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The 20-Minute Medicare Visit

The 20-Minute Medicare Visit. David B. Reuben, MD Archstone Foundation Chair and Professor David Geffen School of Medicine at UCLA. Disclosure of Financial Relationships. David B. Reuben, MD, FACP Name.

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The 20-Minute Medicare Visit

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  1. The 20-Minute Medicare Visit David B. Reuben, MD Archstone Foundation Chair and Professor David Geffen School of Medicine at UCLA

  2. Disclosure of Financial Relationships David B. Reuben, MD, FACP Name Has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

  3. Overview of Next Hour • What’s the problem here? • Fixing the problem • Changes you can make on Monday • Longer term practice redesign changes • Does practice redesign work? • Learning more

  4. The Problem Physicians are unable to provide high quality of care for conditions affecting older persons within the context of busy primary care practices.

  5. Health care quality for vulnerable elderly • Assessing Care of the Vulnerable Elderly (ACOVE) project • identified elders at increased risk for death or functional decline, • created quality indicators based on literature review and expert panel for 22 conditions

  6. ACOVE results • Overall, 55% of Quality Indicators passed • Compliance for geriatric conditions was worse than for general medical conditions (31% versus 52%) • Care for specific conditions varies greatly • Stroke 82%; end-of-life care 9% Wenger NS et al. Ann Int Med 2003

  7. Barriers to good health care • Insufficient cognitive capacity • Not enough time • The health care system isn’t a system • Rewards are wrong

  8. Insufficient cognitive capacity • Too much to know • During 2001, the US National Library of Medicine added more than 12,000 new articles per week to its on-line archives • To maintain current knowledge, a general internist would need to read • 20 articles per day • 365 days per year • Shaneyfelt TM. JAMA 2001; 286:2000-2601

  9. Insufficient cognitive capacity • Too much to know • Too much to remember • Heart failure management • 10 ACEIs • 7 ARBs • 3 Beta-blockers • 2 aldosterone antagonists • All with different starting and target doses

  10. Not Enough Time • Assuming • practice size 2500 patients • age and chronic disease distribution of US population • following guidelines for 10 chronic diseases • Would take 10.6 hours per day! • Plus time for management of other problems. • Ostbye, Ann Fam Med 2005; 3:209-214.

  11. The Health Care System isn’t a System • Duplication • Reordering tests rather than looking for results • 34% sometimes or often • Unavailability of needed clinical info • 72% sometimes or often Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

  12. The Health Care System isn’t a System • Behind the times • In 2006, only 12.4% of offices had EMRs that had: • Computerized orders for prescriptions and tests • Test results and clinical notes • Source: NAMCS 2007 • But 73% use IT for electronic billing • Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

  13. The Wrong Reward System • Productivity is most important factor in determining income • Having more time to spend with patients is best method for improving quality • Over half believe that providing higher quality of care often/sometimes means less income Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

  14. Yes, these are barriers for other physicians but not our group

  15. 2007 QI Project • Sample • All full-time faculty geriatricians seeing patients in IMS or SM Geriatrics office (N=13) • Arrived unannounced to clinic • Sat in remote corner and did not speak • > 3 patients/physician were observed (N=48)

  16. Most Common Structure • Opening • Getting up to speed • Listening to symptoms • Getting more information • General examination • Plan formulation/discussion/education • Closing

  17. Opening • Almost always open-ended • “How are you doing” • Allowed patient to bring up problem • May ask about specific symptom, treatment, event • “So I got the request for PT” • “I heard that Dr.___ contacted you” • Patient-centered

  18. Getting up to speed • Spending time going through computer or notes, right after opening • Looking up labs • Big trouble when medical record, notes from other providers, or PVQ (for new patients) were not available

  19. Listening to symptoms • Usually patient or family generated • Often multiple, cover wide range • Physicians focus on 1-3 conditions/problems

  20. Getting more information • Interrogation to refine Dx/Rx possibilities • Focused examination • Often right in middle of history gathering (e.g, leg, hand, skin) • Hard copy records • UCLA • Outside • Computer labs/documents

  21. Getting more information • Resources rarely used • PDA (Epocrates) • Pocket guides • Internet (Up-to-date, Pub-med) • Books

  22. General Examination • Usually brief (heart, lungs, organ of interest) • Occurred at various times of the visit • Often with patient in chair and clothed

  23. Plan formulation/discussion/education • Physicians usually shared their thinking with patients and family • Provide explanations for symptoms that patients can’t figure out • Dismiss symptoms that aren’t important • Give common sense remedies/advice (e.g., nutrition, constipation, warm milk)

  24. Closing • Almost all asked if there was anything else the patient wanted to raise • Several patients raised new/big issues • Addressed them on the spot • Said they would call to discuss • Said that they would address next visit • Leftovers/unfinished business • I’ll talk to Dr. ___” • “I’ll look it up”

  25. Observations • Geriatricians behaved like geriatricians • Patient-centered • Zeroed in on geriatric issues (e.g., driving, mobility, function, living situations, polypharmacy) • Spent less time managing chronic diseases and used acute care approach • Usually had only data from last visit • No systematic approach to monitoring

  26. Fixing the Problem • Ground rules • Run a more efficient practice • Things you can do on Monday • Longer term changes: practice redesign

  27. Ground rules (assumptions) • Follow-up visit cannot take more than 20 minutes • General medical care cannot be compromised • No electronic medical record • Office staff can provide some help

  28. Run a More Efficient Practice 1) Delegate data collection

  29. Physician-Patient Encounter $$$$ Out-of-Office Preparation Office Visit $$ $ • Reduce time but increase effectiveness/efficiency of the inner circle • Always push to outermost possible circle whenever possible

  30. Delegation to Patients • Pre-visit questionnaires • Initial • Follow-up

  31. Pre-visit Questionnaire 1. Past medical history- Current medications- Drug allergies- Surgical & medical hospitalization- Social history (habits, sociodemographics)- Preventive services, including lifestyle 2. Home safety checklist 3. Advance Directives

  32. Pre-Visit Questionnaire • Specific questions on: • Vision • Hearing • Dentition • Falls • Urinary incontinence • Nutrition • Depressive symptoms • Functional status

  33. Follow-up Questionnaires • General • 2 most important issues • Mini-ROS • Other doctors they have seen • Medications • Condition-specific • Keeps issues on the table • Monitors adherence and response to treatment • Prompts asking questions about next steps

  34. Delegation to Patients • Pre-visit questionnaire • Initial • Follow-up • Lists • Diaries

  35. Delegation to Office Staff • Screening/Case identification • History gathering • Following up on triggers • Medications/allergies • Enhanced vital signs/physical exam • Orthostatic blood pressure readings • Visual acuity testing • Patient education

  36. Run a More Efficient Practice • ) Delegate data collection • ) Minimize data recording time • Dictation • Templates • Computerized medical records

  37. Strategies for Savings Time in Clinical Practice 3) Keep information needed for decision-making readily available • Pocket guides • PDA programs • Useful books • Computer retrieval system • ) Delegate plan execution • Network of health professionals • Health educators

  38. Longer Term Practice Redesign Changes • To improve care, change must focus on three key levels • patient • provider • practice • Must fundamentally change the office visit • Does not need to be expensive

  39. So, how does this work?(an example)

  40. Practice Redesign (ACOVE-2) • Case finding (identification) • Delegation of data collection • Structured visit notes that lead physicians through appropriate care processes • Physician and patient education • Linkage to community resources

  41. Case Finding • Several options • Telephone call prior to visit • Medical staff prior to placing patient in room • Pre-visit questionnaires in waiting room • Brief questions to identify bothersome incontinence, memory loss, and falls or fear of falling • Responses are given to provider at clinic appointment along

  42. Structured Visit Note • History items and simple procedures (completed by office staff) • More detailed H & P, ordering tests (completed by physician) • Impression and plan (completed by physician)

  43. Patient educational materials • Assembled for each condition • Readily available to the clinician to facilitate treatment • Community resources • Follow-up visit sheet

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