# Presentation: 676085

## How to Conduct a Shared Medical Appointment in Heart Failure Clinic

- Mark Dunlap, MDJulie Gee, RN, MSN, CNP
- Louis Stokes Cleveland VAMC
- MetroHealth Medical Center
- Cleveland, OH

**Notes:**
How to Conduct a Shared Medical Appointment in Heart Failure Clinic

Mark Dunlap, MDJulie Gee, RN, MSN, CNP
Louis Stokes Cleveland VAMC
MetroHealth Medical Center
Cleveland, OH

## Shared Medical Appointment (SMA)

- Original definition: Multiple patients receive education and physical exams in a group setting
- Our definition:  a multidisciplinary disease management program intended to provide specialized extended care in a group setting to individuals diagnosed with a chronic illness.

**Notes:**
Shared Medical Appointment (SMA)

- Original definition: Multiple patients receive education and physical exams in a group setting
- Our definition:  a multidisciplinary disease management program intended to provide specialized extended care in a group setting to individuals diagnosed with a chronic illness.

## Patient Outcome Goals (the “ideal HF patient”)

- Patients will:
- Learn about HF disease process, symptoms, medications, and goals of treatment
- Be proactive with self-monitoring
- Experience a reduction in HF symptoms
- Be well-medicated
- Demonstrate adherence to treatment (meds, diet, appointments)
- Know when and how to call the HF clinic

**Notes:**
Patient Outcome Goals (the “ideal HF patient”)

Patients will:
Learn about HF disease process, symptoms, medications, and goals of treatment
Be proactive with self-monitoring
Experience a reduction in HF symptoms
Be well-medicated
Demonstrate adherence to treatment (meds, diet, appointments) 
Know when and how to call the HF clinic

## Clinic Outcome Goals

- Minimize ER visits
- Minimize hospitalizations
- Improve productivity
- Open more clinic slots  open access
- Decrease costs
- Maintain reimbursement
- Result in good health outcomes

**Notes:**
Clinic Outcome Goals

Minimize ER visits
Minimize hospitalizations
Improve productivity
Open more clinic slots  open access
Decrease costs
Maintain reimbursement
Result in good health outcomes

## The “How To” Part: Preparation

- Secure the support of your administration
- Establish the health care team
- Decide on a minimum/maximum census (10 patients for 1 provider)
- Identify your patient population
- Identify space for a conference room with an exam room and bathroom close by
- Establish a scheduling system

**Notes:**
The “How To” Part: Preparation

Secure the support of your administration
Establish the health care team
Decide on a minimum/maximum census (10 patients for 1 provider)
Identify your patient population
Identify space for a conference room with an exam room and bathroom close by
Establish a scheduling system

## Development phase:
Letter to patients explaining concept
Education based on AHA/ACC guidelines
Templated note
Symptom questionnaire
Patient satisfaction survey
Database
Weight log
Home-going clinic instruction sheet
HIPAA confidentiality statement

- Letter to patients explaining concept
- Education based on AHA/ACC guidelines
- Templated note
- Symptom questionnaire
- Patient satisfaction survey
- Database
- Weight log
- Home-going clinic instruction sheet
- HIPAA confidentiality statement

- The “How To” Part: Preparation (cont.)

**Notes:**
The “How To” Part: Preparation (cont.)

Development phase:
Letter to patients explaining concept
Education based on AHA/ACC guidelines
Templated note
Symptom questionnaire
Patient satisfaction survey
Database
Weight log
Home-going clinic instruction sheet
HIPAA confidentiality statement

## The clinic note

- Templated and computerized
- Components:
- Allergies, medications, Past medical, social and family history, testing data (echo, cath, ETT), etiology, BMP, dig level, TSH, lipid, and Hgb/Hct
- Current HF symptoms from questionnaire
- Focused Physical exam (JVP, cardio, pulm, abd, extremities)
- Volume status and NYHA Functional Class
- Plan (medication changes)
- Next f/u visit
- Details of education taught

**Notes:**
The clinic note

Templated and computerized
Components:
Allergies, medications, Past medical, social and family history, testing data (echo, cath, ETT), etiology, BMP, dig level, TSH, lipid, and Hgb/Hct
Current HF symptoms from questionnaire
Focused Physical exam (JVP, cardio, pulm, abd, extremities)
Volume status and NYHA Functional Class
Plan (medication changes)
Next f/u visit
Details of education taught

## The note:Individual information

**Notes:**
The note: Individual information

Graphic

## The note:Group information

**Notes:**
The note: Group information

Graphic

## Reimbursement issues

- Address billing and any system issues before starting
- Contact local insurers or contracted entities to identify possible billing issues
- Potential for much higher level of billing
- New consults 99315
- Follow-up patients 99314
- Extended care code 99354 or 99355 if over 30 minutes spent with patient (need to document total time spent)

**Notes:**
Reimbursement issues

Address billing and any system issues before starting
Contact local insurers or contracted entities to identify possible billing issues 
Potential for much higher level of billing
New consults 99315
Follow-up patients 99314
Extended care code 99354 or 99355 if over 30 minutes spent with patient (need to document total time spent)

## A typical clinic

- HF Team prepares the charts prior to the start of clinic
- Patients receive a letter explaining the Shared Medical appointment
- Upon arrival a HIPAA statement is signed by patient and guest(s)
- A clinic nurse takes vital signs
- Patients are brought to a conference room and given a packet of materials

**Notes:**
A typical clinic

HF Team prepares the charts prior to the start of clinic
Patients receive a letter explaining the Shared Medical appointment
Upon arrival a HIPAA statement is signed by patient and guest(s)
A clinic nurse takes vital signs
Patients are brought to a conference room and given a packet of materials

## Contents of the pt. packet

- HF symptom questionnaire with a templated physical exam form on the back
- Educational session handout
- Printout of their personal medication list, PMHx, Echo, cath, recent labs, wt, BP and pulse trends
- Daily weight log
- HF clinic instruction sheet

**Notes:**
Contents of the pt. packet

HF symptom questionnaire with a templated physical exam form on the back
Educational session handout
Printout of their personal medication list, PMHx, Echo, cath, recent labs, wt, BP and pulse trends
Daily weight log

## At each visit
HF symptom questionnaire completed
Visit takes 90 minutes 
HF educational topic is discussed
Patients are given  tools (scales, BP cuffs, med fill boxes, wt. logs)

- HF symptom questionnaire completed
- Visit takes 90 minutes
- HF educational topic is discussed
- Patients are given  tools (scales, BP cuffs, med fill boxes, wt. logs)

- A typical clinic (cont.)

**Notes:**
A typical clinic (cont.)

At each visit
HF symptom questionnaire completed
Visit takes 90 minutes 
HF educational topic is discussed
Patients are given  tools (scales, BP cuffs, med fill boxes, wt. logs)

## Team Members

- Clinic Nurse/medical assistant
- Moderator
- Provider
- Documenter

**Notes:**
Team Members

Clinic Nurse/medical assistant
Moderator
Provider
Documenter

## Team member roles:Clinic Nurse

- Obtains VS and ECG’s
- Assists patients with filling out  HF symptom questionnaires
- Assist with checking patients in, documentation of clinic, moderating clinic, assisting patients to clinic room
- Assist the patient with medication needs and update medication lists

**Notes:**
Team member roles: Clinic Nurse

Obtains VS and ECG’s
Assists patients with filling out  HF symptom questionnaires
Assist with checking patients in, documentation of clinic, moderating clinic, assisting patients to clinic room
Assist the patient with medication needs and update medication lists

## Could be Nurse, Pharm D, clinical psychologist, medical interns/students
Provides a structured education session and facilitates group discussion
Answers clinical questions
Assists with refills
May double as documenter if necessary

- Provides a structured education session and facilitates group discussion
- Answers clinical questions
- Assists with refills
- May double as documenter if necessary

- Team member roles:Moderator

**Notes:**
Team member roles: Moderator

Could be Nurse, Pharm D, clinical psychologist, medical interns/students
Provides a structured education session and facilitates group discussion
Answers clinical questions
Assists with refills
May double as documenter if necessary

## Could be NP, MD, or PA
Takes one patient out of the room at a time to exam room
Assess functional capacity and notes responses on HF symptom questionnaire
Escort pt to the exam table
Discusses symptoms as a physical exam is performed

- Takes one patient out of the room at a time to exam room
- Assess functional capacity and notes responses on HF symptom questionnaire
- Escort pt to the exam table
- Discusses symptoms as a physical exam is performed

- Team member roles:Provider

**Notes:**
Team member roles: Provider

Could be NP, MD, or PA
Takes one patient out of the room at a time to exam room
Assess functional capacity and notes responses on HF symptom questionnaire
Escort pt to the exam table
Discusses symptoms as a physical exam is performed

## Review med list, discuss patient/ provider goals, treatment plan written on the PE sheet AND the patient’s HF clinic instruction sheet
Next follow-up appointment interval is discussed
Patient returned to the group conference room
PE sheet handed to documenter and the next patient is taken out of clinic

- Next follow-up appointment interval is discussed
- Patient returned to the group conference room
- PE sheet handed to documenter and the next patient is taken out of clinic

- Team member roles:Provider (cont.)

**Notes:**
Team member roles: Provider (cont.)

Review med list, discuss patient/ provider goals, treatment plan written on the PE sheet AND the patient’s HF clinic instruction sheet
Next follow-up appointment interval is discussed
Patient returned to the group conference room
PE sheet handed to documenter and the next patient is taken out of clinic

## Enters HF symptoms and PE sheet information into a templated computer note during clinic
The plan is left to the end so the provider and other team members can put a collaborative plan in together
Must have clinical background and understand medical terminology
The documenter may also assist with facilitation of the group

- The plan is left to the end so the provider and other team members can put a collaborative plan in together
- Must have clinical background and understand medical terminology
- The documenter may also assist with facilitation of the group

- Team member roles:Documenter

**Notes:**
Team member roles: Documenter

Enters HF symptoms and PE sheet information into a templated computer note during clinic
The plan is left to the end so the provider and other team members can put a collaborative plan in together
Must have clinical background and understand medical terminology
The documenter may also assist with facilitation of the group

## May act as moderator
Most useful for new consults
New patients are asked to bring in their bottles and an accurate/updated medication list is put in the system
Assist with specific pt. education

- Most useful for new consults
- New patients are asked to bring in their bottles and an accurate/updated medication list is put in the system
- Assist with specific pt. education

- Team member roles:Pharm D

**Notes:**
Team member roles: Pharm D

May act as moderator
Most useful for new consults
New patients are asked to bring in their bottles and an accurate/updated medication list is put in the system
Assist with specific pt. education

## Practical Tips

- Have depth to your team
- Cross-Train team members
- Always have a planned education session/ ’structured format” with a well-prepared introduction
- For follow-up patients, assess needs ahead of time to the extent possible
- Maintain control of clinic, redirect if they get off subject
- Address personal issues such as substance abuse and erectile dysfunction in private (if the patient brings it up that is okay)

**Notes:**
Practical Tips

Have depth to your team
Cross-Train team members
Always have a planned education session/ ’structured format” with a well-prepared introduction
For follow-up patients, assess needs ahead of time to the extent possible
Maintain control of clinic, redirect if they get off subject
Address personal issues such as substance abuse and erectile dysfunction in private (if the patient brings it up that is okay)

## In what order do you see patients?

- Depends on the needs of your patient
- New patients are usually seen last so more time can be spent with them initially
- Follow-up patients are seen first
- Really sick are pulled out of clinic at the beginning and assessed, they may need to be admitted or treated in clinic

**Notes:**
In what order do you see patients?

Depends on the needs of your patient
New patients are usually seen last so more time can be spent with them initially
Follow-up patients are seen first
Really sick are pulled out of clinic at the beginning and assessed, they may need to be admitted or treated in clinic

## HF Education Sessions (modeled on HFSA)

- What is HF?
- What are the symptoms of HF?
- How to monitor weight and use diuretics properly
- How do I watch my sodium intake?

- What activities can I do?
- What medications am I on and why am I on them?
- Planning for my future
- Psychosocial issues of Heart Disease

**Notes:**
HF Education Sessions (modeled on HFSA)

What is HF?
What are the symptoms of HF?
How to monitor weight and use diuretics properly
How do I watch my sodium intake?

What activities can I do?
What medications am I on and why am I on them?
Planning for my future
Psychosocial issues of Heart Disease

## Our experience:Cleveland VA Medical Center

**Notes:**
Our experience: Cleveland VA Medical Center

## 47% Increase in Productivity

|  | SMA | Traditional |
| --- | --- | --- |
| Time | 1.6 years | 2.25 years |
| # patients seen | 268 | 256 |

- HF NP practices at two sites:
- Main campus SMA’s
- Satellite    “Traditional” HF clinic
- Both sites:  two 1⁄2-day clinics per week
- SMA
- Patient/provider team exposure 1.5-2 hrs ea
- ~8-12 pts seen
- Traditional
- 30 min clinic slots, total 4 hours
- 7-8 pts seen

**Notes:**
47% Increase in Productivity

HF NP practices at two sites:
Main campus SMA’s
Satellite    “Traditional” HF clinic
Both sites:  two 1⁄2-day clinics per week
SMA
Patient/provider team exposure 1.5-2 hrs ea
~8-12 pts seen
Traditional
30 min clinic slots, total 4 hours
7-8 pts seen

TABLE

## Medication doses and VS inSMA vs. traditional clinic

|  | Clinic | n | Baseline | 6 mo |  |
| --- | --- | --- | --- | --- | --- |
| ACE inhibitors
(enalapril mg=) | SMA | 266 |   27.9* | 29.3 |   1.4^ |
|  | Traditional | 253 | 20.6 | 23.1 |   2.5^ |
| -blockers
(metop mg=) | SMA |  | 123.5* | 142.4 | 18.9 |
|  | Traditional |  | 89.8 | 110.5 | 20.7 |
| Diuretic
(lasix mg=) | SMA |  | 51.6 | 44.7 | -6.9 |
|  | Traditional |  | 42.8 | 42.4 | -0.4 |
|  |  |  |  |  |  |
| HR (bpm) | SMA |  | 75.0 | 71.3 | -3.7 |
|  | Traditional |  | 73.5 | 72.1 |   -1.4^ |
| BP (mmHg) | SMA |  | 129/71 | 123/67 | -6/-4 |
|  | Traditional |  | 126/69 | 122/67 |   -4/-2^ |

- * = p<0.05 SMA vs. Traditional	^ = P<0.05

- Medication doses and VS inSMA vs. traditional clinic

**Notes:**
Medication doses and VS in SMA vs. traditional clinic

TABLE

## Wait Times:Average number of days

**Notes:**
Wait Times: Average number of days

GRAPH

## Number of Slots: 60% increase in productivity

**Notes:**
Number of Slots: 60% increase in productivity

GRAPH

## No show rates decreased from 28% to less than 10%

- Wording of the letter is important: Do not call it “group”, called it “Shared Medical appointment”
- Promotion by staff as ENHANCED care, not less care
- Reminder call by a staff member/Have schedulers verbally contract with patient
- Call the patient and find out why they no-showed

**Notes:**
No show rates decreased from 28% to less than 10%

Wording of the letter is important: Do not call it “group”, called it “Shared Medical appointment”
Promotion by staff as ENHANCED care, not less care
Reminder call by a staff member/Have schedulers verbally contract with patient
Call the patient and find out why they no-showed

## Patient Satisfaction:  Thoroughness inanswering questions

**Notes:**
Patient Satisfaction:  Thoroughness in answering questions

GRAPH

## Patient Satisfaction: Needs were met in time allotted during visit

**Notes:**
Patient Satisfaction: Needs were met in time allotted during visit

GRAPH

## Patient Satisfaction: Usefulness of group interaction and peer support

**Notes:**
Patient Satisfaction: Usefulness of group interaction and peer support

GRAPH

## Patient Satisfaction: The visit overall

**Notes:**
Patient Satisfaction: The visit overall

GRAPH

## Would you recommend this group to your family or friends?

**Notes:**
Would you recommend this group to your family or friends?

GRAPH

##  Potential Barriers

- Clinic space (need a conference room, area to do VS, and clinic room)
- 3-4 Team members
- Administrative support
- Need on-going communication with staff
- Computerized system is ideal
- Keeping it fresh

**Notes:**
Potential Barriers

Clinic space (need a conference room, area to do VS, and clinic room)
3-4 Team members
Administrative support
Need on-going communication with staff
Computerized system is ideal
Keeping it fresh