• Average A1C
• Percentage of patients with  LDL < 100
• Percentage of patients with a BP <130/80
• Percentage of patients with an annual dilated retinal exams
• Percentage of patients with an annual foot exams
• Percentage of patients with an annual micro albumin
• Flu vaccination rates
• Pneumovax vaccination rates
• Percentage of patients with self management goals/Action plans
• SF-12(for Shared Medical Appointment patients)

Shared Medical Appointments were adopted by the Family Practice Center in September, 2002 as part of a larger effort to improve care to patients with diabetes. This innovative model for delivering care was also determined to be a method through which Family Medicine residents would be trained in how to incorporate elements of the Care Model   into everyday practice. Monthly two hour sessions were held led by a multi-disciplinary team of practice champions, and a set of measures were monitored for both the shared medical appointment cohort and a control group who received standard care.

• Developed a multi-disciplinary team to provide care at the shared medical appointments, with clearly defined roles and responsibilities.
• Designed and implemented a modified Cooperative Health Care Clinic model for a cohort of diabetic patients.
• Provided education to faculty, staff and residents on shared medical appointments, as well as an opportunity to observe or participate in sessions.
• Carved out time for pre and post-session “team huddles” to continually improve the process.
• Developed and adopted documentation tools to aid in efficiency of documentation and ability to code and bill effectively.
• Developed and adopted self-management tools for providers/staff and patients to enhance collaborative goal setting.
• Implemented a Chronic Illness Registry to track key measures.
• Developed community partnerships to enhance patient self care and education.
• Developed and implemented a process improvement curriculum for Family Medicine residents, which requires participation in shared medical appointments.

There was a substantial improvement in the average A1C, as well as in other process and clinical our measures for the patient cohort (n=17) who participated in the shared medical appointments, which were greater  than the results for the control group (n=125) who received standard care, and have been better sustained over the past nine months.  Patient, provider and staff satisfaction was improved, and patients had an improvement in self perception of health status, as reported  on SF-12 Health Surveys done at 6 and eighteen months. As a result of this effort Shared Medical Appointments have expanded to include sessions for patients with cardiovascular diseases, the five year well child visit and preventive care for middle school and high school aged children.

• Work as a team.  Collaboration amongst all team members is vital to the success of the sessions.  Each member must understand their roles and responsibilities, as well as the importance of the patient central to the team.
• Let go. It is easy for providers to try to control the group rather than allow for the group to be self directed. It is vital to allow group dynamics to happen, and for providers to remember to be coaches and facilitators in this process.
• Be flexible and creative.  Once the group becomes self directed almost anything can and will happen during the sessions! Planning ahead and knowing your players is very helpful, and thinking about what potentially could happen can help make the sessions flow more smoothly.
• Partner with the patient.  Foster and environment of collaborative learning to help allow the patient to play a central role in managing their health care.
• Communicate, communicate.  Make sure there is time allotted for the team to meet and discuss needs, concerns and issues.
• Have the patient take the role of teacher.  Patients have much to teach us and each other about how to better care for themselves.  Stay open to their stories and encourage them to share their experiences.
• Take advantage of local resources.  There is an abundance of community resources available to help you and your patients. Learn how to see the community differently in order to take full advantage of those resources.

Jacquelyn Cawley, DO, Assistant Chief of Family Medicine
Maine Medical Center, Family Practice 
cawlej@mmc.org

[Storyboard presentation at IHI's National Forum, December 2004]