Shared medical visits
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Shared Medical Visits. Jauch Symposium – May 17, 2014. Personal information. Stephen Sorensen, MD Family Physician Faculty member of Genesis Family Medicine Residency Program, Davenport, Iowa Director of Quality and Clinic Operations No financial obligations to report.

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Shared medical visits

Shared Medical Visits

Jauch Symposium – May 17, 2014


Personal information

Personal information

  • Stephen Sorensen, MD

    • Family Physician

    • Faculty member of Genesis Family Medicine Residency Program, Davenport, Iowa

    • Director of Quality and Clinic Operations

  • No financial obligations to report


Current state of medicine in the united states

Current state of medicine in the United States

  • Problem:

    • Significant shortage of primary care physicians

      • AAFP projects a shortage of 150,000 physicians by 2020

      • HRSA projects a shortage of 65,000 PCP by 2020

    • Physicians are being asked to see more patients in the same amount of time

    • Accountable Care Act – an additional strain on clinics as additional patients are seeking to establish care with PCP’s


Current patient experience

Current patient experience:

  • Typical office visit

    • Present to front desk

      • Asked to arrive early

      • Bottle neck – 5-10 minutes of waiting

    • Sit in waiting room

      • Read an out-of-date magazine – 10-15 minutes of waiting

    • Brought back to exam room

      • Wait for physician – 10-15 minutes of waiting

    • Physician in the room

      • 15-20 minutes

  • Total time in office – 40 to 60 minutes, less than half that time is actually spent talking to the physician!


What has to occur during an office visit for diabetes

What has to occur during an office visit for Diabetes?

  • A physician is asked to address:

    • Blood glucose control

    • Nutrition

    • Physical activity

    • Foot care

    • Eye care

    • Address co-morbidities:

      • Hypertension

      • Hyperlipidemia

      • Cardiovascular disease

    • Order additional lab work

    • Review and establish goals

    • Arrange for follow up appointment


Another way to look at this

Another way to look at this?

  • During a typical diabetes follow-up appointment, a physician:

    • Addresses 17 topics, questions or symptoms

    • Writes on average 2 prescriptions

    • Discusses nutrition and medication changes

    • All within 17 minutes

  • Parchman ML, et al: Encounters by patients with type 2 diabetes – complex and demanding: an observational study. Ann Fam Med 4:40-45, 2006.


One possible solution

One possible solution?


Shared medical visits1

Shared Medical Visits

  • Multiple names for this:

    • Shared Medical Visits

    • Shared Medical Appointments

    • Group Medical Visits

    • Group Medical Appointments

  • Not common in the Midwest – (yet!)

  • Much more common in areas with HMO’s

  • Now a requirement for family medicine residency programs to teach


Shared medical visits2

Shared Medical Visits

  • Can take many different forms:

    • Acute care visits:

      • (i.e.: URI’s)

    • Chronic care visits:

      • Asthma

      • COPD

      • Heart Failure

      • Type 2 Diabetes

      • Pregnancy

  • We have chosen to focus on conducting SMV’s with diabetic patients, now in our 8th year.


Shared medical visits3

Shared Medical Visits

  • What do they look like

    • 8-10 patients per visit

    • All given the same appointment time (i.e.: 10:30 – 12:00)

    • Each patient seen individually for 2-3 minutes on arrival by physician

      • Very brief physical exam

      • Ask if there are any questions they have about their care

    • Patients gather in a conference room for remainder of visit

    • Vast majority of the visit (60 minutes) spent on education, group discussion, visiting experts, etc.

    • Each visit attended by a physician, an observing resident physician, behavioral scientist, nurse and health coach


Is there any evidence that these actually work

Is there any evidence that these actually work?


Randomized trials

Randomized Trials

  • Managed Care Setting:

    • Monthly, 2 hour SMA’s with multidisciplinary team vs.. usual care

    • A1C’s > 8.5%

    • Results for SMA patients:

      • Greater reduction in A1C (1.3% to 0.2%, p < 0.001)

      • Lower hospital admission rates (P = 0.04)

      • Improved self efficacy in balancing food intake (P = 0.003)

      • Improved self-treatment of hypoglycemia (P = 0.03)

      • Improved management of glucose when ill (P = 0.001)

  • Sadur CN, et al: Diabetes management in a health maintenance organization: efficacy of care management using cluster visits. Diabetes Care 22:2011-2017, 1999


Randomized trials1

Randomized Trials

  • Five year follow-up study, 112 patients with Type 2 DM

    • Group appointments vs. usual care

    • Received four educational sessions on weight control, meal planning, improved glycemic control, preventing complications

    • Results for the group appointments:

      • Knowledge of DM2 improved (+12.4 vs. -3.4, P =0.001)

      • Improved problem solving ability (+5.7 vs. -2.3, P = 0.001)

      • Improved quality of life over 5 years (-23.7 vs. +19.2, P = 0.001)

      • Improved A1C control (-0.1% vs. +1.7%, P = 0.001)

  • Trento, M, et al: A 5 year randomized controlled study of learning, problem-solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care 27:670-675, 2004.


Randomized trials2

Randomized Trials

  • Primary Care Clinic

    • 12 month trial, 186 patients, monthly group visits vs. usual care

    • Results:

      • Significantly greater concordance with ADA process of care indicators

  • Primary Care Clinic

    • 6 month trial, 120 patients, group medical apptsvs. usual care

    • Baseline A1C was 10.3% vs. 10.6%

    • Results:

      • No significant improvement in A1C

      • Higher “trust in physician” scores (P = 0.02)

      • More successful in meeting ADA care indicators (P = 0.001)

  • Clancy DE, et al: Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med 22:620-624, 2007.

  • Clancy DE, et al: Group visits in medically and economically disadvantaged patients with type 2 diabetes and their relationships to clinical outcomes. Top Health Inf Manage 24:8-14, 2003.


Nonrandomized trials

Nonrandomized Trials

  • 13 month study, Hmong refugees with type 2 DM

    • Group medical appointments

    • Results:

      • Improved anxiety scores (P = 0.05)

      • No difference in A1C, BP, or lipids

  • Synchronous PCP visits and educational sessions, 44 Hispanic patients

    • Results:

      • Significantly improved A1C (P = 0.001)

  • Culhane-Pera K, et al: Group visits for Hmong adults with type 2 diabetes mellitus: a pre-post analysis. J Health Care Poor Underserved 16:315-327, 2005.

  • Gold R, et al: Synchronous provider visit and self-management education improves glycemic control in Hispanic patients with long-standing type 2 diabetes. Diabetes Educ 3:990-995, 2008.


How about our data

How about our data?


Family medical center

Family Medical Center

  • Data collected in 2010

  • Pre-post evaluation of diabetic data

  • Used resident and faculty patients

  • Separated out patients who had been coming to group visits for less than and greater than 18 months

  • Evaluated for changes in:

    • Weight

    • A1C

    • Blood Pressure

    • LDL


Patient satisfaction

Patient satisfaction

  • Patients uniformly enjoy shared medical visits

    • Every patient that we surveyed stated that they would recommend these to others

    • However, it is a self-selecting population

  • Most difficult thing is getting them to attend the first!


Shared medical visits4

Shared Medical Visits

  • Disadvantages of shared medical visits

    • More logistics involved

    • Need for appropriate space to meet with a large group

    • Need to have someone review medical record before the visit to identify opportunities for care

    • Less “one-on-one” time spent with physician


Shared medical visits5

Shared Medical Visits

  • Benefits of shared medical visits:

    • Systematic approach to diabetic patients

      • May assist in meeting standards of care

    • No special training required

    • Offers additional support to patients

      • Patients regularly discuss lifestyle changes with each other

    • Structured opportunities for dieticians, pharmacists, exercise physiologists to meet with patients

    • No additional costs involved

    • Reimbursement is the same as regular office visits

      • Potential for increased revenue

    • Patients enjoy them!


Questions

Questions?

[email protected]


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