Optimising Practice Efficiency to Promote Team Effectiveness

2. Optimising Practice Efficiency to Promote Team Effectiveness

3. DEVELOPED BY: Rob Wedel, MD, CCFP, FCFP Family Physician, Associate Medical Centre, Taber Palliative Care Physician, South Zone, Alberta Health Services Co-Chair, Alberta AIM Chair, Advisory Committee on Primary Care, College of Family Physicians of Canada Board of Directors, Quality Improvement and Innovation Partnership, Ontario  FACULTY: Kenneth Bayly, MD, CCFP, Physician General Practice, Saskatoon District Health, Saskatoon, SK Mel Cescon, MD, MCFP, Family Physician, Kitchener , ON Board Quality Improvement and Innovation Partnership, Ontario Brian Craig, MD, MCFP, Family Physician, St. John, NB Lorraine Tessier, MD, MCFP, Family Physician, Hôpital du Sacré-Coeur de Montréal , Montréal, QC CONTRIBUTOR: Maureen Clement, MD, CCFP, Medical Director, Diabetes Education Centre, Vernon Jubilee Hospital, Vernon , BC This program was supported in part by an Educational Grant from AstraZeneca Canada. Group Patient Visits

4. Disclosures MD Name of Facilitator • Clinic/City Financial Disclosures: • ABC Pharma • XYXZ Pharma RN/Np or other Facilitator • Clinic/City Financial Disclosures: • ABC Pharma • XYXZ Pharma

5. Objectives • After completing this session, attendees will be able to: • Identify clinical gaps to address and outcomes desired within their own practice • Identify the appropriate GPV model • Develop a Clinic Acton Plan to: • Plan a group visit • Conduct a group visit • Evaluate a group visit

6. Clinic Team Members Attend CHE- MD, RN, NP, Admin Staff etc Part 2: Group Patient Visits CHE Program

7. Agenda Group Patient Visits Presentation •  What are Group Patient Visits? •  Step 1: Planning Group Patient Visits •  Step 2: Conducting Group Patient Visits • Step 3: Measure Effectiveness •  Step 4: Refine and Repeat Workshop- Building a Clinic GPV Action Plan • Step 1: Assessing Needs – Clinic and Patients (10 minutes) • Step 2: Creating a Plan of Action • Patient Group Needs (10 minutes) • Identifying YOUR clinic purpose or improvement goals? (5 minutes) • Building your FIRST diabetes or COPD GPV agenda (15 minutes) • How will you determine success? (10 minutes) • Team Roles & Responsibilities in Planning your GPV (10 minutes) Group Discussion and General Feedback • Group Discussion (15 minutes) • Summary and measure effectiveness (10 minutes)

8. Group Patient Visits • Developed in the 1990’s by Drs. John Scott and Ed Noffsinger • Motivated to deliver patient-centered care with improved quality and outcomes despite: • An aging population with complex medical needs1 • Deteriorating access2 • Substantially increased physician workloads2 • Growing patient demands and expectations2 • Rapidly expanding patient panels2 FHT. Guide to Chronic Disease management and Prevention, September 2005. Noffsinger EB. The Permanente Journal. Fall 1999; 3(3): 58-67.

9. What are Group Patient Visits? • An effective means to deliver integrated healthcare • An expanded medical appointment delivering most elements of an individual visit including: • Personal examinations (e.g., collection of vital signs, history taking, physical exam) • Formal and informal education • Social and psychological support Patient Self-mgmt

10. Why Would We Want to Conduct Group Patient Visits? Increased practice effectiveness and efficiency • capacity to care for more chronically ill patients in less time • efficiency as a result of staff working in appropriate roles and assuming appropriate responsibilities • job satisfaction among staff • delivery of quality patient care

11. Why Would We Want to Conduct Group Patient Visits? (cont’d) Better ‘Comprehensive Care Plan’ (CCP) Patient Management • An opportunity to follow your patients with CCPs • Monitor and support patient adherence • Update CCPs as required • Provide necessary education • Demonstrate practice team support for the CCP • Regular scheduled follow-ups • Recognize patient success in following CCP

12. Further Benefits of Group Patient Visits1 General Practice Services Committee (GPSC) Group Patient Visits (www. gpscbc.ca/psp-learning/module-overview/group-medical-visits)

13. What Evidence is There to Support Group Patient Visits?

14. Chronic Care Clinics for Diabetes in Primary Care. A System-wide Randomized Trial. • 35 primary care practices: 14 randomized to conduct GPV; 21 maintained usual care clinics1 • Patients in each group were similar 1 • Data collection at baseline, 12 and 24 months1 • Patients that participated in GPV were more likely to have: • Received preventive procedures (P=0.02)1 • Undergone a microalbuminuria test (P=0.04) 1 • Participated in patient education (P<0.05) 1 • Used and found helpful one-on-one counseling (P=0.0001)1 Aim: Assess the impact of Group Patient Visits on diabetic patient care process and outcomes Wagner EH, et al. Diabetes Care 2001;25:695-700

15. Outcomes Corresponded Positively to GPV Attendance Wagner EH, et al. Diabetes Care 2001;25:695-700

16. Shared Medical Appointments Based on the Chronic Care Model: A Quality Improvement Project to Address the Challenges of Patients with Diabetes with High CV Risk. • Primary care clinic1 • High CV risk defined as one or more of the following: • A1c levels >9%1 • Systolic Blood Pressure (SBP) > 160 mm Hg1 • Low Density Lipoprotein cholesterol (LDL-c) >3.53 mmol/L1 • Patient characteristics for each group were similar1 Aim: Improve outcomes for diabetic patients at high cardiovascular risk via Group Patient Visit implementation. Kirsh S, et al. Qual Saf Health Care 2007;16:349-353.

17. Better Cardiovascular Risk Reduction was Observed in Patients Attending GPV’s Kirsh S, et al. Qual Saf Health Care 2007;16:349-353.

18. Better Cardiovascular Risk Reduction was Observed in Patients Attending GPV’s Reductions noted in CV parameters for patients attending GPVs: Patients participating in GPV experienced greater benefits in HbA1c, LDL-c and SBP levels compared to usual care patients. Kirsh S, et al. Qual Saf Health Care 2007;16:349-353.

19. Medical Clinics Versus Usual Care for Patients with Both Diabetes and Hypertension. A Randomized Trial. • 239 patients with poorly controlled hypertension and diabetes were randomized to either GPV’s or usual care1 • Poorly controlled hypertension and diabetes: • Systolic BP >140 mm Hg or Diastolic BP >90 mm Hg, and HbA1c level >7.5%1 • Patients in each group were similar1 • Data collection at baseline, midpoint (~6 mos) and study end (~12 mos)1 Aim: Assess the effectiveness of Group Patient Visits for the management of diabetes and hypertension Edelman D, et al. Ann Int Med 2010;152:689-96.

20. Reductions in SBP and DBP were Associated with GPV Attendance Better Systolic and Diastolic BP measurements seen with diabetic GPV patients may contribute to reduced CV morbidity and mortality. Edelman D, et al. Ann Int Med 2010;152:689-96.

21. Further Benefits Observed with GPV Attendance • Fewer ER visits (p<0.001) • Fewer Primary Care visits (p=0.010) • Enhanced perceived competence for engaging in healthier behaviour (p<0.001) Patients attending GPV benefited from CV risk reduction and an enhanced sense of empowerment. Edelman D, et al. Ann Int Med 2010;152:689-96.

22. Primary Care Practices are the Cornerstone of Effective Chronic Disease Management • Health outcomes are a function of continuity of care by the same family physician1 • Attachment, or the frequency that a patient seeks services from the same medical practice, keeps patients healthier and reduces costs1 • Group Patient Visits may facilitate attachment by enhancing patient access, time with the medical team, and supportive services provided2 Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44. Steering Group Communication. Noffsinger EB. The Permanente Journal 1999 ; 3 (3): 58-67.

23. Increasing Value for Money in the Canadian Healthcare System: New Findings on the Contribution of Primary Care Services Diabetes and CHF – RUB 5 (2007-2008) Cost Reduction Attributable to Attachment Congestive Heart Failure (CHF) Diabetes $ (CDN) $13,250 $16,114 Proportion of Total Cost Attributable to Hospital Costs 65% Percentage of Attachment Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44.

24. Primary Care Practices Are Invaluable for Chronic Disease Management • Individuals with a primary care practitioner that they saw on a regular basis had lower rates of hospital use, specialist use and costs. Attachment to a practice was the best predictor of a patient’s overall healthcare costs – more so than other variables such as patient age, gender, income or physician gender and practice span. Hollander MJ, et al. Healthcare Quarterly 2009;12(4): 32-44.

25. How Do We Implement Group Patient Visits in Our Practice?

26. Implementation Process identify and plan ahead for change, analyze and predict the results PLAN: DO: STUDY: ACT: execute the plan, taking small steps in controlled circumstances check and study the results take action to improve the process The process is flexible…….Engage in continual planning, study and refinements at all stages

27. Model for Improvement • Three Questions • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in improvement? Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

28. The PDSA Cycle for Learning and Improvement PLAN ACT Objective Questions and predictions (why) Plan to carry outthe cycle (who, what, where, when) What changes are to be made? Next cycle? STUDY DO Carry out the plan Document problems and unexpected observations Begin analysis of the data • Complete the • analysis of the data • Compare data to predictions • Summarize what was learned

29. Multiple Cycles to Implement a Change in Diabetes Care Improving Diabetic Foot Exam Rates Foot exam protocol in place within one month of initial test Cycle 5: Implement process for all patients as a clinic protocol Learning Cycle 4: Put foot care stamp in EMR to prompt RPN. Test. All patients received foot exam Cycle 3: RPN rooming patient removes shoes and socks. Test w/5 patients next day. 4 of 5 feet examined. RPN forgot to one patient Cycle 2: Post sign to prompt patients to remove shoes and socks. Test with 5 patients next day. Most patients did not understand. How can practice ensure feet are examined? Cycle 1: Monofilament placed on exam table to prompt provider. Test with 5 patients on one day. No exams done. Provider ran out of time.

30. Implementing Group Patient Visits Step 1: Planning Group Patient Visits (PLAN) • Conduct Needs Assessment to identify gaps and patient groups • Select Group Patient Visit model • Create Plan of Action Step 2: Conducting Group Patient Visits (DO) • Identify specific patients • Organize resources and conduct Group Patient Visits Step 3: Measurement and Evaluation (STUDY) • Evaluate results and make adjustments • Identify methods to sustain change Step 4: Refine and Repeat (ACT) • Plan more Group Patient Visits

31. Planning Group Patient Visits • Know your Practice and Your Patients • Select the Appropriate Group Patient Visit Model • Create an Action Plan

32. Know Your Practice and Your Patients • Does your clinic have a Patient Registry? • A Registry is a very important step in patient management • EMR Systems- registry is populated via data search • Clinical outcomes (eg HbA1C >7%; BP >130/80 etc) • Manual Registries-tracking patients via commercially available spreadsheets • Populated by chart review, when lab results are received, at diagnosis of a chronic disease (eg diabetes) etc • For info: www.aafp.org/fpm/2006/0400/p47.html1 Oritz, p. 51

33. Conduct a Clinic Needs AssessmentKnow Your Practice and Your Patients • Know the patients in your practice and their care needs • Identify your Priority Population • Define characteristics of your unique patient list • Determine patients with chronic conditions • Identify priority target populations

34. Conduct a Clinic Needs AssessmentKnow Your Practice and Your Patients • Identify need for improved practice efficiency • Are there gaps in care you would like to address? • What specific goals could be addressed or accomplished through Group Patient Visits? • Identify your priority patient groups • What are the Top 10 Conditions patients visited your clinic for in the past year? • What was the frequency of those visits? • Are you successful with Comprehensive Care Plan implementation and follow up?

35. Select Appropriate Group Patient Visit Model

36. Group Patient Visit Models by Conditions

37. Group Patient Visit Model Fluidity

38. Create an Action Plan • Action Plan is a detailed summary of steps to be accomplished and allows you to analyze and predict results. • Plan Includes: • Group Patient Visit details • Determine goals and objectives • Identify specific patient group • Frequency • Specific Action Plan • Tasks • Resources and roles • Determine what to measure

39. Sample Planning Timeline

40. Conducting Group Patient Visits • Identify specific patients within your “priority patient group” • Invitations • Identify and organize resources • The Visit

41. Conducting Group Patient Visits Identify specific patients to participate • Relatively stable and will benefit from education • Function well in a group setting • Good cognitive, sight and hearing function Patient Invitations • Explains the GPV and the patient’s role as a participant • Multi-pronged approach may be needed/effective

42. Conducting Group Patient Visits (cont’d) Identify and Organize Resources • Team member roles and responsibilities • Patient charts and medical equipment • Patient information binder • Educational materials • Forms (e.g., attendance sheets, confidentiality agreements, evaluations, etc)

43. Conducting Group Patient Visits (cont’d) The Visit • Success is dependent on productive interactions • Time management is critical • Agenda and expectations • Group Norms • Confidentiality Ensure that confidentiality is addressed early on in every meeting – this helps establish trust among the group.

44. Measurement and Evaluation What to measure to assess benefit of GPV’s? • Practice Utilization: • Demand for one-on-one appointments • Reduced waiting times • Medical team satisfaction • Clinical Outcomes: • % patients meeting clinical guidelines • Increased patient self-management and satisfaction • Patient’s commitment to Complex Care Plan • Pre/post medical tests (eg : HbA1c, BP, Lipids etc ) • Reduced utilization of ER/hospital admissions Don’t try to measure everything…..start with small steps such as vital signs and key lab work.

45. Practice Resource Use and Satisfaction All identified topics for education. staff Very informative and happy time. These meetings are very helpful! patient Hopefully it will provide help and interest as it continues. patient Great way to learn what is needed to teach self-management. medical student All voiced they would like to come again. staff This meeting was very good because we could see how other people did under similar conditions. It also gave answers to so many questions I wasn’t sure of. patient Very important team-based experience. medical student

46. Refine and Repeat • Planning More Group Patient Visits Did the chosen model work? YES NO Expand GPVs to other patients, perhaps with more complex conditions and co-morbidities • Revise the model • Work with the same patient group before expanding

47. Sustaining Group Patient Visits in Your Practice • PATIENTS • Know your panel • Appropriate clinical info • MEDICAL TEAM • Support • Appropriate resourcing • Role alignment • Action plan • Refinement • Repetition Group PatientVisits • INTERACTIONS • Effective facilitator • Targeted education • Self-management support Informed, Engaged Patients Productive Interactions Prepared, ProctiveMedical Team Productive, Group Interactions ENHANCED OUTCOMES, EFFICIENCY, AND SATISFACTION Adapted from Kirsh s, et al. Qual Saf Health Care 2007;16:349-353.

48. Interactive WorkshopBuilding a Clinic Group Patient Visits Action Plan

49. Objectives and Goals of Workshop • To reflect on the information you have learned about Group Patient Visits • To develop a simple and practical Clinic Action Plan for patients with Type 2 diabetes To be prepared to organize your first Group Patient Visit in the next 6-8 weeks!!!

50. Group Patient Visit Workshop • Divide into groups, preferably with your clinic team • You will have 60 minutes to discuss/prepare an action plan as a group • You may want to designate a ‘note-taker’