1. Build it…and they will come
Build it…and they will come. GROUP MEDICAL VISITS Sustaining Tips and Avoiding Foreclosure
Konrad C. Nau, MD
Angela Oglesby, MD
Gus Glassford, MD
Sarah McLaughlin, MD
West Virginia University
Rural FM Residency Program
STFM Practice Improvement Conference
Kansas City, Missouri November 2009

3. Rural Family Medicine Residency Program
History
Founded 1996
4:4:4
Rural Health Clinic
Women’s Health & Maternity Center
25 bed Critical Access Hospital
P4 Residency Program 2007
GROUP VISITS
DM/HTN/Lipids DM
OB Prenatal
Well Child
Exercise as Medicine
Chronic Pain

4. Disclosures

5. Hypothesis: Transform Synchronous Encounters

6. Learning Objectives
Identify five common perceived barriers to medical group visits, & strategies to overcome barriers
Utilize patient-centered agendas and shared group lab and vital sign tables to keep your group visits personalized and motivating.
Evaluate the ACGME Competencies achieved by residents and the status of patient and provider satisfaction.

8. Family Medicine

9. Group Medical Visits

10. Barriers to Group Visits

11. Why not conduct Group Medical Visits
Why not conduct Group Medical Visits? Talen, Schirmer, and Shahady Study
Uncertain what to do (49%)
Not enough staff (49%)
Not enough preparatory time (45%)
Lack of patient interest (22%)
Loss of revenue (32%)
Afraid of audits (9%)
Confidentiality (8%)

12. Barriers to Group Visits
Inertia
Performance anxiety
Privacy
Teaching residents
Billing & Coding (and collecting !)

13. Inertia
The property of a body which makes it resist a change in motion.
Sluggishness of uterine contractions during labor.

14. Strategies to Overcome Group Visit Inertia
Understand the benefits
Educate office champions
Have a plan

15. Published Benefits of Group Visits
Increase patient
Satisfaction
HbA1C/BP/Lipid control
Increase physician
Productivity
Decrease/Neutral healthcare system costs
Decreased hospital/Emergency visits
Increased immunization rates

16. Educate Clinic Champions
Visit construction sites
IHI Meetings
STFM Meetings
Hire a sub-contractor
Invite a guest lecturer

17. Have a Plan http://www.ihi.org Search :Group Visit Starter Kit Date
Action
Who
Done
Comment
2 months before first GV
Meet with leadership identify potential patient list
Marty MD
1 month before first GV
Send out invitations
Mary MA
1 week before first GV
Create notebooks for patients
1 day before first GV
Call patients to remind
Rita Pt Rep
Day of first GV
Set up room and pull labs for chart and notebooks
Lulu LPN

18. Infrastructure is crucial

19. Have a Plan: The Group Visit Agenda
5 min Introductions/Welcome
45 min The “visits”
10 min Patient education topic
10 min Q&A
5 min Planning & Closing
15 min 1:1 visits
30 min Charting time

20. Have a Plan: The Patient Agenda
Name
Date
Weight BP
My visit agenda _
□ I need a brief private visit with the doctor
□ I need medication refills of____________
My visit summary
Instructions
Medication changes

21. Privacy Concerns HIPPA consent form
No known HIPPA violations from group visits reported to date

22. Performance Anxiety It’s not all about you !!!!
Nurse
Resident
Behaviorist
PATIENTS
Ask questions to engage the group
You don’t have to lecture

23. Teaching Residents Reality = faculty and residents learning together
Behaviorist role for “beginner” faculty and chronic pain group visits.
“Dose” response to learning group visits is UNKNOWN

24. Resident Blueprint for Learning
Multiple questions and situations generated from group interactions
Focus conversations back to medical relevance
Actively thinking on your feet
Staying up to date on information: Diets, nutrition, exercise, medicine recalls

25. Resident Blueprint for Learning
Being viewed as a group leader despite being young physician
Establishing rapport with group vs. individual
Ability to accurately document visits
Work quickly on labs and scripts to keep visits flowing
Being male physician in OB group

26. Resident Group Visits Topics
Portion Distortion & activity estimator
Maintain don’t gain over the holidays
Trans fats
Cinnamon as therapy
Diabetic foot exam
Glycemic index
Shingles vaccine
Toxins causing diabetes
Dangers of “too tight” Diabetes control
Zetia controversy
Grapefruit/food interactions
Medicare drug benefits (the donut hole)
Arthritis of the hands

27. Experience a Group Visit

28. 5/12
7/10
9/6
11/5
Bob -3 -4 -7
Carol -2 -1
Joe Ed +3 +1
Mary
Dale
-11
-14 -8
Sue
Nate +2
Carlos
Tim
TOTAL
-19
-22
-16

29. Coding and Billing

30. Coding and Billing
Documentation from Centers for Medicare & Medicaid Services point out
"...under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E & M visit (CPT code or similar code depending on level of complexity) to a patient that is observed by other patients.
From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary."

31. Coding and Billing
99213
99214
We avoid “time based” billing because of compliance concerns

32. E & M Coding Requirements
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 Focused
Low 15
99214
Detailed
Moderate 25
99215
Comp
High 40

33. History of Present Illness Past medical, family, social history
History Component
Requirement
History of Present Illness
Brief
(1-3 components)
Review of Systems
Pertinent to problem
(1 system)
Past medical, family, social history
None

34. Diagnostic Procedure Ordered Management options selected
99213/4 Decision Making
LEVEL OF
RISK
Presenting Problem
Diagnostic Procedure Ordered
Management options selected
MIN.
LOW
MOD.
One stable chronic illness
2 or more stable chronic illnesses
Lab tests
Physiologic tests not under stress
Endocopy
Cardiovascular imaging w/contrast
OTC drugs
PT, OT
Prescription Drugs

35. E & M Coding Requirements
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 Focused
Low 15
99214
Detailed
Moderate 25
99215
Comp
High 40

36. Group Medical Visit Competency Evaluation
WVU Rural Family Medicine Residency Program
Group Medical Visit Competency Evaluation

37. 1=Novice/No Experience 2=Beginner
WVU Rural Family Medicine Residency Group Medical Visit Competency Evaluation
1=Novice/No Experience
(requires direct supervision with every patient)
2=Beginner
(independent in H&P skills; requires supervision with most patients)
3=Advanced Beginner
(requires intermittent supervision; seeks guidance as needed)
4=Approaching Competence
(developing independence; occasional supervision needed)
5=Competent
(independent; supervision needed for complex cases only)

38. PATIENT CARE 1 2 3 4 5
Demonstrates adequate knowledge and skills to successfully facilitate a group visit.
Demonstrates ability to perform brief, focused medical exams as appropriate to the central medical issue of the group.

39. MEDICAL KNOWLEDGE 1 2 3 4 5
Demonstrates adequate medical knowledge about chronic disease condition or central medical issue of group. (includes knowledge of etiology, assessment, treatment, and life-style modifications for targeted issues)
Demonstrates adequate medical knowledge of a broad range of medical issues, other than central medical issue of group, which may arise in the group visit.

40. PROFESSIONALISM 1 2 3 4 5
Prepares for and attends group visit in a focused and timely manner.
Documents group medical visit in a timely and compliant manner.

41. INTERPERSONAL AND COMMUNICATION SKILLS1 2 3 4 5
Demonstrates appropriate interviewing skills to successfully facilitate group. (includes eliciting patients’ health vision, development of relevant self-management plans, encourages self-care decisions, and enhances group problem-solving conversations)
Provides appropriate patient-centered education and leads group discussion in a patient-centered fashion.

42. PRACTICE BASED LEARNING & IMPROVEMENT1 2 3 4 5
Demonstrates ability to identify meaningful outcomes (medical, functioning, satisfaction, cost) and develop a plan to monitor these over the course of the group.
Demonstrates ability to appropriately bill and provide necessary supporting documentation for group medical visits.
Demonstrates ability to assess own facilitation of group, seek out feedback from patients in group and team members, and incorporate these in improving future group visits.

43. SYSTEMS BASED PRACTICE1 2 3 4 5
Partners with team in planning, debriefing, sharing process, defining roles
Demonstrates appropriate collaboration with and referral to other health professionals and community resources to manage patients’ care.
Demonstrates knowledge of the systems issues essential to group visits. (includes confidentiality, HIPAA, billing and coding, scheduling, consent, and team support)

44. OVERALL COMPETENCY 1 2 3 4 5
Demonstrates overall competency to perform and facilitate group visits.

47. Chronic Pain Group Visits

48. Chronic Pain Group Visits
Why ???
Patient selection
Pain contracts
Goal = living better with pain
The team

49. Chronic Pain Group Visits
Discussion topics
Stigma
Depression and pain
Non-drug pain treatments
Relaxation response
Vitamin D deficiency and chronic pain
Stretching in your chair
Questions we do not ask
Rate your pain 1-10 !!!!

50. Chronic Pain Group Visits
Outcomes
Attrition
Narcotic dose escalation
Use of pain adjuvants
Newly discovered Vit D deficiency/insufficiency
Improvement in other medical conditions
Social support

51. Chronic Pain Group- Attrition
Started with 11 group members and now have 8, one year later
2 patients moved out of the area
1 patient preferred private visits

52. Chronic Pain Group- Med Changes
One patient required an increase in his pain medication.
One patient is scheduled for insertion of a spinal cord stimulator.
We were not able to decrease anyone’s pain medication.

53. Chronic Pain Group- Adjuvants
Two patients have had significant improvements in their moods with the addition of anti-depressants.
One patient has had improvements in her pain with the addition of Neurontin to her regimen.
At our last meeting, a member requested a letter so that she would be able to have a dog in her apartment.

54. Chronic Pain Group- Vit D
Three patients were found to be deficient in Vitamin D and started on supplementation.

55. Chronic Pain Group- Health Issues
Two of the group members have significantly decreased their cigarette use.
We have seen improvements in group member’s Hemoglobin A1C levels.
Some group members have lost weight.
There have been improvements in cholesterol levels.

56. Chronic Pain Group- Social Support
There is sharing within the group about family, jobs, accomplishments, and hardships.
This Christmas the group requested to do a gift exchange.

57. Exercise as Medicine Group Visit

58. Exercise as Medicine Recruitment/Sign up Up to 12 per group
Diverse medical background
2 sessions – 1 month apart
Team

59. Exercise as Medicine - Structure
1st Visit
Meet and greet
Introduction to concept
Benefits of regular physical activity
Discussing misinformation on exercise
Physical activity and aging
Brief discussion on diet and bad habits
Discuss individual expectations and goals
Homework (exerciseismedicine.org)

60. Exercise as Medicine - Structure
2nd Visit
Discuss incentives and barriers to exercise
Time
Physical ability
Pain
Discuss success/failures since last visit

61. Exercise as Medicine - Structure
2nd Visit cont’d
Re-evaluate barriers
Group brainstorm on breaking through barriers
Personalized action plan
Outdoor group exercise

62. OB Group Visits

63. Residency Maternal/Child Group Visit Model
Women’s Health Rotation (4 wks)
Maternity Group Visit Observation
PGY1
Pre-Rotation Group Visits
Maternity Rotation (12 wks)
PGY2
Maternity Group Visits
Well-Child Group Visit
Longitudinal
PGY3
Well-Child Group Visits

64. Evaluating Patient & Resident Satisfaction
“Hits the nail on the head”
-or-
“something else”

65. OB Group Visit Patient Satisfaction Survey
14 Questions
Scale of 5 – 1 used
5 = Strongly Agree
4 = Agree
3 = Neutral
2 = Disagree
1 = Strongly Disagree
Comments

66. I did not have to wait to see my provider.
WVU Rural Family Medicine Residency
OB Group Visit Satisfaction Survey
Your input is important to us. We ask that you take a moment to answer the following questions about your group visit. Please answer each question by circling the number that best indicates your opinion. These questions pertain to your group visit only. Your answers will help us improve our services.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree 1 2 3 4 5
I did not have to wait to see my provider.
I spent more time with my provider.
I was able to discuss issues that were important to me.
I enjoyed keeping a record of my prenatal care.
I was comfortable discussing issues in a group.

67. OB Group Visit Patient Satisfaction
We were able to solve our own problems in a group.
I was comfortable sharing common life experiences.
I developed a relationship with my provider.
I felt I had a more active role in my care.
I enjoyed sharing concerns and joys with other women who were at similar times in their pregnancy
I enjoyed knowing that my appointments would be the same time/day for every visit
I enjoyed having the same provider that I saw in my group deliver my baby.
I was satisfied with my group experience

68. OB Group Visit Patient Satisfaction
What would you change about the group visits?
What would improve your group visit experience?
If you had received traditional care for your pregnancy in the past, how does the group visit experience differ?
Would you recommend group prenatal visits to others:
When you were first asked to participate in the group, what were your concerns?
How did those concerns change once you were involved in the group?

69. OB Group Visit Patient Satisfaction
4.9

70. Resident Overall Satisfaction with Group Visits

71. Resident Satisfaction with Group Visits as a Patient Experience

72. Resident Satisfaction with Group Visits as a Learning Experience

73. Medical Group Visits Build it….and they will come