Group Visits for Diabetes: An improved model for care Jessica McIntyre M.D.

Objectives ► To describe the effectiveness of group medical visits for patients with diabetes, both medically and in terms of patient satisfaction ► To identify resources that will be helpful in setting up a diabetic group visit ► To discuss logistics of a group medical visit, including billing and coding. ► To demonstrate group visit skills and discuss challenges of facilitating a group visit

Why Group Medical Visits? National numbers tell us we need to look for new solutions– National numbers tell us we need to look for new solutions– Only 48% at A1c goal, 33% at LDL and BP GOALS and only 7% at goal for all three at the same time ► GMV are an innovative way to help patients’ achieve diabetic goals – focus on chronic not acute care ► Improved access to “face-time” with providers ► Use of group dynamics to motivate behavioral change and improve outcomes ► Group visits generate income-can charge a for 8 to 10 patients.

Group Visits Improve Metabolic Control in Type 2 Diabetes. Diabetes Care. 2001;24: Group Visits Improve Metabolic Control for Type 2 Diabetics: ► At the end of 2 years Patients participating in Group visits: ► HbA1c levels lower ► HDL cholesterol levels increased ► BMI lower ► Triglyceride level lower ► Improved knowledge of diabetes ► Increased appropriate health behaviors ► Improved quality of life

Group Visits: A Qualitative Review of Current Research. Jaber et all. JABFM 2006; 19:27-90 Group Visits Improve Other Important Aspects of Care  Improved patient & physician satisfaction  Improved quality of care and quality of life  Decreased emergency department and specialist visits  Improvement in ADA standards of care  Increased sense of trust with physician  Improved care coordination and cultural competence

Resources for Group Visits ► Family Medicine Digital Resource Library ► and affiliated “Wiki’s” ► ( kiId=15) kiId=15http:// kiId=15 ► Starter kits, competency forms, sample progress notes, billing and coding ► Diabetes Master Clinician Program ► ► Links to ADA Standards of Care ► Patient Handouts on various topics ► Training Manuel for Group Visits

Group Medical Visit: Sample Agenda 1:30 - 1:45pm Patients arrive; taken to room; vitals taken 1:45 - 2:00pm Ice Breaker 2:00 - 2:30pm Diabetic Educator, MA, or other speaker works with group; individualizes education when possible 2:30 - 3:45pm Resident physician leads individualized diabetic-focused medical check-ins, physical exams, and continues to engage the group regarding common issues; Behavioral Scientist assesses previous goal attainment and facilitates new goal setting 3:45 - 4:00pm Goals reviewed; final questions; wrap-up

Documentation Items: Group Medical Visit ► Vitals ► Physical Exam  Heart  Lungs  Foot exam ► Random Blood Sugar ► Blood sugar log checked ► Health maintenance notes  Compliance  Hypoglycemic episodes  Side effects ► Prescriptions needed/provided ► Labs needed ► Time spent on education ► Lifestyle/Behavior Change Goals

Coding and Billing the Group Visit ► 250 means diabetes but without the 4th and 5th digit it is not accurate ► 5th digit 250.XX indicates the type of diabetes and level of control  250.X0 indicates Type 2 controlled  250.X1 indicates Type 1 controlled  250.X2 indicates Type 2 not controlled  250.X3 Indicates Type 1 not controlled ► 4th digit 250.XX indicates the complications  250.0X indicates no complications  250.4X indicates renal complications  250.5X indicates eye complications  250.6X indicates neurological complications

History: CC History: HPI History: ROS History: PFSH Medical decision making 99213Required 1-3 elements Pertinent Not required Low complexity 99214Required 4+ elements (or 3+ chronic diseases) 2-9 systems 1 element Moderate complexity Adapted from Coding "Routine" Office Visits: or 99214? Family Practice Management Coding and Billing the Group Visit

Video: Types of Group Medical Visits ► While you watch:  Think about advantages/challenges of GMV  Think about how physician’s role is different than traditional role  Observe facilitation of physicians; how is this different than teaching?

Video: Types of Group Medical Visits ► Link to video from website: ► pmodules/groupvisits pmodules/groupvisits pmodules/groupvisits Then Click on Group Medical visits (Watch video)

Group Session ► In Groups of 4-5, choose one “scribe”, one facilitator and one spokesperson ► 10 minutes to discuss the following: (To be reported to whole group)  What are the differences in the roles as a physician in a group visit as compared to a usual one to one medical visit?  How would this role change be a challenge for you? How would it be a help to you?  Describe the differences between “facilitating” and “teaching”?

Traditional vs. Group Visits Traditional ► MD as expert/ teacher ► Doctor-speak ► One on one, 15 minute “do it all” visits ► Physiological focus Group Visit ► MD as facilitator ► Doctor-listen ► Group or community, 2-3 hours, topic focused ► Biopsychosocial focus

Facilitating vs. Teaching a Group ► Foster connections among members, through deferring answers to group members ► Ask questions, and elicit patient stories, experiences and successes ► Use of patients own language, paraphrasing and “circular” questions ► Ask members for their opinions, THEN clarify misinformation

Wrap Up! ► Group medical visits are an evidenced-based, effective way to provide care to our patients, improving both medical outcome and patient satisfaction. ► Many resources exist to help you start and facilitate GMV ► Charting, billing and coding are “do-able” ► The role of the physician is one of facilitator at a GMV

References 1. Group Visits Improve Metabolic Control in Type 2 Diabetes. Diabetes Care. 2001;24: Group Visits: A Qualitative Review of Current Research. Jaber et all. JABFM 2006; 19: Further Evaluating the Acceptability of Group Visits in an Underinsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetics. The Diabetes Educator 2007;33: Further Evaluating the Acceptability of Group Visits in an Underinsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetics. The Diabetes Educator 2007;33: Diabetes Master Clinician Program, Evaluating Group Visits in an Uninsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetes. The Diabetes Educator. 2003;29: Evaluating Concordance to American Diabetes Association Standards of Care for Type 2 Diabetes Through Group Visits in an Uninsured or Inadequately Insured Patient Population. Diabetes Care. 2003;26: Models for Patient-Centered Health Care Delivery. Group Practice Journal. 2003;52:1-6 7.Models for Patient-Centered Health Care Delivery. Group Practice Journal. 2003;52:1-6