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A Guide to Tobacco Cessation Group VisitsBy Mary Theobald, MBA and Steven Masley, MD, FAAFP, CNS

Reviewed by: Pamela Rodriguez, CAE; Patrick McGarry, PhD; Thomas J. Weida, MD, FAAFP; Kent Moore; and Sandra Sheehy, BSN, MBA

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Eight to twelve weeks in advance:1. Choose a time and date that suits your audience and staff:

•Mid-afternoonforseniors

•Earlyeveningsforworkingadults

•Tuesday,WednesdayandThursdayappear tobethemostpopulardays

•Saturdaymorningsworkforsomegroups(about1/3 to1/4ofthosewillingtoparticipateingroupvisits)

2.Meetwithyourteamandadministrative/clinicalmanagertodevelopanimplementationplandelineatingrolesforstaffandproviders.Assignresponsibilitiesanddeterminewho will:

•Developarecruitmentplan(i.e.,letter,noticein theoffice,phonecallsfromreceptionist, 1-pageflyer,etc.).

•Reservethespaceforthesessionwellinadvance.

3.Arrangeaback-upclinicalcoverageplan.

One month in advance:1.Createatemplatetoregisterpatients.

2.Identifyandinvitepotentialparticipants:

•Pulldiagnosiscodesfrombillingdata, ICD-9code305.1,TobaccoCessation.

•Createregistriesatpatientvisits.

•Empoweryourstafftoenrollpatients.

•Reviewpharmacyprescriptiondata.

•CreateanExcelfileoraRegistryfileoftobacco usersthatyoucanupdateatscheduledintervals.

•Writealetter—postaloremail—totobaccousers inyourpracticeencouragingthemtoschedulean appointmentforthegroupvisit(seesample,page6).

Three weeks in advance:•Calltoscheduleappointmentsand/orleaveamessage

regardingtheopportunity(seesample,page6).

•Createasatisfactionsurveyforthegroupvisit.

•1hourtopreparedidacticmaterialsandtocoordinate with your staff

•1hourforchartreviewspriortothevisit

•15minutesforintroduction

•30minutesforpresentation/interaction

•30minutesfortwotothreenurses/physicianassistantstocollectdataandforyoutomeetwithpatientsanddocumentspecificplans

•30minutesforwrap-upandansweringquestions

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Why offer group visits?GroupvisitswereidentifiedintheFutureofFamilyMedicineprojectasoneoftenfeaturesthathaveadirecteffectonpractices.Theprojectestimatedthatgroupvisitshavethepotentialtogenerate$15,411perphysicianperyear.1

Well-organizedgroupvisitsprovidebetteraccessatlowercosts.Researchindicatestheycanalsoprovideanimprovedqualityofcareandahigherlevelofpatientandphysiciansatisfaction.2

Preparing for a tobacco-cessation group visit

What are group visits?Thereareseveralmodelsforgroupmedicalvisits.TheCooperativeHealthCareClinicconcept,whichwasdevelopedbyKaiserColorado,aswellastheHighRiskCohortmodeldevelopedbyMasleyetal.,3 have been proveneffectiveforchroniccarepatientsandarethebases for this guide.

Groupvisitsincludeagroupeducationalsessionplusmostcomponentsofindividualvisits,includingone-on-onemedicalevaluationsconductedbyaphysicianornursepractitioner.

A group visit is NOT a class or a group therapy session.

How much time do you need for a group visit?

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One week in advance:•Havereceptionistcalltoremindpatientsoftheir

appointment.

•Makeplanfor/orderhealthyrefreshments.

•Makesigns,nametagsandsign-insheet.

•Obtainororganizeteachingmaterialsforyourpresentation.

One or two days in advance:•Pullandreviewcharts/medicalrecordsforthosewhowill

be attending.

•Createprogressnotes.Anofficenursecangatherthedataandthedoctorcanreviewthecompletedprogressnotes(seesample,page7).

•Createalistoftargetsforyourpatientstoachieve.

•Prepareacartwithpencils,bloodpressurecuffs,medicalrecords,etc.(seecartlistatright)

Day of event:•Haveatleasttwomedicalassistantsor

otherstaffarriveearlytoplacesignsandsetuptheroom(seesampleroomlayout).Theyshouldbringnametags,cart,asign-insheet, and refreshments.

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Group visit cart contents

1. Name tags for all members and staff

2. Sign-insheets

3. Agendaoutline

4. Calendar

5. Patients’medicalrecords(or computersforEHRsystems)

6. Educationalmaterials

7. Portablebloodpressurecuffs (includinglargesize)

8. Stethoscope

9. Syringes,alcoholwipes,bandaids, sharpscontainer

10.Radiologyrequestforms

11. Labrequestforms

12. Extrahealthmaintenanceexamforms

13. Extraprogressrecordsheets

14. Tape,markers,3-holepunch, pens,pencils

15. Scale

16. Peakflowmeters

MD

Nurse

projector

easel padscreen

refreshments

NurseGroup visit room layout

• Horseshoeshapeworkswell

• Privacycurtainsareoptional

• Prepareacartwithbloodpressurecuffs, charts,materials,extrapens,etc.

• Consideratableforhealthyrefreshments

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Havestaffgreetpatientsandcollectco-payments.Askpatientstowritetheirfirstnamesonnametags,findachairandcompletetheHIPAAandconfidentialityformsandthesubjectiveaspectoftheSOAP(subjective,objective,assessment,plan)note(seesamplesinthisguide).

Start the session on time. Begin with a sincere welcome and explaintheexpectationsforconfidentiality.Introduceyourstaff,thenaskpatientstointroducethemselves,givingtheirfirstnamesandabriefoverviewofwhythey’rethere.Introductionsshouldn’ttakemorethan15minutes.

Staff task checklist

Before meetingqGetsign-insheet.

qPrepare,post,andmakecopiesofagenda.

q Make sure charts are available. Review medical records

withprogressnotesinmind.

qStampprogressnoteformwithgroupvisitstamp.

Writeorstampnamesofattendeesoneachform.

qBringgroupvisitcart.

qPutdirectionalmeetingsignsupoutsideroom.

qSetuptables.

qSetuprefreshments.

qNotifyancillarystaff,asappropriate.

As patients arriveqGreetpatients;triageforspecialneedsorMD

appointmentaftermeeting;answerquestions.

qHavepatientssigninormarkattendanceonroster.

q Start taking vital signs if time allows.

qPassouthandouts/formstopatients.

Conducting the visit

During the meetingq Look for missing charts if needed.

qHelpwithpresentationasneeded.

qBookappointmentsasneeded.

After the meetingqMakechartnotesonpatientswhoattended.

q Take down meeting signs.

qNote“show”or“noshow”attendanceforfollow-up.

q Review who needs health maintenance, etc.

andmakelistfornextmeeting.

qReturncompletedcharts.

qWorkoncoordinatingfollow-upgroupvisits.

qMaintainfileofcompletedattendancerosters

andspeakerhandouts,etc.

qSubmitcoding/billing.

Next,provideeducationalinformationontobaccocessation:pharmacotherapy,healthbenefitsofquittingandlifestylechanges.Pointoutthatpreviousquitattemptscanhelpthem be more successful this time. You can find information and handouts at:

•www.askandact.org – Click on Ask and Act Practice ToolkittoaccesstheAAFPPatientStopSmokingGuide.

•FamilyDoctor.org – Patient education materials in EnglishandSpanish.

•www.cancer.org – American Cancer Society.

Encouragequestionsandinteraction.Tohelpwithinteraction,referquestionstothegroupwhenpossible.Theeducationalportionofthevisitshouldtakenolongerthan30minutes.Beforeyourbreak,explainwhat’sgoingtohappennext.

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Tips for conducting group visits1. Youdon’tneedtoaddressyourpatientsinagroupany

differently than you would normally address them as individuals because:

a. Yourpatientsalreadylikeyouortheywouldnot begoingtoyouforcare.Youdon’thavetobeastand-upcomic!Justbeyourself.

b.Yourpatientswillvaluegettingtospendmuchmoretimewithyouthantheywouldinaone-on-onevisit.

2. Themoreyoupracticetheroleoffacilitator,themoreyouwillenjoythegroupvisitsandthemoreyourpatientswillgain from them. Facilitation involves:

a.Fosteringquestionsanddiscussion.

b.Encouragingpatientstoanswerotherpatients’questions,whenappropriate.

c.Encouragingallpatientstoparticipateindiscussions,includingaskingquietpatientstooffertheirthoughtsandquestions.

d.Politelycorrectingpatientanswersthatareincorrect.Firstthankthemfortheirinput.Youmightthenwanttogiveseveralpatientstheopportunitytoanswerthequestionandstopafteronegivestheright(ornearlyright)answer.Youshouldrestatethecorrectanswerinsimplelanguage.

e.Periodicallyquizzingpatientsaboutmaterialalreadycoveredtotestretentionandtoreinforceimportantinformation.

f.Repeatingimportantinformationseveraltimestoreinforce retention.

Whilepatientsbreakforrefreshments,beginyourindividualvisits.Havepatientsmeetfirstwithnursesorphysicianassistants who should:

•Weighpatients,takebloodpressure,etc.

•CompleteSubjectiveandObjectivepartofthe SOAPnote.

•Giveimmunizations,flushots,etc.

Patientsshouldadvancefromthenurses’stationstothedoctor’sstation.Here,youshouldconductabriefvisitwitheachpatientand:

•Clarifyyourassessment(yousmoke,itisharmful,andIadviseyoutostopusingtobacco).

•Discussatreatmentplan—possiblywriteaprescriptionfor a smoking cessation medication.

Havestaffavailabletoscheduleappointmentsforthosewhohaveissuesoutsideofthetopicofthegroupvisit.Thebreakandindividualvisitsshouldtakenolongerthan30minutes.

Afterthebreak,reconvenethegroupforafinalquestionand answer session. Thank the attendees for coming and congratulatethemontheircommitmenttoquittingtobaccouse.

Patient confidentialityAlthoughHIPAAdoesn’tpreventpatientsfromvoluntarilydiscussingpersonalhealthinformation,it’simportanttohavepatientssignaconfidentialityformandHIPAAdisclosureformpriortothegroupmedicalvisit(seesamples,page5).Youshouldhavethesereviewedbyyourcomplianceofficerorlegal counsel before using them. Attach your Notice of Privacy Practices to the form.

Youandyourstaffshouldnotdiscussanypatient’smedicalhistoryorconditionswiththegroupasawhole.Patientsmaychoose to share this information on their own.

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See page 8 for more information on addressing challenging group participants.

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Sample group visit payment and confidentiality form

I have read and I agree to the following:

• Iagreetomeetwithagroupofpatientsandmydoctor.IunderstandthatIhavethechoicetobeseenby myphysicianinthisgrouporindividually.

• Iagreetokeepallinformationregardingotherpatientsattendingthegroupvisitsprivateandconfidential.

• Iagreetoberesponsibleforthebilland/orco-paymentassociatedwiththisdoctor’svisit.

Signed ___________________________________________

Date ____________________________________________

Sample group visit HiPAA notice

Duringagroupvisit,itispossiblethatsomeofmyindividuallyidentifiablehealthinformationwillbedisclosed.Forexample,atagroupvisitfortobaccocessation,itmightbeassumedthateveryoneattendingusestobacco.Ihaveread and I understand the following statements about my rights:

• IrealizethatIhavetheoptiontobeseenindividually.

• IunderstandthatIamnotrequiredtosignthisformtoreceivehealthcaretreatment,benefits,orpayment.

• Iunderstandthatdiscussionsmayoccurregardingindividuallyidentifiablehealthinformationduring agroupvisit.

• Itispossiblethattheinformationthatisusedordisclosedinagroupvisitmayberedisclosedby otherparticipantsinthegroupvisit.

• Ihavebeennotifiedofthispotentialdisclosure,andIvoluntarilywishtoparticipateinthegroupvisit.

ThisGroupVisitHIPAANoticesupplementstheNoticeofPrivacyPracticeoriginallyprovidedtome,acopyof which is attached.

Signed ___________________________________________

Date ____________________________________________

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Sample invitation letter to patients

Date

Dear ,

Iwouldliketoinviteyoutoparticipateinagroupmedicalappointmentformypatientswhousetobaccoandwishtostop.Manystudieshaveshownthatbyparticipatinginagroupvisityoucanmarkedlyincreaseyoursuccessinmakinglifestylechanges.

Ofcourseyouhavetheoptionofbeingseenindividuallywithoutchangingourrelationshipinanyway.Patientswhochoosetobeseeninagroupappointmentcanalsocontinuetobeseenindividuallyandmaydropoutofthegroupformatatanytime.

Wehaveselectedalimitednumberofpatientstoparticipateinthisprogram.Bychoosingtobecomeaparticipantyouwill:

• Participateinatwo-hourmedicalvisitwithme.ThegroupandIwilladdressissuesbothmedicalandnon-medicalthat are related to tobacco cessation.

• Payforservices,justasyoudowithanyregularofficevisit.

• Keepinmindthatitispossibleforpersonalhealthinformationtobedisclosedatagroupvisitsuchasthediagnosis oftobaccouseorhealthproblemsassociatedwithit.YouwillbeaskedtosignaHIPAAdisclaimeracknowledgingthis during the visit.

Ourfirstgroupmedicalappointmentwillbeheldon at o’clock.Iplantohave15-25patientsparticipateinthisgroup.Ifyouareinterested,pleasereplybycallingusat . The meeting will be held at our office from until .Lightrefreshmentswillbeprovided.

Ifyouhaveanyquestions,pleasecall , at .Ianticipatethissessionwillgreatlyenhanceyourabilitytostopsmoking.

To your health,

Dr.

Sample script for recruitment calls for group visits

HelloMr.Johnson,

Dr. isofferingagroupmedicalappointmentforpatientswhowanttostopsmoking.He/sheaskedme tocallandinviteyoutoattend.Theappointmentwilllastabouttwohours.ThiswillgiveDr. ampletime toreviewhowyoumightsuccessfullystopsmokingandminimizeanysymptomsyoumayhaveduringthetransition. Dr. feelsitwouldbenefityoutoattendthissession.Wouldyoulikemetoscheduleyoufortheappointmentat o’clockon .

OfcourseyoualwayshavetheoptionofcontinuingtoseeDr. inaone-on-onesetting.Attendingagroupvisitwillnotchange this in any way.

Ialsowantyoutounderstandthatthisvisitwillbechargedjustlikeanyotherdoctor’sappointment,andtheusual co-paysandinsurancesubmissionwillapply.Ialsoneedyoutoknowthatsinceeveryoneattendingthisappointmenthasahistoryoftobaccouse,it’spossiblethatsomeofyourpersonalhealthinformation,suchasyourdiagnosis,couldbedisclosedduringtheappointment.

Yourspouseoranotherfriendorfamilymemberiswelcometoattendthisvisitwithyou.Welookforwardtoseeingyou.

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Sample tobacco cessation SOAP note

Name: Date:

ID #:

HPi: Subjective

Years you have used tobacco? Averagenumberofcigarettesperday?

Howmanytimeshaveyoutriedtoquit?

Whatmethodsdidyouusetotrytoquit?

At what time of day do you smoke your first cigarette?

Haveyouexperiencedrecentheartburn? q yes q no

Haveyouexperiencedsmoker’scough? q yes q no

Doyouhavesinusproblems? q yes q no

Anyspecificissuesyouwantaddressedatthisappointmentwiththegroup?

ROS:

Hasyouractivitylevelbeenrecentlylimitedbybreathingissues? q yes q no

Anychestpainwithexercise? q yes q no

Anyproblemswithinsomnia? q yes q no

Past Med History: (Seechartfordetails)

Meds:(Seechartmedsheet)

Objective

Wt BP BMI RR

Peakflowtoday

Assessment:

Otherrelateddiagnoses?

Plan

qQuitdateplanned

qBehavioraloptionstoquitreviewed

qMedicationoptionsreviewed.Risks,benefits,andsideeffectsdiscussedandquestionsanswered.

qRx

q Additional Plan

Billing: (circleallthatapply) 99212 99213 99214 99215 G0436 G0437 99406 99407 ICD-9 305.1 V15.82 Other

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Addressing challenging group participants

Participant Style Response Options

The Too-Talkative Person -Establishnormsearly.Clarifypurpose,process,andtimelimits.

-Refocusbysummarizingtherelevantpointandmoveon.

-Privatelyspendtimelisteningtoperson.Praise.Askforhelpingettingothersinvolved.

-Assignabuddy.

-Don’tlookattheperson.Usebodyposturetoengageornot.

-Say,“I’mnotgoingtocallonsomeonetwiceuntilallhavehadachance.”

The “Yes, but…” Person -Acknowledgeconcerns.

-Recruit.Ask,“Hasanyoneelseexperiencedthissituation?”

-Afterthree,“Yes,buts”,statetheneedtomoveonandoffertotalkaftergroup.

-Remindthepersonthattheintentistogenerateideas,notcritiquethem.

The Arguer -Beconsciousofyourreactions.Keepyourtemper.Don’tletthegroupgettooexcited.

-Recruit.Callonotherstocontribute.

-Privatelyaskthepersonhowtheythinkthegroupisgoingandaskfor suggestionsforimprovement.

-Askforaninformationsourceorforthemtosharetheirreferencelater.

-Offertodiscusstheconcernaftersession.

The Angry or Hostile Person -Keepinmindthatfightingfirewithfirewillonlyescalatethesituation.

-Getonthesamephysicallevel,preferablysittingdown.

-Speakinalow,quiet,andclearvoice.

-Activelylisten.Validateperceptions,interpretationsand/oremotionswhenyoucan.

-Listen.Paraphrase.

-Disarm.Ask,“Atthistime,whatwouldyoulikeustodo?”or “Whatwouldmakeyouhappy?”

The Questioner -Don’tbluff.Ifyoudon’tknow,justsay,“Idon’tknow,butwillfindout.”

-Redirect.Say,“That’saninterestingquestion.Whowouldliketorespond?”

-Offertodiscussthequestionlater.

-Acknowledge,“Youhavelotsofgoodquestionsthatwedon’thavetimetoaddress.”

The Know-it-All -Limitcontributionsbynotcallingontheperson

-Establishguidelinesatthestartofthesession.

-Thankthepersonforpositivecomments.

-Evoketherulesofdebate:Eachpersonhastherighttospeaktwotimesonanissue butcannotmakeasecondcommentuntilothermembershavespoken.

The Misinformed -Validatetheinformation.Say,“I’veheardmanydoctorssaythataswell.”

-Ask,“Couldyouinvestigateandcomebacknextvisitandreporton this with sources and how you reached your conclusion?”

-Provideevidence.Say,“Myunderstandingis , based on .”

AdaptedbyJulieSchirmer,withpermission.Living Well with Chronic Illness Training Manual.CopyrightStanfordUniversity.

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tobaccouse,orwho[are]takingatherapeuticagentwhosemetabolism or dosing is affected by tobacco use as based on FDA-approvedinformation.”4TheseservicesaresubjecttoPartBdeductiblesandcoinsurance.Claimsshouldinclude305.1andadiagnosiscodethatreflectstheconditionthatisadverselyaffectedbytheuseoftobaccoorthetherapeuticagentthatisaffectedbytheuseoftobacco.UsetheseCPTcodes:

• 99406:Smokingandtobacco-usecessation counselingvisit;intermediate,greaterthan3minutesupto10minutes.

• 99407:Smokingandtobacco-usecessationcounselingvisit;intensive,greaterthan10minutes.

Keepinmindthatyoushouldbillforone-on-onetime(notgrouptime)youand/oranotherqualifiedMedicareprovider(nursepractitioner,physicianassistant,etc.)spendscounselingthepatient.Asignificant,separatelyidentifiableE/Mserviceprovidedonthesamedateastobaccocessationcounselingmaybebilledseparatelywithmodifier25appendedtotheE/Mcode.

MedicaidManystatesnowofferatleastsomepaymentforindividualtobacco treatment counseling. To learn more about Medicaid coverage in your state, contact your state Medicaid office.5

GroupvisitsarenotspecificallycoveredbyMedicareor mostprivatehealthinsuranceplans.Practiceorbusinessofficemanagersshouldmakeinquiriestothepractice’s mostcommonhealthinsuranceplans(andifaMedicaidprovider,tothestateMedicaidplans)todeterminecoverageandbillingpoliciesasapartoftheplanningprocessforinitiatinggroupvisits.

Masley et al. have been successful in documenting and billing forservicesperformedforindividualpatients.3 Documentation fromCentersforMedicare&MedicaidServicespointoutthataphysiciancanprovideamedically-necessaryface-to-faceEvaluationandManagement(E/M)visitthatisobservedbyotherpatientsbutmustnotallowanyactivitiesassociatedwiththepresenceoftheobservers,orwithanysubsequentgroupcounselingencounter,toimpactthelevelofservicereportedforthehistory,exam,counseling,instruction,ormedicaldecisionmakingfurnishedduringtheface-to-faceencounterwiththepatient.

TobillforE/Mservicesprovidedtoindividualpatients,useanappropriatelevelofficevisitcode(99212-99215) based on theindividualpatient’shistory,exam,andthemedicaldecisionmaking you document.

MedicareMedicarewillpayfortwoquitattemptsperyear,bothofwhichcanincludeuptofourintermediateorintensivesessions.Uptoeightsessionsina12-monthperiodarecovered.

Patientswhoareaymptomaticofconditionsrelatedtotobacco use are eligible for tobacco cessation counseling asapreventiveserviceandareexemptfromtheMedicaredeductibleandcoinsurance.Reportthesepreventiveserviceswitheitherdiagnosiscode305.1forcurrenttobaccouseorcodeV15.82forhistoryoftobaccouseand:

• G0436:Smokingandtobaccocessationcounselingvisitfortheasymptomaticpatient;intermediate,greaterthan3minutes,upto10minutes.

• G0437:Smokingandtobaccocessationcounselingvisitfortheasymptomaticpatient;intensive,greaterthan10minutes.

YoumayalsobillMedicareforcounselingofpatientswhousetobacco and have a “disease or an adverse health effect that hasbeenfoundbytheU.S.SurgeonGeneraltobelinkedto

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Billing for group visits

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For more information:CodingforGroupVisitswww.aafp.org/online/en/home/practicemgt/codingresources/groupvisitcoding.html

“CodingRoutineOfficeVisits:99213or99214?”JensenP.Family Practice ManagementSeptember2005

“GroupVisitsforChronicIllnessCare:Models,BenefitsandChallenges.”JaberR,Braksmajer,Trilling,J.Family Practice Management,January2006

“GroupVisitsHittheRoad.”DrefferD.Family Practice ManagementSeptember2004:39-41.

“GroupVisits101.”HouckS,KiloC,ScottJC.Family Practice ManagementMay2003:66-68.

“Group-VisitConsentForms(AskFPM).”MasleyS.Family Practice ManagementFebruary2003:56.

“PlanningGroupVisitsforHigh-RiskPatients.”Family Practice ManagementMasleyS,SokoloffJ,HawesC.June2000:33-37.(Includesadiabetesencounterform.)

SharedMedicalAppointments/GroupVisitsAAFPPolicy(2008)www.aafp.org/online/en/home/policy/policies/s/sharedmedapptsgrpvisits.html

www.askandact.org

PortionsusedwithpermissionfromStevenMasley,MD.Copyright2012.Allrightsreserved.

References1SpannSJ.TaskForceSix.Reportonfinancingthenewmodeloffamilymedicine.AnnFamMed.2004;2Suppl3:S1-S21.

2JaberR,BraksmajerA,TrillingJS.Groupvisits:aqualitativereviewofcurrentresearch.JAmBoardFamMed.2006May-Jun;19(3):276-90.

3MasleyS,SokoloffJ,HawesC.Planninggroupvisitsforhigh-riskpatients.FamPractManag2000;7(6):33-7

4Centers for Medicare & Medicaid Services. Decision memo for smoking & tobacco use cessation counseling.Availableat:www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAld=130&ver=16&NcaName=Smoking+%26+Tobacco+Use+Cessation+counseling&DocID=CAG-00241N&bc=gAAAABAAEAAA&?fromdb=true.Accessed4/6/2012.

5Helping Smokers Quit: State Cessation Coverage,AmericanLungAssociation,2011. www.lungusa.org/assets/documents/publications/smoking-cessation/helping-smokiers-quit-2011.pdf.Accessed4/6/2012.

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www.askandact.org

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