Group Visits for High-Risk Cohort Program

The following outline is copied from my PowerPoint presentation. You are welcome to read and use, but any commercial use is strictly copyrighted to Steven Masley, M.D.:
This information is not intended for medical decision making. Always consult your own physician who knows your personal medical history before making medical decisions.

Group Visits for High-Risk Cohort Program
Designed by Steven Masley, M.D.

GROUP VISIT TALK OUTLINE

What are group visits?
Why should you offer group visits?
What are the outcomes from using groups visits?
How do you organize and schedule a group visit?
How you bill & document a group visit?

GROUP VISITS COMPENSATE YOU TO PROVIDE BETTER PATIENT EDUCATION

Group Visits Provide an Effective Way to Manage High Risk Cohorts
Maximize educational time by working with 15-30 patients at a time
Many patients prefer group visits
Group visits offer a billable service
Any medical provider can offer group visits (doctors, nurses, pharmacists, mental therapists, dieticians, etc.--a physician and a dietician can even do a visit together)

GROUP VISITS CAN BE ANNUAL OR LONGETUDINAL

Annual visits share information and reach set targets (e.g., annual foot exams in diabetics or lipid levels for people with coronary artery disease)

Longitudinal group visits can substitute many individual doctor visits (e.g., many diabetics present 10-15 times yearly to manage their diabetes, which can be done in a group setting)

SUCCEEDING IN CHANGING LIFESTYLES WITH GROUP VISITS

Group visits help many patients succeed in making lifestyle changes
Involve partners and family in lifestyle changes
Food monitoring and scoring improves diet compliance
Provide menu plans to improve diet changes
In "motivated patients," major changes can be more successful than simple ones. Group visits allow time for discussion and support.

What is the Difference Between a Group Visit and a Class?

A class provides information to a group
A group visit must gather information and document it in the patient record, label an assessment, and note a plan. A pretyped form prepared for the visit, works well.
A group visit is a billable service. I code an extended physician visit for the first session because of an extended chart review, and a limited visit thereafter.

Why Should You Offer Group Visits?

Share more information in less time
Improve clinical outcomes
Improve patient satisfaction for many patients
Save money on the cost of providing care
Improve provider satisfaction
This is a rare Win/Win/Win/Win/Win opportunity

Patient Satisfaction Can Improve with Group Visits

At Kaiser in Colorado, a study randomized patients to group visits or a control group. They evaluated patient satisfaction. 419 pts contacted and 208 agreed to participate.

What is the Willingness of Patients to Participate in Group Visits?
About 50%
At Kaiser in Colorado, 419 contacted to enroll 208
In the Olympia GHP Type 2 Diabetic case study, 40 contacted to enroll 20 (for 10 visits over 1 year-15 out of 20 had > 75% attendance)
In the Olympia GHP GERD study, 560 contacted to enroll 400 (for a single visit and one phone call)
In the Olympia GHP DIET (cardiac trial) 240 contacted to enroll 126 (for 15 visits over 1 year)
Anticipate 10-20% drop out rates within 2-3 visits (Drop-outs still benefit!)

OUTCOME DATA FROM GROUP VISIT STUDIES

Evidence to date for Groups visits is limited to intermediate markers for disease states

The identical intervention randomization to Group Visit or Individual Visit sessions has not occurred

Types of Cohorts

Diabetes
GERD (Gastro esophageal reflux disorder)
Coronary Artery Disease
Asthma
CHF
Weight Loss
Irritable Bowel Syndrome
Hearing Impaired Group Visits
Sports Physicals
High-Risk Senior Groups

COST DATA: Group Visits for Type 2 Diabetics

We compared the total nine month cost of caring for 19 diabetic pts prior to, and during group visit.

The group classes were asso-ciated with a 6% decrease in the total cost of care for each pt.

OUTCOME DATA: Group Visits for Type 2 Diabetics

We followed 20 Type 2 diabetics HbgA1C levels and Total Cholesterol/ HDL ratios over time. Both levels decreased within 90 days and remained reduced over 20 months.

Diabetic monitoring targets (i.e., annual eye & foot exams, urinary micro-albumin, and blood work screen frequency improved from 60-70% to >90%)

Cost Data: Group Visits for GERD

400 patients with GERD were enrolled and randomized to a single group visit focusing on lifestyle changes, and a single follow-up phone call. They were followed for per-member-per-month cost data and cardiac event outcomes.

333 patients were available with the health plan for PMPM expense analysis one year after the study.

ORGANIZING & SCHEDULING GROUP VISITS

How You Can Identify Cohorts for Group Visits?

Review pharmacy prescription data (e.g., patients Rx’d with diabetic meds)
Pull diagnosis codes from billing data
Create registries at patient visits or after refill requests
Create an Excel file or a Registry file which you can update at scheduled intervals

Plan in Advance for Group Visits

Schedule them at least 6-8 weeks in advance
Schedule 2-3 MA/LPN level providers for the first 15-30 minutes to collect data: BPs, wts, foot exams, handout lab slips, etc.
Prepare overheads and handouts, or choose reading material in advance
Prepare chart note forms in advance

GROUP VISIT ORGANIZATION

ORGANIZATION BRINGS ORDER

DISORGANIZATION PRODUCES CHAOS

How Much Time Do You Need To Provide a Group Visit?

Allow 4 hours total time for a group visit with 20-30 patients/session. This allows:
1 hour to prepare materials
1 hour for chart reviews prior to visit
1/2 hour for 2-3 nurses to collect data, and for the provider to document specific plans
1/2 hour for wrap-up (planning for the next group visit session, and seeing a rare individual patient--i.e. a pt for an earache)

How Do I Organize My Time During a Group Visit Session?

30 minutes to collect patient data
15 minutes for the group to address their concerns to me and each other
45 minutes to introduce material and information
30 minutes to answer questions and plan for the next group visit together, and on occasion, to see a couple patients alone for brief evaluations

Selecting Patient Material

Pick evidence-based objectives and targets, and give them to your patients
Recommend a book addressing lifestyle changes for your class (e.g., an asthma book, Masley’s The 28-Day Antioxidant Diet Program, Ornish’s Reversing Heart Disease, the AHA’s Cholesterol Reduction Meal Plan, Bland’s The 20-Day Rejuvenation Diet Program, or The McDougall Program)
Request ADA or AHA handout materials
Make evidence-based materials yourself

PREPARE YOUR CHART NOTE IN ADVANCE

Have a typed, fill in the blank note for your chart reviews
Fill in targets and recent labs prior with the chart review
Choose targets you want to reach for the note
Leave data for a nurse to collect

CORONARY ARTERY DISEASE TARGETS

Encourage tobacco cessation
Add anti-coagulation
Reach and follow lipid targets
Manage HTN and hyperglycemia
Improve endothelial function
Improve diet and activity levels
Address new angina or CHF

SAMPLE CAD PROGRESS NOTE

Subjective

Any new angina / signs CHF?
Activity Level
- no activity
- moderate 2-3 times / w
- moderate 4-6 times / wk vigorous <4 times / wk vigorous 4 or more x / wk
Fat Intake
- Most common fat intake
Produce serving intake
- less than 3 daily
- 3-4 daily
- 5 or more daily
Past Med Hx: (See chart)
Meds:
Tobacco Use:

Objective

Wt, BP, Recent lipid profile, FBS or HbgA1C

Assessment

CAD; At target?
Plan
Treat and follow lipids
ASA daily

Encourage activity and healthy diet

Review med options: risks, benefits, effects

Mange HTN & glycemia

>50% visit in counseling

DIABETIC TYPE 2 TARGETS

Improve glycemic controls--follow and manage HgbA1C

Reach lipid targets

Enhance diet and activity levels

Follow diabetic screening goals, and intervene when indicated

Look for an Ace-Inhibitor indication

Anti-coagulation

Encourage tobacco cessation

SAMPLE DIABETES PROGRESS NOTE

Subjective

Recent hypoglycemia?

Activity Level

no activity

moderate 2-3 times / wk

moderate 4-6 times / wk vigorous <4 times / wk vigorous 4 or more x / wk

Fat Intake

Most common fat intake

Produce serving intake

less than 3 daily

3-4 daily

5 or more daily

Past Med Hx: (See chart)

Meds:

Tobacco Use:

Objective (dated)

Wt, BP, Recent HbgA1C, lipids, urinary microalbumin, creatinine

Foot and eye exams

Assessment

Type 2 Diabetes, (controlled/uncontrolled)

Plan

HgbA1C management

ASA daily

Encourage activity

Encourage diet

Review med options: risks, benefits, side effects (Including ace-inhib.)

Manage lipids, HTN, proteinuria

>50% visit in counseling

Pitfalls in Offering Group Visits

Call coverage, especially OB call
Consider your own child care plan
Minimize patient "NO SHOWS" with:
- Reminder calls 1-2 days prior, "Your MD expects you at this visit!
- Advertise guest speakers or cooking demonstrations
- If the patient’s physician isn’t going to lead the group visit, a physician letter encouraging the session improves attendance

LIFESTYLE ISSUES TO ADDRESS

Food choices (Adding foods, changing fat intake, reducing fat intake)
Medications and supplements
Lab testing topics
Exercise topics
Shopping, dining, and cooking skills
Food label reading 101
Understanding lipid levels and targets
Stress management

ENHANCE YOUR SUCCESS AT CHANGING LIFESTYLES

Involve partners and family members
Monitor food choices. Monitoring food records decreases fat intake by 10%.
ADD FOODS to your patients diets! *
Providing menu plans to motivated patients can be as effective as providing food *

Studies show that major diet changes can have higher compliance than minor ones

Group visits enhance compliance *

GROUP VISITS ARE EFFECTIVE

Finally, You can get paid to educate your patients during a group visit and:

Improve outcomes
Improve patient satisfaction
Reduce health care expenses
Enhance provider satisfaction