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Table 2 Analysis of SMAs Innovation: Translating SMA into Local Context (February 2005)

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

Dimension of SMA Innovation – Basic guidelines that needed to be translated Starting Point: Initial Decisions Promoting Factor Hindering Factor
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
Focus: disease-specific or non-specific Diabetes (reduce cardiovascular risk) Provided focus consistent with strong core team  
Drop-in or Schedule Patients Scheduled Able to call and remind; able to plan Limits number and requires more coordination
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
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
1 or more variety of Disciplines Health Psychologist; Registered nurse   Different supervisors; Workload credit
Group of patients (8–20) 4–8 patients (8 invited) Flexibility to pilot test with small numbers of patients Questions raised about inefficiency
Target population Local registry to identify patients Sufficient numbers who would benefit  
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
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
Time and Frequency: Meet for 90–120 minutes and variable regarding frequency 90 minutes and to meet weekly (Friday afternoons)   
Techniques and Processes for conducting SMA Modification of chronic care model as a guide   
Didactics Keep at a minimum   Many team members most comfortable with 'teaching' rather than facilitating group discussion
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  
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
Clinical component Group chart display   
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
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
Space Remote training rooms not available and negotiated clinic space Able to secure some space Limited options especially given construction
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
Size and arrangement Small conference room with computers and crowded Table seating conducive to group sharing Limited in size and mobility; configuration not ideal
Mechanics    
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  
  1. 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.