1. Group Care Through the Lifecycle Kathy Trotter, MSN, CNM, FNP trott004@mc.duke.edu

2. OBJECTIVES Describe your current practice in terms of how care is rendered, its ef fi ciency, and current satisfaction and outcomes for you and your patients. Discuss how patients make self management decisions and lifestyle decisions Describe the group care model as an alternative to the traditional system. Name at least fi ve applications of the group care model. Review techniques of group facilitation.

3. Traditional vs. Group Care waiting room time No wait exam room Group space provider central Empowerment referral for other care Multidisciplinary

4. Imagine as a provider... l Having time to really listen to your patients l Getting help from the group with problem- solving l Needing to say things only once l Working with really activated patients l Finding work fun and energizing

5. As an administrator, imagine... l Better access for your patients l Freed-up exam rooms for paying procedures l Happy providers/staff….less turnover l Great marketing program l Better outcomes l Predictable clinic time schedules

6. Now imagine… l Group Care from: l Beautiful birth to – Peaceful death

7. Group Care for: l Diabetes l NICU follow-up l Seniors l Menopause l Hyperlipidemia l Special needs l Chronic pain l Cardiac rehab l Physical medicine l Pre/post operative

8. Group Care for: Well Baby Eating disorders Asthma Smoking Cessation Pregnancy Oncology Obesity

9. Jared Lazarus Duke Photography

10. Jared Lazarus Duke Photography

11. Groups provide… l A vehicle for social change l An opportunity to learn from each other l Fun and interesting sharing

12. WHY GROUPS? Honors need for affiliation Provide an efficient conduit for information Encourage active participation Efficient for the health care system Cost neutral thus far (unable to getMcare reimbursement yet for CPT=99078, group visit code, so use Estab. Codes-99213, 99214)

14. Kaiser Permanente, Seniors l Chronically ill older adults – Fewer hospital admissions (p=.012) – Fewer ED visits (p=.008) – Fewer professional services (p=.005) – $42/member/month cost savings Information taken from: Scott JC, Conner DA, Venohr I, et al. Effectiveness of a Group Visit Model for Chronically Ill older Health Maintenance Organization Members: A 2-year Randomized Trial for the Cooperative HealthCare Clinic. J Am Geriatr Soc. 2004;52:1463-1470.

15. Comprehensive HealthCare Clinic (CHCC) Developed in 1991 with plan to improve the care of the geriatric patient 2-2 ½ hour monthly visit 15-20 patients and caregivers Same patients typically attend every visit Long term commitment to regularly scheduled visits Physician, nurse, and other prn

16. 10 Additional findings  Higher satisfaction with their primary care physician (p =.022)  Overall quality of care (p =.048)  Better quality of life (p=.002)  Greater self-efficacy for communicating with their physician (p =.03)  No difference in clinic visits, pharmacy refills, or outpatient hospital visits, or home health visits

17. 11 What Group Participants Value  Enhanced relationships with members of the health care team  Being with others dealing with similar health issues (I’m not the only one)  Education  Opportunity to ask questions  Social environment

18. Diabetes Groups, 5 year ControlGroupp Value HbA 1c 9.0 ± 1.67.3 ± 1.0 <.001 Quality of Life (lower = better) 89.2 ± 30.143.7 ± 7.2 <.001 DM knowledge18.0 ± 8.527.9 ± 5.7 <.001 Problem solving (Self Efficacy) 10.0 ± 3.817.1 ± 2.4 <.001 Colorado Kaiser Permanente

19. Drop In Group Medical Appt. (DIGMA) Noffsinger(1996), Kaiser/San Jose with primary purpose to improve access Useful in most primary and specialty care settings

20. Typical DIGMA Schedule  1 ½-hour weekly visit  10 to 16 patients and 2 to 6 caregivers  Most common model includes heterogeneous population  Different patients with different conditions attend only when they have medical need  Some patients attend by appointment and some drop in  Facilitated by a provider with the assistance of a behaviorist

21. CenteringDiabetes Extremely successful: Average attendance, 25 – 28 Changing attitudes toward condition Improving self management 60% retention Patients willingly travel large distances on slow buses Remarkable--other clinic medical providers have difficulty getting patients to: Make appointments for annual exams Comply with dietary restrictions

22. Process of Facilitative Group Sessions is Key to the Empowerment Process and thus self management of their health Essential Elements of Group Care

23. RCT on CenteringPregancy Group Care Intervion and effect on Preterm Delivery, Stratified by Study Condition Note: All analyses controlled for study site, factors that were different by study condition despite randomization (race, prior preterm delivery prenatal distress) and clinical risk factors assoc with birth outcomes (smoking, prior miscarriage/stillbirth). Ickovics, et al. (2007)Obstetrics & Gynecology. 110(2): 3230-39. OR=.67, (.44-.99) OR=.59 (.31-.92) 33% 41% Per 1000 women in group, 40 preterm deliveries averted; 60 per 1000 for African American women

24. Why Group Visits Work  Increased contact time for communication  Enhanced provider-patient relationship  The therapeutic milieu (Yalom) Instillation of hope Universality Imparting information Altruism Corrective recapitulation of the primary family group

25. Summary A group visit is a medical appointment (not a class, or support group) Group visits require planning and commitment Group visits must be modified and molded to meet your unique needs Group visits offer the potential for improved quality of care, clinical outcomes, access, and satisfaction for patients and health care providers

26. Focus on your practice Imagine your current practice-where could you try this model? What outcomes need the most improvement? Which types of patients could bene fi t from this? Facilitation skill building

27. Essential Elements of the Centering model 1. Assessments (check-ups) are conducted within the group space. 2. Women/patients are involved in self-care activities 3. A facilitative leadership style is used. 4. Each session has an over-all plan. 5. Attention is given to the core content; emphasis may vary. 6. There is stability of group leadership.

28. Essential Elements 7. Group conduct honors the contribution of each member. 8. The group is conducted in a circle. 9. The composition of the group is stable, but not rigid. 10. Group size is optimal to promote the process. 11. Involvement of family support people is optional. 12. Opportunity for socializing within the group is provided 13. There is on-going evaluation of outcomes.

29. Group Facilitation l A cooperative partnership between provider/facilitator and members l The art of listening to one another

30. The Facilitative Process Acknowledge: the concern of the member Refer: the concern to the group for processing Return: to the member to see if the concern has been met

31. The Facilitative Process… “I hear that…is a concern for you and perhaps for others…” “What do the rest of you think?” “How are you feeling about our discussion..?”

32. The Facilitative Group “Conductor” l Helping the group to move together l Trying to achieve a blend: no member too loud or too soft l Each member contributing to the benefit of all