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RRP 07-277 – QUERI Project

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RRP 07-277
Diabetes Shared Medical Appointments: System Redesign & Implementation
Susan R Kirsh MD
Louis Stokes VA Medical Center, Cleveland, OH
Cleveland, OH
Funding Period: August 2007 - February 2008

BACKGROUND/RATIONALE:
Incorporating shared medical appointments (SMAs) (group visits) into clinical practice to improve care and efficiency has become a popular intervention, but the processes to implement and sustain them and their benefits have not been well described nor has the impact on medical education been assessed. Understanding these issues is critical because SMAs necessitate system redesign that includes all levels of the system and have the potential to train medical students in unique ways.


OBJECTIVE(S):
During this study, we developed and evaluated the implementation of an SMA training toolkit at a community based outpatient clinic (CBOC) site and identified enabling, facilitating, and inhibitory factors related to implementation (Aim 1), and collected preliminary data regarding the impact participating in SMAs has on training physicians to attain competency in management of diabetes (DM) (Aim 2).

METHODS:
Mixed-methods (e.g., observation, surveys, focus groups) were used for Aim 1. Prospective pre-post design comparing a group of medical students who participated in DM SMAs with those who did not was used for Aim 2.

To describe implementation, we used case analysis and action research approaches (qualitative) to analyze the local context before and after introducing SMAs, and to describe the system redesign issues that evolved for sustainability. Notes from SMA debriefings/meetings, interviews and observations were utilized and integrated into the training manual and toolkit. To assess impact on medical education, we compared change scores on diabetes attitudes (Diabetes Attitude Survey: DAS-V3) and confidence regarding health care team skills for medical students on 4-week chronic care rotations (those with and without SMA experiences during the rotation).

FINDINGS/RESULTS:
The Diabetes SMA manual/toolkit summarizing the necessary guidelines, information, tools, and resources for starting and conducting successful SMA's for veterans with diabetes, was well received and found helpful. We integrated more specifics (e.g., about selecting patients and motivational interviewing) in response to observations during implementation and interviews with the SMA team at the CBOC. The final version is available on-line via DM QUERI (Aim 1). Students showed some change in confidence working with other members of healthcare teams and increased the scores in understanding the seriousness of diabetes (Aim 2).

IMPACT:
Diabetes management complexity threatens to overwhelm the acute care-oriented health care systems. SMAs are proving to be a successful approach to the delivery of quality chronic illness care and our manual has been and will be used to assist in implementing these appointments in a successful manner. SMAs provide a feasible venue for training about quality care for chronic conditions.

PUBLICATIONS:
None at this time.


DRA: none
DRE: Treatment - Observational
Keywords: Care Management, Diabetes
MeSH Terms: none

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