The Diabetic Group Visit – The Nuts and Bolts€¦ · Diabetes Group Support Packet • Patient interest forms – To be filled out by patients before each session starts. – Reminder

The Diabetic Group Visit The Diabetic Group Visit ––The Nuts and BoltsThe Nuts and Bolts

Marc Shalaby, MDMarc Shalaby, MD

Cindy Cindy PayonkPayonk, CRNP, CDE, CRNP, CDERenee Renee RenshawRenshaw

Lehigh Valley Hospital and Health NetworkLehigh Valley Hospital and Health NetworkAllentown, PennsylvaniaAllentown, Pennsylvania

©2005. American College of Physicians. All Rights Reserved.

Disclosure of Relationships with Disclosure of Relationships with Commercial Companies:Commercial Companies:

Marc Marc ShalabyShalaby, MD, FACP, MD, FACP

ConsultantshipConsultantship: Pfizer: Pfizer

Speakers Bureau: PfizerSpeakers Bureau: Pfizer


Early Strategic PlanningEarly Strategic Planning•• Identify the diabetic populationIdentify the diabetic population•• Identify those with basic diabetes educationIdentify those with basic diabetes education•• Identify interested patients Identify interested patients –– mail mail ““invitationinvitation””

•• Increase patient awarenessIncrease patient awareness•• Identify Outcome MeasuresIdentify Outcome Measures•• Develop documentation toolsDevelop documentation tools

•• Plan out the itinerary for each group sessionPlan out the itinerary for each group session•• Roll Out the group sessionRoll Out the group session•• PostPost--session documentation and data gatheringsession documentation and data gathering


Identifying Our Diabetic PopulationIdentifying Our Diabetic Population

•• Pulled data from scheduling / billing databasePulled data from scheduling / billing database-- From July 2003 to December 2003From July 2003 to December 2003-- counted any patient with ICDcounted any patient with ICD--9 code 250.09 code 250.0

•• CrossCross--referenced our diabetic education listreferenced our diabetic education list

•• Developed final list of patients to be contactedDeveloped final list of patients to be contacted


Invitation LetterInvitation Letter

-- Brief introduction to the programBrief introduction to the program-- Eligibility requirementsEligibility requirements-- Selection ProcessSelection Process-- Invitation to ParticipateInvitation to Participate-- RSVP to Contact PersonRSVP to Contact Person

[Sample Letter included in Handout Packet ][Sample Letter included in Handout Packet ]


Increase Patient AwarenessIncrease Patient Awareness

•• Place a sign in the office waiting room or Place a sign in the office waiting room or in exam roomsin exam rooms

DO YOU KNOWYOUR BLOOD

PRESSURE?

IF YOU AREDIABETIC YOU

SHOULD!

ASK YOURDOCTOR TODAY!!

DO YOU KNOWYOUR

Hemoglobin A1C?


SHOULD!


DO YOU KNOWYOUR LDLCholesterol?


SHOULD!



Develop Outcome MeasuresDevelop Outcome Measures

•• Easily identified Diabetes TargetsEasily identified Diabetes Targets–– Hemoglobin A1CHemoglobin A1C–– LDL LevelsLDL Levels–– Blood PressureBlood Pressure

•• Health Maintenance targetsHealth Maintenance targets–– ASA useASA use–– PneumovaxPneumovax / Flu Vaccinations/ Flu Vaccinations–– Foot / Eye ExamsFoot / Eye Exams

•• Patient Satisfaction SurveyPatient Satisfaction Survey


Documentation ToolsDocumentation Tools

•• Documentation of the group session occurs at the Documentation of the group session occurs at the time of the group visit.time of the group visit.

–– Vitals and Physical Exam (foot exam)Vitals and Physical Exam (foot exam)–– Health maintenance notes (e.g. eye exam)Health maintenance notes (e.g. eye exam)–– Prescriptions needed / providedPrescriptions needed / provided–– Labs slips needed / providedLabs slips needed / provided–– Time spent on educationTime spent on education–– Provider / assistant name and signatureProvider / assistant name and signature[Sample group session note included in the hand[Sample group session note included in the hand--outs]outs]


Group Visit Progress Note Patient Name Provider Med Refills needed: Rx provided [ ] Date Rx provided [ ] Time BP mm Hg Rx provided [ ] Weight lbs. Pulse bpm Labs Needed: Fingerstick Results (3 month average) Rx provided [ ] Fasting Rx provided [ ] 2-hour after meals , , , , , Rx provided [ ] Foot exam: Dilated Eye Exam [ ] date [ ] Pulses [ ] Skin integrity Podiatrist Visit [ ] date

Education [ ] Nails [ ] Monofilament result Time spent on education Provider name initials Provider name initials Notes Provider name initials


Documentation Tools (cont..)Documentation Tools (cont..)

•• Diabetic Flow Sheet filled out at the time of the Diabetic Flow Sheet filled out at the time of the regular office visit.regular office visit.

–– Diabetes targetsDiabetes targets–– Health maintenance targetsHealth maintenance targets–– Group visit participationGroup visit participation

[Sample Diabetic Flow Sheet included in the hand[Sample Diabetic Flow Sheet included in the hand--outs]outs]


Diabetic Care Flow Sheet Name M R# D .O.B Provider Targets/M easures

Frequency Date/Result Date/Result Date/Result Date/Result

Blood Pressure Goal <130/80 mm H g

Q 3-4 mos

LDL Goal < 100 mg/dL

Q 3-4 mos

Hemoglobin A1c Goal <6.5%

Q 3-4 mos

M icroalbumin Goal < 30mg ALB/g

Yearly

Ophtho Exam

Yearly

Pneumovax

Q 6 yrs

Influenza Vaccine

Yearly

Foot Exam

Q 3-4 mos

Group Visit Attendance


Group Session PreGroup Session Pre--workwork

-- Arrange for time in your schedule (2Arrange for time in your schedule (2--hour block) for yourself hour block) for yourself andand a medical assistant / nurse to accompany youa medical assistant / nurse to accompany you

-- Arrange for educator Arrange for educator prnprn (diabetes educator, dietician, etc.)(diabetes educator, dietician, etc.)-- Arrange for conference room (near your office)Arrange for conference room (near your office)

-- Large enough to have people sit in a circleLarge enough to have people sit in a circle

-- Notify patients of meeting time (call is preferable)Notify patients of meeting time (call is preferable)-- Reminder call one week prior to sessionReminder call one week prior to session

-- Prepare a Diabetes Group Support Packet Prepare a Diabetes Group Support Packet


Diabetes Group Support PacketDiabetes Group Support Packet

•• Patient interest formsPatient interest forms–– To be filled out by patients before each session starts.To be filled out by patients before each session starts.–– Reminder of goals of group visitReminder of goals of group visit–– Topics of interest to be discussed now or in futureTopics of interest to be discussed now or in future

•• AgendaAgenda•• Stretching / Warm up exercise sheetsStretching / Warm up exercise sheets•• Educational material pertaining to each sessionEducational material pertaining to each session


Cast of CharactersCast of Characters

•• Primary Care ProviderPrimary Care Provider–– Identifies appropriate patientsIdentifies appropriate patients–– Provide education and health maintenance needsProvide education and health maintenance needs–– Facilitate the meetingFacilitate the meeting–– Provide care and answer questionsProvide care and answer questions

•• Diabetes Educator / NurseDiabetes Educator / Nurse–– Prepares agendaPrepares agenda–– Arranges for Arranges for ““speakersspeakers–– Oversees operationsOversees operations–– Prepares prePrepares pre--session charts and packetssession charts and packets–– CoCo--facilitates the meetingfacilitates the meeting


Cast of Characters (cont.)Cast of Characters (cont.)

•• Support Staff (RN / MA)Support Staff (RN / MA)–– Prepares roomPrepares room–– ““ArrivesArrives”” the patientthe patient–– Takes vitals and gathers informationTakes vitals and gathers information–– Cleans up after sessionCleans up after session–– Insures billing forms are completeInsures billing forms are complete

•• Group MembersGroup Members–– Active participation in discussions, educational sessionsActive participation in discussions, educational sessions


Day of Session PreDay of Session Pre--workwork

•• Generate Billing / Encounter FormsGenerate Billing / Encounter Forms•• Gather blank group progress notesGather blank group progress notes•• Transport charts to conference roomTransport charts to conference room•• Medical assistant to bring BP CuffMedical assistant to bring BP Cuff•• Set up chairs in a big circleSet up chairs in a big circle•• Assistant set up at a table to Assistant set up at a table to ““arrivearrive”” patientspatients


Upon ArrivalUpon Arrival…………

-- Patients pay their coPatients pay their co--paypay

-- Vital signs are takenVital signs are taken

-- Group session progress note partially filled inGroup session progress note partially filled in•• Med refills needed, Labs needed, eye exam, etc.Med refills needed, Labs needed, eye exam, etc.

-- Patient concerns ascertainedPatient concerns ascertained


Group Visit Progress Note Patient Name Provider Med Refills needed: Rx provided [ ] Date Rx provided [ ] Time BP mm Hg Rx provided [ ] Weight lbs. Pulse bpm Labs Needed: Fingerstick Results (3 month average) Rx provided [ ] Fasting Rx provided [ ] 2-hour after meals , , , , , Rx provided [ ] Foot exam: Dilated Eye Exam [ ] date [ ] Pulses [ ] Skin integrity Podiatrist Visit [ ] date

Education [ ] Nails [ ] Monofilament result Time spent on education Provider name initials Provider name initials Notes Provider name initials


The First VisitThe First Visit

•• Sincere welcomeSincere welcome•• Overview of the purpose of the group visitOverview of the purpose of the group visit

-- Emphasize the session is a Emphasize the session is a ““well visitwell visit””-- Preventative health care needsPreventative health care needs-- Educational time / Questions answeredEducational time / Questions answered-- Learn and share experiences Learn and share experiences -- Enjoy each otherEnjoy each other’’s companys company-- General outline of how sessions will runGeneral outline of how sessions will run-- Address concerns / questions taken earlierAddress concerns / questions taken earlier


Group Session AgendaGroup Session Agenda

1:00 1:00 –– 1:15 pm1:15 pm Patients are Patients are ““arrivedarrived””1:15 1:15 –– 1:20 pm1:20 pm Introduction / Introduction / ““Ice breakerIce breaker””1:20 1:20 –– 1:30 pm1:30 pm Exercises / Warm upExercises / Warm up1:30 1:30 –– 1:50 pm1:50 pm Education SessionEducation Session1:50 1:50 –– 2:00 pm2:00 pm Questions / Answers Questions / Answers 2:00 2:00 –– 2:30 pm2:30 pm Foot exams / Time with DoctorFoot exams / Time with Doctor2:30 2:30 –– 2:40 pm2:40 pm Wrap Wrap ––upup2:40 2:40 –– 3:00 pm3:00 pm Documentation of visit / sign Documentation of visit / sign

billing formsbilling forms


Potential Educational TopicsPotential Educational Topics

•• General information about diabetesGeneral information about diabetes•• Goals and TargetsGoals and Targets•• Diabetes health maintenanceDiabetes health maintenance•• Medications and how they workMedications and how they work•• Foot CareFoot Care•• General Nutrition / Reading LabelsGeneral Nutrition / Reading Labels


Ideal Group SessionsIdeal Group Sessions

•• Involve 8Involve 8--12 patients12 patients•• Sessions last 2 hours (including 30 minutes for Sessions last 2 hours (including 30 minutes for

documentationdocumentation•• Patients have some previous diabetic teaching Patients have some previous diabetic teaching •• Every 2Every 2--4 4 mosmos between regular office visits, but between regular office visits, but

may be more frequent early onmay be more frequent early on•• Cover general education topics Cover general education topics –– allows for more allows for more

efficient office visits.efficient office visits.


A little about billingA little about billing……....

•• This is medical visit and is treated as suchThis is medical visit and is treated as such

–– Patients pay their usual coPatients pay their usual co--paypay–– Billed as a LevelBilled as a Level--3 return visit (99213)3 return visit (99213)

–– ““Site of ServiceSite of Service”” Rules applyRules apply


Financially Feasible / Lucrative ??Financially Feasible / Lucrative ??

•• Normally our average is 6 return visits / 2 hoursNormally our average is 6 return visits / 2 hours–– Billing is $ 70 x 6 = Billing is $ 70 x 6 = $ 420$ 420

•• Group sessions need 6 patients to break evenGroup sessions need 6 patients to break even

•• Group sessions with 10Group sessions with 10--12 patients 12 patients –– Billing is $70 x 10 (or 12) = Billing is $70 x 10 (or 12) = $ 700 $ 700 -- $840$840–– Equivalent to seeing a patient every 10Equivalent to seeing a patient every 10--12 minutes in the 12 minutes in the

office for two hoursoffice for two hours


Do the group visits affect outcomes? Do the group visits affect outcomes?

BeforeBefore AfterAfterAverage BPAverage BP 138/73138/73 128/69128/69% at BP goal% at BP goal 44%44% 60%60%Average Average HgbHgb A1cA1c 7.567.56 7.127.12% at % at HgbHgb A1c<6.5A1c<6.5 20%20% 28%28%Average LDLAverage LDL 9090 8989% at LDL <100% at LDL <100 64%64% 84%84%


SummarySummary…….Diabetic Group Visits.Diabetic Group Visits

•• Promote disease awarenessPromote disease awareness•• Improve communication and contact timeImprove communication and contact time•• Nice change of paceNice change of pace•• Improve outcomesImprove outcomes•• High satisfaction rate with patients and providersHigh satisfaction rate with patients and providers•• Can make the office visits more efficientCan make the office visits more efficient•• Financially viable if documented appropriatelyFinancially viable if documented appropriately


All you need to get startedAll you need to get started……....

•• DownDown--loadable files available from ACPloadable files available from ACP

–– Copy of this talkCopy of this talk–– Invitation LetterInvitation Letter–– Diabetes Group Visit Support PacketDiabetes Group Visit Support Packet–– Diabetic Flow SheetsDiabetic Flow Sheets–– Group Visit Progress NotesGroup Visit Progress Notes


Thanks for your attention.Thanks for your attention.


Documents

The Diabetic Group Visit – The Nuts and Bolts€¦ · Diabetes Group Support Packet • Patient interest forms – To be filled out by patients before each session starts. – Reminder