Group Care Through the Lifecycle

Kathy Trotter, MSN, CNM, FNPtrott004@mc.duke.edu

OBJECTIVES

Describe your current practice in terms of how care is rendered, its efficiency, 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 five applications of the group care model.

Review techniques of group facilitation.

Traditional vs. Group Care

waiting room time No wait

exam room Group space

provider central Empowerment

referral for other care Multidisciplinary

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 oncel Working with really activated

patientsl Finding work fun and energizing

As an administrator, imagine...

l Better access for your patientsl Freed-up exam rooms for paying

proceduresl Happy providers/staff….less turnoverl Great marketing programl Better outcomesl Predictable clinic time schedules

Now imagine… Now imagine…

l Group Care from: l Beautiful birth

• to

– Peaceful death

Group Care for: Group Care for:

l Diabetesl NICU follow-upl Seniorsl Menopausel Hyperlipidemia

l Special needsl Chronic painl Cardiac rehabl Physical medicinel Pre/post operative

Group Care for:

Well Baby Eating disorders

Asthma Smoking Cessation

Pregnancy Oncology

Obesity

Jared Lazarus

Duke Photography

Jared Lazarus

Duke Photography

Groups provide…Groups provide…

l A vehicle for

• social change

l An opportunity to • learn from each • other

l Fun and • interesting sharing

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)

Kaiser Permanente, Kaiser Permanente, SeniorsSeniors

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.

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

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

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

Diabetes Groups, 5 yearDiabetes Groups, 5 year

Control Group p Value

HbA1c 9.0 ± 1.6 7.3 ± 1.0 <.001

Quality of Life (lower = better)

89.2 ± 30.1 43.7 ± 7.2 <.001

DM knowledge 18.0 ± 8.5 27.9 ± 5.7 <.001

Problem solving(Self Efficacy)

10.0 ± 3.8 17.1 ± 2.4 <.001

Colorado Kaiser Permanente

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

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

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

Process of Facilitative Group Sessions is Key to the Empowerment Process and thus self management of their health

Essential Elements of Group Care

RCT on CenteringPregancy Group Care Intervion and RCT on CenteringPregancy Group Care Intervion and effect on Preterm Delivery, effect on Preterm Delivery, Stratified by Study ConditionStratified 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

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

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

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 benefit from this?

Facilitation skill building

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.

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.

Group Facilitation

l A cooperative partnership between provider/facilitator and members

l The art of listening to one another

The Facilitative ProcessThe 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

The Facilitative Process…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..?”

The Facilitative Group The Facilitative Group “Conductor”“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