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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


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



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


Remote training rooms not available and negotiated clinic space

Able to secure some space

Limited options especially given construction


Primary Care Clinic Conference Room


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



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.