Background/Purpose:   Fibromyalgia is a complex chronic pain condition with patients often presenting with multiple somatic complaints that are difficult to address in standard new patient visit. Primary care providers have considerable discomfort in diagnosing fibromyalgia due to the lack of specific diagnostic modalities prompting a referral for verifying the diagnosis. The increased demand in rheumatologic consultation, compounded by the constraints in staffing, necessitated the creation of a new care model for patients with fibromyalgia. We describe a fibromyalgia shared medical appointment (SMA) that evaluates, educates, enhances timely access, and improves patient satisfaction.

Methods:   We assembled an interdisciplinary team of a rheumatologist, 2 nurse practitioners, a chaplain and a secretary. All referrals, notes, and ancillary studies, with an indication of myalgia or fibromyalgia were reviewed by a staff rheumatologist (NMO). Eligible patients were called using a standardized script by the secretaries explaining the visit details. A patient history questionnaire was mailed prior to the appointment. Primary care providers were notified by letter about the SMA and its format, and asked to perform specific labs if not performed already. Patients arrive simultaneously to our clinic on the visit day with nursing staff measuring vital signs and reconciling medications. Each patient is examined individually for confirmation of the diagnosis. A facilitated discussion by a trained chaplain followed by a short presentation by the clinician permits ensuing time for discussion and questions among the group. The session concludes with a demonstration of mindfulness techniques by the chaplain for managing chronic pain.

Results:   The SMA format was designed between January and April 2015 and implemented in June 2015. Between June 1^st, 2015 and June 30, 2016, 67 patients have been evaluated. The visit length was 2.5 hours. Using Plan-Do-Study-Act methodology, we made incremental changes to the session including location, length, flow, content of the presentation and different mindfulness techniques. Post-session surveys identified uniform themes. First, all patients strongly agreed/agreed that the SMA would assist in managing their condition. Most patients (95%) found that interacting with others in a peer-to-peer support environment with the same condition was extremely helpful. Longer appointment times were welcomed by patients to allow for additional question/answer time than would be offered during routine new patient visits. Clinical efficiency in assessing multiple new patients in a defined period of time was observed. The SMA improved wait times for fibromyalgia patients from 3 months to 1 month. The SMA also freed up new patient consultation slots for other conditions. Estimated additional work Relative Value Units (wRVUs) generated as a result of the SMA since its inception is 113.

Conclusion:   Considerable benefits were observed in the use of a SMA in an academic, rural consultative rheumatology practice. Future work will enhance and optimize the visit, expand its use, address referring provider satisfaction and examine post-visit resource utilization.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/use-of-a-shared-medical-appointment-for-patients-with-fibromyalgia-in-a-rural-academic-medical-center-a-process-improvement-initiative-for-the-development-of-a-new-care-model/