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Friday, May 28, 2010

You don't have to do it all: Connecting patients with community resources

When our practice was first introduced to the medical home concept, we were overwhelmed by the amount of services we should be providing to our patients. For example, the medical home model emphasizes patient self management, especially for chronic diseases. That means that patients with diabetes need guidance on diet, exercise, medications, injections and lifestyle changes. While we thought we were doing a pretty good job at this, fitting all this guidance into four 15-minute visits per year was probably not enough. How could we provide this care better – without adding FTEs? The answer became linking patients to existing resources in the community to supplement our in-office care.

Treating your patients as part of a larger population or community was an important part of the National Demonstration Project (NDP). Practices in the NDP soon discovered that they could not by themselves provide all the services implicit in a medical home. Financial, time and geographic barriers prohibited the provision of all services to all patients.

Dietary counseling, pharmaceutical services and therapy are some of the elements that may best be provided by facilities outside the medical home office. Costs of providing these services can be defrayed if practices tap outside sources to provide these services. We have a diabetic educator in our larger health system who does a very good job educating patients about their diet. The problem is that there is only one of her, and we have a LOT of diabetics. Furthermore, patients have to travel 20 minutes and navigate a large medical complex to get to her. Compliance with recommendations and follow-up suffers. But then we became aware that one of our favorite local pharmacists had become a certified diabetic educator, so we began having patients see him for diet and exercise advice. He also threw in medication advice. Since the pharmacy is in our town, patient compliance and follow-up was terrific.

If your practice does not have diabetic educators nearby, there are other resources. Visit http://www.diabetes.org/ for a plethora of free patient education ideas and support for professionals.

Our practice also utilizes home health to supplement our services to patients, and we have had some very good results reducing hospitalization rates for patients with CHF by educating them on diet and the importance of daily weights, with standing instructions for diuretic dosing based solely on daily weight changes. Many insurance companies will give patients a free scale. Recently, Optima Health has been offering scales and a daily phone consultation for CHF patients to assist with managing their fluid status and to recognize, report and treat early signs of an exacerbation. Now, we all know it would be terrific if payers would pay primary care physicians and their offices to provide such intensive management right from the office, but this is not yet a reality in most markets. Taking advantage of other resources can provide patients with much-needed services at no additional cost to the practice.

Another area where community resources are useful is with dementia. This devastating group of illnesses is very time and labor intensive for the family physician's practice. Many communities have Alzheimer’s programs, such as the one in our county: http://www.alzalliance.org. The Alliance offers a wealth of services to help both patients and their families cope with this devastating illness. I have referred several patients to this group and have been thanked for doing so. Helping patients find other individuals in the community who are dealing with similar health issues is very valuable for their overall care. Having a reliable resource to simply answer questions can save time and money in the care of individuals with dementia.

Hopefully these examples will help you explore ways you can connect patients with community resources. This networking approach shifts the cost of complicated care off the practice and encourages the patient to take more responsibility for self-management, core goals of care in the patient-centered medical home.

Friday, May 7, 2010

Group visits

A number of practices in the TransforMed National Demonstration Project (NDP) implemented group visits.  Several practices did diabetes visits, and some did prenatal visits. The practices agreed that group visits greatly improved care outcomes and peer-to-peer support and learning for patients. They did, however, find group visits time-consuming. One practice estimated spending 60 staff hours in preparation for a 2 hour diabetes visit – probably far above the average, but something to think about.

Several years ago, before the NDP, I had experimented with group visits.  I was disturbed by how many of my female patients weighed over 200 pounds.  These were women under 6 feet, so none of them should have weighed that much.  From an EHR search of my 3000+ patients (of whom 75 percent are women), I found that 600 of them weighed over 200 pounds and 200 of them weighed over 300 pounds!  This fact was very distressing.  I felt that my 15 minute face-to-face encounters were not doing the job.  And, to be honest, counseling during occasional 15-minute visits alone is not the best way to help a patient lose weight and learn to eat better.

My office manager and I visited several exercise facilities in the area and were able to secure discount coupons for patients who attended our planned weight-loss group visits. We obtained dietary information handouts from a dietitian friend and BMI calculators from a pharmaceutical rep.  (For the record, my office manager and I spent about 10-12 hours combined to prepare, not 60!)  I then solicited patients for interest based upon office visit content.  I soon had a list of 12 interested patients. We scheduled the visit for a Friday afternoon when the clinic was usually closed.  Three of the 12 who had signed up actually came.  For the second group visit, I charged a “holding fee” of $10, and five of 10 signed up showed up.

I conducted the group as the only provider.  We calculated caloric requirements for weight loss for each person and reviewed general dietary principles, deciding as a group to follow a low-carbohydrate diet. Beginning weights were recorded, and two of the members formed a “walking group,” planning to walk together daily. The group had one follow-up visit, with modest weight losses of 3-4 pounds per member over 1 week.  The group decided they did not want to continue to meet and thought they could maintain the program on their own. I did not bill insurance companies, since weight loss counseling is a “never-covered” service.

The patients paid $10 for a 1 hour group visit.  In retrospect, this was a very low fee, and perhaps we would have had more participation if the fee had been higher.  We did not find this format to be any more successful in helping with weight loss than normal visits.  Most weight loss groups do work by accountability and money committed but charge much higher fees and have more intensive programming.

I have no current plans to schedule more group visits, although I might if I were to measure some clinical outcome that told me that individual visits weren't doing the job in helping patients live with asthma, diabetes, or some other chronic condition.

Though my experiment was not very successful, NDP practices collectively have a wealth of experience with group visits, and I'll benefit from that if I do decide to try again. Diabetes has been the most popular disease state around which to construct a group visit.  Peer education in patients with diabetes is powerful in encouraging adherence to lifestyle changes and therefore in promoting improved control of diabetes.  Group visits can work for a variety of different patient types, however.  Moreover, physicians can get paid for their work in a group visit as long as the visit incorporates one-on-one time with each patient and documentation supports the level of E&M code billed. 

The group visit set-up can provide a change in the daily routine of visit after visit.  The practice works more as a team, pulling in other staff members to do teaching and evaluation.  Many practices in the NDP networked with community providers, bringing in dietitians, dentists, or pharmacists as guest lecturers. If you think you might want to try a group visit, it's easy to learn more. The TransforMed web site provides a list of resources on group visits, the AAFP offers advice on implementing group visits, and Family Practice Management has published several relevant articles and tools, which you'll find in the "Access to care and information" section of the FPM's collection of Patient-Centered Medical Home Resources.

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About the Author

Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.

Note: This blog is no longer updated; this is archived content.

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Real-Life Practice Transformation is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.