Drop-In Group Drop-In Group Medical Medical

AppointmentsAppointments

Virginia Health Care Virginia Health Care FoundationFoundation

Nurse Practitioner Roundtable Nurse Practitioner Roundtable April 16, 2010April 16, 2010

OutlineOutline

• Shared Medical AppointmentsShared Medical Appointments•HistoryHistory• Idealized DIGMA Idealized DIGMA •DIGMA Implementation DIGMA Implementation • Important ConcernsImportant Concerns• Summary Summary •Resources Resources

Shared Medical Shared Medical AppointmentsAppointments

• Shared Medical Appointments [SMA]Shared Medical Appointments [SMA]Multiple patients seen as a group for Multiple patients seen as a group for

follow-up or routine carefollow-up or routine care

•Created primarily to mitigate Created primarily to mitigate increasingly constrained medical increasingly constrained medical practicepracticeEnhance practice efficiencyEnhance practice efficiencyIncrease patient access/satisfactionIncrease patient access/satisfactionDecrease negative health outcomes Decrease negative health outcomes

SMA Sub-TypesSMA Sub-Types

• Drop-In Group Medical Appointment [DIGMA]Drop-In Group Medical Appointment [DIGMA] Group model focused on patients in physician’s Group model focused on patients in physician’s

panelpanel

• Cooperative Health Care Clinic [CHCC]Cooperative Health Care Clinic [CHCC] Group model focused on patient utilization or Group model focused on patient utilization or

diagnosisdiagnosis

• Physicals Shared Medical Appointment [PMSA]Physicals Shared Medical Appointment [PMSA] Theoretically similar to DIGMA model; strong focus Theoretically similar to DIGMA model; strong focus

on physical exams on physical exams

HistoryHistory

Brief HistoryBrief History

•Developed and established in 1996 Developed and established in 1996 by Dr. Edward Noffsingerby Dr. Edward Noffsinger Psychologist at Kaiser Permanente Psychologist at Kaiser Permanente

•Model designed with general intent Model designed with general intent Increase practice efficiency, patient Increase practice efficiency, patient

health outcomes, and provider/patient health outcomes, and provider/patient satisfactionsatisfaction

Better manage practitioner workloadBetter manage practitioner workload

Brief HistoryBrief History

• Development stimulated by confluence of three Development stimulated by confluence of three general problem streamsgeneral problem streams

1.1.ProvidersProvidersDecreased reimbursements, PCP shortages, increased workloadsDecreased reimbursements, PCP shortages, increased workloads

2.2.PatientsPatientsDecreased face time with PCP, increased access to health Decreased face time with PCP, increased access to health

information, decreased patient satisfactioninformation, decreased patient satisfaction

3.3. TheoryTheory Increased understanding of need for holistic care, increased Increased understanding of need for holistic care, increased

understanding of the complexities of chronic disease understanding of the complexities of chronic disease managementmanagement

Brief HistoryBrief History

•Dr. Noffsinger envisions use of DIGMA Dr. Noffsinger envisions use of DIGMA in multiple realms of healthcarein multiple realms of healthcareChronic disease management, Chronic disease management,

ambulatory care, psychiatric care, ambulatory care, psychiatric care, access issues, etcaccess issues, etc

•Use of model has been limitedUse of model has been limitedDiabetes, psychiatric care, heart Diabetes, psychiatric care, heart

conditionsconditions

DIGMA DIGMA According to According to NoffsingerNoffsinger

Current FormsCurrent Forms

• Exists in three formsExists in three formsHomogenous Model Homogenous Model

Patients grouped by diagnosisPatients grouped by diagnosis

Heterogeneous ModelHeterogeneous ModelAll patients invited regardless of diagnosis All patients invited regardless of diagnosis

Mixed-ModelMixed-ModelMeetings segmented based upon diagnostic Meetings segmented based upon diagnostic

groupingsgroupings Cardiopulmonary, weight management/diabetes, Cardiopulmonary, weight management/diabetes,

chronic pain, gastrointestinal chronic pain, gastrointestinal

Ideal DIGMA SessionsIdeal DIGMA Sessions

• Intended to resemble series of Intended to resemble series of individualized office visits in a supportive individualized office visits in a supportive group setting group setting • 10-20 patients 10-20 patients • ~ 90 minute runtime ~ 90 minute runtime • Physicians panel onlyPhysicians panel only•Meets weeklyMeets weekly•Well-Staffed Well-Staffed

head provider [MD/NP/PA], 1-2 assistants, head provider [MD/NP/PA], 1-2 assistants, scheduler, documenter and behavioristscheduler, documenter and behaviorist

Provider DefinitionsProvider Definitions

• Lead ProviderLead ProviderMD, NP, PA MD, NP, PA

•Medical AssistantsMedical AssistantsRN, LPN, CNARN, LPN, CNA

•BehavioristBehavioristSocial worker, psychologistSocial worker, psychologist

•DocumenterDocumenterSpecially trained to take notes in “real-Specially trained to take notes in “real-

time”time”

Individualized Individualized

• Accomplished by incorporation of 5 core Accomplished by incorporation of 5 core actions in each sessionactions in each session

1.1. Provider attends to patients sequentially Provider attends to patients sequentially

2.2. Provision of same medical services to each Provision of same medical services to each patientpatient

3.3. Primary provider never leaves sessionPrimary provider never leaves session1.1. Exceptions: disrobing and private discussion occurs Exceptions: disrobing and private discussion occurs

in adjacent examination room in adjacent examination room

4.4. Comprehensive and individualized chartsComprehensive and individualized charts

5.5. Consistent focus on medical care throughout Consistent focus on medical care throughout session session

Group AtmosphereGroup Atmosphere

• Room should be conducive to group Room should be conducive to group discussiondiscussion Brightly lit, central table/focus, attendees able Brightly lit, central table/focus, attendees able

to face each otherto face each other• Patients informed that discussion should be Patients informed that discussion should be

positive positive • Behaviorist is key to facilitating discussion Behaviorist is key to facilitating discussion

among groupamong group Primary source of patient education within Primary source of patient education within

DIGMA is derived from proper group discussion DIGMA is derived from proper group discussion Guiding such discussion generally requires Guiding such discussion generally requires

extensive training extensive training

DIGMA ResearchDIGMA Research

Current ResearchCurrent Research

• DIGMA specific research indicatesDIGMA specific research indicates Enhanced productivity, patient/provider Enhanced productivity, patient/provider

satisfaction, satisfaction,

• Growing body of research concerning SMAs Growing body of research concerning SMAs provides general consensus of improved provides general consensus of improved rates in rates in Patient quality of life Patient quality of life Health outcomesHealth outcomes Quality of careQuality of care Patient/Provider satisfactionPatient/Provider satisfaction Revenue streamsRevenue streams

SMA Research SMA Research

• Improvements in health outcomesImprovements in health outcomes Decreased HBA1C levelsDecreased HBA1C levels Improved blood glucose control Improved blood glucose control

• Improvements in health indicatorsImprovements in health indicators Decreased ER visits Decreased ER visits Increased Primary Care visitsIncreased Primary Care visits

• Improvements in health behaviorsImprovements in health behaviors Increased fruit/vegetable intake Increased fruit/vegetable intake Reduced consumption of high fat foodsReduced consumption of high fat foods

SMA Research SMA Research

• Improvements in patient satisfactionImprovements in patient satisfactionIncreased satisfaction of diabetic Increased satisfaction of diabetic

managementmanagementIncreased feeling of quality of care Increased feeling of quality of care Improved sense of trust in providerImproved sense of trust in provider

• Improvements in health communicationImprovements in health communicationDecrease in advice-seeking between site Decrease in advice-seeking between site

visitsvisitsIncreased patient self-efficacy in provider-Increased patient self-efficacy in provider-

patient communication patient communication

DIGMA DIGMA Implementation Implementation

Why use DIGMAWhy use DIGMA

•Reasons for use of DIGMA vary widelyReasons for use of DIGMA vary widelyLocation, budgets, PCP levels, MCO Location, budgets, PCP levels, MCO

•Common startup reasonsCommon startup reasonsOverbooked or backlogged scheduleOverbooked or backlogged scheduleReductions in PCPsReductions in PCPsSimilar patient basesSimilar patient basesRepetition of adviceRepetition of adviceBetter quality of careBetter quality of care

Considerations Before StartupConsiderations Before Startup

• Facilities requirementsFacilities requirementsRoom occupancy and availability Room occupancy and availability

• Provider requirements Provider requirements PCP, medical assistants, behaviorist, PCP, medical assistants, behaviorist,

documenterdocumenter

•Billing/fiscal requirementsBilling/fiscal requirementsBilling is not always straight forwardBilling is not always straight forwardInitial start-up funds will be necessary Initial start-up funds will be necessary

however, should be made up in savingshowever, should be made up in savings

Necessary for Start-upNecessary for Start-up

• Leadership Support [“champion”]Leadership Support [“champion”] One individual serves as primary planner and One individual serves as primary planner and

implementer of DIGMA program implementer of DIGMA program

• Patient buy-inPatient buy-in Patients must understand and be convinced of Patients must understand and be convinced of

legitimacy of DIGMA legitimacy of DIGMA

• Provider buy-in Provider buy-in Concerns regarding model must be addressedConcerns regarding model must be addressed Obtainment of behaviorist Obtainment of behaviorist

The ChampionThe Champion

• Acts as lead for entire implementationActs as lead for entire implementation Secures administrative supportSecures administrative support

Rooms, funds, approvals from higher administrative Rooms, funds, approvals from higher administrative levels levels

Secures providersSecures providersEngage potential providers, address provider Engage potential providers, address provider

concernsconcerns

Customizes DIGMA model to practiceCustomizes DIGMA model to practicePatient base, location, reimbursement concernsPatient base, location, reimbursement concerns

• Must possess thorough knowledge of Must possess thorough knowledge of DIGMA theory and practiceDIGMA theory and practice

Patient Buy-InPatient Buy-In

• Patients must be convinced of DIGMA Patients must be convinced of DIGMA legitimacylegitimacy Radical change from standard one-on-one Radical change from standard one-on-one

interactioninteraction

• Introduction of model should be addressed Introduction of model should be addressed at individual office visitat individual office visit Personal setting increases perceived legitimacyPersonal setting increases perceived legitimacy Model explanation should be three-stepModel explanation should be three-step

Verbal explanation Verbal explanation Pamphlet/flyerPamphlet/flyerPersonal invitation to attendPersonal invitation to attend

Provider Buy-in Provider Buy-in

• Providers are skeptics and must be shown Providers are skeptics and must be shown potential and legitimacy of DIGMA modelpotential and legitimacy of DIGMA model Normally convinced by data, application to high-Normally convinced by data, application to high-

risk patients, and case reports of previous usesrisk patients, and case reports of previous uses• Providers should not be ordered to conduct Providers should not be ordered to conduct

DIGMADIGMA Drive for DIGMA must come from provider baseDrive for DIGMA must come from provider base

• Incentives can be used to support providersIncentives can be used to support providers Increased flex-time on days of DIGMA conductionIncreased flex-time on days of DIGMA conduction

• Selection of provider as champion can Selection of provider as champion can enhance buy-inenhance buy-in

Sample SessionSample Session

• Room is prepped for patient arrivalRoom is prepped for patient arrival Refreshments, seating, quality of room Refreshments, seating, quality of room

• Patients check-inPatients check-in Escorted to room; medical assistant can take Escorted to room; medical assistant can take

vital signs vital signs • Providers welcome patientsProviders welcome patients• PCP examines patients individually PCP examines patients individually

Behaviorist promotes group discussion Behaviorist promotes group discussion concerning patients medical issues. concerning patients medical issues.

Documenter follows PCPDocumenter follows PCP• Termination of SessionTermination of Session

Barriers to successful Barriers to successful DIGMADIGMA

• Top-down dictation to providersTop-down dictation to providers Providers should not be ordered to conduct DIGMAProviders should not be ordered to conduct DIGMA Desire to conduct DIGMA must come from Desire to conduct DIGMA must come from

providersproviders• Inadequate space to conduct DIGMAInadequate space to conduct DIGMA

DIGMA attendance and atmosphere requirements DIGMA attendance and atmosphere requirements necessitate adequate space planningnecessitate adequate space planning

• Inadequate schedulingInadequate scheduling Scheduler greatly increases chances of reaching Scheduler greatly increases chances of reaching

necessary attendance necessary attendance • Low attendanceLow attendance

Productivity increases of DIGMA predicated on Productivity increases of DIGMA predicated on high attendance rates high attendance rates

Important IssuesImportant Issues

ConfidentialityConfidentiality

• Primary source of confidentiality Primary source of confidentiality concerns comes from providersconcerns comes from providers•Nature of DIGMA sessions inherently Nature of DIGMA sessions inherently address some confidentially issuesaddress some confidentially issuesPatients who attend generally Patients who attend generally

comfortable with discussing personal comfortable with discussing personal health information in group settinghealth information in group setting

• Issues of confidentiality may be Issues of confidentiality may be addressed using Noffsinger’s six-step addressed using Noffsinger’s six-step guidelinesguidelines

Noffsinger’s Six StepsNoffsinger’s Six Steps

• Address confidentiality in promotional Address confidentiality in promotional materialsmaterials Clearly indicate group setting and the sharing Clearly indicate group setting and the sharing

of medical information within groupof medical information within group

• Train staff to properly refer patientsTrain staff to properly refer patients Clearly indicate that session is group visit and Clearly indicate that session is group visit and

not extended individualized sessionnot extended individualized session

• Confidentiality agreement drafted by legal Confidentiality agreement drafted by legal professionalprofessional DIGMA specific release should be created; Do DIGMA specific release should be created; Do

not borrow other release formsnot borrow other release forms

Noffsinger’s Six StepsNoffsinger’s Six Steps

• Signing of confidentiality release by Signing of confidentiality release by attendees is mandatory attendees is mandatory Signing of release form occurs before session.Signing of release form occurs before session. May eventually become unnecessary as time May eventually become unnecessary as time

progresses progresses

• Discussion of confidentiality during sessionDiscussion of confidentiality during session Behaviorist briefly discuses sharing of Behaviorist briefly discuses sharing of

information and maintenance of patient information and maintenance of patient anonymity anonymity

• Placement of release in all patients chartsPlacement of release in all patients charts Record keeping procedure; if using electronic Record keeping procedure; if using electronic

medical records then release can be scannedmedical records then release can be scanned

Modifications to Idealized Modifications to Idealized DIGMADIGMA

•Use of original DIGMA form is ideal Use of original DIGMA form is ideal however, real world constraints may however, real world constraints may prevent such applicationprevent such application•Modifications to DIGMA can occur in a Modifications to DIGMA can occur in a variety of areas variety of areas StaffStaffConduction of sessionConduction of sessionCensus levelsCensus levels

Modifications to Idealized Modifications to Idealized DIGMADIGMA

• StaffStaff Documenter can be eliminated Documenter can be eliminated

Primary provider can take notes Primary provider can take notes Reduction in number of medical assistants Reduction in number of medical assistants

• Conduction of session Conduction of session Length of session time can be decreased Length of session time can be decreased Individual examinations can be entirely Individual examinations can be entirely

removed from group; discussion of removed from group; discussion of examination results upon return to group examination results upon return to group

• Census levelsCensus levels Other clinics have done well on lower than Other clinics have done well on lower than

ideal census levels [4-6 patients per session] ideal census levels [4-6 patients per session]

GuidesGuides

• Improving Chronic Illness Care Improving Chronic Illness Care http://www.improvingchroniccare.org/http://www.improvingchroniccare.org/

downloads/group_visit_starter_kit_copy1.docdownloads/group_visit_starter_kit_copy1.doc

• ImpactBCImpactBC http://www.impactbc.ca/files/documents/http://www.impactbc.ca/files/documents/

NHA_Group_Medical_Appointments_Manual.pdfNHA_Group_Medical_Appointments_Manual.pdf

• American Academy of Family PhysiciansAmerican Academy of Family Physicians http://www.aafp.org/online/en/home/http://www.aafp.org/online/en/home/

practicemgt/quality/qitools/pracredesign/practicemgt/quality/qitools/pracredesign/january05.htmljanuary05.html

ResourcesResources

ResourcesResources• Atkins, T., and E. Noffsinger. "Assessing a Group Medical Appointment Atkins, T., and E. Noffsinger. "Assessing a Group Medical Appointment

Program: A Case Study at Sutter Medical Foundation." Program: A Case Study at Sutter Medical Foundation." Group Practice Group Practice JournalJournal 50.April (2001): 42-49. Print. 50.April (2001): 42-49. Print. • Baurd, Stephanie, Todd Marcy, Becky Armor, Jennifer Chonlahan, and Paige Baurd, Stephanie, Todd Marcy, Becky Armor, Jennifer Chonlahan, and Paige

Beach. "Gropu Medical Visits at a Family Medicine Center: Analysis and Beach. "Gropu Medical Visits at a Family Medicine Center: Analysis and Resolution." Resolution." Medscape: Medical News, Full-text Journal Articles & MoreMedscape: Medical News, Full-text Journal Articles & More. . Web. 08 Apr. 2010. <http://www.medscape.com/viewarticle/541549_2>. Web. 08 Apr. 2010. <http://www.medscape.com/viewarticle/541549_2>. • Bronson, David, and Richard Maxwell. "Shared Medical Appointments: Bronson, David, and Richard Maxwell. "Shared Medical Appointments:

Increasing Patient Access without Increasing Physician Hours." Increasing Patient Access without Increasing Physician Hours." Cleveland Cleveland Clinic Journal of MedicineClinic Journal of Medicine 71.5 (2004): 369-77. Cleveland Clinic. Web. 8 Apr. 71.5 (2004): 369-77. Cleveland Clinic. Web. 8 Apr. 2010. <http://www.ccjm.org/content/71/5/369.full.pdf+html>. 2010. <http://www.ccjm.org/content/71/5/369.full.pdf+html>. • Christianson, Jon B., and Louise H. Warrick. Christianson, Jon B., and Louise H. Warrick. The Buisness Case for Drop-In The Buisness Case for Drop-In

Group Medical Appointments: A Case Study of Luther Midelfort Mayo Group Medical Appointments: A Case Study of Luther Midelfort Mayo SystemSystem. Rep. Vol. 611. Commonwealth Fund, 2003. Print. . Rep. Vol. 611. Commonwealth Fund, 2003. Print. • "Clinical Microsystems :: Toolkits : Shared Medical Appointments." "Clinical Microsystems :: Toolkits : Shared Medical Appointments."

Dartmouth Medical School - DMS HomeDartmouth Medical School - DMS Home. Web. 08 Apr. 2010. . Web. 08 Apr. 2010. <http://dms.dartmouth.edu/cms/toolkits/shared_medical_appointments/>. <http://dms.dartmouth.edu/cms/toolkits/shared_medical_appointments/>. • Group Health Research Institute. Rep. Group Health Research Institute. Group Health Research Institute. Rep. Group Health Research Institute.

Web. 8 Apr. 2010. Web. 8 Apr. 2010. <http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_c<http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_copy1.doc.>.opy1.doc.>.

ResourcesResources• "Harvard Vanguard - Shared Medical Appointments." "Harvard Vanguard - Shared Medical Appointments." Harvard Vanguard Harvard Vanguard

Medical Associates, Delivering Comprehensive Healthcare in the Boston Medical Associates, Delivering Comprehensive Healthcare in the Boston Metro AreaMetro Area. Web. 08 Apr. 2010. . Web. 08 Apr. 2010. <http://www.harvardvanguard.org/about/most/index.asp>. <http://www.harvardvanguard.org/about/most/index.asp>. • ImpactBC. ImpactBC. Confidentiality AgreementConfidentiality Agreement. Rep. ImpactBC. Print. . Rep. ImpactBC. Print. • ImpactBC. Rep. ImpactBC. Web. 8 Apr. 2010. ImpactBC. Rep. ImpactBC. Web. 8 Apr. 2010.

<http://www.impactbc.ca/files/documents/NHA_Group_Medical_Appointments<http://www.impactbc.ca/files/documents/NHA_Group_Medical_Appointments_Manual.pdf>. _Manual.pdf>. • Jaber, Raja, Amy Braksmajer, and Jeffrey Trilling. "Group Visits: A Qualitative Jaber, Raja, Amy Braksmajer, and Jeffrey Trilling. "Group Visits: A Qualitative

Review of Current Research." Review of Current Research." Journal of the American Board of Family Journal of the American Board of Family MedicineMedicine 19.3 (2006): 276-90. Print. 19.3 (2006): 276-90. Print. • Harris, Marianne. "Shared Medical Appointments After Cardiac Surgery-The Harris, Marianne. "Shared Medical Appointments After Cardiac Surgery-The

Process of Implementing a Novel Pilot Paradigm to Enhance Comprehensive Process of Implementing a Novel Pilot Paradigm to Enhance Comprehensive Postdischarge Care." Postdischarge Care." Journal of Cardiovascular NursingJournal of Cardiovascular Nursing 25.2 (2010): 124-29. 25.2 (2010): 124-29. Journal of Cardiovascular Nursing. Web. 8 Apr. 2010. Journal of Cardiovascular Nursing. Web. 8 Apr. 2010. <http://journals.lww.com/jcnjournal/Abstract/2010/03000/Shared_Medical_Ap<http://journals.lww.com/jcnjournal/Abstract/2010/03000/Shared_Medical_Appointments_After_Cardiac.7.aspx>.pointments_After_Cardiac.7.aspx>.• ""Group Visits (Shared Medical Appointments) -- Clinical Quality Improvement Group Visits (Shared Medical Appointments) -- Clinical Quality Improvement

-- American Academy of Family Physicians." -- American Academy of Family Physicians." Home Page -- American Academy Home Page -- American Academy of Family Physiciansof Family Physicians. Web. 08 Apr. 2010. . Web. 08 Apr. 2010. <http://www.aafp.org/online/en/home/practicemgt/quality/qitools/pracredesig<http://www.aafp.org/online/en/home/practicemgt/quality/qitools/pracredesign/january05.htmln/january05.html

ResourcesResources• Noffsinger, Edward B. Noffsinger, Edward B. Running Group Visits in Your PracticeRunning Group Visits in Your Practice. New . New

York ; Berlin: Springer, 2007. Print. York ; Berlin: Springer, 2007. Print. • Noffsinger, Edward B. Noffsinger, Edward B. Running Group Visits in Your PracticeRunning Group Visits in Your Practice. New . New

York ; Berlin: Springer, 2007. Print. York ; Berlin: Springer, 2007. Print. • Noffsinger, Edward B. Noffsinger, Edward B. Running Group Visits in Your PracticeRunning Group Visits in Your Practice. New . New

York ; Berlin: Springer, 2007. Print. York ; Berlin: Springer, 2007. Print. • Noffsinger, Edward B. "Will Drop-In Group Medical Appointments Noffsinger, Edward B. "Will Drop-In Group Medical Appointments

(DIGMAs) Work In Practice?" (DIGMAs) Work In Practice?" The Permanente JournalThe Permanente Journal 3.3 (1999): 58- 3.3 (1999): 58-67. The Permanente Journal. Web. 8 Apr. 2010. 67. The Permanente Journal. Web. 8 Apr. 2010. <http://xnet.kp.org/permanentejournal/fall99pj/digma.html>. <http://xnet.kp.org/permanentejournal/fall99pj/digma.html>. • Kirsh, Susan, Sharon Watts, Kristina Pascuzzi, Mary O'Day, David Kirsh, Susan, Sharon Watts, Kristina Pascuzzi, Mary O'Day, David

Davidson, Gerarld Strauss, Elizabeth Kern, and David Aron. "Shared Davidson, Gerarld Strauss, Elizabeth Kern, and David Aron. "Shared Medical Appointments Based on the Chronic Care Model: a Quality Medical Appointments Based on the Chronic Care Model: a Quality Improvement Project to Address the Challenges of Patients with Improvement Project to Address the Challenges of Patients with Diabetes with High Cardiovascular Risk." Diabetes with High Cardiovascular Risk." Quality and Safety in Quality and Safety in Health CareHealth Care 16 (2007): 349-53. BMJ. Web. 8 Apr. 2010. 16 (2007): 349-53. BMJ. Web. 8 Apr. 2010. <http://qshc.bmj.com/content/16/5/349.abstract>. <http://qshc.bmj.com/content/16/5/349.abstract>.