Shared Dietetic Appointments: A New Treatment Model







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Shared Dietetic


A New Treatment Model

Evelina Sands,MS Administrative Director of Operations

Diane Dube, M.Ed., RDN, LDN, CDE Nutritionist/Diabetes Educator North Shore Physicians Group, Peabody, MA

October 20, 2013


Suzanne Neubauer, PhD, RD, CNSC

Professor, Food & Nutrition

Framingham State University

Framingham, MA 01701

Presenter: Evelina Sands, MS

Administrative Director of Operations

North Shore Physicians Group

North Shore Medical Center/Partners Healthcare

Peabody, MA

Certified Lean Six Sigma Black Belt

Virginia Mason Ambulatory Flow Training

Virginia Mason Executive Training

Presenter: Diane Dube, M.Ed., RD, LDN,CDE

Nutritionist/Diabetes Educator

North Shore Physicians Group

North Shore Medical Center/Partners Healthcare

Peabody, MA


Diane Dube LLC Nutrition Consulting

Peabody, MA


Evelina Sands, MS

• Board Member/Advisory Panel – North Shore Physicians Group Board of Trustees

• Consultant

– None

• Employee

– Partners Healthcare, Boston MA

• Research Support – None • Speaker’s Bureau – None • Stock/Shareholder – None. • Other – None


Understand what a shared medical appointment is

(Learning Code 4000)

Review the benefits of shared medical appointments

(Learning Code 6070)

Outline a practical approach for implementation of shared

medical appointments in a practice setting


Who is North Shore Physicians


Multi-specialty Group:

11 Primary Care and 6 Specialty Practices

Internal Medicine, Family Medicine, Internal Medicine/Pediatrics, Endocrinology, Physiatry, Gastroenterology, Geriatrics, Rheumatology, Neurosurgery, OBGYN, Pulmonology, Infectious Disease, Neonatology, Emergency Medicine, Mental Health, Palliative Care

535 Employees

– physicians/allied health professionals and staff

78,304 total unique patients registered in our system

298,650 Total ambulatory visits in FY13

Challenges Faced Today

Poor access to primary and specialty care

Shortage of physicians, esp. PCPs

Long wait times for an appointment

Schedules backlogged

Wait lists are common

Increased readmissions and ED visits

Physician and patient dissatisfaction

My Journey…

What is a Shared Medical Appointment?

90 minute appointment

Provider conducting individual visits in a group setting

Patients sign a confidentiality waiver at every visit

Consultations, Followups (SMA) & Physical Exams (PSMA)

Homogeneous & Heterogeneous groups

Leverages provider’s time via multidisciplinary team effort:

Nurse or MA



What Happens


a Shared Medical


Receive ongoing support for chronic health conditions

Change of renew prescriptions

Order tests or procedures and receive test results

Discuss medications, treatment and surgery options

In certain SMAs, receive medical exams privately when


Anything you would normally do in an individual office visit

can be done in a shared medical appointment

Implementation Plan

Introduce and discuss the SMA concept to the physician and

executive bodies

Develop infrastructure of the program – involving Billing,

Coding, IT, Compliance, Marketing in the development

Creation of space

Determine who has challenges around access

Meet with the individual physician/team to design the program


Implementation Plan (continued)

Observe SMA

Develop Confidentiality Waiver

Train the Behaviorist, Documenter, MA and scheduling staff

Develop scripting for the physician and staff

Develop a Marketing campaign to promote SMAs

Patient Satisfaction Survey

Conduct a “MOCK” session with staff as patients

Meet regularly to discuss adjustments, changes, concerns,


Intake Room

Confidentiality Waiver

Consent Form and Confidentiality Agreement for

Shared Medical Appointments

• Patient Name ______________________________ DOB # _____________________

• Shared Medical Appointments (SMAs) are medical appointments with your doctor that occur in a supportive group setting with other patients and their family members or support persons.

• A multidisciplinary team will also be present in your care experience today – a team that may include nurses, a psychologist or social worker, a documenter and possibly other staff. Your participation in today’s SMA is voluntary; and it is simply meant to provide you with an additional healthcare choice. You can always make a private appointment with your doctor, even after attending a SMA.

• Because your care will be delivered in a group session, your doctor and his/her team will discuss your personal health information with you and other members of the group. You will hear about other participants’ health issues and personal information. As a matter of trust, it is your duty to keep everything you hear confidential. If you violate this confidentiality obligation, you will not be permitted to participate in SMAs in the future. Nothing that identifies a participant in any way (including job, ethnicity, religion, diagnosis, etc.) can be shared outside this group setting. However, you are welcome to take anything you learn of a general nature that is helpful to you in your own health care management and share it with your loved ones, as long as you do not reveal identifying information about others when doing so.

• On occasion, there may be other health care professionals present to observe the SMA for educational purposes. These individuals will be identified to the group and each has agreed to keep the medical information from the group confidential. If you have questions or concerns about the observers, please let a SMA staff member know prior to the beginning of the appointment.

• By signing this Consent Form and Confidentiality Agreement for Shared Medical Appointments, you:

• (1) agree to voluntarily participate in today’s SMA;

• (2) consent to the release of your personal health information in the group setting today;

• (3) agree to respect the confidentiality of the participants of the group by not revealing their medical, personal or other identifying information about them after this visit is over; and

• (4) agree to the presence of health care professionals as observers.

• • • Patient Signature: _________________________ • • Date:_____________________ • •

• Signature of Support Person/Family Member (if any) accompanying Patient: _______________________

• Date: _____________________

• •





148 117 9 0 20 40 60 80 100 120 140 160 Days


SMA Access - Office Visit Improvement



Patient Satisfaction Survey Results




Yes No Not Sure

Prefer SDA appointment

100 0 0

Would schedule SDA in future




Would recommend SDA to 100



family and friends

Responses from SDA Survey

“A useful educational tool!” (referencing SDA’s specifically)

“Excellent- learned so much!”

“Learned how to manage similar problems that others had.”

“Getting different ideas from others.”

“Convenient time & like being able to bring my husband in to

hear it too.”

“I like hearing other ideas, concerns and suggestions so I can


“I enjoyed the sharing and the support provided by others.”

“I don’t feel so alone in managing my diabetes anymore.”

Patient Benefits

•Greater access to their provider •Learn more and ask questions

•Share knowledge and experiences with patients who may be dealing with the same issue.

•Gain confidence in their ability to self manage their own health issue.

•Same copay applies (if one applies to office visit) •Insurance coverage for visit

•Allows for positive role modeling among their peers •More time with their provider

•Repetitive advice •Relaxed environment


Innovative Solutions

•Enhanced Electronic Medical Record System

•Patient Portal – “Patient Gateway”

•Lean Culture – “Virginia Mason”

•Clinical Redesign

•Patient Keeper Charge Capture System

•Enhance Patient Experience


•Coding Webinars

•Behavioral Health

•Nurse Care Managers hired

•Same Day Access

Keys to Success

Leadership and physician buy-in

Administrative and Provider Champions

Encourage all staff involvement

Recruitment of patients

Robust marketing campaign

Provide adequate training to clinicians and staff

Provide adequate space

Maintaining census levels

Solving operational issues immediately.

Get documentation support


Leadership and physician buy-in

Administrative SMA Champion Physician SMA Champion Recruiting patients Marketing campaign

Provide adequate training to physicians and staff Provide adequate space Maintaining census levels Solve operational problems as they arise

Shared Dietetic


A New Treatment Model

Diane Dube, M.Ed., RDN, LDN,CDE

October 20, 2013


Diane Dube, M.Ed., RDN, LDN, CDE

• Board Member/Advisory Panel

– None

• Consultant

– None

• Employee

– Partners Healthcare, Boston MA

• Research Support – None • Speaker’s Bureau – None • Stock/Shareholder – None. • Other – None


At the end of this session, the participant will be able to:

•Learn how Shared Dietetic Appointments are structured and identify appropriate billing codes. Learning Needs Code 1130

•Utilize this treatment model to facilitate improved patient outcomes (weight management, BG/A1c, Creatinine, BUN & eGFR). Learning Needs Code 5390

•Learn how Shared Dietetic Appointments maximize RDN efforts, seeing multiple patients effectively in one treatment setting.


What is a “Shared Dietetic Appointment”?

•Hybridization of an individual appointment, an educationsession,

and a support group

•Comprised of an RDN, scribe/documenter, and patient services representative (to check patients in, verify coverage & collect copays)

•Limited to 4-8 patients who share a specific disease-state

•Ideally suited to follow-up visits for well-known patients

•RDN spends 15 minutes with each participant

•Scribe records interaction in patient’s EMR

•Individual considerations are discussed as well as concerns that may be shared by others in the group

A “Shared Dietetic Appointment” is led by a Registered Dietitian,

which is different than a typical “Shared Medical Appointment” which is led by a physician or a NP/PA.

Dietitians may be involved within a shared medical appointment as a behaviorist, educator or facilitator. Other health care providers are usually present at shared medical appointments (nurses, MA’s, PTs, psychologist, etc.). In this setting, RDs may not play a primary role in the shared appointment.

RDs may do group visits & education and title them as a shared appt, but the model I am presenting today is an individualized MNT appt. in a group setting.

Why Shared Dietetic Appointments?

•The model of a Shared Appointment lends itself to dietetics well:

Minimizes RD reiteration

–Offers patients a longer visit for the same cost/co-pay

–Setting is more relaxed

–Inherent support in a group setting

–Convenient times for patients (both day & evening sessions)

–Family members, support person welcome to attend & be involved in the session

–More education provided in longer session vs. a traditional MNT follow-up visit

How this all got started:

•Began working as behaviorist 2 years ago for Shared Medical Appointments with Dr. Shant Parseghian, endocrinologist

Then I opened my big mouth:

•Spoke with Evelina Sands, Administrative Director of Operations at North Shore Physicians Group about possibility of doing “Shared Dietetic Appointments”

•Researched if anyone else within Partners Healthcare doing these: No

•Did a literature search on “Shared Dietetic Appointments” with 1 citation found: Journal of the American Dietetic Association, Volume 111, Issue 3, page 340, March 2011 entitled “The Group Appointment Trend Gains Traction: How Dietetics Fits into a New Model of Health Care Delivery”

by Karen Stein, MFA

•Spoke with Kathryn Moskal AT-C, who is doing PhD dissertation on Shared Medical Appointments for lifestyle change. Her international literature search showed NO citations for Shared Dietetic Appointments

Billing & Compliance: First Step

•Began discussing with Compliance & Legal Depts how to bill for Shared Dietetic Appointments. Cannot be termed “Shared Medical Appointments” as we do not provide medical care.

•Initial confusion as to use of proper CPT MNT codes. Coders thought this was a nutrition group & wanted us to use 97804 MNT Group Code

•Explained that this was a series of individual visits, 15 minutes in length, with 4-8 patients in a room together, but is not designed as a group meeting per se


In a Shared Dietetic Appointment:

Each participant receives a 15 minute individualized MNT follow-up visit, addressing their own concerns & sharing their successes. These are timed to exactly 15 minutes of face-to-face intervention. The participant may leave after their 15 minute session has concluded

but are encouraged to stay for the full 1.5 hour session. Compliance & Legal Dept agreed this met the terms for a 97803

follow-up visit, 15 minutes for 1 unit of MNT: GREEN LIGHT given to start Shared Dietetic Appointments

Laying the Groundwork:


Initiated discussion with prospective appropriate patients Provider meetings with MDs/NPs to apprise them of SDA’s Meeting with Administration (President, VP, Executive Director) Meeting with Marketing & PR for print/web/social media advertising Listing in Provider Resource Directory


Meeting with IT to set up specific template in EMR


Decision to start with evening SDA (5:30 - 7 pm) Addition of daytime SDA for retirees in the fall/winter

Decision to make SDA’s disease-specific & limited to follow-up visits

Selecting the Participants: the Ideal

Shared Dietetic Appointment attendee

•Met the criteria for having a specific disease state (DM, CKD, IBS, etc.)

that the Shared Dietetic Appointment will be focused on

•Already established as a dietetic patient within my practice at NSPG

•Has insurance coverage for MNT

•Exhibits appropriate behavioral characteristics for a group setting

•Willingness to participate.

Participation in Shared Dietetic Appointment offered to patient as option (could select either group setting or traditional one-to-one office setting for MNT). They are free to switch modalities at any time.

Support Staff Set-Up:

•Patient Services Representative to check participants in, sign consent to bill insurer, collect copayment (if one applies to visit)

•Scribe/Documenter: Ideally a Medical Assistant (knowledge of medical terminology a plus)

Allow Scribe to observe traditional dietetic appt. Review how to use Nutrition Template in EMR Allow Scribe to practice documenting in EMR while RDN is conducting traditional dietetic appt. Scribe also pre-loads participant note in EMR prior to Shared Dietetic Appointment

Additional Support Staff Options:

•Licensed Independent Clinical Social Worker: to function as a behaviorist between “appointments” while RD is completing the MNT note in the patient’s medical record with the scribe/documenter. LICSW can lead a short group discussion regarding any issues that may have arisen in the group, including but not limited to: Compliance Issues (with diet, meds, exercise) Feelings of Diabetic Burnout/Diabetic Denial Depression & Over/Undereating

Athletic Trainer-Certified: to lead gentle exercise session & discuss benefits of exercise in chronic disease & weight management

Insurance Considerations

Ensure with patient’s insurance that MNT is covered benefit •Be aware of any limitation re: # of visits allowed per insurer •Avoid “incident to” billing as patient’s PCP is not on site when care is rendered. SDA’s are held at a central location (Mass General Hospital Center for Outpatient Care). Patients are drawn from a 17-site multi- specialty practice with locations in 8 cities/towns.

Visit is billed to insurance with RD as rendering provider using RD’s NPI number. RD is contracted provider with pt.’s insurer.

•Make sure 15 minutes of session are spent with each participant to meet insurance criteria of 1 unit of face-to-face care


Flow of a Shared Dietetic Appointment:

•Participants arrive at Center for Outpatient Care; are checked in by Pt.

Services Rep, insurances verified & copays collected, given superbill

•Once in the Shared Appointment room, RDN greets participants & discusses how the session will proceed:

1. welcome all to the session

2. review confidentiality statement & have both participant and support person sign & date

3. explain that each person will be seen for 15 min individually 4. ask if anyone needs to leave early (if so, see them first) 5. explain where comfort items are: snacks, water, bathroom 5. introduce scribe & explain role

How Our Shared Dietetic Appointments


•Each participant is “seen” individually for 15 minutes

•Medical record is open & last MNT note briefly reviewed

•Any change in meds/labs discussed

•BG & food logs that participant brings are reviewed

•Questions from participant & support person answered

•New goals/recommendations given (if necessary)

•At conclusion of 15 minute individual session, 3-4 min educational video is shown or LICSW takes over the group for 3-4 minutes of discussion

•During this time, RDN is completing progress note in EMR & sending bill electronically

Using the Nutrition Care Process in a

Shared Dietetic Appointment

•Template in EMR set up using the ADIME documenting style with standardized language & terminology

•Separate Sections on: Nutrition Assessment (including food/nutrition related history, anthropometric measurements, biochemical data, nutrition-focused findings and client’s personal medical, family & social history Nutrition Diagnosis: PESS statement

Nutrition Intervention: Choice of a nutrition intervention strategy (typically nutrition education and/or nutrition counseling would be pertinent to a Shared Dietetic Appointment)

Nutrition Monitoring & Evaluation: Outcome-based; looking for changes in food & nutrient intake, physical activity, nutrition QOL, weight & BMI changes, improvements in BGs/A1c, renal labs

Template in EMR: Visit Information


Nutrition Assessment: Social History

Nutrition Assessment: SBGM (for DM)

Other pertinent labs (cholesterol, A1c, renal labs, etc. ) are imported from patient’s medical record & documented in this area. Home BG monitoring logs may also be scanned into record.

Nutrition Assessment: Exercise

Nutrition Assessment: 24 hour Diet Recall

Food Frequency Questionnaires & Food Logs/Diet Analyses may be scanned into record & included here.


As Evidenced By

Nutrition Intervention

Nutrition Intervention

Nutrition Intervention: Teaching Needs

Nutrition Intervention: Materials Reviewed

Nutrition Monitoring & Evaluation

If follow-up visit, changes in nutrient intake, anthropometrics (weight), biochemical data & nutrition-focused physical findings are recorded here. Future goals are also recorded here.


Time Spent:

Return to Clinic


Dedicated Shared Appointment Room:


Vitals Board

Flat Screen with Internet Access & EMR

At End of Shared Dietetic Appointment:

•Short discussion session re: any lingering questions or concerns

•Follow-up appointments made (if necessary), either a traditional office visit or participation at another Shared Dietetic Appointment

•Appointments made with other providers if necessary (endocrinologist, PCP, behavioral health)

•Completion of Participant Survey

Benefits of Shared Dietetic Appts. for


•Much less time pressure

•Minimal reiteration

•Increased Productivity

•Ease of documentation (with assistance of scribe)

•Opportunity to provide more in-depth education vs. a traditional visit

•Opportunity to work with another clinician in session (LICSW, AT-C, etc.)


•Learn how Shared Dietetic Appointments can be utilized in a dietetic practice to improve patient outcomes & increase RDN productivity

•Learn how to set up Shared Dietetic Appointments in a medical or dietetic practice, including recruiting participants & marketing, insurance & billing, setting up EMR templates and room design

•Learn how to use the Nutrition Care Process when doing Shared Dietetic Appointments

Future Applications of a Shared Dietetic


1. In Patient Centered Medical Homes 2. Ideally suited for Outcome-Based Research

3. Alliance with other health care professionals who are not typically present at traditional dietetic appointments, such as a LICSW, AT-C, NP/PAs etc. to assist with patient education within the Shared Dietetic Appointment framework


Contact Information:

Diane Dube, M.Ed,. RDN, LDN, CDE

North Shore Physicians Group OR Diane R Dube, LLC 331 Highland Avenue 10 Centennial Drive Salem, MA 01970 c/o PHCA Peabody, MA 01960 Mobile: 617-240-6383 Fax: 978-745-7982






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