QUALITY IMPROVEMENT REPORT
Process improvements and shared medical appointments for cardiovascular disease prevention in women Lisa M. Pastore, PhD, MSPH (Assistant Professor)1 , Ann M. Rossi, DNP, NP (Nurse Practitioner)2 , & Amy L. Tucker, MD (Associate Professor of Medicine)2 1 2
Department of Obstetrics/Gynecology, University of Virginia, Charlottesville, Virginia Department of Medicine, University of Virginia, Charlottesville, Virginia
Keywords Chronic cardiac care; group visit; nurse practitioner; shared medical appointments; cardiology; lifestyle modification; health education. Correspondence Correspondence Lisa M. Pastore, PhD, MSPH, Department of Obstetrics/Gynecology, University of Virginia, P.O. Box 800712, Charlottesville, VA 22908-0712. Tel: 434-924-9921(office); Fax: 434-982-3271; E-mail: [email protected] Received: 7 March 2012; accepted: 12 July 2012 doi: 10.1002/2327-6924.12071 This article is in line with the Million Hearts Campaign launched by the Department of Health and Human Services. To learn more about the campaign and for information on heart disease and stroke, please visit http://millionhearts.hhs.gov/about hd.html
Abstract Problem: Cardiovascular disease (CVD) is clinically unique in women and is often underdiagnosed and undertreated. Chronic diseases account for 75% of healthcare expenditures in the United States, of which 70% are preventable through lifestyle changes and active medical management. Lifestyle modification is difficult in the context of the traditional medical visit. Design: The Club Red Clinic uses a novel approach to enhance the care of women at risk for or with CVD. Through shared medical appointments (SMAs) and a multidisciplinary team approach, Club Red provides lifestyle training in addition to evidence-based practice to reduce CVD risk factors in women. In Club Red, nurse practitioners function independently and effectively in delivering lifestyle intervention for the management and prevention of CVD. Setting: The clinic functions within an academic medical school at the University of Virginia. Key measures for improvement: Patient access, patient satisfaction, provider efficiency, and frequency of cardiovascular visits. Effects of change: Process improvements include reduced appointment wait times, improved provider efficiency (more patients seen with the SMAs), high patient satisfaction (96%), and improved adherence to recommended medical monitoring (3.8 visits/year). Lessons learned: Club Red improved patient access, patient satisfaction, medical and behavioral management, and health promotion education for women with or at risk for CVD.
Context Cardiovascular disease (CVD) is the leading cause of death for women within every race/ethnicity subgroup reported by the National Institutes of Health in the United States (Heron et al., 2009). Approximately 360,000 women die each year in the United States from CVD (Xu, Kochanek, Murphy, & Tejada-Vera, 2010), which is one third of all female deaths. Nearly two thirds of women who die suddenly of coronary heart disease (CHD) have reported no previously recognized symptoms (D. Lloyd-Jones, Adams et al., 2010). In a 2005 survey, 36% of women did not perceive themselves to be at risk for CVD (Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010). One in every three Americans has at least one form of CVD (e.g., myocardial infarction, stroke), and 42.7 million women in the United States are “at risk” for Journal of the American Association of Nurse Practitioners 26 (2014) 555–561
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CVD (Rosamond et al., 2008). Recognition of gender differences associated with CVD has led to specific American Heart Association (AHA) guidelines for women (Mosca et al., 2011). Results from Women’s Ischemia Syndrome Evaluation (WISE) and other studies of CVD in women have identified an increasing number of differences in presentation, diagnosis, treatment, and prognosis of CVD between men and women. Women are more likely to have atypical symptoms, are more difficult to diagnose, and have poorer outcomes than men (Bairey Merz et al., 2006; Shaw et al., 2006). Current approaches for detection of coronary artery disease (CAD) in women are less effective than in men because women more commonly have diffuse, rather than focal, anatomical obstructive CAD (Bugiardini & Bairey Merz, 2005; Shaw, Bugiardini, & Merz, 2009). Women often present with microvascular 555
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dysfunction, abnormal coronary activity, and issues related to plaque erosion and distal microembolization (Bugiardini & Bairey Merz, 2005; Shaw et al., 2009). All of these conditions are difficult to diagnose and treat, underscoring the particular importance of prevention in women (Burke, Virmani, Galis, Haudenschild, & Muller, 2003; Shaw et al., 2009). Aggressive prevention and lifestyle modification are important to reducing the risk and subsequent treatment of CVD in women. The importance of lifestyle modification in addition to medical therapy for effective prevention is underscored by studies showing that women who adopt healthy lifestyle habits may prevent up to 80% of heart disease and 90% of type 2 diabetes (Hu et al., 2001; Stampfer, Hu, Manson, Rimm, & Willett, 2000). Healthy lifestyle habits included eating a heart-healthy diet, not smoking, regular physical activity, and a BMI 25.0 mg/kg2 ). Women were referred from the general cardiac clinic at the UVA, from other providers at UVA or in the community, or were self-referred new patients from the community. Current general cardiology patients who qualified for Club Red received a letter from the Club Red Clinic Director that described the clinical operation and invited them to call for an appointment. Club Red participation involved a comprehensive evaluation of CVD risk status and a tailored plan for risk reduction. As illustrated in Figure 1, this model was described to patients as building a heart-healthy home for the woman with a two-part foundation: an interdisciplinary healthcare team, and wellness coaching through shared medical visits. Access to the Club Red Clinic typically occurred within 3–4 days of a referral by a healthcare provider or self-referral by the individual. The program includes education on comprehensive goal-setting and self-management skills with an emphasis on diabetes education, nutrition and physical activity coun-
Women’s Heart Health Club Red Clinic • Medical Management • Lifestyle Coaching Team of Heart Health Experts • Cardiology MD • Cardiology NP • PharmD • Exercise Physiologist • Nutritionist • Endocrinologist • Diabetes Educator
Shared Medical Visit • 6-12 Women • Group Support • 90 Minute Visit with Multiple Providers
Figure 1 Conceptual model of the Club Red Clinic for patients.
seling, weight reduction/maintenance, medication adherence, stress management techniques, management of depression, smoking cessation, and the establishment of a heart-healthy community to support and maintain a healthy lifestyle. Club Red maintains a website (http://www.clubreduva.com/) where these posted items are updated monthly: fitness tips, nutrition including a recipe of the month, medical education, and a news update. Other website content that is updated less frequently includes heart risk assessment survey tool, list of questions to ask your doctor about heart disease prevention, heart attack symptoms for women, and inspiring stories of women who have taken steps to live hearthealthy. Health promotion is the focus of Club Red. Health promotion is one component of “patient engagement,” which is described by the Center for the Advancement of Health as follows: set priorities for changing behavior to optimize health and prevent disease and act on them; identify and secure services that support changing behavior to maximize health and functioning and maintain those changes over time; manage symptoms by following treatment plans including diet, exercise, and substance use agreed upon by the patient and his or her provider (Center for the Advancement of Health, 2010). These are the focus of Club Red.
Multidisciplinary healthcare team with lead NP role The Club Red healthcare team includes cardiologists, endocrinologists, cardiovascular NPs, registered nurses, registered dieticians, certified diabetes educators, a registered pharmacist, and exercise physiologists (Figure 1). Appointment options include a traditional 1:1 with a provider (MD or NP) with team members available for 557
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consultation, or a SMA, which is a 90-min appointment with a provider and the healthcare team. The SMA allows women to interact with other women facing the same challenges and issues. The opportunity to combine both options of individual or shared appointments is also available. Intake evaluations with comprehensive assessment of cardiovascular risk and medical barriers to lifestyle change, as well as periodic medical follow-up, are performed by physicians in traditional or group visits. Lifestyle visits and follow-up for risk factor modification are provided by NP providers, leading a team that includes an RN, nutritionist or diabetic educator, and exercise physiologist. These visits are generally SMAs, although individual visits are offered as well. Individual visits worked better than the group model for women with communication challenges, including those who with severe uncorrected hearing impairment, and cognitive impairment (Noffsinger, 2009).
SMAs and lifestyle modification SMAs offer several advantages over traditional care delivery models, including increased time for education and coaching, expanded capacity, increased provider efficiency, and group support and accountability for patients (Bartley & Haney, 2010). Our vision was that women taking part in an SMA would find the motivation, support and medical oversight needed to make and sustain lifestyle changes such as weight loss, healthy eating, physical activity, or good blood sugar control. Studies on weight loss have shown that group interventions can be effective (Gallagher et al., 2012), women have success when they have a formal program (Kiernan et al., 2012; Pinelli, Brown, Herman, & Jaber, 2011) and women derive motivation in group contexts (Kiernan et al., 2012). Supporting the success of group health models is the work of Irvin Yalom (Cox, Vinogradov, & Yalom, 2008; Yalom & Leszcz, 2005), which identified various restorative factors of group psychological treatment that could be applied to SMA group medical visits (DeVries, DarlingFisher, Thomas, & Belanger-Shugart, 2008). SMAs in Club Red are 90 min from start to finish with no waiting room time. Patients sign a HIPAA-compliance confidentiality form at every visit. Each patient may bring one female support partner, who also must sign a confidentiality form. Vital signs, medicine reconciliation, physical examination, and brief review of past medical history are obtained at each visit. Patients also get medication refills, tests scheduled, referrals made, and follow-up appointments made within the 90-min period. In addition to lifestyle curriculum, physical exams and medical care are provided at every visit. Documenta558
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tion is usually completed during the visit. Within the SMA, patients receive the same medical care as with a traditional 1:1 appointment, plus much more lifestyle intervention and encouragement. Our multidisciplinary approach provides frequent medical interactions for both individual medical management and lifestyle interventions. Through the Club Red model, patients have reported that they learn from the education and management of others who are also attending the same group medical appointment. During the SMA, women have the option to be examined or address personal issues privately with the physician or NP. Lifestyle modification is a major focus in primary CVD prevention (Artinian et al., 2010). Lifestyle interventions for risk modification reveal that 80% of events could be prevented by the following: (a) smoking cessation and avoidance of second-hand smoke; (b) a minimum of 30 min of moderate physical intensity 5 or more days per week; (c) cardiac rehabilitation for those that have been hospitalized for or have had procedures for CVD; (d) nutritional therapy in the form of a heart-healthy diet; (e) weight maintenance/reduction (BMI < 25 kg/m2 ) through diet, exercise, and behavioral counseling; (f) increasing omega three fatty acid intake; and (g) screening and treatment for depression if indicated (Mosca et al., 2011; Stampfer et al., 2000).
Effect of change Process and patient access improvements There are several noteworthy process improvements that occur with the Club Red SMA model. The first is a dramatic reduction in the time between when a woman calls for a medical appointment and when she is actually seen in clinic. For new patients, women in Club Red SMAs are seen by a physician within 4 days on average of requesting an appointment, compared with an average wait of 4 months to be seen by a specific physician in the general cardiology clinic. For routine follow-up, existing patients are seen within 3 days on average in Club Red versus a target of 2 weeks in the general cardiology clinic. The second process improvement is the noteworthy reduction in provider and staff time per visit. Club Red SMAs require a total of 180 min of provider or staff time, with an average of six patients per group. Thus, group visits utilize 30 min of clinic time per patient. New patients in traditional individual visits each require an average of 125 min of combined provider and staff time, with individual follow-up visits utilizing an average of 90 min of provider/staff times for a follow-up visit with a physician and 85 min for a follow-up visit with an NP.
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Patient Satisfaction
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100 98 96 94 92 90 88 86 84
Cardiology Clinic 1 Cardiology clinic 2 Club Red
2009 Q1
2009 Q2
2009 Q3
2009 Q4
Figure 2 Patient satisfaction scores by clinic and quarter in 2009.
Physician provider productivity in SMA initial visits for the first year of operation was 271% of that for individual visits under a traditional healthcare model, and for SMA follow-up visits was 200% greater than traditional clinic follow-up appointments. Those figures are based on the productivity (number of patients seen clinically per hour) of the same provider within the Club Red clinic compared to non-Club Red clinics. NP provider productivity (number of patients seen clinically per hour) for SMA followup visits was 176% greater than traditional clinic visits. At UVA, the standard scheduling for individual appointments provides 1 hour for an initial visit and 30 min for a follow-up appointment. The SMA format created additional provider capacity resulting in improved patient access for emergent, initial, or follow-up visits. The standard wait time for the “next available” general cardiology appointment follow-up was approximately 15 days for follow-up visits and for the SMA group was ≤3 days, representing an improvement of 12 days.
Higher patient satisfaction The patient satisfaction scores for Club Red are the same or greater than for the two general cardiology clinics in every quarter of 2009 (Figure 2). The mean patient satisfaction score for the year 2009 was 96% for Club Red and 94% for both general cardiology clinics combined. These data support the a priori expectation that women would perceive value and be satisfied with the new care model. Within Club Red, 94% of patients said they would schedule another SMA and 100% would recommend it to others. The increase in patient satisfaction in this specialized women’s clinic is theorized to be related to no waiting room time and/or a 90-min visit with the provider in a supportive and interactive environment.
Adherence to routine screenings Women with CVD risk factors and diabetes risk factors are recommended to have routine medical visits to mon-
itor changes in their health. Among female patients only at our institution, the annualized frequency of CVD medical visits in 2008–2009 within the UVA general cardiology clinic was 2.6 (median 2.1). The frequency of medical monitoring was higher among the Club Red patients, where the mean number of annual medical visits was 3.8 (median 3.0, nonparametric Wilcoxon p < .0001). Within the Club Red patient population, the women who had at least one SMA had more frequent medical visits (mean 4.8, median 3.7) than the Club Red patients who never attended a group appointment (mean 2.7, median 2.1, nonparametric Wilcoxon p < .0001). Thus, there was improved adherence to medical monitoring and greater patient engagement with their provider within Club Red, and participation in a group visit increased the likelihood of routine medical monitoring even further.
Conclusion The Club Red Clinic model in context The individual patient benefits of an SMA model for CVD were the availability of a multidisciplinary medical team at a single clinic appointment, and the time and attention devoted to lifestyle modification in addition to the usual medical management of cardiovascular risk. Others have reported that the SMA approach affords improvement in patient access and provider efficiency (Bronson & Maxwell, 2004), the latter of which is a benefit to the medical organization, and our experience concurs. As reported elsewhere (Miller, Zantop, Hammer, Faust, & Grumbach, 2004; Oehlke & Whitehill, 2006), patients in this multidisciplinary model for women reported greater patient satisfaction with care and had shorter wait times to appointments compared with women seen in the general cardiology clinics. For Club Red, this occurred in the context of increased provider efficiency, capacity, and productivity. 559
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Lesson learned: Implications for nursing practice The implications for nursing practice include the NP as a key provider in the Club Red SMA model. The NP utilizes the chronic care model (CCM), which recommends evidence-based interventions within six areas known to improve patient outcomes and processes of care: organizational support, information technology systems, delivery system design, decision support, self-management support, and linkages to the community (Bodenheimer, Wagner, & Grumbach, 2002). The effectiveness and feasibility of including an advanced practice nurse in the CCM medical team has been demonstrated (Dancer & Courtney, 2010; Watts et al., 2009). The NP incorporates the education of other health professionals, and maintains reliability within the team members of the SMA team (nurse, nutritionist, diabetes educator, pharmacist, and exercise physiologist) as the consistent provider. Additionally, the NP encourages patient self-management through the use of information exchange and motivational interviewing in the SMA as opposed to the provider instructing and providing the plan of care to the patient. The NP as provider eliminates barriers to care through improving patient access and the resultant increase in provider productivity. NPs function independently and cost-effectively in the medical management of chronic diseases such as CVD (Boville et al., 2007). NPs at Club Red played a leadership role in the multidisciplinary care team by providing education, support, and active management of medical and lifestyle issues within Club Red. Others have reported similar nursing roles (Herrmann & Zabramski, 2005).
Next steps The next steps with the Club Red model are to refine the educational offerings based on participant feedback, develop new educational materials in order to maintain the current patient base, increase the metrics both for improved evaluation of the clinical as well as to provide feedback to the participants, and to increase the monitoring and analysis of financial and human resource decisions in order to optimize the financial operation. The analysis of the patient biometrics in Club Red is not yet available (submitted manuscript).
Summary UVA has found this Club Red specialized CVD clinic for women to be beneficial for patients and the institution. We believe this multidisciplinary approach is not only time-effective, but is a realistic means to help women 560
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achieve lifestyle modifications that they can incorporate into their daily lives, with the ultimate goal of having those modifications last long enough to reduce the patient’s CVD incidence, severity, and/or morbidity in the future.
Acknowledgments The authors are grateful to Will Rourk in the University of Virginia Digital Media Lab for the creation of Figure 1, and to Greg Megginson at the University of Virginia for provision of data. This work was supported by the Buchanan Endowment at the University of Virginia.
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Process improvements and shared medical appointments for cardiovascular disease prevention in women Lisa M. Pastore, PhD, MSPH (Assistant Professor)1 , Ann M. Rossi, DNP, NP (Nurse Practitioner)2 , & Amy L. Tucker, MD (Associate Professor of Medicine)2 1 2
Department of Obstetrics/Gynecology, University of Virginia, Charlottesville, Virginia Department of Medicine, University of Virginia, Charlottesville, Virginia
Keywords Chronic cardiac care; group visit; nurse practitioner; shared medical appointments; cardiology; lifestyle modification; health education. Correspondence Correspondence Lisa M. Pastore, PhD, MSPH, Department of Obstetrics/Gynecology, University of Virginia, P.O. Box 800712, Charlottesville, VA 22908-0712. Tel: 434-924-9921(office); Fax: 434-982-3271; E-mail: [email protected] Received: 7 March 2012; accepted: 12 July 2012 doi: 10.1002/2327-6924.12071 This article is in line with the Million Hearts Campaign launched by the Department of Health and Human Services. To learn more about the campaign and for information on heart disease and stroke, please visit http://millionhearts.hhs.gov/about hd.html
Abstract Problem: Cardiovascular disease (CVD) is clinically unique in women and is often underdiagnosed and undertreated. Chronic diseases account for 75% of healthcare expenditures in the United States, of which 70% are preventable through lifestyle changes and active medical management. Lifestyle modification is difficult in the context of the traditional medical visit. Design: The Club Red Clinic uses a novel approach to enhance the care of women at risk for or with CVD. Through shared medical appointments (SMAs) and a multidisciplinary team approach, Club Red provides lifestyle training in addition to evidence-based practice to reduce CVD risk factors in women. In Club Red, nurse practitioners function independently and effectively in delivering lifestyle intervention for the management and prevention of CVD. Setting: The clinic functions within an academic medical school at the University of Virginia. Key measures for improvement: Patient access, patient satisfaction, provider efficiency, and frequency of cardiovascular visits. Effects of change: Process improvements include reduced appointment wait times, improved provider efficiency (more patients seen with the SMAs), high patient satisfaction (96%), and improved adherence to recommended medical monitoring (3.8 visits/year). Lessons learned: Club Red improved patient access, patient satisfaction, medical and behavioral management, and health promotion education for women with or at risk for CVD.
Context Cardiovascular disease (CVD) is the leading cause of death for women within every race/ethnicity subgroup reported by the National Institutes of Health in the United States (Heron et al., 2009). Approximately 360,000 women die each year in the United States from CVD (Xu, Kochanek, Murphy, & Tejada-Vera, 2010), which is one third of all female deaths. Nearly two thirds of women who die suddenly of coronary heart disease (CHD) have reported no previously recognized symptoms (D. Lloyd-Jones, Adams et al., 2010). In a 2005 survey, 36% of women did not perceive themselves to be at risk for CVD (Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010). One in every three Americans has at least one form of CVD (e.g., myocardial infarction, stroke), and 42.7 million women in the United States are “at risk” for Journal of the American Association of Nurse Practitioners 26 (2014) 555–561
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CVD (Rosamond et al., 2008). Recognition of gender differences associated with CVD has led to specific American Heart Association (AHA) guidelines for women (Mosca et al., 2011). Results from Women’s Ischemia Syndrome Evaluation (WISE) and other studies of CVD in women have identified an increasing number of differences in presentation, diagnosis, treatment, and prognosis of CVD between men and women. Women are more likely to have atypical symptoms, are more difficult to diagnose, and have poorer outcomes than men (Bairey Merz et al., 2006; Shaw et al., 2006). Current approaches for detection of coronary artery disease (CAD) in women are less effective than in men because women more commonly have diffuse, rather than focal, anatomical obstructive CAD (Bugiardini & Bairey Merz, 2005; Shaw, Bugiardini, & Merz, 2009). Women often present with microvascular 555
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dysfunction, abnormal coronary activity, and issues related to plaque erosion and distal microembolization (Bugiardini & Bairey Merz, 2005; Shaw et al., 2009). All of these conditions are difficult to diagnose and treat, underscoring the particular importance of prevention in women (Burke, Virmani, Galis, Haudenschild, & Muller, 2003; Shaw et al., 2009). Aggressive prevention and lifestyle modification are important to reducing the risk and subsequent treatment of CVD in women. The importance of lifestyle modification in addition to medical therapy for effective prevention is underscored by studies showing that women who adopt healthy lifestyle habits may prevent up to 80% of heart disease and 90% of type 2 diabetes (Hu et al., 2001; Stampfer, Hu, Manson, Rimm, & Willett, 2000). Healthy lifestyle habits included eating a heart-healthy diet, not smoking, regular physical activity, and a BMI 25.0 mg/kg2 ). Women were referred from the general cardiac clinic at the UVA, from other providers at UVA or in the community, or were self-referred new patients from the community. Current general cardiology patients who qualified for Club Red received a letter from the Club Red Clinic Director that described the clinical operation and invited them to call for an appointment. Club Red participation involved a comprehensive evaluation of CVD risk status and a tailored plan for risk reduction. As illustrated in Figure 1, this model was described to patients as building a heart-healthy home for the woman with a two-part foundation: an interdisciplinary healthcare team, and wellness coaching through shared medical visits. Access to the Club Red Clinic typically occurred within 3–4 days of a referral by a healthcare provider or self-referral by the individual. The program includes education on comprehensive goal-setting and self-management skills with an emphasis on diabetes education, nutrition and physical activity coun-
Women’s Heart Health Club Red Clinic • Medical Management • Lifestyle Coaching Team of Heart Health Experts • Cardiology MD • Cardiology NP • PharmD • Exercise Physiologist • Nutritionist • Endocrinologist • Diabetes Educator
Shared Medical Visit • 6-12 Women • Group Support • 90 Minute Visit with Multiple Providers
Figure 1 Conceptual model of the Club Red Clinic for patients.
seling, weight reduction/maintenance, medication adherence, stress management techniques, management of depression, smoking cessation, and the establishment of a heart-healthy community to support and maintain a healthy lifestyle. Club Red maintains a website (http://www.clubreduva.com/) where these posted items are updated monthly: fitness tips, nutrition including a recipe of the month, medical education, and a news update. Other website content that is updated less frequently includes heart risk assessment survey tool, list of questions to ask your doctor about heart disease prevention, heart attack symptoms for women, and inspiring stories of women who have taken steps to live hearthealthy. Health promotion is the focus of Club Red. Health promotion is one component of “patient engagement,” which is described by the Center for the Advancement of Health as follows: set priorities for changing behavior to optimize health and prevent disease and act on them; identify and secure services that support changing behavior to maximize health and functioning and maintain those changes over time; manage symptoms by following treatment plans including diet, exercise, and substance use agreed upon by the patient and his or her provider (Center for the Advancement of Health, 2010). These are the focus of Club Red.
Multidisciplinary healthcare team with lead NP role The Club Red healthcare team includes cardiologists, endocrinologists, cardiovascular NPs, registered nurses, registered dieticians, certified diabetes educators, a registered pharmacist, and exercise physiologists (Figure 1). Appointment options include a traditional 1:1 with a provider (MD or NP) with team members available for 557
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consultation, or a SMA, which is a 90-min appointment with a provider and the healthcare team. The SMA allows women to interact with other women facing the same challenges and issues. The opportunity to combine both options of individual or shared appointments is also available. Intake evaluations with comprehensive assessment of cardiovascular risk and medical barriers to lifestyle change, as well as periodic medical follow-up, are performed by physicians in traditional or group visits. Lifestyle visits and follow-up for risk factor modification are provided by NP providers, leading a team that includes an RN, nutritionist or diabetic educator, and exercise physiologist. These visits are generally SMAs, although individual visits are offered as well. Individual visits worked better than the group model for women with communication challenges, including those who with severe uncorrected hearing impairment, and cognitive impairment (Noffsinger, 2009).
SMAs and lifestyle modification SMAs offer several advantages over traditional care delivery models, including increased time for education and coaching, expanded capacity, increased provider efficiency, and group support and accountability for patients (Bartley & Haney, 2010). Our vision was that women taking part in an SMA would find the motivation, support and medical oversight needed to make and sustain lifestyle changes such as weight loss, healthy eating, physical activity, or good blood sugar control. Studies on weight loss have shown that group interventions can be effective (Gallagher et al., 2012), women have success when they have a formal program (Kiernan et al., 2012; Pinelli, Brown, Herman, & Jaber, 2011) and women derive motivation in group contexts (Kiernan et al., 2012). Supporting the success of group health models is the work of Irvin Yalom (Cox, Vinogradov, & Yalom, 2008; Yalom & Leszcz, 2005), which identified various restorative factors of group psychological treatment that could be applied to SMA group medical visits (DeVries, DarlingFisher, Thomas, & Belanger-Shugart, 2008). SMAs in Club Red are 90 min from start to finish with no waiting room time. Patients sign a HIPAA-compliance confidentiality form at every visit. Each patient may bring one female support partner, who also must sign a confidentiality form. Vital signs, medicine reconciliation, physical examination, and brief review of past medical history are obtained at each visit. Patients also get medication refills, tests scheduled, referrals made, and follow-up appointments made within the 90-min period. In addition to lifestyle curriculum, physical exams and medical care are provided at every visit. Documenta558
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tion is usually completed during the visit. Within the SMA, patients receive the same medical care as with a traditional 1:1 appointment, plus much more lifestyle intervention and encouragement. Our multidisciplinary approach provides frequent medical interactions for both individual medical management and lifestyle interventions. Through the Club Red model, patients have reported that they learn from the education and management of others who are also attending the same group medical appointment. During the SMA, women have the option to be examined or address personal issues privately with the physician or NP. Lifestyle modification is a major focus in primary CVD prevention (Artinian et al., 2010). Lifestyle interventions for risk modification reveal that 80% of events could be prevented by the following: (a) smoking cessation and avoidance of second-hand smoke; (b) a minimum of 30 min of moderate physical intensity 5 or more days per week; (c) cardiac rehabilitation for those that have been hospitalized for or have had procedures for CVD; (d) nutritional therapy in the form of a heart-healthy diet; (e) weight maintenance/reduction (BMI < 25 kg/m2 ) through diet, exercise, and behavioral counseling; (f) increasing omega three fatty acid intake; and (g) screening and treatment for depression if indicated (Mosca et al., 2011; Stampfer et al., 2000).
Effect of change Process and patient access improvements There are several noteworthy process improvements that occur with the Club Red SMA model. The first is a dramatic reduction in the time between when a woman calls for a medical appointment and when she is actually seen in clinic. For new patients, women in Club Red SMAs are seen by a physician within 4 days on average of requesting an appointment, compared with an average wait of 4 months to be seen by a specific physician in the general cardiology clinic. For routine follow-up, existing patients are seen within 3 days on average in Club Red versus a target of 2 weeks in the general cardiology clinic. The second process improvement is the noteworthy reduction in provider and staff time per visit. Club Red SMAs require a total of 180 min of provider or staff time, with an average of six patients per group. Thus, group visits utilize 30 min of clinic time per patient. New patients in traditional individual visits each require an average of 125 min of combined provider and staff time, with individual follow-up visits utilizing an average of 90 min of provider/staff times for a follow-up visit with a physician and 85 min for a follow-up visit with an NP.
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Patient Satisfaction
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100 98 96 94 92 90 88 86 84
Cardiology Clinic 1 Cardiology clinic 2 Club Red
2009 Q1
2009 Q2
2009 Q3
2009 Q4
Figure 2 Patient satisfaction scores by clinic and quarter in 2009.
Physician provider productivity in SMA initial visits for the first year of operation was 271% of that for individual visits under a traditional healthcare model, and for SMA follow-up visits was 200% greater than traditional clinic follow-up appointments. Those figures are based on the productivity (number of patients seen clinically per hour) of the same provider within the Club Red clinic compared to non-Club Red clinics. NP provider productivity (number of patients seen clinically per hour) for SMA followup visits was 176% greater than traditional clinic visits. At UVA, the standard scheduling for individual appointments provides 1 hour for an initial visit and 30 min for a follow-up appointment. The SMA format created additional provider capacity resulting in improved patient access for emergent, initial, or follow-up visits. The standard wait time for the “next available” general cardiology appointment follow-up was approximately 15 days for follow-up visits and for the SMA group was ≤3 days, representing an improvement of 12 days.
Higher patient satisfaction The patient satisfaction scores for Club Red are the same or greater than for the two general cardiology clinics in every quarter of 2009 (Figure 2). The mean patient satisfaction score for the year 2009 was 96% for Club Red and 94% for both general cardiology clinics combined. These data support the a priori expectation that women would perceive value and be satisfied with the new care model. Within Club Red, 94% of patients said they would schedule another SMA and 100% would recommend it to others. The increase in patient satisfaction in this specialized women’s clinic is theorized to be related to no waiting room time and/or a 90-min visit with the provider in a supportive and interactive environment.
Adherence to routine screenings Women with CVD risk factors and diabetes risk factors are recommended to have routine medical visits to mon-
itor changes in their health. Among female patients only at our institution, the annualized frequency of CVD medical visits in 2008–2009 within the UVA general cardiology clinic was 2.6 (median 2.1). The frequency of medical monitoring was higher among the Club Red patients, where the mean number of annual medical visits was 3.8 (median 3.0, nonparametric Wilcoxon p < .0001). Within the Club Red patient population, the women who had at least one SMA had more frequent medical visits (mean 4.8, median 3.7) than the Club Red patients who never attended a group appointment (mean 2.7, median 2.1, nonparametric Wilcoxon p < .0001). Thus, there was improved adherence to medical monitoring and greater patient engagement with their provider within Club Red, and participation in a group visit increased the likelihood of routine medical monitoring even further.
Conclusion The Club Red Clinic model in context The individual patient benefits of an SMA model for CVD were the availability of a multidisciplinary medical team at a single clinic appointment, and the time and attention devoted to lifestyle modification in addition to the usual medical management of cardiovascular risk. Others have reported that the SMA approach affords improvement in patient access and provider efficiency (Bronson & Maxwell, 2004), the latter of which is a benefit to the medical organization, and our experience concurs. As reported elsewhere (Miller, Zantop, Hammer, Faust, & Grumbach, 2004; Oehlke & Whitehill, 2006), patients in this multidisciplinary model for women reported greater patient satisfaction with care and had shorter wait times to appointments compared with women seen in the general cardiology clinics. For Club Red, this occurred in the context of increased provider efficiency, capacity, and productivity. 559
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Lesson learned: Implications for nursing practice The implications for nursing practice include the NP as a key provider in the Club Red SMA model. The NP utilizes the chronic care model (CCM), which recommends evidence-based interventions within six areas known to improve patient outcomes and processes of care: organizational support, information technology systems, delivery system design, decision support, self-management support, and linkages to the community (Bodenheimer, Wagner, & Grumbach, 2002). The effectiveness and feasibility of including an advanced practice nurse in the CCM medical team has been demonstrated (Dancer & Courtney, 2010; Watts et al., 2009). The NP incorporates the education of other health professionals, and maintains reliability within the team members of the SMA team (nurse, nutritionist, diabetes educator, pharmacist, and exercise physiologist) as the consistent provider. Additionally, the NP encourages patient self-management through the use of information exchange and motivational interviewing in the SMA as opposed to the provider instructing and providing the plan of care to the patient. The NP as provider eliminates barriers to care through improving patient access and the resultant increase in provider productivity. NPs function independently and cost-effectively in the medical management of chronic diseases such as CVD (Boville et al., 2007). NPs at Club Red played a leadership role in the multidisciplinary care team by providing education, support, and active management of medical and lifestyle issues within Club Red. Others have reported similar nursing roles (Herrmann & Zabramski, 2005).
Next steps The next steps with the Club Red model are to refine the educational offerings based on participant feedback, develop new educational materials in order to maintain the current patient base, increase the metrics both for improved evaluation of the clinical as well as to provide feedback to the participants, and to increase the monitoring and analysis of financial and human resource decisions in order to optimize the financial operation. The analysis of the patient biometrics in Club Red is not yet available (submitted manuscript).
Summary UVA has found this Club Red specialized CVD clinic for women to be beneficial for patients and the institution. We believe this multidisciplinary approach is not only time-effective, but is a realistic means to help women 560
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achieve lifestyle modifications that they can incorporate into their daily lives, with the ultimate goal of having those modifications last long enough to reduce the patient’s CVD incidence, severity, and/or morbidity in the future.
Acknowledgments The authors are grateful to Will Rourk in the University of Virginia Digital Media Lab for the creation of Figure 1, and to Greg Megginson at the University of Virginia for provision of data. This work was supported by the Buchanan Endowment at the University of Virginia.
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