Chronic Care Model: The Role of the Group Visit In Diabetes Care & Management
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1 Chronic Care Model: The Role of the Group Visit In Diabetes Care & Management Pam Allweiss MD, MPH Gwen Short, MSN, MPH University of Kentucky College of Nursing, & Department of Family & Community Medicine
2 Group Visit Topic Outline The Academic Chronic Care Collaborative Background & Supportive Research Nuts & Bolts of the Group Visit Getting Started Billing Issues Resources Questions & Answers
3 The Academic Chronic Care Collaborative (ACCC) A partnership between the Association of American Medical Colleges (AAMC Improving Chronic Illness Care (ICIC and 22 academic institutions Rationale: health professions students and residents should learn in settings that strive to deliver the highest standard of care achievable
4
5 Plan-Do-Study-Act (PDSA) Plan conduct group visit Do develop guidelines and content, invite patients, present content on foot care, perform foot exams, provided snacks, provide 1:1 time, Q&A time Study debrief w/ faculty and staff, obtain patient feedback & ideas for upcoming topics of discussion Act continue group visits on a monthly basis, address no-show rate, continue to include residents as teachers
6 UK ACCC Location: University of Kentucky Hospital Affiliation: UK Hospital Residency Programs: UK Family Medicine & UK Internal Medicine Residency Clinical Sites: UK Clinics Previous Collaborative Experience: Very little
7 Pilot Sites/Focus Population Pilot Site & Location Residency Program Chronic Condition/Pilot Population # University of Kentucky Clinics Lexington, KY Family Medicine Internal Medicine Diabetes/ 625 Diabetes 762
8 Project Aims Improve clinical outcomes of patients with diabetes. Integrate the CCM into residency and health professions education programs. Change focus of care from provider to patient by developing a true team approach to health care. Improve collaborative relationships between the AHC and the community.
9 Summary of Current Status Accomplishments 1. Faculty & staff have increased their teamwork activities. 2. One faculty physician has assumed the role of Director of Quality Improvement, and is an active participant in the UK ACCC.
10 Group Visit Topic Outline The Academic Chronic Care Collaborative Background & Supportive Research Nuts & Bolts of the Group Visit Getting Started Billing Issues Resources Questions & Answers
11 Future of Primary Care Medicine Primary care providers need to learn strategies to better manage chronic disease PCPs will provide a medical home to patients Pay for performance physicians will be held accountable for patient outcomes Improving chronic disease management makes good business sense Group visits have the potential of generating an additional $15,400/physician/year Martin, JC, et al. (2004). The future of family medicine: a collaborative project of the family medicine project. Annals of Family Medicine 2:S3- S32.
12 Background & Supportive Research Group visits are an example of an improvement in delivery system design Origin of group visits Appeared in the field of mental health Chronic Illness Edward Noffsinger, Ph.D. Kaiser Permanente San Jose, CA
13 Background & Supportive Research Why do group visits? Improved patient outcomes Better dietary compliance Decreased total cholesterol/hdl ratios Reduction in HbA1C Decreased health care expenses Improved patient and provider satisfaction
14 Background & Supportive Research Scott, J.C., et al. (2004) Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic. Journal of the American Geriatric Society, 2004, 52(9), Intervention: monthly group meetings held by patients primary care physician Results: fewer hospital admissions, ED visits, and professional services, decreased costs, higher satisfaction with their PCP, better quality of life, greater self-efficacy. No changes in health status, ADLs, outpatient/pharmacy/home health/skilled nursing facility services.
15 Background & Supportive Research Trento, M. et al. (2001). Group visits improve metabolic control in Type 2 Diabetes. Diabetes Care, 24(6), Intervention: Q 3 month group visits versus usual care Results: Improved knowledge of diabetes, lower AbA1C, increased HDL cholesterol, decreased triglyceride levels, improved quality of life, more appropriate health behaviors, less total time spent by physicians with longer interaction time with patients
16 Background & Supportive Research Wagner, EH, et al. (2001). Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care, 2001, 24(4), Intervention: ½ day chronic care clinic (group visit), consisting of time with PCP, nurse, clinical pharmacist, education/peer support meeting. Results: increased receipt of preventive procedures, increased helpful patient education, significant improvement on 2/5 health status indicators, slightly more primary care visits, decreased specialty and ED visits. Among intervention participants, an association was shown between # of chronic care clinics attended and increased patient satisfaction and improved HbA1C levels.
17 Background & Supportive Research Graue, M. et al. (2005). Evaluation of a programme of group visits and computer-assisted consultations in the treatment of adolescents with Type 1 diabetes. Diabetes UK. Diabetic Medicine, 22, Intervention: group visits every 3 months over a 15 month period, with computer-assisted consultation Results: Improved scores on disease impact, diabetes-related worries, mental health, and general behavior among participants older than 14 years of age. No changes in HbA1C. No significant changes in younger teens.
18 Background and Supportive Research Culhane-Pera, K., et al. (2005). Group visits for Hmong adults with Type 2 diabetes mellitus: a pre-post analysis. Journal of Health Care for Poor & Underserved, 16(2), Intervention: group visit versus usual care Results: improved mental health. No change in clinical outcomes.
19 Group Visit Topic Outline The Academic Chronic Care Collaborative Background & Supportive Research Nuts & Bolts of the Group Visit Getting Started Billing issues Resources Questions & Answers
20 Nuts & Bolts of the Group Visits Getting Started What is included in a group visit? Group education & interaction Individual patient visit (vital signs, history taking, PE) Differs from a support group, which are generally led by peers and do not include one-on-one consultation with a physician
21 Getting Started Types of Group Visits The CHCC (Cooperative Health Care Clinic) Model Focus on patient population or disease state The DIGMA (Drop-In Group Medial Appointment) Model Focus on patient panel of each individual physician An extended medical appointment with the physician
22 Getting Started Typically, group visits... Are 1 ½-2 ½ hours, at least 30 minutes of which allocated for individual sessions Include 20 patients or less Meet weekly, monthly, or quarterly Have at least 1 physician at the group visit, with other clinical personnel as are available
23 Getting Started A typical group visit agenda: 15 minutes introduction & welcome 30 minutes topic of the day 15 minutes break 15 minutes questions and answers 15 minutes planning and closing 30 minutes 1:1 visits with provider and nurse
24 Getting Started What the UKACC team has learned Patients and learners like the group visit format A successful group visit can achieve multiple goals Providing healthy snacks is an incentive Difficult patients often do well in a group setting 90 minutes is probably not long enough
25 Getting Started Resources group visit starter kit Jaber, R. (2006). Group visits for chronic illness care: Models, benefits and challenges. Family Practice Management, 13(1). Retrieved from Masley, S. (2000). Planning group visits for high-risk patients. Family Practice Management, 7(6). Retrieved from Noffsinger, E. (2000). Preventing potential abuses of group visits. Group Practice Journal, May,
26 Group Visit Topic Outline The Academic Chronic Care Collaborative Background & Supportive Research Nuts & Bolts of the Group Visit Getting Started Billing Issues Resources Questions & Answers
27 Billing Issues Reimbursement for group visits is challenging! Physician education to group usually not reimbursed Education & Training for patient self-management (non-physician to group, using standard curriculum) (individual patient) (2-4 patients) (5-8 patients)
28 Billing Issues Non-physician to group, not using a standard curriculum reported in 15 minutes of face-to-face time
29 Billing Issues Medicare, BCBS, Aetna, and others pay for diabetes self-management training G0108 (individuals session, 30 minutes) G0109 (group session, 30 minutes) ADA certification (individual or unit) must be in place
30 Billing Issues Evaluation & Management Code or May be the best option
31 Billing Issues Summary Points Know what types of service are being provided in the group setting Investigate billing opportunities, other than a physician-patient E & M service Check with major insurance payers in advance to collect and review coverage guidelines and billing parameters for group visits Be prepared to submit documentation to support the group visit concept & service Document the amount of time involved
32 Group Visit Topic Outline The Academic Chronic Care Collaborative Background & Supportive Research Nuts & Bolts of the Group Visit Getting Started Billing Issues Resources Questions & Answers
33 Resources Institute for Healthcare Improvement (tools to print, how to manuals) collaboratives done at HRSA clinics, handbook for many chronic conditions information for practitioners
34 Resources Educational materials for patients
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