Shared Medical Appointments for Glycemic Management in Rural Veterans

In 2005, the VA mandated shared medical appointments (SMAs) to improve clinic efficiency and quality of care. Both local and national Advanced Clinic Access meetings endorsed this method for decreasing wait times, improving patient outcome measures, and minimizing cost. Additionally, SMAs offer an opportunity to use nonphysician providers to their fullest potential. The VA has recognized the important role nonphysicians play in improving care for patients, especially patients with chronic illnesses, such as diabetes mellitus (DM).¹

Based on the chronic care model, SMAs are patient medical appointments in which a multidisciplinary/multiexpertise team of providers sees a group of 8 to 20 patients in a 1.5- to 2-hour visit. Chronic illnesses, such as DM, are right for this approach.¹

Diabetes mellitus is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults. It also is a major cause of heart disease and stroke, and the seventh leading cause of death in the U.S. The total cost of diagnosed DM in the U.S. in 2012 was $245 billion compared with $174 billion in 2007.² Direct medical costs accounted for $176 billion, and $69 billion accounted for indirect costs, such as disability, work loss, and premature mortality.² After adjusting for population age and sex differences, the average medical expenses among people diagnosed with DM were 2.3 times higher than medical expenses for those without DM. This figure does not include the cost of undiagnosed diabetes, prediabetes, or gestational diabetes.²

The purpose of this quality improvement study is to describe the results of SMA for management of DM conducted largely among rural veterans. The effectiveness of DM SMAs has been documented in several previous studies.^3-10 However, this study focuses on using SMAs to manage veterans with DM in a rural environment.

Methods

The authors used the Primary Care Almanac (PCA) of the VHA Support Service Center to identify potential study participants at Lake City VAMC in Florida. The PCA is a database of VA primary care patients. The authors identified patients with hemoglobin A_1c (HbA_1c) level > 9% through the DM Cohort Reports Menu. Veterans with behavioral issues and those with high no-show rates were excluded.

The clinic staff called the eligible participants, educated them about SMA, and asked whether they would be interested in attending a DM SMA. If interested, they were scheduled for the next SMA. If uninterested, they were offered DM home telehealth follow-up, an appointment with the DM pharmacist, an appointment with the dietitian, enrollment into a DM education class, or routine follow-up with their primary care provider (PCP). Using this method, 18 patients were scheduled for the DM SMA between November 2010 and April 2013.

SMA Procedures

A physician or advanced registered nurse practitioner (ARNP) led each appointment, and in most cases other staff attended, including a clinical pharmacist, physical therapist (PT), kinesiotherapist (KT), dietician, social worker, registered nurse (RN), patient educator, and mental health provider. A pharmacist and RN attended all SMA appointments. The basic format consisted of a 90-minute appointment and included an abbreviated, clothed physical exam, which included vital signs; auscultation of heart, lungs, and abdomen; and foot exam. If a veteran had not received an eye exam within the year, an eye clinic consult was ordered. There were 10- to 30-minute blocks of time for the support staff who attended. The physician or ARNP usually led the appointment, and in addition to speaking to the group and discussing a daily topic, also spoke one-on-one with each veteran while support staff spoke to other group members.

During the appointment, the pharmacist answered questions and reviewed and adjusted medications as needed. The RN educator acted as a transcriptionist and answered questions. The PT/KT led interactive exercises. The dietitian answered questions, gave out educational materials, and did cooking demonstrations. The psychologist discussed behavioral health goals and asked each veteran to set a health goal to evaluate at the next meeting. The nursing staff in the primary care clinic checked in the patients. One nurse checked-in 1 to 2 patients and gave the patient a medication list.

Appointments were held every 2 to 3 months. All veterans attending were invited to come to the next appointment, and new patients were enrolled throughout the study. The new veterans were invited based on HbA_1c readings pulled from the PCA database.

Hemoglobin A_1c, blood pressure (BP), weight, and lipid level data were collected. Participation ended when HbA_1c improved to < 8%, a patient was no longer interested, or after the patient did not show up for an appointment and did not call to cancel.