TABLE 3.

Qualitative Codes, Definitions, and Illustrative Quotes About Diabetes Shared Medical Appointments in North Carolina

Qualitative Code	Definition	Illustrative Quote
Satisfaction	Clinicians prefer SMAs to usual care and derive greater satisfaction from SMA care redesign.	“[We] saw it as another way to see a lot of patients and prevent provider burnout, particularly in primary care and family medicine, where the model is seeing a patient every 15 minutes.”
	This includes SMAs reducing provider burnout.
		“The theory is that it could help take complicated patients from providers who were frustrated. We were not able to scale it up enough to test the third theory about provider satisfaction.”
Perceived Advantage	SMAs have perceived advantages for chronic care delivery to support self-management, more time with patients, improved outcomes, improved access, or other positive characteristics that make SMAs preferable to usual care for improving outcomes.	“Our goal is: enable people to take care of their diabetes themselves. Some people find it easier if they have a weekly meeting to remind them of all of the diabetes habits and skills that are necessary. It’s a little bit like Weight Watchers in that way. A lot of what we do is lifestyle coaching, reminding people of the importance of setting goals.”
		“They like having the extra time with the health care team.”
Self-management Support	SMAs are described as a strategy for improving health behaviors and patient education related to health self-management such as diet, exercise, medication adherence, and stress reduction.	“1 think it’s those guys who [are] just told that they are diabetic or that they are prediabetic and need to make change. Targeting those with a new diagnosis or [who] want to prevent the development of diabetes. This is about [a] more general education resource.”
Peer Support	SMAs enable social or peer support to improve outcomes and accountability.	“[SMAs are a] good way to connect patients to support each other.”
		“We don’t know what types of personalities are drawn to this; anecdotally we found that people that are more drawn to peer support and engaged tended to participate. We don’t have any data to support this.”
Access	SMAs have greater capacity and therefore increase patient access to treatment and care.	“1 was part of the team that recognized the need. The main need we saw was that patients didn’t have access to healthy food and there was a lot of food insecurity”
		“Efficiency as well; no-show rates were high in the low-income population we were trying to reach and serve. Patients were being shuttled to nutrition one day, provider another day, so this was an attempt to integrate those services all into one visit. This could also help us offset the expense of a no-show rate; more efficient for provider, educator, and patient.”
Leadership Support	When the respondent indicates leadership support for delivering SMAs from the health system or clinic level.	“Our leadership is very supportive of SMAs. Our medical director has even sat in to observe. When we’ve needed additional administrative support, she’s been a good advocate. And scheduling the assigned resident can be a bit of a nightmare, and the leadership has continued to view SMAs as a priority. We also have dedicated staff to do personal reminder calls…We have found that reminder calls can make or break a group!”
Team-based Care	SMAs are associated with team-based care.	“On the diabetes side we decided to implement them to help train our physicians better on diabetes and function as an interdisciplinary team.”
		“Julienne is a CDE and pharmacist. Med students are allowed to sit in but not part of care team. Behavioral health specialist (psychologist) does the mind-body spiritual session. RD for nutrition session.”
Efficiency	SMAs are associated with efficiency and improving access or patient volume.	“We felt the clinic was inefficient and diabetes outcomes weren’t great. We cared about the efficiency and also there is so much really basic education going on, so we felt it would save some redundancy. Gain some economy of scale as doing it as a group. A lot of patients struggling with basic diabetes education and self-management and this would be a good way to address this.”
Recruitment	Describes processes, workflows, or strategies for recruiting and referring patients into SMAs.	“It’s been discussed at the monthly clinic-wide meetings. Once the schedule is built, 1 let all the providers know how to refer, who to refer. An e-mail is sent to all of the providers. Each pharmacist meets with their PACT team every week—it’s always encouraged for us to tell providers to refer to groups to meet HEDIS measures. The RN case managers have done a great job at taking the lead at finding patients to come to the group. We have a flyer (not put up yet).”
		“We’ve had them going on for so long they’re pretty established. Reiterate them at staff meetings.”
Patient Population	When the patient population of interest for receiving an SMA intervention is described. This could include patient characteristics, knowledge, skills, and abilities of patients that participate or of patients that derive the greatest benefit.	“We tend to target sicker patients to justify an intensive approach like this—patients at very high risk of complications—so for example A1C over 8, high blood pressure, also patients that would do well in a group.”
		“There really isn’t any [eligibility criteria]. They could be diabetes, prediabetic, or advanced diabetes.”
		“Anyone who walks in. We have a surprising number of type 1 diabetics. Anyone who is interested in learning more about diabetes. Some people come in with spouses or family members, some of them don’t have diabetes.”
		“Those who are closest to goal… the self-management things we focus on tend to help them achieve that goal. 1 can move somebody that’s not so far off, as opposed to someone who is far off and there are all kind of barriers. The closer people are to the overall A1C goal, we can move those people, because they’re so close. The further from the goal, less likely to benefit from this approach since it’s focused on lifestyle and behavior.”
		“I’ve found that it’s been helpful for veterans who were diagnosed a long time ago and their sugars are creeping up—so it can be helpful for the people that have fallen off the bandwagon.”
		“1 definitely think the recently diagnosed can benefit the most because they’re overwhelmed and may not know what questions to ask. They don’t have time to ask questions like, “What is diabetes?” Those patients benefit a lot because they learn about what diabetes is and goals. There’s also a lot of time dedicated to nutrition, which is really helpful for them.”
		“It is the people that are prediabetic that have an [A1C test] over 6.5% within three years of their initial diagnosis. They should either be managing with diet and lifestyle or oral medication only. For people on injectable drugs, it’s harder to move the needle. Why? People still have hope. People are motivated nearer to the diagnosis. Less time for complications. Less naive about drug/treatment options, so we have choices that we haven’t tried already.”
		“[We] believe this is beneficial for a wide array of patients. Especially newly diagnosed or for patients experiencing] complications. Even can be good for patients who have lived with diabetes for a long time and sugars are way out of control. Would not consider this type of program appropriate for patients with a cognitive impairment or severe persistent mental illness.”
		“A big part of this is the continuity of relationship (with both providers and other patients) because they are more likely to set goals with each other. Women seem a little bit more comfortable with this format and connecting with strangers and engaging with other people. 1 think people who are struggling are the ones who benefit the most because they come with things they want to talk about. Newly diagnosed is helpful too. The people that are newly diagnosed and not worr[ied] about it are probably not going to come. The important moderator here is personality, how invested people are in it. Female-female relationships seem to form the fastest.”
		“SMAs benefit men in particular; we saw when multiple men were in a group they really thrived the most.”
SMA Delivery or Characteristics	Intervention characteristics and delivery such as educational content, activities, clinical activities, or group discussion that occur during the SMA visit.	“Presentation of educational content, group discussion on educational content, and goal-setting along with the intake and elements of the medical visit. The goal-setting discussion is done during the one-one-one visit with the provider, so that people aren’t just sitting there. People take their own weight and they write down their weight on their sheet. We make them responsible for their numbers. Group time happens after all of the intake and goal-setting, then group discussion and educational portion begins.”
		“We have a ‘dialogue sheet.’ It’s each person’s most recent A1C, cholesterol, blood pressure—and then the definition of ‘goal’ ranges for those values. 1 will look up patients to see meds and [Hemoglobin A1C test results], we make sure to order them if the labs are past due. Have they had a recent eye test? All of those HEDIS measures. And then the nurse calls everyone back, then 1 come in and introduce myself and the visit. 1 start off by asking what the participants’ concerns are related to diabetes. 1 try to identify some of those common concerns that people have—we put those upon the board to make sure we address them. A quick review of what causes diabetes. We go through a very simple description of pancreas, muscles, etc. Then 1 go into the uncontrolled diabetes and the consequences. Then we talk about blood sugar goals, when to check, what numbers should you see. We talk about hypoglycemia and appropriate ways to treat a low blood sugar. Here’s your Hemoglobin A1C value and then how does it relate to your blood sugar levels that you’re measuring each day.”
Workforce Development	The extent to which additional skills, knowledge, and ability of staff and clinicians is required to deliver SMAs.	“Facilitation training is key. 1 received that through CenteringPregnancy training. If you do not understand how to be a facilitator and quiet down the person talking too much or invite quiet people to join the group, or you as a facilitator are talking too much, you need to do a good job engaging the group.”

Note. SMA, Shared Medical Appointment; CDE, Certified Diabetes Educator; HEDIS, Healthcare Effectiveness Data and Information Set; PACT, Patient Aligned Care Team; RN, Registered Nurse; RD, Registered Dietician