Practice Innovations: Group Visits for the Diabetic Patient Nuts & Bolts of a Patient Centered Medical Home June 25

1. Practice Innovations: Group Visitsfor the Diabetic PatientNuts & Bolts of aPatient Centered Medical HomeJune 25, 2010 Janet Albers, MD Cynthia Ledbetter, APN, CDE

2. Objectives • Discuss the impact of diabetes and its comorbidities on cardiovascular risk • Apply the chronic disease model to the management of type 2 diabetes • Describe the basic components of a diabetes management program • Develop a group-visit intervention for patients with type 2 diabetes • Understand how to code for group visits for type 2 diabetes management • Describe how group visits can support quality improvement initiatives in primary care

3. Type 2 Diabetes:Epidemiology and Impact Affects 23.8 million U.S. children and adults (7.8 million are undiagnosed) 1 in 3 Americans born in 2000 will develop type 2 diabetes in their lifetimes Fifth leading cause of death in US Economic cost (2002): $132 billion Accounts for 10% of health care dollars spent in the U.S. Source: American Diabetes Association. Diabetes Statistics. http://www.diabetes.org/diabetes-statistics.jsp.

4. Complications of Type 2 Diabetes • Heart • Coronary artery disease • Cardiovascular disease • Blood Vessels • Peripheral artery disease • Intermittent claudication Hyperglycemia • Kidneys • Microalbuminuria • Nephropathy • Nerves • Neuropathy • Gastroparesis • Eyes • Retinopathy • Glaucoma Source: American Diabetes Association. Diabetes Care 2006;29(Suppl 1):S4-S42.

5. Glycemic Control Reduces Risk of Type 2 Diabetes Complications Risk reduction with 1% decline in updated A1c P=0.021 P<0.0001 P<0.0001 P=0.035 Micro-vascular disease Stroke PVD MI Heart failure Cataract excision Source: Stratton IM, et.al (UKPDS). BMJ 2000;321:405-412.

6. Enhancing Diabetes Management in the Group Visit • Patient centered medical home • Chronic disease model • Group visit (planned visit) • Stages of change • Self management • Goal setting

7. Patient Centered Medical Home • Personal primary health care • Patient physician relationship • Improved health access across a continuum of referrals and services • Improved care outcomes • Improved satisfaction • Improved quality • Improved safety

8. Chronic Disease Care Model Health System Community Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared Proactive Practice Team Informed Activated Patient Productive Interactions Improved Outcomes

9. Chronic Disease • The Chronic Care Model (CCM) was developed to improve chronic disease care, but it may also inform delivery of other types of preventive care • Chronic disease care shows positive impact on patient health and self-management by physicians, patients and care managers -attributed to the a strong "partnership"

10. Group Visits • Group visits are a promising approach to chronic care management for the motivated patient • Group sessions provide opportunities for efficient patient education, socialization and empowerment J AM Board fam Med, 2006; Jaber; qualitative review of group viists

11. Outcomes Correlated with Group Visits • Enhanced dietary compliance • Improved intermediate markers for diabetes and coronary heart disease (cholesterol and AIC) • Reduced health care expenses • Increased patient and provider satisfaction with care

12. Group visits: Promoting adherence to Diabetes Guidelines • To evaluate the effect of group visits on clinical outcomes, concordance with 10 American Diabetes Association (ADA) guidelines • A 12-month randomized controlled trial • 186 diabetic patients comparing care in group visits with traditional patient-physician dyad. • clinical outcomes (HbAlc, blood pressure [BP], lipid profiles) were assessed at 6 and 12 months • quality of care measures (adherence to 10 ADA guidelines and 3 USPSTF cancer screens) at 12 months • Results: HbA1c, BP, and lipid levels did not differ for patients attending group visits verses usual care • Patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators, breast and cervical screening.

13. Shared Medical Appointment (SMA) • SMA in which groups of patients (8-20) are seen by a multi-disciplinary team in a 1-2 h appointment • To improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk • Quasi-experimental • Each group had up to 8 patients • Patients participated in 1-7 visits • AIC>9%, SBP>160 mmHg, LDL-c>130mg/dl • Results: reductions in A1c in %, SBP, and LDL-c were greater in the intervention group relative to the control group, but the difference was not statistically significant

14. Effects of incorporating group visits on the metabolic control of type 2 Diabetic patients • 1200 patients • ½ monthly medical consult with 1 hr group visits • ½ patients and routine visits (monthly one-to-one medical consultation) • The evolution on FPG, cholesterol, SBP, DBP and BMI were compared • Results: at 15 month follow up. Lower FPG & SBP and DBP were lower in group visit participants. NO differences for cholesterol or BMI.

15. Improving the Health of Diabetic Patients through Resident-initiated Group Visits • Six group visits were conducted in the evening. • Patients could attend as many visits as they desired • 2 hours and included a 30-minute presentation on a diabetes topic followed by Q&A • This was followed by individual physician visits • HbA1c & LDL at baseline and every 3 months and 1 year • Self-administered surveys were collected from patients at the end of 1 year • 72% of the patients reported making a lifestyle change as a result of attending visits • 40% stated that the visit provided a support group • No statistically significant changes in HbA1c or LDL levels.

16. Pharmacist Led Group Visit • Randomized controlled trial • 4 weekly sessions 40- to 60-minute educational component followed by pharmacist-led behavioral and pharmacological interventions • Of 118 participants to attain target goals in HTN, BS, lipids, and smoking compared to usual care recommended by ADA • 109 completed the study • A greater proportion of participants versus controls achieved an A1C of less than 7% and a systolic blood pressure less than 130 • No significant change was found in lipid control or tobacco use between the 2 study arms

17. Reducing Emergency visits in older adults with chronic illness • ER use may be an important sentinel event signifying a breakdown in care coordination • A randomized controlled trial of group visits (2-year) • 295 older adults (> or = 60 years of age) with frequent utilization of outpatient services and one or more chronic illnesses. • Monthly group visits (8 to 12) with a physician, nurse, and pharmacist held in 19 physician practices • Visits emphasized self-management of chronic illness, peer support, and regular contact with the primary care team • Conclusion: Monthly group visits reduce emergency department utilization for chronically ill older adults

18. Group visits effective for elderly w/ chronic illness • HMO members over age 65 within provider panels to a group visit intervention (n=160) or usual care (n=161). • Functional status, utilization of inpatient and outpatient services, and patient and provider satisfaction with care –followed for 1 year • 8 patients in each two-hour group session, (time for socialization, multidisciplinary education on self care, health maintenance and 1-1 visits with their physician) • Group participants had significantly fewer emergency room visits, subspecialist visits, calls to physicians, repeat hospital admissions, higher immunization percentages, and higher satisfaction with care compared to usual care group. • Group participants had more calls and visits to nurses, No change in health of functional status • Physicians reported higher satisfaction with group care

19. Group Visit Process • Comfort and training of providers • Multidisciplinary team • Customization in each unique practice • Space • Recruiting patients • Confidentiality • Billing

20. Diabetes Self-Management Education (DSME) • Diabetes disease process and treatment options • Nutrition management and physical activity into lifestyle • Use medication safely and therapeutic effectiveness • Monitoring blood glucose, interpretation, and self management decision making • Acute and Chronic complications and problem solving • Psychosocial issues and healthy coping

21. Stages of Change Pre-contemplation (no) Contemplation (on the fence) Preparation/determination (small changes) Action (go!!) Maintenance (cruising) Relapse (learning opportunity, not failure)

22. The Diabetes Management Team Endocrinologist Mental health professional Neurologist Patient Primary Provider Family/Caregiver Diabetes educator Dietitian Care Coordinator Qualified eyecare provider Nephrologist Cardiologist/ Vascular or General Surgeon Pharmacist Podiatrist/ Wound care

23. Self Management • Six principles of diabetes self management: • Knowledge, agreed upon treatment plan, shared decision making process, monitoring and management, recognition of physical, emotional, social impact, lifestyle to promote health • Steps to support self management: • Patient perspective, overcoming barriers, link resources, planned and/or group visits. • Self care review

24. Goal Setting • Collaborate to set goal • Action plan • Measurable • Assess barriers • Assess confidence • Referral for skills • Follow-up plan (time/place)

25. Group Visit • Monthly (group of poorly controlled) • Quarterly (3, 6, 12 months) • Yearly • One time or series sessions (opportunity to return) • Pre-diabetes, new diabetes, uncontrolled diabetes, high risk • Gestational and type 1 diabetes • Referred from primary provider or run by primary provider or team

26. Components of a Group Visitcustomize to your practice • Pre work including documentation template • Scheduling and space • Individual visit (if necessary) • Group confidentiality • Intake and introduction • Interactive learning experience • Break and healthy snack • Action planning and self-management • Summary and future planning

27. Group Visit nuts and bolts • Prior to visit: • Education in practice/determine need • Selecting appropriate participants • *Define roles of team members (staff) • Number of patients to be scheduled and how often • Room, time, topics or flow (facility and documentation) • In-house referral to group/schedule/invitation • Review individual diabetic care indicators *scheduler, reception, nursing, group facilitator/team

28. Group visitNuts and bolts • Individual care: • Nursing-BP, BS, weight, foot exam, update meds, immunizations, protocols (titrations, smoking) • Provider with patient –diabetes care indicator, review lab and medication, depression screen, blood sugar log, smoking/alcohol, supplies, *immunizations, *foot check • Brief consultation and recommendations for changes in therapy • Refills, referrals (retinal, foot, dental), and follow up • Acute concerns 10 min each *provider will cover if abnormal or orders needed

29. Group visitNuts and bolts • Group (interactive learning): • Confidentiality • Introductions • Information sharing: What is diabetes • Targets for control, complications, high/low sugars, home glucose monitoring • Self management support-nutrition, exercise, smoking cessation, foot care, stress, weight reduction, taking medicine, monitoring blood sugars • Questions and answers • Self management goal setting (action plan, confidence, individual or group) • Invite quarterly/Follow up with primary provider • Complete any one on one • Documentation 4-6 pts, 1-1 1/2 hour, NP CDE lead

30. Planned Visit • Review of meds-intensity of care • Meds (comply, access, additions/subtractions) • Glycemic/BP/ lipid control (labs, a1c, microalbumin, lipids, creatinine) • Exam (limited physical/foot) • Needed Metrics (depression, retinal, dental podiatry • Self care review • smoking, exercise, diet, monitoring • Self management goal setting • collaborate to set goal • Action plan • Measureable, assess barriers, confidence, referral for skills or community resources • Follow up plan annually scheduled diabetes care visit-25 min-hour.

31. Reimbursing Group Visits • Evaluation and Management methods in standard one on one office visits • Documentation is critical • Use a template • Individual portion: labs, meds, history, vitals, general assessment, educational discussion, assessment and plan, foot exam, time spent (99213 or 99214 with ICD- 9 diabetes diagnosis code 250.xx) • Medicare reimburses the group education component of a group visit only when it is provided by CDE. • Time 25min 1-1 99214/ >40 min 99215

32. Conclusion on group visits • Early diagnosis and aggressive management • Treat to target strategies • Group visits for chronic illness within the health care delivery system can improve quality • Technology support and creative work force design • Identify and track patients and incorporate evidence based care • Proactive team and motivated patient • Future research structure, process of care, content of visits, outcome measures

33. References • DiabetesStatistics.http://www.diabetes.org/diabetes-statistics.jsp. • American Diabetes Association. Diabetes Care 2006;29(Suppl 1):S4-S42. • Stratton IM, et.al (UKPDS). BMJ 2000;321:405-412. • J Am Board Fam Med. 2008 Sep-Oct;21(5):370-4 • J Am Board Fam Med. 2010 May-Jun;23(3):295-305 • J Am Board Fam Med. 2006 May-Jun;19(3):276-90. • J GENERAL IM 22: 5: 620-624;MAY 2007 • Qual Saf Health Care. 2007 Oct;16(5):349-53 • REVISTA MEDICA DE CHILE:13710)1323-1332;OCT 2009 • FAMILY MEDICINE: 41(2): 116-119: FEB 2009  • DIABETES EDUCATOR:36 (1)109-117:JAN-FEB 2010  • Eff Clin Pract. 2001 Mar-Apr;4(2):80-1 • The Cooperative Health Care Clinic. J Am Geri Soc 1997; 45:543-549.