Shared Medical Appointments: Facilitating Care for Children With Asthma and Their Caregivers

Article Outline

• Abstract
• Background and Literature Review
• Theoretical Framework
  • Social Cognitive Theory
  • Application of Social Cognitive Theory to the Shared Medical Appointment
• Methods
  • Shared Medical Appointment Program Setting
  • Ethics and Human Subjects Participants
  • Program Description
  • Participants
  • The SMA Health Care Team for Pediatric Asthma
  • The Shared Medical Appointment
  • Shared Medical Appointment Satisfaction Survey
• Results
• Conclusion
• References
• Biography
• Copyright

Abstract 

As important members of the health care team, patients and caregivers must be empowered to recognize their asthma status and to act accordingly. Education about asthma, complications, and successful management of asthma provide the best way to empower children and their caregivers. A Shared Medical Appointment (SMA) is a unique health care delivery approach that integrates disease management and patient education. The SMA described here is a 90-minute group appointment for four to nine patients who share a diagnosis of asthma, bronchospasm, or wheeze and their caregivers. The appointment includes a brief individual examination, health education delivered to the group, and the opportunity for interaction between group members. Because a supporting theoretic framework is not identified in the original design proposals for the SMA model or in the literature on its use, for the purposes of this project, Social Cognitive Theory is identified as the theoretical framework that best explains and reinforces the benefits of the SMA. The theoretic framework is important to direct the development and continued success of this treatment model. This project report describes the first nurse practitioner-led SMA as a tool for improving quality of care and service for children with asthma and their caregivers.

Key words: Shared medical appointment, asthma, pediatrics, Social Cognitive Theory, nurse practitioner

The focus of this article is the effectiveness of an innovative group medical appointment model, the Shared Medical Appointment (SMA), for the management and treatment of children with asthma. The SMA addresses the challenges of providing health care to children with asthma and their caregivers. These challenges include: (a) access for patients, (b) treatment of the whole patient, including the emotional, behavioral, psychological, and lifestyle factors, (c) ongoing support and education, (d) partnerships between the patient and the clinician, (e) greater satisfaction for the clinician, and (f) economic feasibility (Schmucker, 2006). The challenges and success of this approach described in this article can inform the practice of other nurse practitioners (NPs) as a model of care for improving the management and treatment of children with asthma. Published literature on the SMA describes its use for adults and for general medicine and chronic illness, and thus this is not only the first known NP-led SMA but also the first known SMA for children with asthma in a pediatric primary care setting.

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Background and Literature Review 

The effective treatment of pediatric asthma strains the resources of primary care settings. The efforts of health care providers to control asthma are clearly inadequate. A review of the literature confirms that the number and severity of asthma cases in children is increasing (American Academy of Allergy, Asthma and Immunology, 2008, American Lung Association, 2007, Centers for Disease Control and Prevention & National Institutes of Health, 2006). In addition, asthma is a growing problem for health care providers (Centers for Disease Control and Prevention & National Institutes of Health, 2006, Children & Asthma in America, 2004, Rance, 2008). Working with time and cost constraints of current treatment models, providers fall short of recommended treatment goals, including follow-up health care visits, lung function testing, written asthma action plans, and other treatment goals set by the National Heart, Lung and Blood Institutes (NHLBI) (NHLBI, 2007). Studies show that additional time and effort on the part of the clinician to diagnose and treat patients or to teach patients and their families about asthma in a group setting improves asthma outcomes (Coffman, Cabana, Halpin, & Yelin, 2008; Gebert et al., 1998; Lurie, Bauer, & Brady, 2001). However, no evidence-based practice model that struck a balance between treatment cost-effectiveness and effective asthma-management policies was found in the literature.

An SMA model addresses the challenge of finding the balance between cost-effectiveness and providing a setting that can be especially beneficial in the management of asthma. SMA is a group medical appointment that affords the clinician an efficient way in which to “deliver medical care in an informative and supportive group setting that includes other patients” (Noffsinger, 2009). In this model, a group visit appointment is a medical appointment in which a group of patients and their caregivers meet together with their clinician and members of the health care team. The appointment includes one-on-one patient-physician encounters, opportunities for clinician and other members of the team to provide information to the group as a whole that is normally difficult to address in a brief individual appointment, and opportunities for patients to share their experiences and discuss common issues with each other. The purpose of the group appointment is to provide improved access to the primary care clinician and health care team and to establish an environment for peer and social support and sharing of educational information (Carlson, 2003, Schmucker, 2006).

This article reports on the implementation and evaluation of an NP-led SMA for children with asthma and their caregivers that was undertaken in an effort to balance cost and quality of care for patients with pediatric asthma. The following sections describe the theoretic framework, the SMA program, implementation, evaluation, and implications for advancing pediatric asthma care and outcomes.

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Theoretical Framework 

It has long been established that the concepts of (a) parental participation in children's health care, (b) partnership and collaboration between the health care team and parents in decision making, (c) family-friendly environments that normalize as much as possible family functioning within the health care setting, and (d) care of family members as well as of children is critical to the successful management of asthma (Bursch, Schwankovsky, Gilbert, & Zeiger, 1999; Franck & Callery, 2004). Although the benefits and increased efficiencies of an SMA in relation to the health care institution have been studied, the current literature does not address the health promotion activities that support the benefits for patients. It is important to describe the link between the model and improved behavioral and health outcomes in order to identify and preserve the aspects of the SMA that support the health promotion benefits. Practically speaking, a clear theoretical framework can be used to explain how the health promotion implicit in the structure of an SMA creates benefits for the patients. This explanation provides a defense of the model from administrative modifications, for example, to reduce staff, increase the number of patients, or hold the sessions irregularly. A theoretical framework that explains and reinforces the benefits of the SMA will direct the development and continued success of this treatment model. One such framework, Social Cognitive Theory (SCT), focuses specifically on the interaction between individuals and their immediate environment and explains how people acquire and maintain certain behavioral patterns (Edberg, 2007). Bandura (1986) emphasized the importance of observing and modeling new behaviors and the positive and negative reinforcement of the behaviors through the attitudes and emotional reactions of others.

Social Cognitive Theory 

The four major principles of SCT are: (a) the highest level of observational learning is achieved by organizing and rehearsing behavior and enacting it overtly; (b) coding modeled behavior into words, labels, or images results in better retention; (c) individuals are more likely to adopt a modeled behavior if the one modeling it is similar to the observer and has admired status; and (d) individuals are more likely to adopt a modeled behavior if it results in outcomes they value (Bandura, 1986). The application of these principles can be observed in the interactions among clinicians, patients, and caregivers in the SMA. They explain how the SMA successfully reinforces social and cultural change in the patient's self-management that leads to improved clinical outcomes.

Application of Social Cognitive Theory to the Shared Medical Appointment 

First, group and individual teaching and demonstrations explicitly “organize and rehearse the asthma management behaviors, enacting them overtly” (Bandura, 1986, p. 101). Patients both practice the behaviors themselves and observe others learning them. Second, both the facilitator in individual interactions and the behaviorist in the group provide an explanation of the management practices that “codes the modeled behavior into words, labels, and images” (Bandura, 1986, p. 104). The teaching reinforces the procedures and provides context and a rationale for the importance of the practice. Third, a homogeneous SMA focused on pediatric patients with asthma provides the patients with contact with others, as both modelers and observers, who are similar to themselves. Older patients have an “admired status” among the younger patients, and patients more experienced in managing their asthma enjoy demonstrating their expertise (Bandura, 1986). Finally, the teaching of the staff and the evidence of other patients who are successfully managing their asthma reinforces the positive outcomes the patients can expect from learning and practicing the self-management techniques.

The SMA model helps patients, through group interaction, to gain a more balanced perspective of their disease. Through interactions with other patients they may realize that, despite their disease, they still are able to engage in activities that other patients aren't able to do, or they may find reason to hope that they will be able to improve as others have. They can build on their own and others' strengths. Group visits also reduce the stigma of their illness. Patients often state how much they had wanted to talk with someone experiencing the same health problems but never knew anyone until they attended a group (Noffsinger & Scott, 2000). Even resistant and non-compliant patients are more prone to change their behavior when members of the group who have experienced the benefits of treatments reinforce participation in the recommended treatments (Noffsinger, 1999b). This project analyzes the question of whether the integration of an individual medical visit, health promotion teaching, and group interactions as offered in a pediatric nurse practitioner (PNP)–led SMA can increase self-efficacy and satisfaction with care for children with asthma and their caregivers.

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Methods 

Shared Medical Appointment Program Setting 

The SMA program was introduced to Harvard Vanguard Medical Associates (HVMA) in December 2007. HVMA is a non-profit, multispecialty medical group practice that provides care to more than 450,000 adult and pediatric patients at more than 20 offices across eastern Massachusetts.

HVMA physicians, challenged to adopt a new model of care, implemented the first adult SMA in January 2008 in the Internal Medicine Department to provide the physicians with tools to solve access, service, and quality of care problems. According to Noffsinger (1999a), the SMA is a means to leverage physician time and increase efficiency and productivity, while also improving quality of care and service. The benefits from the traditionally physician-led SMA include improved access and physician productivity (Noffsinger, 2001); providing a more relaxed setting to treat patients; the opportunity to connect with patients; assistance in problem solving from the physician and other patients; and physician promptness (Noffsinger & Scott, 2000).

The benefits that result from a physician-led SMA also apply to an NP-led SMA. In an effort to improve the care and quality of life of children with asthma and their caregivers, Dr. Wall-Haas implemented the first nurse practitioner–led Pediatric Asthma Shared Medical Appointment program in April 2008. The SMA for children with asthma and their caregivers follows the adult SMA model, that is, a homogeneous group of patients with the same disease and their caregivers are scheduled together (Noffsinger, 1999a, Schmucker, 2006). The project was approved in December 2007 by the Harvard Vanguard Clinical Research Department and in September 2009 by the University of Virginia Institutional Review Board. The Institutional Review Board waived informed consent for this project under CFR 46 116 (d).

Ethics and Human Subjects Participants 

SMAs for children with asthma were designed to be relevant to and in keeping with HVMA's research objectives because of their potential to improve care, provide useful information, and contribute to the activities of HVMA's Central Pediatric Asthma Program. No new pharmacy or drug administration was involved. HVMA committed to providing data for this project, and the confidentiality and privacy of all information regarding the subjects was protected as Protected Health Information. Identifiable health information in written, electronic, or oral form created or received during implementation of this project was not included in the project report or publications.

Program Description 

The SMA for children with asthma and their caregivers included patients 2-18 years old from the pediatric asthma population at HVMA and their primary caregivers (parent or legal guardian) who volunteered for the program. The SMA format excluded parents or caregivers who were unable to speak and understand English or who were hearing impaired because extra time was not included in the group meeting for translation. Each SMA typically included both new patients and repeat patients.

Eleven SMA sessions for children with asthma and their caregivers were held between April 29, 2008, and August 26, 2008, with a total attendance over all the sessions of 56, involving 51 individual children. Disregarded were the five instances when a child attended a SMA for a second or third time in this period. Of the 51 children, 39 were eligible for inclusion in this project. Twelve children were excluded from the study: nine because they were younger than 2 years old, one because the child did not have a diagnosis of asthma, and two because the children was new to the practice and did not have a 4-month history at the clinic prior to attending the SMA.

Participants 

The age, gender, race, and insurance status of the SMA participants are detailed in Table 1, along with information about the caregiver who accompanied the child to the appointment. The average age of participants was 9 years. More boys than girls attended; the majority was White (non-Hispanic) and accompanied by their mothers. Most of the children had private insurance. The participants in the SMA consisted of children seen in the HVMA practice with a diagnosis of asthma, wheeze, or bronchospasm, and their primary caregiver. Asthma severity risk ratings differed among the participants and ranged from 0 to 14. Of the 39 children in the SMA, three children were not given a severity or risk rating because they had a diagnosis of wheeze and not asthma. Children with a diagnosis of asthma, wheeze, or bronchospasm and their caregivers received a letter from the nurse practitioner asthma nurse educator inviting them to attend an SMA. In addition, children were invited when they were scheduled for an office visit for asthma, wheeze, or bronchospasm; when there was a diagnosis or history of asthma; when wheeze or bronchospasm was noted at a routine physical or annual examination; when the child needed prescription refills for asthma medications; or when Asthma Action Plans or medication authorization letters were requested to allow the child to take medication at school, day care, and/or camp.

Table 1. Characteristics of participants (N = 39)

NHP, neighborhood health plan.

∗Mean age: 9 years.

†Harvard Vanguard Medical Associates rating based on National Heart, Lung and Blood Institute guidelines.

The SMA Health Care Team for Pediatric Asthma 

The SMA Health Care Team consisted of five members including the SMA facilitator, who was an NP; the behaviorist, who was a registered nurse (RN); a licensed practical nurse (LPN); a medical assistant (MA); and a documenter (also an MA). The HVMA pediatric department employed the staff who volunteered to train for and work with the SMA group (see the Box for SMA health care team responsibilities).

The Shared Medical Appointment 

Four to nine patient/parent dyads participated in each SMA group. After checking in, the patient and the parent or caregiver was met by an MA and a licensed practical nurse, who took pertinent vital signs. When the group was complete, the behaviorist entered and made brief introductory comments about the purpose of the group and its intended benefits to the patients and outlined issues of confidentiality. Concerns addressed included issues of Health Insurance Portability and Accountability Act (HIPAA) compliance during the SMA. In the shared medical appointment, patients or their caregivers voluntarily discuss information about themselves during the group. Violations of HIPAA occur only when the clinician or staff person share information about a patient in front of the other patients (Schmucker, 2006). To minimize the risk of a breach of confidentiality, staff must complete an annual competency on HIPAA. Also, patients received a packet detailing the SMA, which included a discussion about the confidentiality statement. Parents and patients older than 18 years were required to sign.

Following introductory remarks, the behaviorist asked each parent or patient for one or two questions they might have had about asthma, cough, wheeze, or allergy, and wrote them on a board. During the SMA, the behaviorist addressed each of these questions. When the NP entered, the focus shifted to the delivery of medical care. The NP clarified or elaborated on the first parent/patient's questions. The NP obtained the patient's recent health history, including any symptoms of asthma, wheeze, or bronchospasm, along with medications used, after which, with the parent's permission, an abbreviated examination focusing on lung sounds was conducted discretely in front of the group. During the individual examination, the documenter transcribed the visit. Following the examination, the NP reviewed updates to the patient chart with the documenter (MA) while the behaviorist addressed additional issues around asthma, cough, wheeze, and allergies with the group. For example, the behaviorist might discuss the use of the peak flow meter and might have an “experienced” patient demonstrate its use to the group. After a few minutes, the NP was again available and attention turned to the next patient's questions and individual examination. This process continued until all questions were answered and all patients were examined. Each patient and the parent or caregiver, in turn, then visited the after-care coordinator (MA) to review the patient instructions as indicated in the patient's chart by the NP. At this time, the patient's treatment plans were updated, annual physical examinations were scheduled, routine immunizations or the flu vaccine were administered, and confirmation of refills and new prescriptions, asthma action plans, allergy action plans, and medication authorization letters were generated. Parents could schedule future appointments and receive reminders of any appointments previously scheduled, and referrals could be ordered, for example, to the allergist.

In addition to providing the improved patient access and clinician productivity common to all SMA implementations, the SMA is particularly appropriate for a group focusing on pediatric asthma because the emphasis on teaching and group interactions fosters an environment for peer and social support and the sharing of educational information (Carlson, 2003, Schmucker, 2006).

Shared Medical Appointment Satisfaction Survey 

A testament to the quality and focus of this project is reflected in the degree of satisfaction of the patients and their caregivers. The satisfaction survey used in this project was designed by Dr. Edward Noffsinger specifically to evaluate patients' responses to the group experience (Noffsinger, 2009). It has been used extensively in implementations of SMAs to help evaluate the effectiveness of SMAs in the organization. In this project, the results of the satisfaction survey will be used to address specific quality improvement efforts in the treatment of children with asthma.

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Results 

Eighteen-year-old patients and caregivers of patients younger than 18 years responded to questions about their level of satisfaction with several aspects of the SMA. Frequency distributions were run to examine the satisfaction items. Responses measuring satisfaction can be found in Table 2, Table 3, Table 4. The survey was voluntary, and 30 of the 39 caregiver/patient dyads, including one of two 18-year-old patients, returned the survey.

Table 2. Patient satisfaction survey part 1: Component rating of SMA experience (N = 30)

SMA, shared medical appointment.

Table 3. Patient satisfaction survey part II: Patient experience of SMA appointment compared with prior individual appointments (N = 30)

SMA, shared medical appointment.

Table 4. Patient satisfaction survey part III: General satisfaction (N = 30)

HVMA, Harvard Vanguard Medical Associates; SMA, shared medical appointment.

A 5-point Likert-type scale (“poor,” “fair,” “good,” “very good,” and “excellent”) was used to measure satisfaction with eight components of the SMA. Table 2 presents the percentage of the 30 surveys. High levels of satisfaction are expressed in all areas. Four patients and caregivers did not respond to the question about the behaviorist. It is possible that some caregivers were late for the appointment and missed the introduction of the behaviorist or simply did not understand that the RN was the behaviorist.

In the second section on satisfaction (Table 3), respondents compared the SMA experience with the experience of past appointments, and in three of the five areas, more than half of the respondents rated the SMA higher, with the remainder saying it was the same. No one responded that it was worse in any respect.

In the third section of the survey (Table 4), patients and caregivers rated their satisfaction with two key elements of the SMA, “increasing patient satisfaction through increased accessibility, and continuity of care with one's clinician” (Noffsinger, 1999a). In all eight questions responses were very positive. Seven respondents indicated that they would have preferred an individual appointment to the SMA.

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Conclusion 

Although managing any chronic illness is time consuming, studies have shown that incorporating illness concerns in well visits may improve chronic illness management (Looman, O'Conner-Von, & Lindeke, 2008). However, obstacles cited by physicians that affect delivery of care are the same as those identified by NPs in primary care (Van Leuven & Prion, 2007). By improving access to regular visits for patients with asthma, the SMA provides opportunities for introducing and anticipating illness concerns in a non-emergent visit.

There is an abundance of evidence demonstrating that children with asthma benefit from interventions to control asthma, but there is less evidence to demonstrate how these findings translate into routine clinical practice. NPs can provide the comprehensive approach to managing asthma in children. Intervention must focus on implementation of an evidence-based approach following the 2007 NHBLI and National Asthma Education and Prevention Program guidelines for the treatment of asthma.

Education and interpretation of asthma symptoms is a multistep process, and it is clear that insufficient time exists in an individual appointment to accomplish all these interventions. SCT concepts best describe how the SMA group model reinforces behaviors that help patients understand and manage their asthma. Modeling and vicarious processes are key behaviors for the members of the group. Studies document that NP-led clinics are especially cost-effective and a good value for the money (Mason, Freemantle, Gibson, & New, 2005), and benefits from physician-led SMAs also have been established. Education on using these tools of identification and management of asthma and a plan of action can produce real results in terms of improved outcomes and satisfaction (Schmucker, 2006). Evaluation of the effectiveness of the SMA in meeting the 2007 NHLBI asthma guidelines and the SMA's effect on nurse productivity have been completed and have proved to be very positive. The SMA provides the ideal setting in which to foster healthy lifestyle issues central to asthma care and to improve outcomes for children with asthma.

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