1. 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

2. 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.

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

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

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

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

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

8. 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

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

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

11. 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.

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

22. 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

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

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

25. 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
(27.7)
9/20/06
(26.2)
01/25/07
Patient B
14.9
10/23/06
xxx
(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)
(34.9)
Patient D
8.1
11/29/06
7.0
05/02/07
(32.7)
237.8 (33.2)
Patient E
9.7
9.0
04/25/07
290.8 (48.5)
01/17/06
(46.9)
05/23/07
Patient F
7.8
12/13/06
7.1
04/04/07
(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
(32.2)
08/30/06
(30.3)
03/26/07
Patient I
12.7
10/11/06
10.3
(45.9)
274.2 (45.7)

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

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

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

29. 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

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

31. 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.

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

33. 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

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

35. 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

36. 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

38. Discussion