Shared Medical Appointments (SMAs)-group sessions of Veterans with the same medical condition led by a multi-disciplinary/multi-expertise team of providers-are now being widely implemented at VA facilities nationwide. Efficacy trials have found that SMAs in VA increase access to care and improve participants' self-management, clinical, and Veteran-centered outcomes during and immediately after completion of the SMAs. Less is known about the effectiveness of SMAs as implemented on a large scale in different VA health systems, nor about the extent to which gains achieved through SMAs are maintained over time and, if not, what additional scalable approaches can best maintain improvements in self-management and clinical outcomes. Moreover, factors influencing effective implementation of SMAs and follow-up maintenance programs in diverse settings are poorly understood. One potentially scalable approach is telephone-based peer support in which fellow Veterans provide support to each other. Because peers share similar characteristics, this approach is intrinsically culturally sensitive. Moreover, because most contacts are over the telephone, it is accessible to vulnerable patients who face obstacles to accessing clinic-based care.
This project will evaluate the implementation of diabetes SMAs in five VA health systems with some cohorts also being offered a novel program found in a recent VA randomized, controlled trial to significantly improve VA patients' diabetes-specific social support, insulin starts, and glycemic control compared to usual nurse care management. The program uses periodic group sessions in conjunction with calls between paired patients with diabetes to promote more effective care management as well as peer-to-peer (P2P) communication among diabetes patients who both have poor glycemic control and are working on similar care goals. Participants are matched with another patient of similar age and facing similar self-management challenges. "Peer buddies" are encouraged to talk by phone at least weekly to provide mutual support and share their progress on meeting their self-management goals. The goal of this service is to enhance the effect of shared medical appointments (SMAs), a service model demonstrated to be effective in improving outcomes among patients with diabetes and other chronic conditions and now being widely implemented in VA. Based on the success of the efficacy trial of this intervention, we now seek to evaluate a wider-scale implementation of this program.
Based on the success of separate efficacy trials of diabetes SMAs and of the P2P program, this project will examine the comparative effectiveness of SMAs alone, SMAs + P2P, and usual care without either of these programs and study the implementation process at five diverse VA facilities. Outcomes measured at 6- and 12-months post-enrollment include: 1) changes in participants' glycemic and blood pressure control and statin use; 2) service utilization; 3) satisfaction with VA care; 4) diabetes-specific distress; 5) diabetes social support; and 5) diabetes self-management behaviors. Constructs from the Consolidated Framework for Implementation (CFIR) have already been used in a completed pre-implementation formative evaluation at the study sites that was used to refine the implementation plan at each site. CFIR constructs will also be used during the post-implementation evaluation process to identify recommendations for facilitating widespread dissemination efforts and to contribute to the implementation science literature. Data will be gathered throughout implementation on staff effort required in order to calculate costs of the program.
This project is still in the data collection phase.
This study will provide important information on the comparative effectiveness and barriers faced when SMAs and P2P are implemented as part of existing clinical processes.
- Kowalski CP, Veeser M, Heisler M. Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption. BMC family practice. 2018 Jul 7; 19(1):109.
- Heisler M, Burgess J, Cass J, Chardos JF, Guirguis AB, Jeffery SM, Strohecker LA, Tremblay AS, Wu WC, Zulman DM. The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study: study protocol for a randomized trial. Trials. 2017 May 26; 18(1):239.