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Table 1 Defining the local context prior to introducing shared medical appointments (SMAs)

From: Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes

Care System Components

Defined via Local Diabetes Care Context

Existing Diabetes Care-Based Practices Pre-SMA (January 2005)

Supramacro

VHA Central Office

Initiatives on outpatient quality with necessity to figure out how to operationalize locally

  

Advanced Clinic Access mandate to reduce waiting times; increase efficiency

  

Chronic Disease Index (a series of performance measures) emerging as a priority

  

Electronic medical record tracking performance measures & providing feedback

Macro

Cleveland Dept. of Veterans Affairs Medical Center

Pursue current mandate: Advanced Clinic Access to reduce waiting times for appointments

  

Meetings about intermediate diabetes care goals

  

Wanted updates about how goals were going to be met

  

Primary care clinics focus on medical training not quality care

  

Longer-term major construction creating space constraints

Mesosystems

Primary care clinics

Monthly reports about meeting diabetes care goals

  

Monthly clinic meetings review & allocate resources

  

No formal process to identify and refer high-risk patients

  

Individual meetings with silo representatives

  

Go to macro level for change if needed

 

Other services

Primary care provider is additional signer on notes for patients

 

Clinical pharmacy

Individual referral to education (meds and adherence)

  

Medication algorithms (augment/adjust; problems)

 

Health Psychologist

Referral to education: Medication adherence; barriers

 

Nursing

Nurse manager meeting & viewed separately

 

Clerks

Make appointments for follow-up/referrals

Microsystems

Individual Units

One-on-one meetings with patient

Intra-micro

~1,500 with A1c > 9%

Come for individual visits (every 3 months recommended)

Patient

High-risk

Follow-up with referrals to other services including:

  

Pick-up new medications now and then see:

  

Clinical pharmacist to change medications (1 month)

  

Lab work prior to next visit

Nurse

2 Licensed practical nurses

Take vital signs, updates from patient, etc.

 

4 Registered nurses

Provide case management/education as referred

Provider

Primary care provider with diabetes patient:

Expected to meet performance measures but limited support

  

Worked individually with patient

 

8 Part-time attendings

Goals A1c < 9%; LDL-cholesterol < 100 mg/dL; systolic blood pressure < 140 mmHg

 

5 Nurse practitioners

Receive scores regarding % of patients meeting goals

 

1 Physician assistant

If patient not meeting measures, then educate patient via:

 

Preceptors (5 new)

Referrals for Consults to one or more (variable) specialists →

 

Residents (60/year)

Nurse; Clinical Pharmacist; Nutritionist; Endocrinologist/Diabetologist

  

Clinic; Health Psychologist ; Diabetes Self-management classes

  

*Primary focus: medications to get to goal