patient to be sent a laboratory form for testing several days before the SMA. Encourage the use of the patient
portal, this will streamline the process and make the results visible to both yourself and the patient.


11. Prepare group rules and privacy agreements.

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


A useful New Zealand guide has been developed by Pinnacle in partnership with the Healthcare Home Collaborative, available on:

www.healthcarehome.org.nz/sma

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.

Information for patients.jpg

Privacy and confidentiality

In preparation for an 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 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.

 

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 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 an 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


It is also helpful to agree to some group rules with participants at the beginning of each SMA. These could initially be attached to the privacy agreements people sign, as well as displayed on a wall during the visit and briefly referred to at the beginning of each session. Here is an example you can use or adapt:

During this session 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.

Running a shared medical appointment

Running a shared medical appointment.jpg

Example programme for first SMA session

Example programme for first SMA session.jpg
Example programme for first SMA session2.jpg
Example programme for first SMA session3.jpg
Example programme for first SMA session4.jpg

Supplies

 

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

  • 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.

Feedback from attendees and clinical teams
 

As well as asking participants whether they found the 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.

Feedback from attendees and clinical teams.jpg

For more resources about shared medical appointments

 

Visit the Self Management Support website 

 

https://www.smstoolkit.nz/group-visits

 
 
 
 
 
 
 
 
 
 

Appendix 1: A brief summary of the literature

An online search was conducted to look at the evidence for group visits/SMAs. Eight articles which were less than 10 years old and specific to group visits/SMAs were selected.


A 2018 study conducted by Kahkoska et al. investigated whether the SMA model could be incorporated in a free clinic run by students for Type 2 diabetes in North Carolina. They concluded that clinic efficiency was increased by using a SMA model as the clinic could accommodate more patients in a month compared to individual clinic appointments. The SMA-led clinic also allowed trainees to gain educational opportunity. Although 29 patients were enrolled in this study, only 8 patients had retrospective data for analysis of diabetes outcomes. Kahkoska et al. found that 6 out of 8 patients had decreased HbA1c after attending SMA. Limitations of this study include small sample size. (Kahkoska et al., 2018)


Group visits or SMAs were found to be useful for adolescents seeking breast reduction surgery. Braun et al. conducted a study in 2017 looking at how the clinic implemented SMAs, evaluated changes in clinic efficiency, measured patient 
quality of life before surgery, and assessed patient and provider satisfaction with the SMA model. The research found “high patient and provider satisfaction and increased clinic efficiency, without sacrificing time spent on education or with the surgeon.” (Braun et al., 2017)


A study conducted by Doorley et al. in 2017 looked at the retention rate of an SMA for treatment after starting  buprenorphine in a homeless clinic for opioiddependent patients. The research found that “in a patient population with 
complex social and mental health histories, buprenorphine treatment via a SMA had high retention rates. Findings can help guide the development of unique delivery systems to serve real-world complex patients with opioid dependence.” 
(Doorley et al., 2017)

Pascual et al. looked at whether the SMA model could be incorporated into a culturally sensitive, cost effective care programme for Latino patients with Type 1 diabetes, as Latino patients face language and cultural barriers leading to poor outcomes. They concluded that patients have 98% satisfaction rate and improved HbA1c after attending a shared medical appointment care programme. (Pascual et al., 2019)


Tkachenko et al. conducted a study in 2019 implementing SMAs for patients with vitiligo and looked at outcomes such as patient satisfaction, time to appointment, number of new patients seen per month, and generated revenue. The research concluded that patients were highly satisfied with both shared medical appointments and traditional appointments. Time to appointment was faster for shared medical appointments and significantly more new patients were seen monthly with this model. (Tkachenko et al., 2019).


A study conducted by Schneeberger et al. in 2019 investigated the effectiveness of group visits on breast cancer survivors’ quality of life and control of risk factors. They found decreased body weight, changes in psychosocial variables of perceived stress, depression, patient activation, and quality of life trended in a positive direction, but did not reach statistical significance. The research also found a significant decrease in average weekly fat consumption. Most patients found the program educational and enjoyable, and nearly half of them described it as life changing. (Schneeberger et al., 2019)


Mejino et al. conducted a study looking at patients, parents, and healthcare providers’ perspectives on SMAs for children and adolescents with Type 1 diabetes. According to Mejino et al., healthcare providers feel more information was discussed during a shared medical appointment. Patients also feel they received more information about lifestyle modification.

 

Although generally children and adolescents were satisfied about the performance of healthcare providers, 46.7% of patients thought that the amount of information about lifestyle provided was the same as in an individual visit. They also concluded that patients’ satisfaction decreased after 3 months of attending SMAs. This study has a small sample size and only examines one type of SMA. (Mejino et al., 2012)

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, 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