USING GROUP OFFICE VISITS IN THE FPC SETTING Problems, Solutions, and Outcomes Ehab Molokhia, MD Associate Program Director, Medical Director Allen Perkins, MD Professor and Chair, Program Director University of South Alabama

Workshop Objectives Discuss dynamics of initiating group office visits. Maintaining profitability (billing and coding). Share our experience incorporating group office visits into our residency training. Discuss barriers to implementation of a successful program and identify solutions. Identify patient and learner outcomes.

How many are involved in group office visits? What are the: Advantages? Disadvantages?

How We Initiated Group Office Visits Patient selection process Facilitation of discussion Care coordination Involving the residents

Patient Selection Process Evolution Stage 1 Physician referral only Criteria Chronic disease specific Uncontrolled Willingness / behavioral traits

Stage 2 Physician referral only (unchanged) Criteria Chronic disease specific Uncontrolled Willingness / behavioral traits

Stage 3 (currently) Physician referral and open access (DIGMAs) Criteria Chronic disease specific

Future Anticipated Changes Adding “Chronic Disease Group Office Visits” Based on shared patient experiences To focus on: Patient self management Stress management Medication compliance Exercise Diet

Facilitation of Discussion Participants: Patient Provider Midlevel practitioner Nurse Physician (resident) Group facilitator Resident education Facilitation of group office visits

Highlights of the Discussion Equal participation Inspire patient generated solutions Patient empowerment through education

Resident’s Learning Goals Minimizing direct education through playing a non-dominant role. Learn how to steer and facilitate a discussion For example: Learn to deal with dominant and less involved patients. How to involve the entire group in an individual’s concern.

One on one interview: History. Recent laboratory values. Medication refills. Ensure appropriate follow-up. Meet with team following the interviews to discuss observations and plan for next visits.

Care Coordination Resident’s role Coordinate care: Emphasis in patient empowerment through education in regards to: Lifestyle modifications Compliance Problem solving Written and verbal feedback to the PCP PCP to make any necessary changes Efforts made to avoid making any changes during the group office visits

Maintaining Profitability Billing and Coding Established Patient Office Visit (2 out of 3) LEVEL HISTORY EXAM DECISION MAKING TIME 99211 Physician presence not required 5 99212 Problem Focused Straight Forward 10 99213 Expanded Problem Foc Low 15 99214 Detailed Moderate 25 99215 Comp High 40

Maintaining Profitability Billing and Coding Established Patient Office Visit (2 out of 3) LEVEL HISTORY EXAM DECISION MAKING TIME 99211 Physician presence not required 5 99212 Problem Focused Straight Forward 10 99213 Expanded Problem Foc Low 15 99214 Detailed Moderate 25 99215 Comp High 40

Maintaining Profitability Billing and Coding Established Patient Office Visit (2 out of 3) LEVEL HISTORY EXAM DECISION MAKING TIME 99211 Physician presence not required 5 99212 Problem Focused Straight Forward 10 99213 Expanded Problem Foc Low 15 99214 Detailed Moderate 25 99215 Comp High 40

Expanded Problem Focused History History Component Requirement History of Present Illness (HPI) Brief (1-3 components) Review of Systems (ROS) Pertinent to problem (1 system) Past medical, family, social history None

Low Medical Decision Making LEVEL OF RISK Presenting Problem Diagnostic Procedure Ordered Management options selected LOW Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury Physiologic tests not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies OTC drugs Minor surgeries with no identified risk factors PT OT IV fluids without additives

Low Medical Decision Making LEVEL OF RISK Presenting Problem Diagnostic Procedure Ordered Management options selected LOW Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury Physiologic tests not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies OTC drugs Minor surgeries with no identified risk factors PT OT IV fluids without additives

Incorporating Group Office Visits in Residency Barriers & Solutions Physician barriers: Lack of experience Motivation & interest Duty hours Scheduling

Incorporating Group Office Visits in Residency Barriers & Solutions Implementation barriers: Continuity barriers Tendency to discontinuation when exclusively dependant on residents Physical barriers; Nontraditional space Privacy

Outcomes Patient outcomes Resident / Learner outcomes Disease specific Patient satisfaction Resident / Learner outcomes Resident experience

USA FMC Patient Population Medically Underserved Community 75% African American 60% Medicaid

Diabetes Group Office Visits Clinical Outcomes START HgA1C DATE FOLLOW UP HgA1C START WEIGHT (BMI) FOLLOW UP WEIGHT (BMI) Patient A 8.0 07/07/06 7.4 12/11/06 178 (27.7) 9/20/06 168 (26.2) 01/25/07 Patient B 14.9 10/23/06 xxx 219 (33.4) 01/17/07 231.6 (35.3) 02/13/06 Patient C 12.1 11/02/06 6.9 02/21/07 246.4 (36.5) 236 (34.9) Patient D 8.1 11/29/06 7.0 05/02/07 234 (32.7) 237.8 (33.2) Patient E 9.7 9.0 04/25/07 290.8 (48.5) 01/17/06 281 (46.9) 05/23/07 Patient F 7.8 12/13/06 7.1 04/04/07 294 (47.6) 298.4 (48.3) Patient G 8.2 08/24/06 05/09/07 218.6 (32.3) 09/01/06 218.2 (32.3) Patient H 6.6 08/16/06 02/26/07 205 (32.2) 08/30/06 193 (30.3) 03/26/07 Patient I 12.7 10/11/06 10.3 275 (45.9) 274.2 (45.7)

Weight management Group Office Visits Clinical Outcomes START WEIGHT (BMI) DATE FOLLOW UP WEIGHT Patient A 324 (61.3) 11/29/06 313 (59.3) 01/25/07 Patient B 234 (32.7) 237.8 (33.2) 05/02/07 Patient C 246.4 (36.5) 11/02/06 236 (34.9) 02/21/07

Patient Satisfaction Surveys Was the group office visit you attended today educational? n=36

Patient Satisfaction Surveys Were you able to discuss your problems today? n=36

Patient Satisfaction Surveys After experiencing today’s group office visit, do you prefer dealing with your chronic illness in a group setting or one on one? n=36

Patient Satisfaction Surveys Will this visit today change the way you think about or handle your chronic illness? n=36

What did the patients like most about the group office visit? Talking in a group. Learning new things. Being together with others who have the same problems. Being able to talk about my problems. Exchanging ideas. Being able to discuss their bad habits freely.

Resident Surveys How did you find the group office model in the care of chronic illness compared to the traditional method? n=9

Resident Surveys If you had the appropriate system in place (staffing/space etc), would you carryout group office visits in your practice after finishing residency? n=9

Resident Surveys Perceived Barriers: Recruiting patients Time consuming Educating patients on a new mode of learning

Resident Evaluations Professionalism Responsibility and dependability in following through with assignments. Interpersonal skills and communications Communication skills with patients: One on one discussions Group discussions Improvement throughout the rotation in moderating group office visits

System-Based Practice Medical Knowledge Evidence of use of appropriate texts and current literature. System-Based Practice Ability to work as part of a multidisciplinary team to achieve a common goal. Physician assistant Group facilitator

Discussion