# Presentation: 772580

## Group Clinics

- Paul A. Heineken, M.D.
- ACOSAC, SFVAMC
- Clinical Professor, UCSF

## Goals: 

- Be clear about your goals and potential conflicts between goals
- Medical outcome
- Patient satisfaction
- Value = medical outcome / cost
-     (also called efficiency)

## Medical Outcome: How can group visits bring improvement?

- Self-care
- Improved quality indicators
- EPRP prevention and practice guideline compliance
- Disease specific outcomes
- Diabetes: A1C levels
- CHF: fewer hospitalizations
- Chronic geriatric care:  fewer complications

## SFVAMC Primary Care Groups

- Diabetes self-care
- Diet, home glucose monitoring, insulin/medication teaching, foot care
- Advanced directive education
- Bereavement support
- Dementia caregiver support
- Medi-Cal planning

## Patient SatisfactionThree examples

- Kaiser model, single provider’s panel identified high users
- Ongoing groups, 10-15 pts, visit shared with RN, pharmacist, guests
- Vitals, short individual attention by health professional, group teaching
- Outcomes: high patient satisfaction, fewer individual visits

## Group Health Cooperative of Puget SoundColeman et.al. JAGS 47:775-783, 1999

- Chronic Care Clinic for frail elderly
- Patient satisfaction improved
- No other outcome measures did:
-   incontinence, falls, depression scores, hospitalizations, hospital days, ER visits, AC visits, medication costs, and total cost of care unchanged

## SFVAMC High User ClinicEzekiel and Jain, submitted 2002

- Frequent ER/Urgent Care visitors generally aren’t satisfied
- Identified high ER/Urgent Care, > 5 visits in 9 months
- Patients recruited from multiple providers
- Invited patients by mail or phone call, “group would help their overall care”
- Scheduled group sessions for 9 months
- Post-intervention use of ER/Urgent Care

## Intervention

- Monthly group visits
- ~9 patients expected in each
- Average attendance >50%
- Opened by doctor and “blessed”
- 1.5 hours total with a facilitator--RN or social worker, and a guest--pharmacist, nutritionist, podiatrist, etc.
- Topics: medication use, flu shots, advanced directives, healthy diet, foot care, etc.

## High Users Urgent/ER visits 9 months before and after intervention:9 months of monthly group visits

|  | Pre-intervention | Post- intervention | Difference in Means |
| --- | --- | --- | --- |
| Study
 N=26 |   5.73 |   2.65 |   -3.08* |
| Comparison N=26 |   4.12 |   5.42 |     1.3 |

## Medical Practice Orientation Clinic (MPOR)	

- Observations:
- New PC patients had high no-show rate
- “new” slots were unavailable while no-shows wasted valuable slots
- Goal 1: Improve value, through better access for new patients, and improved clinic efficiency
- Don’t waste valuable slots on no-shows

## Medical Practice Orientation Clinic, continued 

- Observations
- VHA screening and prevention requirements (not guidelines) mushroomed
- Centralized electronic documentation required
- Goal 2:
- Nurses complete most required screening and documentation
- Allow primary providers to concentrate on high yield interventions at their visit

## Long before ACA...

- SFVAMC required an orientation visit for each non-urgent new primary care referral
- Staffed by an RN
- Patient sent letter in advance explaining purpose of visit
- Medical questionnaire, including health maintenance, medication, and immunization history completed
- Nutrition, (MST, and Hep C risk) screens completed

## Visit content

- Check-in, including Means Test if required
- Vitals
- One-on-one review of health questionnaire with RN, for completeness and positive screening results
- Immunizations provided by RN or LVN under standing orders
- Obvious triage (anticoagulation, derm, etc.)

## Group Teaching

- Clinic procedures
- Appointments, urgent needs, contacting provider, telephone care
- Pharmacy, co-managed care
- Outside medical records
- Co-payments
- Advanced directives education

## Prevention Activity:Templated note entered by RN

- Risk factor identification: tobacco, alcohol, nutrition, exercise, depression, MST, Hepatitis C
- Behavioral counseling: diet, exercise, tobacco use
- Prostate cancer screening information

## Prevention Effectiveness

- Screening activity only, realistically one group visit won’t change behavior
- Group visits, and counseling about multiple behavioral changes at one time are NOT the procedures used in the “evidence” upon which VA prevention recommendations are based
- At best, MPOR identifies some veterans who are ready for a change—when they visit their provider or specialist, e.g. nutritionist
- At worst, it is a documentation exercise for EPRP

## Advanced Directive CompletionDipko, Xavier, Kohlwes, submitted for publication

| Group | Number | Completed | Percent |
| --- | --- | --- | --- |
| No teaching | 11972 |    251 |      2.1 |
| Individual  SWS session, once |    1522 |    246 |    16.2 |
| Multiple individual SWS sessions |      216 |      73 |     33.8 |
| Group session once |      151 |      49 |     32.5 |
| Group plus individual session |        52 |      20 |     38.5 |

## MP Orientation Clinic Outcome measure success:

- No show rates: **YES!**
- dropped from 45% to 18%, between MPOR and first provider visit. Jain and Chou, J Gen Int Med 2000;15:878-880
- EPRP scores:  **YES!**
- Patient satisfaction:  **yes **and** ****no**
- 82% satisfied, some resented not seeing a provider and making an extra trip, especially from distance
- Nutrition screen f/u:  **yes**

## Nutrition Screen F/u GroupSept 01-Mar 03Ceresa and Arnold, SFVAMC, 2003

| High nutritional risk, 
All invited to class |     709 |
| --- | --- |
| Moderate and low nutritional risk
Not invited |      
     663 |
| Attended class
 |    218 (31%) |

## What About the MPOR No-shows?

- Population: Urban, high prevalence of substance abuse and homelessness
- Required scheduled primary care wastes slots on habitual no-show patients
- “Episodic” primary care accessibility is essential
- ACA model may work, if patients are assigned to primary care teams after failing MPOR and episodic primary care is made acceptable

## Group Clinics Problems

- Competing goals--efficiency vs. outcome vs. patient satisfaction
- Recruiting patients from multiple providers
- MPOR easier to fill than high-user groups
- Behavior change groups have high no-show rate
- Multiple personalities may not mix
- Confidentiality (what seems appropriate for one, may not be comfortable for all)

## Group Clinics Conclusions

- Set goals
- Assign a leader & team
- Plan duration and outcome measures
- Realistic expectations
- Re-evaluate