While they may not be entirely financially viable (yet), they appear worthwhile for patients with chronic conditions.
The problem with general practice is there’s no money and no time, noted one delegate at last week’s WONCA conference.
Victorian GP Dr Bernard Shiu and medical educator Dr Michael Axtens were there to propose a model of care aimed at solving at least one of these problems, one that is still touted as “new” despite operating in Australia for over 20 years.
The model? Shared medical appointments (SMAs).
Built with a focus on acute disease and injury, primary care consultations traditionally occur as one-on-one sessions.
But for complex, chronic conditions, consultations often require large chunks of information to be repeated for most, if not all, patients.
Dr Axtens, who moved out of his position as a practising GP to focus on research into SMAs, described how the model of SMAs he used worked so well for chronic conditions.
“When you’re testing someone’s blood pressure, you give the same talk over and over again,” said Dr Axtens.
“So why not take people with hypertension, have two hours with them [as a group]?”
Dr Axtens’ sessions bring together a group of usually no more than ten patients with the same chronic condition for a series of sequential sessions delving into shared experiences and providing concurrent care.
The sessions start with a facilitator, often an allied health professional with a particular interest in the topic, say a dietitian for an eating disorder, who encouraged patient discussion of “themes” to address as a group, using the Cambridge Calgary mode of communication.
“Once you’ve got the themes, the facilitator’s job is to try to prioritise what is most relevant to most patients and what is medically most important,” said Dr Axtens.
“There’s the patient’s agenda, the medical agenda and what is going to be most engaging.”
Following these group discussion sessions, the GP provides care to each patient in succession within the group setting. This may include physical examinations, queries or information sharing.
“We are surprised if we’re not deprescribing and achieving improvements in biomarkers,” he said of his sessions on type 2 diabetes.
Dr Axtens referred to research by Coordinare, who have conducted substantial research into the model, noting that the results speak for themselves.
In their proof-of-concept trials, run at eight medical centres on the south coast in 2018 to target obesity, 73% of patients said they would prefer SMAs to one-on-one sessions for weight control.
Over 30% of male and 18% of female patients achieved clinically significant weight loss over the course of the study.
The engagement was great – over 250 patients attended SMAs, with 78% attending at least four out of six sessions, said Dr Axtens.
All patients reported improvements in health literacy, sleep, stress management and self-management.
Patients reported feeling like they had time to explore their understanding of the disorder, were empowered to speak up and ask questions and enlightened by questions asked by their peers.
But beyond patient improvements, practitioners reported improved patient relationships and a renewed inspiration.
According to Dr Axtens, one of the major surprises was the reported improvement in practitioner quality of life or “burnout antidote”.
According to the study, providing the same level of information to each patient took a quarter of the usual time.
But, unsurprisingly, funding remained a barrier.
“Economically, it’s a model that needs subsidy from up top, you can’t make a business model out of it,” said Dr Axtens.
“Because we’re doing research, we have been bulk billing – that’s part of the ethics.
“I’m doing this for passion and to watch the amazing outcomes.”
To qualify for Medicare, each patient must give consent and it must be clearly specified that SMAs involve simultaneous consultations, not simply education.
At the moment, each patient is generally bulk billed an item 23 by the GP for their individual time, said Dr Axtens, meaning they “just cut even”.
Allied professionals who facilitate the service are often providing their services for free, added Dr Shiu, but are allowed to advertise their services.
But there are examples of shared medical appointments that are run by psychologists that are more effectively funded by Medicare, added Dr Shiu; it’s just about tweaking these to make them applicable to general practice.
“We’re just hoping that we can raise more awareness so that the government [can help implement SMAs] or any one of our colleagues will be able to try to use this module to address this crisis of healthcare.”
The current project is to develop a “roadmap” for introducing this highly flexible and adaptive model in general practice, said Dr Axtens.
WONCA was held in Sydney October 26-29.
