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Presenter: Devin Sawyer, MD, Program Director, St. Peter Family Medicine Residency Program
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Planned and Mini-Group Medical Visits
Change Concepts for Practice Transformation
The “New” Medical Assistant: More than Just the Vital Signs
Rebuilding Chronic Care… Three Patients at a Time
Devin Sawyer MD & Jamacca Larman CMA Providence St Peter Family Medicine, Olympia WA
January 10th, 2013
St Peter Family Medicine Olympia, Wa
• Family Medicine Residency Training Program • 7 Family Docs, 3 ARNP’s • 21 Residents • 4 RN’s • 18 Medical Assistants
Population
• 390 with diabetes • 30,000 visits a year • 45% DSHS • 12% Medicare • 35% Commercial Insurance
The Patient The Medical Assistant
The Provider
Leaves with scripts, referrals, and Instructions “A passive experience”
Role of MA…
• The MA traditionally “roomed” and “vital’ed” the patient prior to the PCP visit. • The MA was dependent on the PCP direction.
• The MA-Patient Relationship was not well developed.
• Job performance measured by ability to perform tasks
and keep the provider moving
The Patient
The Medical Assistant
The Provider
Other Activated Patients
The Non-Clinical Staff
• MA:patient develop a meaningful relationship • Shared responsibilities with PCP develop • MA DM visits, registry review • Huddles & Walkie Talkies • Chart reviews for issues beyond chief complaint • Follow-up calls with patient • Provider has more time during their visit because of the
pre-planning and preparation: happy clinicians
The NEW Medical Assistant
Patient Productive Interactions
Provider
Delivery System Design
Decision Support
Clinical Information
Systems
Self- Management
Support
The “system” is the key
Improved Outcomes
Proactive Team
Activated Motivated
MA & Delivery System Design: Key Services…
• Planned Visits with MA and Patients. • MA Organized Group Visits with PCP and Patients.
– Mini-group visits – Open-Office Group Session
MA & Decision Support:
• Standing Orders- support MA planned visit
• Laboratory Results- available for provider at patient visit
• Immunizations- done at planned visit
• Foot Checks- done by MA
MA & Clinical Information Systems • EMR (Centricity, now EPIC) • Internet access in every room • Data Input into Dashboard
– A1c – Lab Results – Immunizations – Eye Exams – Smoking Cessation Counseling – Medications – Vital Signs – Self-Management Goals
Diabetes Dashboard In Centricity
The Provider- taught how to negotiate a medical plan and integrate with a patient-oriented self-management action plan (SMG)
NON-DIRECTIVE COUNSELLING
Precontem-plation
“I WON’T” “I CAN’T”
Contemplation “I MAY”
Preparation “I WILL”
Action “I AM”
Maintenance “I STLL AM”
Directive
Nondirective
An ah-ha moment…
MA AND Provider Support Patient Self-Management Support
• Emphasize patient goal setting- start with Readiness to Change Model,
then coach/motivational interviewing approach
• MA planned visit, provider visit, and
follow-up phone calls to “check-in”
The Beauty of Primary Care…
Self-management support • Coaching patients to set goals at EACH
CONTACT, helping support goals between visits, and re-enforcing their efforts each contact.
I will paint the fence with my friend, Tom Sawyer, each morning for one hour for the next week
Physical Activity
10 Action Be with my friends, get fit, make a pretty fence, get to know Becky
No time, paint stains, Tom has a crush on Becky
Percent of Patients with Self-Management Goals
• Data from our Robert Wood Johnson ADSM Grant work
Self-Management Project
What difference does it make? Survey Data
• Patients… – “value and trust the medical assistants” – “felt well cared for, better supported, and more successful
and confident” • MAs…
– “want to be more involved in patient care, did gain knowledge and confidence in diabetes and self management, and were more satisfied with their job”
• Providers… – “modest improvements in comfort with, and perceived
effectiveness in providing self management support”
Does it make a difference? The HbA1c…
• Phase I: The mean change = -0.42 P-value = 0.0012
7.3
7.4
7.5
7.6
7.7
7.8
7.9
8
First Last Phase II
HbA1c
Top Participants… • Patient participants had lower HbA1c’s than the clinic
average and that difference increased over time
Percent of Patients with HbA1c < 9.5%
81 82 80 80 80 77 7571 72 70 72 73
78 76 7673 70 71 72 72 71 71 68 68 68 70 69 68 69 69 67 68 68 67 68 69 68
81 81 81 81 81 78 79 79 79 82 82 86 89 89 89 86 89 89 89 93 93 93 93 93 89 89 89 89 89 89 86 86 86 86 89 89 89
0.010.020.030.040.050.060.070.080.090.0
100.0
Dec-03
Jan-0
4
Feb-04
Mar-04
Apr-04
May-04
Jun-0
4Ju
l-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-0
5
Feb-05
Mar-05
Apr-05
May-05
Jun-0
5Ju
l-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-0
6
Feb-06
Mar-06
Apr-06
May-06
Jun-0
6Ju
l-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
perc
ent
Total Pop Goal Participants
Goal = 85%
Patients with 2 A1c’s… 4.0 6.0 8.0 10.0 12.0 14.0 16.0
Initial A1C
4.0
6.0
8.0
10.0
12.0
14.0
16.0
End A1C
4.0 6.0 8.0 10.0 12.0 14.0 16.0
Initial A1C
-7.50
-5.00
-2.50
0.00
2.50
5.00
7.50
Change in A1C
Figure 2: change in A1c from initial Figure 1: first and last A1c
Worse
Better
Worse
Better
Became Abnormal
Became normal
Stayed normal
HBA1c and the Group Visits…
# GroupVisit dichot, difference res2-res1 Pearson Correlation .117(*) Sig. (2-tailed) p-value .017 N 419
0.0 2.5 5.0 7.5 10.0
Total P/G visits
0.0
5.0
10.0
15.0
20.0
final
ha1
c
Blood Pressure and BMI… no difference
80 100 120 140 160 180 200 220
first BP syst
80
100
120
140
160
180
200
220
last BP syst
0.00 20.00 40.00 60.00 80.00 100.00
BMI_first
0.00
20.00
40.00
60.00
80.00
BMI_last
Figure 4: first and last systolic BP Figure 5: first and last BMI
LDL, first and last…
50.0 100.0 150.0 200.0 250.0
First LDL
0
10
20
30
Cou
nt
50.0 100.0 150.0 200.0 250.0
Last LDL
0
10
20
30
Cou
nt
LDL and the Planned Visit… 0 2 4 6 8 10
# Planned visits
-150.00
-100.00
-50.00
0.00
50.00
100.00
150.00
diff res2-res1
R Sq Linear = 0.003
LDL change by # of planned visits
# Planned visits, difference res2-res1 Pearson Correlation -.143(**)
Sig. (2-tailed) p-value .005 N 389
In Conclusion…by the numbers
• For all patients the only significant sustained improvement was with LDL reduction
• Planned visits are associated with greater LDL reduction
• Group visits are associated with lower HBA1c and greater A1c reductions
• HAb1c: Top patient participants diverged from the practice averages the longer they participated
MA Training
• A Step by Step Instruction to prepare MAs for work within Primary Care using the CCM.
• Incorporates MA Peer to Peer Instruction. • Two four hour sessions that are fun and
exciting!!
Group Visits; defined…
• Patients connected in some way, meeting together with their health care team to take care of their health care needs
• Not a support group, not education classes, although they often feel better supported and become better educated
Group Visits; why try?
• Disease outcomes • Efficient, planned care • $$ • Patient love them • Patients self-manage • Patients feel better • Providers MAY like them • Staff usually like them
• Diversify our services and give patients CHOICES
Group Visits; which patients? • already know what it is you need to do • without a symptom • benefit from meeting others with the same
problem • self-management is critical
Group Visits: first step…
• Identify the need, identify the patients (registry, EMR)
• Start small (PDSA cycles- start with just a few patients, one visit, minimal staff, use existing documentation and space)
• STUDY the experience and plan for the next
Where we started…
• “Traditional” group visits • DGV- Open Office • DGV- “Mini” visit…a breakthrough
Diabetes group visit choices… • Mini-group visit
– 3 patients – Q 3-4 months – Replace routine visit – Same PCP – Share appt time – MA planned visit first – Small conf rm – Blackboard – 20/20/20 rule – Non-directive tx plan – SMG – One MA – Bill as usual
• Open-Office visit – 10-15 patients – Q 4 months, lasts 2 hours – DOES NOT replace visit – Any PCP, “facilitate” – Larger conf rm – Patient driven agenda – No planning or prep work – Meet the patients needs “in the
moment” – Facilitate problem solving and
end with SMG – Document patient specific info
and plan – Bill as usual
DMGV… 20/20/20 rule • Just before…
– The black board… the data (A1c, BP, LDL, weight change, meds, smoking status)
– Set provider agenda (what would you do if you had the choice) • 1st 20 mins
– Patient’s background, barriers, successes… – A conversation, no provider problem solving – Take notes on board, facilitate
• 2nd 20 mins – Ask permission to share the data – Be non-directive with your plan
• 3rd 20 mins – Refer back to list of issues/topics raised – Coach to SMG – Blend with medical plan that has been negotiated
Group Visits: Other… • Adolescent OB Group Visit • Group Well Child Care
– Matched by age – Matched by family (the group family health
maintenance visit)
• The Group Family Home Visit
Another ah-ha moment…
… we do better with depression management and healthy coping…patients feel better when empowered to participate and when able to problem solve
2 of my patietns… 1. 55 yo man with moderate obesity, fasting BS’s 110-
120, seen 1x/yr for “CPX”… • and his doctor thinks to himself… I wish he just became diabetic
so I could actually help him
2. 50 yo women with clinical depression, pre-diabetes, and mild obesity…
• and her doctor thinks to himself… I wish she just became diabetic so I could actually help her depression
This is when I knew we got it right… (at least for diabetes)
Group Visits: What’s next?
• Mini-group visits for issues other than Diabetes… – Smoking cessation – Poly-pharmacy – Health maintenance – Weight loss – Depression – Chronic pain
Billing (not necessarily reimbursement)… • Document and charge for what you do • Use existing E&M codes
– 99211 (most MA planned visits. Provider signed standing orders, provider on-site, $37)
– 99212 (more complicated MA planned visit with brief provider involvement, and most of Open-Office visits, $82)
– 99213 (straight forward provider visit, some of Open-Office visits and some of DMGV, $137)
– 99214 (more complicated provider visit, and most of the DMGV, $207)
– 99215 (rarely used, $277) – 90471 (immunization administration, $50 1st, $22 each
additional) plus cost of vaccine, ($22 flu, $69 pneumo) – 36415 lab draw fee, roughly $4 (no one pays) – 93000 ECG perform and read, $44) – Conversion factor (currently $80) X RVU = amount billed,
range reimbursed is highly variable
MADM Billing example
• Big MA Planned visit: – 99211, 99471 (flu and Pneumovax), 36415 – $37, $50 & $22, $22 & $69, $4 – $204 billed – 30-60% reimbursed
• Small MA Planned Visit – 99211 = $37, 30-60% reimbursement
Q & A
Planned and Mini-Group Medical Visits
Project Funders We would like to thank the following for the generous support:
The Commonwealth Fund (Project Sponsor)
Co-Funders:
Colorado Health Foundation Jewish Healthcare Foundation Northwest Health Foundation
Partners HealthCare The Boston Foundation
Blue Cross Blue Shield of Massachusetts Foundation Blue Cross of Idaho Foundation For Health
Beth Israel Deaconess Medical Center
