Drop-In Group Medical Appointments

1. Drop-In Group Medical Appointments Virginia Health Care Foundation Nurse Practitioner Roundtable April 16, 2010

2. Outline • Shared Medical Appointments • History • Idealized DIGMA • DIGMA Implementation • Important Concerns • Summary • Resources

3. Shared Medical Appointments • Shared Medical Appointments [SMA] • Multiple patients seen as a group for follow-up or routine care • Created primarily to mitigate increasingly constrained medical practice • Enhance practice efficiency • Increase patient access/satisfaction • Decrease negative health outcomes

4. SMA Sub-Types • Drop-In Group Medical Appointment [DIGMA] • Group model focused on patients in physician’s panel • Cooperative Health Care Clinic [CHCC] • Group model focused on patient utilization or diagnosis • Physicals Shared Medical Appointment [PMSA] • Theoretically similar to DIGMA model; strong focus on physical exams

5. History

6. Brief History • Developed and established in 1996 by Dr. Edward Noffsinger • Psychologist at Kaiser Permanente • Model designed with general intent • Increase practice efficiency, patient health outcomes, and provider/patient satisfaction • Better manage practitioner workload

7. Brief History • Development stimulated by confluence of three general problem streams • Providers • Decreased reimbursements, PCP shortages, increased workloads • Patients • Decreased face time with PCP, increased access to health information, decreased patient satisfaction • Theory • Increased understanding of need for holistic care, increased understanding of the complexities of chronic disease management

8. Brief History • Dr. Noffsinger envisions use of DIGMA in multiple realms of healthcare • Chronic disease management, ambulatory care, psychiatric care, access issues, etc • Use of model has been limited • Diabetes, psychiatric care, heart conditions

9. DIGMA According to Noffsinger

10. Current Forms • Exists in three forms • Homogenous Model • Patients grouped by diagnosis • Heterogeneous Model • All patients invited regardless of diagnosis • Mixed-Model • Meetings segmented based upon diagnostic groupings • Cardiopulmonary, weight management/diabetes, chronic pain, gastrointestinal

11. Ideal DIGMA Sessions • Intended to resemble series of individualized office visits in a supportive group setting • 10-20 patients • ~ 90 minute runtime • Physicians panel only • Meets weekly • Well-Staffed • head provider [MD/NP/PA], 1-2 assistants, scheduler, documenter and behaviorist

12. Provider Definitions • Lead Provider • MD, NP, PA • Medical Assistants • RN, LPN, CNA • Behaviorist • Social worker, psychologist • Documenter • Specially trained to take notes in “real-time”

13. Individualized • Accomplished by incorporation of 5 core actions in each session • Provider attends to patients sequentially • Provision of same medical services to each patient • Primary provider never leaves session • Exceptions: disrobing and private discussion occurs in adjacent examination room • Comprehensive and individualized charts • Consistent focus on medical care throughout session

14. Group Atmosphere • Room should be conducive to group discussion • Brightly lit, central table/focus, attendees able to face each other • Patients informed that discussion should be positive • Behaviorist is key to facilitating discussion among group • Primary source of patient education within DIGMA is derived from proper group discussion • Guiding such discussion generally requires extensive training

16. DIGMA Research

17. Current Research • DIGMA specific research indicates • Enhanced productivity, patient/provider satisfaction, • Growing body of research concerning SMAs provides general consensus of improved rates in • Patient quality of life • Health outcomes • Quality of care • Patient/Provider satisfaction • Revenue streams

20. SMA Research • Improvements in health outcomes • Decreased HBA1C levels • Improved blood glucose control • Improvements in health indicators • Decreased ER visits • Increased Primary Care visits • Improvements in health behaviors • Increased fruit/vegetable intake • Reduced consumption of high fat foods

21. SMA Research • Improvements in patient satisfaction • Increased satisfaction of diabetic management • Increased feeling of quality of care • Improved sense of trust in provider • Improvements in health communication • Decrease in advice-seeking between site visits • Increased patient self-efficacy in provider-patient communication

22. DIGMA Implementation

23. Why use DIGMA • Reasons for use of DIGMA vary widely • Location, budgets, PCP levels, MCO • Common startup reasons • Overbooked or backlogged schedule • Reductions in PCPs • Similar patient bases • Repetition of advice • Better quality of care

24. Considerations Before Startup • Facilities requirements • Room occupancy and availability • Provider requirements • PCP, medical assistants, behaviorist, documenter • Billing/fiscal requirements • Billing is not always straight forward • Initial start-up funds will be necessary however, should be made up in savings

25. Necessary for Start-up • Leadership Support [“champion”] • One individual serves as primary planner and implementer of DIGMA program • Patient buy-in • Patients must understand and be convinced of legitimacy of DIGMA • Provider buy-in • Concerns regarding model must be addressed • Obtainment of behaviorist

26. The Champion • Acts as lead for entire implementation • Secures administrative support • Rooms, funds, approvals from higher administrative levels • Secures providers • Engage potential providers, address provider concerns • Customizes DIGMA model to practice • Patient base, location, reimbursement concerns • Must possess thorough knowledge of DIGMA theory and practice

27. Patient Buy-In • Patients must be convinced of DIGMA legitimacy • Radical change from standard one-on-one interaction • Introduction of model should be addressed at individual office visit • Personal setting increases perceived legitimacy • Model explanation should be three-step • Verbal explanation • Pamphlet/flyer • Personal invitation to attend

30. Provider Buy-in • Providers are skeptics and must be shown potential and legitimacy of DIGMA model • Normally convinced by data, application to high-risk patients, and case reports of previous uses • Providers should not be ordered to conduct DIGMA • Drive for DIGMA must come from provider base • Incentives can be used to support providers • Increased flex-time on days of DIGMA conduction • Selection of provider as champion can enhance buy-in

31. Sample Session • Room is prepped for patient arrival • Refreshments, seating, quality of room • Patients check-in • Escorted to room; medical assistant can take vital signs • Providers welcome patients • PCP examines patients individually • Behaviorist promotes group discussion concerning patients medical issues. • Documenter follows PCP • Termination of Session

32. Barriers to successful DIGMA • Top-down dictation to providers • Providers should not be ordered to conduct DIGMA • Desire to conduct DIGMA must come from providers • Inadequate space to conduct DIGMA • DIGMA attendance and atmosphere requirements necessitate adequate space planning • Inadequate scheduling • Scheduler greatly increases chances of reaching necessary attendance • Low attendance • Productivity increases of DIGMA predicated on high attendance rates

33. Important Issues

34. Confidentiality • Primary source of confidentiality concerns comes from providers • Nature of DIGMA sessions inherently address some confidentially issues • Patients who attend generally comfortable with discussing personal health information in group setting • Issues of confidentiality may be addressed using Noffsinger’s six-step guidelines

35. Noffsinger’s Six Steps • Address confidentiality in promotional materials • Clearly indicate group setting and the sharing of medical information within group • Train staff to properly refer patients • Clearly indicate that session is group visit and not extended individualized session • Confidentiality agreement drafted by legal professional • DIGMA specific release should be created; Do not borrow other release forms

36. Noffsinger’s Six Steps • Signing of confidentiality release by attendees is mandatory • Signing of release form occurs before session. • May eventually become unnecessary as time progresses • Discussion of confidentiality during session • Behaviorist briefly discuses sharing of information and maintenance of patient anonymity • Placement of release in all patients charts • Record keeping procedure; if using electronic medical records then release can be scanned

38. Modifications to Idealized DIGMA • Use of original DIGMA form is ideal however, real world constraints may prevent such application • Modifications to DIGMA can occur in a variety of areas • Staff • Conduction of session • Census levels

39. Modifications to Idealized DIGMA • Staff • Documenter can be eliminated • Primary provider can take notes • Reduction in number of medical assistants • Conduction of session • Length of session time can be decreased • Individual examinations can be entirely removed from group; discussion of examination results upon return to group • Census levels • Other clinics have done well on lower than ideal census levels [4-6 patients per session]

40. Guides • Improving Chronic Illness Care • http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_copy1.doc • ImpactBC • http://www.impactbc.ca/files/documents/NHA_Group_Medical_Appointments_Manual.pdf • American Academy of Family Physicians • http://www.aafp.org/online/en/home/practicemgt/quality/qitools/pracredesign/january05.html

41. Resources

42. Resources • Atkins, T., and E. Noffsinger. "Assessing a Group Medical Appointment Program: A Case Study at Sutter Medical Foundation." Group Practice Journal 50.April (2001): 42-49. Print. • Baurd, Stephanie, Todd Marcy, Becky Armor, Jennifer Chonlahan, and Paige Beach. "Gropu Medical Visits at a Family Medicine Center: Analysis and Resolution." Medscape: Medical News, Full-text Journal Articles & More. Web. 08 Apr. 2010. <http://www.medscape.com/viewarticle/541549_2>. • Bronson, David, and Richard Maxwell. "Shared Medical Appointments: Increasing Patient Access without Increasing Physician Hours." Cleveland Clinic Journal of Medicine 71.5 (2004): 369-77. Cleveland Clinic. Web. 8 Apr. 2010. <http://www.ccjm.org/content/71/5/369.full.pdf+html>. • Christianson, Jon B., and Louise H. Warrick. The Buisness Case for Drop-In Group Medical Appointments: A Case Study of Luther Midelfort Mayo System. Rep. Vol. 611. Commonwealth Fund, 2003. Print. • "Clinical Microsystems :: Toolkits : Shared Medical Appointments." Dartmouth Medical School - DMS Home. Web. 08 Apr. 2010. <http://dms.dartmouth.edu/cms/toolkits/shared_medical_appointments/>. • Group Health Research Institute. Rep. Group Health Research Institute. Web. 8 Apr. 2010. <http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_copy1.doc.>.

43. Resources • "Harvard Vanguard - Shared Medical Appointments." Harvard Vanguard Medical Associates, Delivering Comprehensive Healthcare in the Boston Metro Area. Web. 08 Apr. 2010. <http://www.harvardvanguard.org/about/most/index.asp>. • ImpactBC. Confidentiality Agreement. Rep. ImpactBC. Print. • ImpactBC. Rep. ImpactBC. Web. 8 Apr. 2010. <http://www.impactbc.ca/files/documents/NHA_Group_Medical_Appointments_Manual.pdf>. • Jaber, Raja, Amy Braksmajer, and Jeffrey Trilling. "Group Visits: A Qualitative Review of Current Research." Journal of the American Board of Family Medicine 19.3 (2006): 276-90. Print. • Harris, Marianne. "Shared Medical Appointments After Cardiac Surgery-The Process of Implementing a Novel Pilot Paradigm to Enhance Comprehensive Postdischarge Care." Journal of Cardiovascular Nursing 25.2 (2010): 124-29. Journal of Cardiovascular Nursing. Web. 8 Apr. 2010. <http://journals.lww.com/jcnjournal/Abstract/2010/03000/Shared_Medical_Appointments_After_Cardiac.7.aspx>. • "Group Visits (Shared Medical Appointments) -- Clinical Quality Improvement -- American Academy of Family Physicians." Home Page -- American Academy of Family Physicians. Web. 08 Apr. 2010. <http://www.aafp.org/online/en/home/practicemgt/quality/qitools/pracredesign/january05.html

44. Resources • Noffsinger, Edward B. Running Group Visits in Your Practice. New York ; Berlin: Springer, 2007. Print. • Noffsinger, Edward B. Running Group Visits in Your Practice. New York ; Berlin: Springer, 2007. Print. • Noffsinger, Edward B. Running Group Visits in Your Practice. New York ; Berlin: Springer, 2007. Print. • Noffsinger, Edward B. "Will Drop-In Group Medical Appointments (DIGMAs) Work In Practice?" The Permanente Journal 3.3 (1999): 58-67. The Permanente Journal. Web. 8 Apr. 2010. <http://xnet.kp.org/permanentejournal/fall99pj/digma.html>. • Kirsh, Susan, Sharon Watts, Kristina Pascuzzi, Mary O'Day, David Davidson, Gerarld Strauss, Elizabeth Kern, and David Aron. "Shared Medical Appointments Based on the Chronic Care Model: a Quality Improvement Project to Address the Challenges of Patients with Diabetes with High Cardiovascular Risk." Quality and Safety in Health Care 16 (2007): 349-53. BMJ. Web. 8 Apr. 2010. <http://qshc.bmj.com/content/16/5/349.abstract>.