DESIGNING YOUR GROUP VISIT PROGRAM FOR OPTIMAL BENEFIT DropIn Group Medical Appointments DIGMAs Coop

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DESIGNING YOUR GROUP VISITPROGRAM 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 theDIGMAmodel_at_aol.com
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WORK SMARTER, NOT HARDER!? Quality ?Access
? Outcomes ? 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!!!

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WHY PATIENTS LIKEDIGMAs 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

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DESIGN 4 FACTORS IN to 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

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DIGMA CHARACTERISTICS

• Typically 90-min. Weekly Sessions-daily OK
• Heterogeneous, Homogeneous, Mixed Subtypes
• Open to Most of MDs 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

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FLOW OF A TYPICAL DIGMA

• 10-16 Different Pts Register
• Most by Appt. (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 Behaviorists 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)

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PATIENTS 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

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WHAT IS REQUIRED FOR DIGMAs 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
• Provider
• Behaviorist
• 1-2 Nurses
• Documenter
• Dedicated Scheduler
• (Very important for full groups)
• In Larger Systems
• Champion
• (Needed to rapidly expand program)
• Program Coordinator
• (Assist champion, monitor census, etc)

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GETTING PAIDThe Efficient Delivery of Quality
Care to a Group of Pts that Addresses Each
Pts 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 behaviorists time
  
• No current EM codes (Are they needed for DIGMAs
  Physicals SMAs?)
• Not fully resolvedadjust to any future changes
  in rules
• Almost All Primary Specialty Care Settings

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Patient SatisfactionCleveland Clinic

• 87 of patients rescheduled into a future DIGMA
• This excludes Physicals SMAs which are not
  rescheduled

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VA PILOT Primary Care Heterogeneous DIGMA Feb.
04 ? MD Productivity 520 Patient
Satisfaction 4.58/5.0
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Improved Access-Pilot MDs
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INCREASED MD PRODUCTIVITYPilot Study at Sutter
Medical Foundation (Pt Sat. 4.7/5)
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TYPICAL 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
• MDs 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

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1 MDs ? PRODUCTIVITY Through Physicals
SMAs(Pre-SMA productivity 2.2 individual
physicals / 90 min.)
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PATIENT SATISFACTION RESULTS(Individual Vrs
Physicals SMA VisitsPlastic Surgery)
Discussed all my questions Comfortable with
decision Understand complications Received
amount info. wanted How long waited for
appt. Confidence in physician Overall rating of
visit
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MEDICAL SPECIALTIES (TO DATE) (Launched Over 400
DIGMA PSMA MDs20,000 Pt Visits)

• Internal Medicine
• Family Practice
• Allergy
• Cardiology
• Dermatology
• Endocrinology
• General Surgery
• Gynecology
• Nephrology
• Nurse Practitioners
• Obstetrics
• Oncology
• Ophthalmology

• Orthopedic Surgery
• Pediatrics
• Physiatry
• Plastic Surgery
• Podiatry
• Psychiatry
• Rheumatology
• Sports Medicine
• Travel Medicine
• Urgent Care
• Urology
• Weight Management
• Womens Health

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SMA OPERATIONAL CHALLENGES SMAs Must Be
Properly Designed, 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

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LESSONS LEARNED IN PRACTICE All Programs Must
Be Carefully Designed, Supported, Promoted, Run

• First Get Admin. Support
• Use Skilled Trained Team
• Best possible champion PC
• ? Nurse/behaviorists roles
• Try to get documenter
• Use a dedicated scheduler
• Engage MDs operational staff
• Train MDs support staff
• MD Delegates to Team

• Always Maintain Census
• Promote program effectively
• Use quality marketing materials
• Use well designed Pt Packet
• Foster Group Interaction
• Have Pts Stay All Session
• Start Finish on Time
• Solve Any System Problems
• Ongoing SMA Evaluation