SHARED MEDICAL APPOINTMENTS (SMAs), since their initial conceptualization by Dr Edward Noffsinger (Bronson & Maxwell, 2004), have gained much popularity, with potentials for increasing access to care, for patient education about medical illness, and for physician productivity (Sikon & Bronson, 2010). In these visits, physicians treat patients individually yet in a group setting of 6 to 12 patients in a 90-minute appointment. While some may raise skepticism regarding the reaction of patients to having personal medical issues discussed in front of others, data from studies have shown patients to be very satisfied with their experience and these visits can significantly impact management of chronic medical illnesses (Bronson & Maxwell, 2004; Sikon & Bronson, 2010). In a weight loss SMA, those who attended the sessions had a significantly higher weight loss compared with those who did not (Palaniappan et al., 2011). Recently, SMAs have also been uniquely adapted to serve the pediatric population for asthma and reactive airway disease (Wall-Haas et al., 2012).

Shared medical appointments are typically staffed by a provider, behaviorist, documenter, and/or nurse and generally fall into 1 of 2 categories-follow-up chronic medical illness care or annual physical examinations, each having their own sets of logistical challenges (Bronson & Maxwell, 2004; Berger-Fiffy, 2012). Typically for follow-up care SMAs, patients may need to pay co-pays and physical examinations are done in the group setting (Bronson & Maxwell, 2004). In preventive care visits, a smaller number of patients are seen and examinations are conducted in an independent room, with patients remaining in the group room during the nonexamination component (Bronson & Maxwell, 2004).

For a successful SMA, both patient selection (Sikon & Bronson, 2010) and physician selection are crucial (Bronson & Maxwell, 2004). Appropriate physicians tend to be those who have challenges with patient access or those who provide repetitive advice over the course of a day, which can be delivered more effectively in a group setting (Bronson & Maxwell, 2004). Challenges to organizing any SMA include finding appropriate medical personnel, convincing patients that it is worthwhile to attend, including paying co-pays for a shared appointment, having appropriate patient volume, creating smooth transitions from the rooms when private physical examinations are required, appropriately documenting the individualized care, and not turning the SMA into a lecture (Bronson & Maxwell, 2004).

At Hartford HealthCare Medical Group, SMAs were started in April 2013, with 3 physicians piloting 3 different models, 1 being for the annual wellness visit (AWV), which is an annual preventive visit covered by Medicare. There are several benefits to an AWV SMA, which make it ideal for the shared experience-there is no physical examination requirement, there are standard risk assessments that contribute to a robust discussion, there is no co-pay or significant financial burden on the patient, and the patients are of similar age. Other unexpected benefits include allowing couples to have the option of a visit together, and to address certain quality measures including discussion of and obtaining Advance Directives. Two major challenges exist in conducting such a SMA. The first challenge is the preparation work that is required ahead of time, including updating medication lists, mailing out patient questionnaires, and performing a chart review to obtain background information and to anticipate the patient's needs for the visit. In addition, there is a logistical challenge with regard to the speed at which initial vitals and vision/hearing tests can be done, which sets the pace for the rest of the SMA.

The AWV SMA team at Hartford HealthCare Medical Group includes a physician, a medical assistant (serving primarily as a documenter), a nurse (obtaining vitals, administering vaccines, and facilitating checkout), and a behaviorist. The SMA is held in a large conference room with ample space to obtain vitals, and it is equipped with a telephone, wireless Internet, projector, printer, and portable copy machine. Beverages and snacks are brought to each session.

Approximately half an hour before the appointment, the medical assistant and nurse organize the room, and organize the necessary paperwork, some of which has been done during the prior weeks. Upon arrival, patients are escorted for a hearing screening if indicated, and subsequently directed to the behaviorist, who greets the patients and obtains completed paperwork and reviews their preprepared folders, which includes the confidentiality agreement, blank patient preventive care plan, and other educational information. Patients are subsequently directed to the nurse, who obtains vitals and administers physician-recommended immunizations (identified through chart review), while the documenter begins to enter the data from the home-screening questionnaires in the electronic medical record and identifies which patients screen positive on the questionnaires. Once the physician arrives, an interactive PowerPoint presentation/discussion ensues reviewing the current United States Preventive Services Task Force recommendations for age-based and risk-based screening for patients, including screening procedures, laboratory studies, and immunizations. Subsequently, the physician addresses each patient's recommendations after reviewing the individual's screening questionnaire, and initiating a discussion on topics pertaining to that patient, including Advance Directives, falls, exercise, independence, medication management, etc. These discussion topics are then augmented by patient participation and facilitation by the behaviorist. Before concluding recommendations for a particular patient, the physician makes follow-ups for any positive screening questions that require further discussion in a subsequent visit and reviews medications to reconcile. During the individualized patient care portion, the behaviorist notes recommendations on the paper plan, and the documenter enters the appropriate orders in the electronic medical record. Once all individual patient plans are made, a formal checkout process occurs wherein patients receive copies of their preventive care plan, orders for laboratories and tests, and follow-up/referral information. They can subsequently proceed to the laboratory if needed or to radiology for any imaging, both facilities being housed in the same building. The written documentation is subsequently scanned in the electronic medical record as part of the chart.

Patient feedback has been excellent based on the 3 sessions conducted so far, with 95% of patients (18/19) agreeing or strongly agreeing that they would recommend a SMA, and only 1 patient being undecided. Except for 1 patient, all patients felt that their questions were sufficiently answered, were comfortable asking questions in the group environment, and learned from other patients.

From a financial perspective, the reimbursement for an AWV is at least equal to or greater than a moderate complexity visit, indicating a significant financial benefit for the organization, in addition to providing quality care for the patient by addressing many preventive health issues, which may not always happen in follow-up visits devoted to chronic disease management. Because there is no major financial burden on the patient to attend such a visit, the recruitment process is also significantly easier.

While the traditional models of SMAs have been for follow-ups of chronic diseases as well as for preventive visits, which include physical examinations, our experience with the AWV SMA has allowed patients to have all the benefits from the group appointment, has eliminated patient co-pay costs for the visit, has removed the logistics of having to perform an appropriate physical examination (whether in the group setting or privately), and has resulted in high provider satisfaction. We acknowledge several limitations to the AWV SMA, particularly the preparation work required by all staff for the visit, which is not accounted for in terms of a time-cost analysis; the challenge in terms of timeframe in which vitals and hearing screening have to be completed; and the form of documentation, which is not completely electronic as some of the information has to subsequently be scanned into the chart. Nevertheless, we have found this type of visit to be very rewarding for all those involved, and it upholds the spirit of the shared medical experience.

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