Developing a model of health assessment and education in primary-care based Shared Medical Appointments (SMAs) at the Durham VA

Project Summary

Personalized Health Planning in Shared Medical Appointments (PHP SMA) is one of three clinical pathways for personalized health care at the Durham VA Medical Center (DURVAMC) and Community Based Outpatient Centers (CBOCs) that was funded by the 2016-2018 Whole Health Design Site grant. In groups of up to twelve Veterans, participants engage in facilitated instruction of various wellness topics in an eight-session curriculum over the course of four months. Topics include mental, physical, and emotional well-being. A formal mindfulness meditation practice is conducted at each session. Participants are recruited based on a pre-diabetic a1c reading between 5.7 and 6.4. Participants complete a Personal Health Inventory (PHI) at Session 1 and at Session 2, patients then synthesize their priorities and goals with the provider’s health assessment to create shared SMART goals in a Personal Health Plan (PHP).  Patients receive a 1:1 with the provider at each subsequent session to follow up on SMART goals and action steps. At the conclusion of the program, Veteran participants will have taken steps toward establishing effective health self-management strategies that improve patient outcomes and experience through a unique model that synergizes personalized health care and peer support.


  • Evaluate Veteran participants’ current health status and conduct Health Risk Assessment (HRA)
  • Determine what is important to the patient and what the individual’s health goals are through a health self-assessment
  • Develop therapeutic goals based upon the current health status and HRA along with other input from the patient to create a treatment plan;
  • Synthesize the provider’s treatment plan with the priorities of the patient to create actionable shared goals
  • Provide comprehensive health promotion education coupled with peer support and mindfulness meditation instruction.
  • Track goal progress through a system of behavioral support, care coordination, and accountability for the patient to maintain between sessions
  • Provide Veterans the opportunity to partake in a peer support and accountability environment

Contribution to Practice

  • Examine the feasibility of implementing evidence-based personal health planning in the context of a Shared Medical Appointment for Veterans in a primary care-based setting
  • Collect preliminary efficacy data on this specific approach to Shared Medical Appointments in a primary care-based setting
  • Evaluate the value of a wellness based curriculum in a Personalized Health Planning Shared Medical Appointment


Meagan Cannady – meagan.cannady@duke.edu