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: theDIGMAmodel@aol.com

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