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Analysis of SMAs Innovation: Translating SMA into Local Context (February 2005) |
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| Dimension of SMA Innovation – Basic guidelines that needed to be translated |
Starting Point: Initial Decisions |
Promoting Factor |
Hindering Factor |
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| Shared Medical Appointment Initiation |
Core team with strengths related to diabetes were open to change and working together |
Mandate from Central Office; Training provided; no specific guidelines; local facility has long history of supporting novel methods of care delivery |
No specific guidelines; limited resources |
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| Focus: disease-specific or non-specific |
Diabetes (reduce cardiovascular risk) |
Provided focus consistent with strong core team |
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| Drop-in or Schedule Patients |
Scheduled |
Able to call and remind; able to plan |
Limits number and requires more coordination |
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| Multi-disciplinary Professional Team |
Collaboration with key disciplines present |
Strong, committed core team, including one member representing key leadership within primary care clinic |
Difficulty coordinating, and finding and freeing up time to participate |
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| 1 or more with prescribing Authority |
Physician (Medical Director of Clinic); Endocrine nurse practitioner; Clinical pharmacist |
Built-in redundancy of prescribers assisted with efficiency |
Team members had different supervisors; Workload credit and credit for SMAs |
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| 1 or more variety of Disciplines |
Health Psychologist; Registered nurse |
Different supervisors; Workload credit |
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| Group of patients (8–20) |
4–8 patients (8 invited) |
Flexibility to pilot test with small numbers of patients |
Questions raised about inefficiency |
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| Target population |
Local registry to identify patients |
Sufficient numbers who would benefit |
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| Primary care provider pool (pull from one or more) |
All Primary care providers' patients eligible |
Able to include all high- risk patients |
Threatened provider-patient relationship |
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| Patient pool |
A1c > 9%; systolic blood pressure > 130 mmHg; LDL-cholesterol > 100 mg/dL |
Getting several patients there; Viewed as difficult and non-compliant; concern about no-show rates |
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| Time and Frequency: Meet for 90–120 minutes and variable regarding frequency |
90 minutes and to meet weekly (Friday afternoons) |
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| Techniques and Processes for conducting SMA |
Modification of chronic care model as a guide |
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| Didactics |
Keep at a minimum |
Many team members most comfortable with 'teaching' rather than facilitating group discussion |
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| Information display and Sharing |
Large board with patient lab values and other outcomes (e.g., A1c, systolic blood pressure and LDL-cholesterol); prepared by Clinical pharmacists |
Summarized key points and helped solidify take home messages despite concern about non-lecture format |
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| Group discussion |
Peer support Motivational interviewing by Health Psychologist |
Learning by all is possible even if not sharing; Simplified and focused individual session that followed group encounter |
Some patients uncomfortable in groups |
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| Clinical component |
Group chart display |
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| Forms: General information |
ABCs of diabetes care (A1c, blood pressure, cholesterol, etc), foot care, etc. |
Able to help meet performance measures; document patients educated |
Hard to clarify for others what exactly was covered |
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| Forms: Patient-specific |
Patient completed form with current values (copied from board), goals, med changes, plan of care outlined |
Felt patients were getting individual information and tailoring |
Preparation time |
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| Space |
Remote training rooms not available and negotiated clinic space |
Able to secure some space |
Limited options especially given construction |
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| Location |
Primary Care Clinic Conference Room |
Familiar |
Displaced providers who use the room and limited access to computers available in the primary care clinic conference room |
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| Size and arrangement |
Small conference room with computers and crowded |
Table seating conducive to group sharing |
Limited in size and mobility; configuration not ideal |
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| Mechanics |
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| Documentation (suggest/identify individual to take responsibility) |
Initially used a group note field in electronic record system, but recognized that modifications would need to be made.1 |
User friendly, consistent with usual methods of documenting |
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1The group note fieldallows text to be entered that will appear in the note of every patient in the group. However, it was recognized early on that such a note did not allow for customization. Therefore, we initiated the development of a templated note with embedded guidelines that was user-friendly and facilitated the efficiency of documentation and standardization and completeness of individual treatment plans. This development took place over a period of several months. | |||
Kirsh et al. Implementation Science 2008 3:34 doi:10.1186/1748-5908-3-34 |
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