Group Clinics

1
Group Clinics

• Paul A. Heineken, M.D.
• ACOSAC, SFVAMC
• Clinical Professor, UCSF

2
Goals

• Be clear about your goals and potential conflicts
  between goals
• Medical outcome
• Patient satisfaction
• Value medical outcome / cost
• (also called efficiency)

3
Medical Outcome How can group visits bring
improvement?

• Self-care
• Improved quality indicators
• EPRP prevention and practice guideline compliance
• Disease specific outcomes
• Diabetes A1C levels
• CHF fewer hospitalizations
• Chronic geriatric care fewer complications

4
SFVAMC Primary Care Groups

• Diabetes self-care
• Diet, home glucose monitoring, insulin/medication
  teaching, foot care
• Advanced directive education
• Bereavement support
• Dementia caregiver support
• Medi-Cal planning

5
Patient SatisfactionThree examples

• Kaiser model, single providers panel identified
  high users
• Ongoing groups, 10-15 pts, visit shared with RN,
  pharmacist, guests
• Vitals, short individual attention by health
  professional, group teaching
• Outcomes high patient satisfaction, fewer
  individual visits

6
Group Health Cooperative of Puget SoundColeman
et.al. JAGS 47775-783, 1999

• Chronic Care Clinic for frail elderly
• Patient satisfaction improved
• No other outcome measures did
• incontinence, falls, depression scores,
  hospitalizations, hospital days, ER visits, AC
  visits, medication costs, and total cost of care
  unchanged

7
SFVAMC High User ClinicEzekiel and Jain,
submitted 2002

• Frequent ER/Urgent Care visitors generally arent
  satisfied
• Identified high ER/Urgent Care, 5 visits in 9
  months
• Patients recruited from multiple providers
• Invited patients by mail or phone call, group
  would help their overall care
• Scheduled group sessions for 9 months
• Post-intervention use of ER/Urgent Care

8
Intervention

• Monthly group visits
• 9 patients expected in each
• Average attendance 50
• Opened by doctor and blessed
• 1.5 hours total with a facilitator--RN or social
  worker, and a guest--pharmacist, nutritionist,
  podiatrist, etc.
• Topics medication use, flu shots, advanced
  directives, healthy diet, foot care, etc.

9
High Users Urgent/ER visits 9 months before and
after intervention9 months of monthly group
visits
10
Medical Practice Orientation Clinic (MPOR)

• Observations
• New PC patients had high no-show rate
• new slots were unavailable while no-shows
  wasted valuable slots
• Goal 1 Improve value, through better access for
  new patients, and improved clinic efficiency
• Dont waste valuable slots on no-shows

11
Medical Practice Orientation Clinic, continued

• Observations
• VHA screening and prevention requirements (not
  guidelines) mushroomed
• Centralized electronic documentation required
• Goal 2
• Nurses complete most required screening and
  documentation
• Allow primary providers to concentrate on high
  yield interventions at their visit

12
Long before ACA

• SFVAMC required an orientation visit for each
  non-urgent new primary care referral
• Staffed by an RN
• Patient sent letter in advance explaining purpose
  of visit
• Medical questionnaire, including health
  maintenance, medication, and immunization history
  completed
• Nutrition, (MST, and Hep C risk) screens
  completed

13
Visit content

• Check-in, including Means Test if required
• Vitals
• One-on-one review of health questionnaire with
  RN, for completeness and positive screening
  results
• Immunizations provided by RN or LVN under
  standing orders
• Obvious triage (anticoagulation, derm, etc.)

14
Group Teaching

• Clinic procedures
• Appointments, urgent needs, contacting provider,
  telephone care
• Pharmacy, co-managed care
• Outside medical records
• Co-payments
• Advanced directives education

15
Prevention ActivityTemplated note entered by RN

• Risk factor identification tobacco, alcohol,
  nutrition, exercise, depression, MST, Hepatitis C
• Behavioral counseling diet, exercise, tobacco
  use
• Prostate cancer screening information

16
Prevention Effectiveness

• Screening activity only, realistically one group
  visit wont change behavior
• Group visits, and counseling about multiple
  behavioral changes at one time are NOT the
  procedures used in the evidence upon which VA
  prevention recommendations are based
• At best, MPOR identifies some veterans who are
  ready for a changewhen they visit their provider
  or specialist, e.g. nutritionist
• At worst, it is a documentation exercise for EPRP

17
Advanced Directive CompletionDipko, Xavier,
Kohlwes, submitted for publication
18
MP Orientation Clinic Outcome measure success

• No show rates YES!
• dropped from 45 to 18, between MPOR and first
  provider visit. Jain and Chou, J Gen Int Med
  200015878-880
• EPRP scores YES!
• Patient satisfaction yes and no
• 82 satisfied, some resented not seeing a
  provider and making an extra trip, especially
  from distance
• Nutrition screen f/u yes

19
Nutrition Screen F/u GroupSept 01-Mar 03Ceresa
and Arnold, SFVAMC, 2003
20
What About the MPOR No-shows?

• Population Urban, high prevalence of substance
  abuse and homelessness
• Required scheduled primary care wastes slots on
  habitual no-show patients
• Episodic primary care accessibility is
  essential
• ACA model may work, if patients are assigned to
  primary care teams after failing MPOR and
  episodic primary care is made acceptable

21
Group Clinics Problems

• Competing goals--efficiency vs. outcome vs.
  patient satisfaction
• Recruiting patients from multiple providers
• MPOR easier to fill than high-user groups
• Behavior change groups have high no-show rate
• Multiple personalities may not mix
• Confidentiality (what seems appropriate for one,
  may not be comfortable for all)

22
Group Clinics Conclusions

• Set goals
• Assign a leader team
• Plan duration and outcome measures
• Realistic expectations
• Re-evaluate