Background/Purpose: Patients experience long waits for consultations in Rheumatology at Dartmouth-Hitchcock Medical Center (DHMC).  The cause of this is multi-factorial, including provider referral patterns, patient preferences, constraints on clinic time in an academic medical practice, and system bottlenecks such as lack of available exam rooms. Regardless of the cause, the results are the same: potential for delayed treatment for rheumatologic diseases, pain and anxiety for patients, frustration for referring providers and poor practice performance. While matching capacity to demand improves access, increasing practice capacity without encroaching on physician teaching, research, and administrative time is challenging. To capitalize on this opportunity, the Rheumatology Access Team (RATE) adapted a shared medical appointment (SMA) to meet the needs of gout patients.

Methods: Following an SMA guide developed at DHMC, the team mapped an “ideal” pathway of patient care for the appointment; verified adequate patient volumes; secured access to meeting space and exam rooms; and produced written and electronic patient education materials. A physician, scribe, nurse, and SMA coordinator staff the SMA. The physician evaluates patients in brief, private exams and develops individual care plans while the scribe uses a template to record the history of present illness and exam findings. The nurse greets patients, takes vital signs, and facilitates discussion amongst the participants. The SMA coordinator schedules patients and enters lab orders (signed by the provider) to ensure labs are actionable at the time of the appointment. Feedback elicited from patients and staff informed iterative changes in the appointments using a continual improvement model. Billing is the equivalent of a regular gout follow up appointment.

Results: A gout SMA takes place every two months and includes education on diet and metabolic syndrome per patient requests. The current appointment has the capacity to serve up to 12 patients in a two-hour session for one provider. This increases potential new patient capacity in the clinic by a net of 4 visits per SMA. During the course of multiple interventions, access to Rheumatology improved steadily from April 2011 to April 2012 (107 to 56 days) but it has not reached our goal of 14 days. Patient satisfaction with the availability of an appointment in Rheumatology “when you wanted it” increased from 35% to 60% excellent during the intervention.

Conclusion: A gout SMA may improve access in Rheumatology, however a robust change in the wait times will require an increase in referrals to the SMA. The SMA is an excellent opportunity to practice principals of team-based iterative change. The SMA allows providers to operate at their level of training by eliminating order and data entry and allows them to focus on patients rather than computers during the visit. This model has potential to work within the framework of an accountable care organization. Further study of outcomes will be helpful in determining if these appointments provide value for patients and the institution beyond increasing access.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-access-and-patient-education-in-rheumatology-the-gout-shared-medical-appointment-a-quality-improvement-initiative/