designing your group visit program for optimal benefit
TRANSCRIPT
DESIGNING YOUR GROUP VISITDESIGNING YOUR GROUP VISITPROGRAM FOR OPTIMAL BENEFITPROGRAM FOR OPTIMAL BENEFIT
Drop-In Group Medical Appointments (DIGMAs) Cooperative Health Care Clinics (CHCCs)
Physicals Shared Medical Appointments (Physicals SMAs)
Edward B. Noffsinger, Ph.D.Phone: (831) 427-1011
E-Mail: [email protected]
WORK SMARTER, NOT HARDER!WORK SMARTER, NOT HARDER! Quality Quality Access Access Outcomes Outcomes Cost Cost
Leverage Existing Resources Productivity (200-300%, or more) Better manage practices & chronic illnesses
Patient & Physician Satisfaction Quality & outcomes (Pt Ed, health maint., injections, etc.) Time, support, compliance, Pt Ed Pt-MD relationships
Have Fun & Make Money ! (A Group Room Can Create 2.5 FTEs)
ALL AT THE SAME TIME!!!
WHY PATIENTS LIKEWHY PATIENTS LIKEDIGMAs & Physicals SMASDIGMAs & Physicals SMAS
Prompt Access & More Time (90’ w/own MD) Pt Education & Psychosocial Needs Max-Packed Visits (1-stop shopping)
Help from Other Pts & Behaviorist Appropriate Privacy Is Maintained Closer Follow-Up Care An Additional Healthcare Choice
DESIGN 4 FACTORS INDESIGN 4 FACTORS IN to DIGMAs & Physicals SMAsto DIGMAs & Physicals SMAs
Maximize QUALITY
Quality Pt Ed & promotional materials Max-pack visits (“one-stop shopping” for Pts) Maximize nurse & behaviorist roles
Consistently Meet CENSUS targets Increase by 300% whenever possible
Contain Overhead COSTS Use appropriate trained personnel & facilities
MEASURE Results on an Ongoing Basis
DIGMA CHARACTERISTICSDIGMA CHARACTERISTICS Typically 90-min. Weekly Sessions-daily OK
Heterogeneous, Homogeneous, & Mixed Subtypes Open to Most of MD’s Practice Different Pts Attend Sessions-w/medical need Medical Care from Start to Finish-no “class” Used in FFS & Capitated Systems
Series of 1 MD-1 Pt encounters with observers Most Care & Exams Delivered in Group Private Discussions & Exams as Needed Behaviorist & Often a Documenter Expanded Nurse & Behaviorist Roles
FLOW OF A TYPICAL DIGMAFLOW OF A TYPICAL DIGMA
10-16 Different Pts Register
Most by App’t. (some drop-in )
Pts Often Get “Patient Packet”
Sign “Confidentiality Release”
Nurse(s) Starts Vitals Early
Pts Sit in Circle (with SPs)
MD Sits Next to Behaviorist
Starts with Behaviorist’s Intro.
Start with Pts Leaving Early
History & Medical Decision Making
Exams As Needed (mostly in group)
Chart After Each Pt (must support bill)
MD Delivers Care to Rest (1 at a time)
Last 5-10’ for Private Exams/Talks
Start & End on Time
Behaviorist Stays Late (not MD)
PATIENTS FOR DIGMAsPATIENTS FOR DIGMAs
Include:
Intakes & Routine F/U Care
Stable Chronically Ill
Difficult & Problematic Pts High or low utilizers Non-compliant & compliant Pts Extensive info/psychosocial issues Pts needing time/peer support
Pts willing to attend (voluntary)
Exclude:
Pts w/Different Language
Demented/Hearing Impaired
Serious Infectious Illnesses
Medical Emergencies
Complex Medical Procedures
Any Pts MD Wants Excluded
Pts Refusing to Attend
WHAT IS REQUIRED FORWHAT IS REQUIRED FOR DIGMAs & Physicals SMAsDIGMAs & Physicals SMAs
Administrative Support
MD & Staff Buy-In
Facilities Requirements DIGMA
Group room for ~ 25 1 Nearby equipped exam room
Physicals SMA Smaller group room for ~ 12-15 ~4 Equipped exam rooms
Quality Promotional Materials
Staffing ProviderProvider BehavioristBehaviorist 1-2 Nurses1-2 Nurses DocumenterDocumenter Dedicated SchedulerDedicated Scheduler (Very important for full groups)
In Larger Systems: Champion(Needed to rapidly expand program)
Program Coordinator(Assist champion, monitor census, etc)
GETTING PAIDGETTING PAID“The Efficient Delivery of Quality Care to a Group of Pts that “The Efficient Delivery of Quality Care to a Group of Pts that
Addresses Each Pt’s Unique Medical Needs Individually”Addresses Each Pt’s Unique Medical Needs Individually”
Voluntary Practice Management Tool Series of 1MD-1Pt Encounters, with Observers Address Each Pts Unique Medical Needs Ind. Complete Exams & F/Us (medical care throughout) Typically Billed by:
Level of Care Delivered & Documented Documentation must support bill No bill for counseling time or behaviorist’s time No current E&M codes (Are they needed for DIGMAs & Physicals SMAs?) Not fully resolved—adjust to any future changes in rules
Almost All Primary & Specialty Care Settings
Patient Satisfaction—Patient Satisfaction—Cleveland ClinicCleveland Clinic
87%87% of patients of patients rescheduled into a rescheduled into a future DIGMAfuture DIGMA
This excludes This excludes Physicals SMAs— Physicals SMAs— which are not which are not rescheduledrescheduled
Rescheduled Back Into DIGMA
Individual13%
Group87%
VA PILOTVA PILOT Primary Care Heterogeneous DIGMAPrimary Care Heterogeneous DIGMA Feb. ‘04Feb. ‘04 MD Productivity = 520% Patient Satisfaction = 4.58/5.0 MD Productivity = 520% Patient Satisfaction = 4.58/5.0
2.53
13 15
0
2
4
6
8
10
12
14
16
Primary Care
Current Prod.Current Sched.Pilot DIGMAScheduled
Improved Access-Improved Access-Pilot MDsPilot MDs
44.6%32.759.0Avg. # Days Wait For 2nd Available Return Appointment
34.0%68103Dr. C – Podiatry
64.1%1439Dr. B – Family Practice
54.3%1635Dr. A – Internal Med/Endo
% Decrease in Wait List
Sept. 28, 2000
(1 Day after launch)
Aug. 4, 2000 (8 weeks prior to
launch)
Pilot Physician
Number of Days Until 2nd Available Return
INCREASED MD PRODUCTIVITYINCREASED MD PRODUCTIVITYPilot Study at Sutter Medical FoundationPilot Study at Sutter Medical Foundation ((Pt Sat. = 4.7/5Pt Sat. = 4.7/5))
% Increase in MD Product.
Avg. # Pts
/Wk# Pts/Wk# Pts/Wk# Pts/Wk# Pts/Wk# Pts/Wk# Pts/Wk
256.4%41.865 / 433 / 441 / 436 / 431 / 335 / 4Total
202.1%9.5913661310Dr. D – Family Practice
Initial # Pts / 60’ = 4.7Min. Census = 9.4
228.6%9.6148117Cancel(Ill)
8Dr. C - Family Practice
Initial # Pts / 90’ = 4.2Min Census = 12.6
300.0%8.71778965Dr. B - RheumatologyInitial # Pts / 90’ = 2.9Min. Census = 8.7
311.1%14.025516141212Dr. A - Internal Med.Initial # Pts / 90’ = 4.5Min. Census = 13.5
TotalWeek #6
2/7/00
Week #5
1/17/00
Week #4
1/10/00
Week #3
1/3/00
Week #2
12/13/99
Week #1
12/6/99
Type of DIGMA
TYPICAL PHYSICALS SMATYPICAL PHYSICALS SMA
Model Design Held Each Week for 90’
Mixed Subtype (by age/sex)
Private Exams 1st, then Grp.
Behaviorist runs group while exams are done
Nurse & Behaviorist Roles
MD’s Own Pts Scheduled Also from other MDs’ wait lists
Or pre-screened new Pts
Start and End on Time w/doc. done
Flow Of Physicals SMA Send Pt Packet 2 Wks Ahead
Pts Return Questionnaire/Tests
6-9 Same-Sex Pts Register-PC 300% MD productivity
Exams at Beginning (min. talk) Use ~4 Exam Rooms While behaviorist runs group
Followed by Group (2nd half) Basically a small DIGMA
Documentation Support
Minor Procedures at End
1 MD’s 1 MD’s PRODUCTIVITY PRODUCTIVITY Through Physicals SMAsThrough Physicals SMAs
(Pre-SMA productivity = 2.2 individual physicals / 90 min.)
0.00%
50.00%
100.00%
150.00%
200.00%
250.00%
300.00%
350.00%
400.00%
Sessions 1-4 Sessions 5-8 Sessions 9-10
Percentage Increase In Physician's Productivity
0
1
2
3
4
5
6
7
8
9
Sessions 1-4 Sessions 5-8 Sessions 9-10
One Physician's Physical's SMA Productivity
PATIENT SATISFACTION RESULTSPATIENT SATISFACTION RESULTS(Individual Vrs Physicals SMA Visits—Plastic Surgery)(Individual Vrs Physicals SMA Visits—Plastic Surgery)
0% 20% 40% 60% 80% 100%
Individual Visit Physicals SMA
PPh
Discussed all my questions
Comfortable with decision
Understand complications
Received amount info. wanted
How long waited for app’t.
Confidence in physician
Overall rating of visit
MEDICAL SPECIALTIESMEDICAL SPECIALTIES (TO DATE)(TO DATE) (Launched Over 400 DIGMA & PSMA MDs—20,000 Pt Visits)(Launched Over 400 DIGMA & PSMA MDs—20,000 Pt Visits)
Internal MedicineInternal Medicine Family PracticeFamily Practice Allergy Allergy CardiologyCardiology Dermatology Dermatology EndocrinologyEndocrinology General SurgeryGeneral Surgery Gynecology Gynecology Nephrology Nephrology Nurse PractitionersNurse Practitioners Obstetrics Obstetrics OncologyOncology OphthalmologyOphthalmology
Orthopedic SurgeryOrthopedic Surgery PediatricsPediatrics PhysiatryPhysiatry Plastic SurgeryPlastic Surgery PodiatryPodiatry PsychiatryPsychiatry RheumatologyRheumatology Sports MedicineSports Medicine Travel MedicineTravel Medicine Urgent CareUrgent Care UrologyUrology Weight ManagementWeight Management Women’s HealthWomen’s Health
SMA OPERATIONAL CHALLENGESSMA OPERATIONAL CHALLENGES “SMAs Must Be Properly Designed, “SMAs Must Be Properly Designed,
Supported, Promoted, & Run”Supported, Promoted, & Run”
Introduce Change
Major Paradigm Shift
Magnifies System Probs.
Physician Buy-In
Training Issues
Address Confidentiality
Must Promote Effectively
Group & Exam Rooms
Competing Resource Demands
Ongoing Evaluation
Launch Targeted # / Year
Always Maintain Census
LESSONS LEARNED LESSONS LEARNED IN PRACTICEIN PRACTICE
“All Programs Must Be Carefully Designed, Supported, Promoted, & Run”“All Programs Must Be Carefully Designed, Supported, Promoted, & Run”
First Get Admin. SupportFirst Get Admin. Support
Use Skilled & Trained Team Best possible champion & PC
Nurse/behaviorist’s roles
Try to get documenter
Use a dedicated scheduler
Engage MD’s operational staff
Train MD’s support staff
MD Delegates to TeamMD Delegates to Team
Always Maintain Census Promote program effectively Use quality marketing materials Use well designed Pt Packet
Foster Group InteractionFoster Group Interaction
Have Pts Stay All SessionHave Pts Stay All Session
Start & Finish on TimeStart & Finish on Time
Solve Any System Problems
Ongoing SMA Evaluation