1. Enlightening Experiences with Shared Medical Appointments
Byron L. Haney, MD
This project is supported by grant number R18HS from the Agency for Healthcare Research & Quality

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3. Enlightening Experiences Shared Medical Appointments
with
Shared Medical Appointments
Byron L. Haney, MD
© Brent Jaster, MD, & JasterHealth inc, 2011

4. Byron L. Haney, MD Family Health Care of Ellensburg (WA)
Family Physician
Family Health Care of Ellensburg (WA)
SMA Consultant
Pacific Northwest University
Associate Professor
© Brent Jaster, MD, & JasterHealth inc, 2011

5. Objectives Discuss SMAs meeting the four aspects of Triple Aim +1
Describe the power of a SMA to engage patients in behavioral modification
Identify the essential elements of the SMA model
Provide example out comes of our SMAs
How I came to do SMA’s
© Brent Jaster, MD, & JasterHealth inc, 2011

7. White Board (Mondopad)
Names and Stats in Chronological Order
Let everyone hear and see all aspects of the SMA (Write patient information on a board; such as labs, blood pressure, weight, tobacco, plans...)

8. Family Health Care of Ellensburg
Ideal Health
Care Reform
Decreased Cost of Care
Improved Outcomes
Improved Patient Experience
Provider Satisfaction
Increased Access
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of health care
The +1 is that we improve the life and quality of clinicians
© Brent Jaster, MD, & JasterHealth inc, 2011

9. Why SMAs? “SMAs are Pure Joy.” John Scott, MD
Better Outcomes/Quality/Satisfaction
Lower Costs/Increased Productivity
Improved Self-Management
Patients are a Resource in Care Delivery
60% consider career change; Increased productivity
1) Why are people here considering groups? 2) We cannot continue to see more patients in less time.
3) Massachusetts? Hal Holman, MD and Kate Lorig, DrPH– Chron dis mgmt the PCProvider is the pt.
Positive return from the start
Decreased last ditch medicine and inc. 1, 2nd and tx of dis-sease.
© Brent Jaster, MD, & JasterHealth inc, 2011

10. FHC Provider Index Result
© Brent Jaster, MD, & JasterHealth inc, 2011

11. Why SMAs?
ESTIMATES:
7.4 hrs/day needed to provide preventive medical care
10.6 hrs/day needed to provide chronic disease care for 10 conditions
3.5 hours when stable
No time for treatment of other health care problems,…
-Yarnall et al. Ostbye et al.
© Brent Jaster, MD, & JasterHealth inc, 2011

12. Chronic Disease Self-Management Increased Access Aging
Growing Care Needs
Chronic Disease
Self-Management
Increased Access
Aging
Meeting Patient Care Needs
One-on-One office visit
14-18 Minutes
Only 50% Face-to-Face
Talk Faster
Walk Faster
Don’t Eat
Don’t Pee
Neglect Self/Loved Ones
JUST BURNOUT
© Brent Jaster, MD, & JasterHealth inc, 2011

13. Why Groups Work? Instillation of hope Universality
Imparting information
Imitative behavior
Interpersonal learning
Altruism
Group cohesiveness
Catharsis
Corrective recapitulation of the primary family group
Existential factors
I’m glad I have brain cancer and not that.
This is better than ER.
Instillation of hope: encouragement that recovery is possible
Universality: Feeling of having problems similar to others, not alone
Imparting information: helpful to learn factual information from others
Imitative behavior: modeling another’s manners and recovery skills
Interpersonal learning: Achieving greater self-awareness through group feedback on their behavior and impact on others.
Altruism: Helping and supporting others
Group Cohesiveness: Feeling of belonging to and valuing their group.
Catharsis: relief of emotional tension by telling their story to a supportive audience, gaining relief from chronic feelings of shame and guilt.
Corrective recapitulation of the primary family experience: Identifying and changing dysfunctional patterns and roles one carries out in their family.
Existential factors: Learning one must take responsibility for one’s own life and the consequences of one’s decisions.
-Yalom I.
© Brent Jaster, MD, & JasterHealth inc, 2011

14. Why Groups Work
Instillation of Hope: encouragement that recovery is possible
Universality: Feeling of having problems similar to others, not alone
Imparting Information: helpful to learn factual information from others
Imitative Behavior: modeling another’s manners and recovery skills
Note how the underlined areas contribute to increased immunization rates.
Questions: To what percentage do you want to prevent __x__ infection? Sent this as a goal in writing.
What is the risk for this infection unimmunized?
What is the morbidity/mortality of that infection?
What is the risk for the side effect? What is the morbidity/mortality of that side effect?
Let the group/provider do homework assignment for the above information to be brought back.
Acknowledge that you understand they are trying to do the right thing for child.
Offer least concerning immunizations first, “which immunization would you like to do today”.
Be willing to space out immunizations.
© Brent Jaster, MD, & JasterHealth inc, 2011

15. Altruism: Helping and supporting others
Interpersonal Learning: Achieving greater self-awareness through group feedback on their behavior and impact on others.
Altruism: Helping and supporting others
Group Cohesiveness: Feeling of belonging to and valuing their group.
Catharsis: relief of emotional tension by telling their story to a supportive audience, gaining relief from chronic feelings of shame and guilt.
Corrective Recapitulation of the Primary Family Experience: Identifying and changing dysfunctional patterns and roles one carries out in their family.
Existential Factors: Learning one must take responsibility for one’s own life and the consequences of one’s decisions.
Immunization rates increase due to:
1-Learning from others > than the provider
2-realization where their bias comes from
3-being able to express their fears
4-feeling of belonging to and evaluating their group
© Brent Jaster, MD, & JasterHealth inc, 2011

16. Evaluations: What Did You Like Best?
“Knowing I am not alone”
“More informative”
“Receive a better understanding”
“Others experience is interesting and valuable”
“Comparison of individual labs and stats”
“Comparison of previous visit progress and correlation”
“See changes compared to time of the year”
“More time with my provider”
“Opportunities to ask questions”
“Thank you for inviting me--I left more hopeful”
“Motivational”
“Peer pressure: good to share and compare”
“I learned from the experience of others”
“Supportive”
“Dr. Haney’s willingness to share his information”
“I feel the care in the room”
“Atmosphere”
“Shared problem forum”
“Meet people”
“Relaxed feeling and setting”
“I Love This!”

17. Paradigm Change Caregivers depart from paternalistic care
Motivational Interviewing
Become a facilitator
Talk less--Use your patients as your experts (facilitate, direct and educate them to be experts)
Care decision making steps
Patient first
Group members second
Provider last
Motivational interviewing:
1-Motivation to change is elicited from the patient and not the provider
2-It is the patient's task, not the provider, to articulate and resolve his or her ambivalence
3-Direct persuasion is not an effective method for resolving ambivalence
4-The SMA style is generally quiet and elicits information from the client
5-The counselor facilitates the patient to examine and resolve ambivalence
6-Readiness to change is not a trait of the patient, but a fluctuating result of interpersonal interactions in the group
7-The therapeutic relationship resembles a partnership or companionship
© Brent Jaster, MD, & JasterHealth inc, 2011

18. Target Patient Population
Low utilizers
High utilizers
Easy
Difficult
Simple
Complicated
When pt that dominates your time in a group, start one person to right/left and proceed in opposite direction
Pt who inappropriately uses 911. Patient who comes in every 2 weeks with new complaints and a laundry list of questions, patient who never listens to you, but brings you 100 pages of info from the internet. . .
Difficult pts are usually easier in the group envt.
© Brent Jaster, MD, & JasterHealth inc, 2011

19. Family Health Care of Ellensburg
Current SMAs
Metabolic Syndrome
Diabetes
Pre-Diabetes
Annual exams
Welcome to Medicare
Medicare Wellness
Designed SMAs
Acne
Well Child Checks
Asthma
ADHD
Pain
DIGMA
Role play
© Brent Jaster, MD, & JasterHealth inc, 2011

20. Group Results Diabetes SMA 5 People Ages 56-66 3 Males, 2 Females
112 Lbs Lost in First Year
Average Of 22 Lbs/Patient
A1c Decreased to 6 Range
Average 1-2 Points
Blood Pressure Returned to Goal Range
LDL at Goal
© Brent Jaster, MD, & JasterHealth inc, 2011

21. Kaiser Permanente, Seniors
Chronically ill older adults in CHCC
Fewer hospital admissions
Fewer ED visits
Fewer professional services
Outpatient visits- No difference
Community Health Care Clinic
-Scott et al.

22. 3 Year Follow Up Diabetic SMA
A1c Average 6.6
Excludes graduated patients (no longer a diabetic)
Includes new to SMA and significantly uncontrolled
84% sustained Weight loss
11.3 #
Includes Diabetics at target weight
Includes those new to SMA

23. 3 Follow Up (continued) Pre Diabetic SMA
Conversion to diabetes-None (at 8 years !)
Physician Production Increased:
Greater the percentage of practice in SMA’s
Despite Medicare highest percent of practice
Physician looking for quality health care spin off work
More devoted Prep time
$970 per new SMA Diabetic
Lean
Nursing work
HCM exam work
© Brent Jaster, MD, & JasterHealth inc, 2011

24. Rewards of SMAs High satisfaction Increased productivity/Cost savings
How satisfied were you- 4.8/5
How likely to return- 4.6/5
Increased productivity/Cost savings
Empowered patients
Improved Self-Management
Less patient calls
Unrushed patient time
5 very satisfied
4 satisfied
3 neutral
1 very dissatisfied
© Brent Jaster, MD, & JasterHealth inc, 2011

25. Conclusions SMAs Enlightened Medical Care!
New Design that meets Triple Aim +1
Improved Patient Experience of their Care
Quality
Satisfaction
Improved Population Health
Reduced per capita cost of health care
Returned Joy to the Provider
Malpractice for me to go back
© Brent Jaster, MD, & JasterHealth inc, 2011

26. Questions

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