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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