Optimising Practice Efficiency to Promote Team Effectiveness

2. Optimising Practice Efficiency to Promote Team Effectiveness

3. DEVELOPED BY: Rob Wedel, MD, CCFP, FCFP Family Physician, Associate Medical Centre, Taber Palliative Care Physician, South Zone, Alberta Health Services Medical Director, Chinook Primary Care Network Co-Chair, Alberta AIM Chair, Advisory Committee on Primary Care, College of Family Physicians of Canada FACULTY: Kenneth Bayly, MD, CCFP, Physician General Practice, Saskatoon District Health, Saskatoon, SK Mel Cescon, MD, MCFP, Family Physician, Kitchener , ON , Quality Improvement and Innovation Partnership, ON Brian Craig, MD, MCFP, Family Physician, St. John, NB Lorraine Tessier, MD, MCFP, Family Physician, Hôpital du Sacré-Coeur de Montréal , Montréal, QC CONTRIBUTOR: Maureen Clement, MD, CCFP, Medical Director, Diabetes Education Centre, Vernon Jubilee Hospital, Vernon , BC This program was supported in part by an educational grant from AstraZeneca Canada. Shared Medical Appointments

4. Disclosure of Potential for Conflict of Interest Dr. Financial Disclosures: • Grants/Research Support:XYZ Pharma Co • Speakers Bureau/Honoraria: • Consulting Fees: XYZ Company • Other: Employee of XXY Hospital Group

5. Module 1 – The What, Why and How of Shared Medical Appointments

6. Objectives • After completing this session, attendees will be able to: • Understand the concepts surrounding a shared medical appointment model of care: • What a shared medical appointment is • The benefits to patients, physicians and teams for a shared medical appointment • The evidence for the use of a shared medical appointment • Guiding principles for planning, conducting and evaluating a shared medical appointment

7. Overview • Shared Medical Appointments fall under a general category of Group Visits. Group Visits also include Group Medical Appointments, and Group Patient Visits. Sometimes the terms are used interchangeably but all have some similar principles.

8. Agenda Shared Medical Appointments Presentation (60 minutes) •  What are Shared Medical Appointments? •  Step 1: Planning Shared Medical Appointments •  Step 2: Conducting Shared Medical Appointments • Step 3: Measuring Effectiveness •  Step 4: Refining and Repeating Group Discussion and General Feedback (30 minutes) • Group Discussion • Q and A

9. Shared Medical Appointments vs Group Medical Appointments vs Group Patient Visits… • All share the same principles of personal exam, group interaction and education with patient self management at the core • Common elements are: • Medical care • Education • Questions/answers • Socializing • Participant feedback about future educational sessions • Different models exist • Terms are usually used interchangeably but some differentiate based on model used

10. Shared Medical Appointments • Developed in the 1990s by Drs. John Scott and Ed Noffsinger • Motivated to deliver patient-centered care with improved quality and outcomes despite: • An aging population with complex medical needs1 • Deteriorating access2 • Substantially increased physician workloads2 • Growing patient demands and expectations2 • Rapidly expanding patient panels2 FHT. Guide to Chronic Disease management and Prevention, September 2005. Noffsinger EB. The Permanente Journal. Fall 1999; 3(3): 58-67.

11. What are Shared Medical Appointments? • An effective means to deliver integrated healthcare • An expanded medical appointment delivering most elements of an individual visit including: • Personal examinations (e.g., collection of vital signs, history taking, physical exam) • Formal and informal education • Social and psychological support Patient Self-mgmt

12. Why Would We Want to Conduct Shared Medical Appointments: Benefits1 General Practice Services Committee (GPSC) Shared Medical Appointments (http://www.gpscbc.ca/psp-learning/group-medical-visits/tools-resources)

13. Why Would We Want to Conduct Shared Medical Appointments (cont’d)? Better ‘Comprehensive Care Plan’(CCP) *Patient Management • An opportunity to follow your patients with CCPs • Monitor and support patient adherence • Update CCPs as required • Provide necessary education • Demonstrate practice team support for the CCP • Regular scheduled follow-ups • Recognize patient success in following CCP * Plans in various provinces for dealing with chronic disease may have other names

14. What Evidence is There to Support Shared Medical Appointments?

15. Medical Clinics Versus Usual Care for Patients with Both Diabetes and Hypertension: A Randomized Trial1 • 239 patients with poorly controlled hypertension and diabetes were randomized to either GMCs or usual care • Poorly controlled hypertension and diabetes: • Systolic BP >140 mm Hg or Diastolic BP >90 mm Hg, and HbA1c level >7.5% • Patients in each group were similar1 • Data collection at baseline, midpoint (~6 mos) and study end (~12 mos) Aim: Assess the effectiveness of Group Medical Clinics (GMCs) for the management of diabetes and hypertension Edelman D, et al. Ann Int Med 2010;152:689-96.

16. Reductions in SBP and DBP were Associated with Group Medical Clinic Attendance Better Systolic and Diastolic BP measurements seen with diabetic GMC patients may contribute to reduced CV morbidity and mortality.1 Edelman D, et al. Ann Int Med 2010;152:689-96.

17. Further Benefits Observed with GMC Attendance • Fewer ER visits (p<0.001) • Fewer Primary Care visits (p=0.010) • Enhanced perceived competence for engaging in healthier behaviour (p<0.001) Patients attending GMCs benefited from CV risk reduction and an enhanced sense of empowerment. Edelman D, et al. Ann Int Med 2010;152:689-96.

18. Primary Care Practices are the Cornerstone of Effective Chronic Disease Management • Health outcomes are a function of continuity of care by the same family physician1 • Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1 • Shared Medical Appointments may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided2 Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44. Steering Group Communication.

19. How Do We Implement Shared Medical Appointments in Our Practice?

20. Implementation Process identify and plan ahead for change, analyze and predict the results PLAN: DO: STUDY: ACT: execute the plan, taking small steps in controlled circumstances check and study the results take action to improve the process The process is flexible…….Engage in continual planning, studying and refining at all stages

21. Model for Improvement: Three Important Questions Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

22. Implementing Shared Medical Appointments Step 1: Planning Shared Medical Appointments (PLAN) • Conduct Needs Assessment to identify gaps and patient groups • Select shared medical appointment model • Create Plan of Action Step 2: Conducting Shared Medical Appointments (DO) • Identify specific patients • Organize resources and conduct Shared Medical Appointments Step 3: Measurement and Evaluation (STUDY) • Evaluate results and make adjustments • Identify methods to sustain change Step 4: Refine and Repeat (ACT) • Plan more Shared Medical Appointments

23. Planning Shared Medical Appointments • Know your Practice and Your Patients • Select the Appropriate Shared Medical Appointment Model • Create an Action Plan

24. Select Appropriate Shared Medical Appointment Model

25. Shared Medical Appointment Models by Conditions

26. Shared Medical Appointment Model Fluidity

27. Conducting Shared Medical Appointments • Patients • Identify specific patients within your “priority patient group” • Invitations • Resources • Identify and organize resources • The Visit

28. Conducting Shared Medical Appointments Identify specific patients to participate • Relatively stable and will benefit from education • Function well in a group setting • Good cognitive, sight and hearing function Patient Invitations • Explains the SMA and the patient’s role as a participant • Multi-pronged approach may be needed/effective

29. Conducting Shared Medical Appointments (cont’d) Identify and Organize Resources • Team member roles and responsibilities • Patient charts and medical equipment • Patient information binder • Educational materials • Forms (e.g., attendance sheets, confidentiality agreements, evaluations, etc.)

30. Conducting Shared Medical Appointments (cont’d) The Visit • Success is dependent on: • Productive interactions • Physical involvement and /or endorsement • Time management is critical • Agenda and expectations • Group Norms • Confidentiality Ensure that confidentiality is addressed early on in every meeting – this helps establish trust among the group

31. Measurement and Evaluation What to measure to assess benefit of SMAs? • Practice Utilization: • Demand for one-on-one appointments • Reduced waiting times • Medical team satisfaction • Clinical Outcomes: • % patients meeting clinical guidelines • Increased patient self-management and satisfaction • Patients’ commitment to Complex Care or other similar plan • Pre/post medical tests (e.g.: HbA1c, BP, Lipids etc.) • Reduced utilization of ER/hospital admissions Don’t try to measure everything…..start with small steps such as vital signs and key lab work.

32. Practice Resource Use and Satisfaction All identified topics for education. staff Very informative and happy time. These meetings are very helpful! patient Hopefully it will provide help and interest as it continues. patient Great way to learn what is needed to teach self-management. medical student All voiced they would like to come again. staff This meeting was very good because we could see how other people did under similar conditions. It also gave answers to so many questions I wasn’t sure of. patient Very important team-based experience. medical student

33. Refine and Repeat • Planning more Shared Medical Appointments Did the chosen model work? YES NO Expand SMAs to other patients, perhaps with more complex conditions and comorbidities • Revise the model • Work with the same patient group before expanding

34. Sustaining Shared Medical Appointmentsin Your Practice • PATIENTS • Know your panel • Appropriate clinical information • MEDICAL TEAM • Support • Appropriate resourcing • Role alignment • Action plan • Refinement • Repetition Shared Medical Appointments • INTERACTIONS • Effective facilitator • Targeted education • Self-management support Informed, Engaged Patients Productive Interactions Prepared, Proactive Medical Team Productive, Group Interactions ENHANCED OUTCOMES, EFFICIENCY, AND SATISFACTION Adapted from Kirsh s, et al. Qual Saf Health Care 2007;16:349-353.

35. Module 2 – Interactive Workshop:Building a Clinic Shared Medical Appointments Action Plan

36. Objectives • After completing this session, attendees will be able to: • Identify clinical gaps to address within their clinical practice and resultant desired outcomes • Identify the appropriate shared medical appointment model to use • Develop a Clinic Action Plan to: • Plan a group visit • Conduct a group visit • Evaluate a group visit

37. Overview • Shared Medical Appointments fall under a general category of Group Visits: • Group Visits also include Group Medical Appointments, and Group Patient Visits. Sometimes the terms are used interchangeably; all have some similar principles

38. Agenda Shared Medical Appointments Presentation • Brief introduction to Shared Medical Appointments (recap of Module 1) (15 minutes) Workshop- Building a Clinic SMA Action Plan • Step 1: Assessing Needs – Clinic and Patients (10 minutes) • Step 2: Creating a Plan of Action • Patient Group Needs (10 minutes) • Identifying YOUR clinic purpose or improvement goals? (5 minutes) • Building your FIRST SMA agenda (15 minutes) • How will you determine success? (10 minutes) • Team Roles & Responsibilities in Planning your SMA (10 minutes) Group Discussion and General Feedback • Group Discussion (10 minutes) • Summary and measure effectiveness (5 minutes)

39. Implementation Process identify and plan ahead for change, analyze and predict the results PLAN: DO: STUDY: ACT: execute the plan, taking small steps in controlled circumstances check and study the results take action to improve the process The process is flexible…….Engage in continual planning, studying and refining at all stages

40. Planning Shared Medical Appointments • Know your Practice and Your Patients • Select the Appropriate Shared Medical Appointment Model • Create an Action Plan

41. Know Your Practice and Your Patients • Does your clinic have a Patient Registry? • A registry is a very important step in patient management • EMR systems - registry is populated via data search • Clinical outcomes (e.g. HbA1c >7%; BP >130/80 etc.) • Manual registries - tracking patients via commercially available spreadsheets • Populated by chart review, when lab results are received, at diagnosis of a chronic disease (e.g. diabetes) etc. • For info: www.aafp.org/fpm/2006/0400/p47.html1 Oritz, p. 51

42. Conduct a Clinic Needs AssessmentKnow Your Practice and Your Patients • Know the patients in your practice and their care needs • Identify your Priority Population • Define characteristics of your unique patient list • Determine patients with chronic conditions • Identify priority target populations

43. Conduct a Clinic Needs AssessmentKnow Your Practice and Your Patients • Identify need for improved practice efficiency • Are there gaps in care you would like to address? • What specific goals could be addressed or accomplished through Shared Medical Appointments? • Identify your priority patient groups • What are the Top 10 Conditions patients visited your clinic for in the past year? • What was the frequency of those visits? • Are you successful with Comprehensive Care or other similar plan implementation and follow up?

44. Select Appropriate shared medical appointment Model

45. Shared Medical Appointment Models by Conditions

46. Shared Medical Appointment Model Fluidity

47. Create an Action Plan • Action Plan is a detailed summary of steps to be accomplished and allows you to analyze and predict results • Plan Includes: • Shared Medical Appointment details: • Goals and objectives • Identification of specific patient group • Frequency • Specific Action Plan: • Tasks • Resources and roles • Determine what to measure

48. Sample Planning Timeline

49. Conducting Shared Medical Appointments • Patients • Identify specific patients within your “priority patient group” • Invitations • Resources • Identify and organize resources • The Visit

50. Measurement and Evaluation What to measure to assess benefit of SMAs? • Practice Utilization: • Demand for one-on-one appointments • Reduced waiting times • Medical team satisfaction • Clinical Outcomes: • % patients meeting clinical guidelines • Increased patient self-management and satisfaction • Patients’ commitment to Complex Care or other similar plan • Pre/post medical tests (e.g.: HbA1c, BP, Lipids etc.) • Reduced utilization of ER/hospital admissions Don’t try to measure everything…..start with small steps such as vital signs and key lab work.