Group Visits

1
Group Visits

• Is it time to join the group?
• Annette Gagnon BSN
• Bob Lyon MD

2
Goals

• To explain the advantages of group visits for
  disease management
• To describe how to effectively run a group visit
• To give you the practical tools to easily
  initiate group visits in your practice

3
New model of care for chronic illnesses

• Elimination of barriers to access
• Team approach to care
• Patient centered care
• Whole person orientation
• Care provided within a community context
• Enhanced practice finance

4
Examples of Group Visits

• Diabetes
• Heart failure/CAD
• Depression
• Asthma
• Obesity
• Life style modification/behavior change
• Prenatal
• Advanced directives
• Sports physicals

5
Advantages of Group Visits

• Makes efficient use of medical resources
• Improves access
• Helps motivate behavioral change
• Provides a diversion from the routine grind of
  patient care- its fun!
• Provides outcome benefits
• High patient satisfaction
• Staff satisfaction

6
Outcome Data

• 30 decrease in emergency department use
• 20 decrease in hospital use / re-admissions
• Delayed entry into nursing facilities
• Decreased visits to sub-specialists
• Increased total visits to primary care
• Decreased same day visits to primary care
• Increased calls to nurses
• Fewer calls to physicians
• Increased patient overall satisfaction with care
• Increased physician satisfaction with care
• Decreased cost PMPM by 14.79
• DM group showed 32 reduction LDL, and 30
  decrease in HgA1c

7
Group size

• Ideally 8-12 patients
• Consider your no-show rate when scheduling
• May include additional family members

8
Visit Frequency

• Variable depending on your goal
• Educational topics Yearly
• OB each trimester
• DM - Monthly

9
Visit Time

• Approximately 1 ½ - 2 hours

10
Patient Selection

• Only 30-50 of patients will be interested in
  group format
• Utilization data- visits, prescription usage
• Disease registries and base decision on control
• Diversify age, gender, control
• Patient specific Will they be a benefit to the
  group dynamics?

11
What do you need?

• Provider
• Nursing support
• Behaviorist (dedicated RN, dietitian,
  psychologist) is helpful but not essential.

12
Invitations

• Physician Best but time consuming
• Provider list-Phone contact for initial
  explanation
• Letter General mailing
• Purpose of meeting
• Office visit - Usual co-pays apply
• Spouses/Family encouraged and free
• Reassure patients who choose not to come

13
Planning

• Accommodations
• Name Tags
• Refreshments
• Education table
• Flip chart

14
Visit Prep

• Reminder call 1-3 days prior to visit
• Review old records
• Is HgA1c, lipids, microalbumin, pneumovax, etc.,
  needed?
• Prescription refills, shots or lab forms can be
  ready before the visit.
• Have DM progress cards filled out in advance
• Determine staffing needs
• Consider serving a sample of a healthy recipe

15
Sample Template

• 145- 215 - patient check-in and MD visits
  (group is meeting with RN or RD or at education
  table while 1 on 1 MD visit occurs)
• 215 220 Introduction
• 220 245 - Review action plans from prior
  meeting
• 245- 300 Education topic
• 300 Hand out healthy snack
• 300 330 Discussion and goal setting/action
  plans based on education topic or other ideas.
  Summarize meeting and plan for next month.
• 330 345 Staff debriefing and finish billing

16
Education topics

• HgA1c
• Hypertension
• Lipids
• Microalbumin
• Foot care
• Nutrition

• Exercise
• Behavioral modification
• Depression
• Tobacco cessation
• Stress/anxiety

17
Other Ideas

• Cooking demonstration
• Pot luck of healthy snacks
• Field trip to grocery store
• Session on reading labels
• Reviewing restaurant menus

18
And so you begin

• Welcome and note significance of attending
• Purpose of group visit it will help you to
  manage your health when you have diabetes
• What we know about group visits
• Some will like it others wont
• Confidentiality
• Learn from each others struggles/successes but no
  obligation to talk

19
Group Visit Norms

• We will
• Encourage everyone to participate
• State opinions openly and honestly
• Ask questions if we dont understand
• Treat one another with respect and kindness
• Listen carefully to others
• Respect information shared in confidence
• Try to attend meetings
• Be prompt so meetings can start on time

20
Managing Group Dynamics

• The group will probably self manage the dynamics
• Typical challenges someone talking to much,
  promoting myths,
• Initially be prepared with guiding questions to
  get the group talking

21
Your Role

• Is NOT to create solutions
• Listen (and learn)
• Facilitate- group interaction is powerful- let
  the group answer questions
• Encourage reflection- here is a day when all of
  your blood sugars are less then 200. Can you tell
  us how you were able to do this?
• Be non judgmental- do not assign a moral value
  to choices pts make in managing diabetes. No
  good or bad choices- some choices may make it
  more difficult to achieve goals.

22
We are more experienced at facilitating non
compliance.

• Our goals vs. their goals
• We tell the patient what we expect them to do
  between now and the next visit
• But we do not ask what is important to them or
  what might prevent them from accomplishing a
  particular task or goal

23
Self Management

• The ability of the patient to deal with all that
  a chronic illness entails
• - symptoms
• - treatment
• - physical and social consequences
• - lifestyle changes

24
Self Management

• Patient self management is inevitable and already
  occurring
• We are experts about diseases, patients are
  experts about their own lives
• Clinical outcomes are dependent on how patients
  manage the components of care

25
Self Management

• Assumes confidence better outcomes
• Goal is to increase pts belief in his ability to
  accomplish a specific behavior or reduction in
  symptoms
• Provide pts with the opportunity to obtain simple
  evidenced based health information
• Acknowledge that knowledge alone does not create
  behavior change

26
Self Management

• Assist to identify skills that could solve the
  problem.
• Skills are generalizable if it worked for
  something else could it work for this?
• Group members will help each other with this

27
Action Plans

• Tool kit
• MY ACTION PLAN
• Date __________________
• I ______________________________ and
  _____________________________
• (name) (name of clinician)
• 1. Choose one of the activities below
• Have agreed, that to improve my health I will
• 1. Choose one of the activities below
• _____ Work on something thats bothering me
• _____ Stay more physically active!
• _____ Take my medications.
• _____ Improve my food choices.
• _____ Reduce my stress.
• _____ Cut down on smoking.
• _____ Other
• 2. Choose your confidence level
• This is how sure I am that I will be able to do
  my action plan
• _____1____________________________5______________
  __________10__
• Not sure Somewhat sure Very
  sure

28
Basics of a Successful Action Plan

• Something the PATIENT wants to do
• Reasonable to accomplish
• Behavior specific (losing weight is not a
  behavior, not eating in front of the TV is)
• Answer the questions What?, How much?, When?
• Maine Medical Center

29
Anticipate Barriers

• Ask what would prevent them from accomplishing
  the goal
• Help to brain storm possible solutions
• They should chose a couple they could try if
  necessary.
• Brain storm what support might be available
  (friends, family professionals, group)

30
Stages of Change Model

• Use as a frame work of understanding in and for
  the group
• Change is a process of identifiable stages
• Relapse at any point in the process should be
  normalized
• Physician (group) can influence by taking
  specific actions

31
Stages of Change

• Pre contemplative - Not thinking about change
• Contemplative- Weighing the benefit vs. cost of
  behavior change
• Preparation-experimenting with small changes
• Relapse feel guilty possibly demoralized
• Action- choose behavior to change
• Maintenance how to maintain behavior over time

32
The Model
33
After Meeting

• Complete progress notes
• Review dynamics of meeting- lessons learned
• May be an opportunity for labs, immunizations
• Plan the after care for the patients
• Ideas for next meeting

34
Finances

• Need to weigh finances vs. purpose of visit
• 2 hour group visitgt8 patients minimum
• Need to consider costs of devoted staff to group
• Need to consider costs of consumables

35
Documentation and Coding

• No specific CPT codes for group visits
• Code according to E/M criteria that are met
  (99212-99214)
• Only need vital signs and history/complexity
  requirements for 99213 or 99214
• Cannot charge for group visit and another
  physician visit the same day
• Collect appropriate co-pay
• G0271 Medical nutrition therapy (30 minutes)

36
99213

• Chief complaint
• 1-3 questions about their diabetes
• 1 ROS question (weight changes, chest pain)
• Vital signs
• Assessment- Controlled or uncontrolled DM
• Plan that deals with DM (med changes, diet
  ,exercise, labs, referrals)

37
99214

• 4 questions related to DM
• 2 ROS questions
• 1 question about PM hx or Soc hx (tobacco, ETOH,
  surgeries)
• Vital signs
• Assessment of uncontrolled DM, HTN, lipids, or
  complications of DM
• Plan needs to satisfy the moderate complexity
  requirement.

38
Summary

• Proven beneficial outcome for patients.
• Positive response from physicians and staff.
• Can get adequately reimbursed for your services

39
Getting started CD

• Time-line/planning
• Invitation letters
• Confidentiality and HIPPA forms
• Sample agendas
• Sample progress notes

• Discussion questions
• Education topics
• Action plans
• Patient satisfaction survey
• Billing information

40
References

• Coleman EA, Eilertsen TB, Kramer AM, Magid DJ,
  Beck A, Conner D. Reducing emergency visits in
  older adults with chronic illness a randomized
  controlled trial of group visits. Effective
  Clinical Practice 20014(2)49-57.
• McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A
  population-based approach to diabetes management
  in a primary care setting early results and
  lessons learned. Effective Clinical Practice
  19981(1)12-22.
• The Robert Wood Johnson Foundation. Improving
  Chronic Illness Care Program Group Visit Starter
  Kit. http//www.improvingchroniccare.org/improveme
  nt/docs/startkit.doc Accessed 4 March 2004.
• Trento MB, Passera P, Tomalino M, Bajardi MB,
  Pomero F, Allione A, et al. Group visits improve
  metabolic control in type 2 diabetes a 2 year
  follow-up. Diabetes Care 200124(6)995-1000.
• Wagner EH, Grothaus LC, Sandhu N, Galvin MS,
  McGregor M, Artz K, et al. Chronic care clinics
  for diabetes in primary care a system-wide
  randomized trial. Diabetes Care
  200124(4)695-700.
• http//www.improvingchroniccare.org/downloads/grou
  p_visit_starter_kit_copy1.doc