David Geffen School of Medicine at UCLA Use of Physician Partners (P2) to Improve the Efficiency of Geriatrics Visits David B. Reuben, MD Janine L. Knudsen Grace I. Chen, MD Eve Glazier, MD Wendy Senelick, MPH Niki D. Alejo Krisan M. Soriano, LVN Brandon K. Koretz, MD David Geffen School of Medicine at UCLA

Background High burnout rates among primary care physicians 21% do not recertify after 10 years Long hours, much paperwork, inefficient offices Electronic health records have not made physicians work easier or reduced time demands

UCLA Physician Partner Pilot Purpose: To develop and test a model of using LVNs or non-professional workers to assist PCPs and improve efficiency and PCP satisfaction 6 month pilot supported by DOM 2 Physician Partners: 1 LVN, 1 AAIII 2 Practices (1 Geriatrics, 1 GIM) Initially 4 MDs, then expanded to 5 MDs

Roles of Physician Partners Before the Visit Pre-populates notes with chronic conditions, recent labs and tests, and health maintenance Reviews recent consults or outside records. During the Visit Transcribes information: HPI, ROS, PE, and assessment and plan. Looks up patient records, recent results, or consults on cView.

Roles of Physician Partners At the conclusion of the Visit Completes laboratory and test requests Processes referrals Schedules follow up visit Processes MA/LVN orders and communicates tasks Reviews how to contact the office during office hours and how to obtain help after hours Provides summary and appointment card to patient and/or family/caregiver

Roles of Physician Partners After the Visit Completes progress note and charge document Progress note is stamped with MD attestation Reviews progress note and charge document with MD who edits and signs these Coordinates follow up tasks with PSR P2 updates medication list on Rcopia, processes new prescriptions or refills, and encounters scheduled appointments Facilitates coding and billing

Methods 6-month implementation period Direct timing of the time the physician spent in the examining room Diaries at the end of the session of time spent before and after the session Physician Satisfaction and Burnout surveys Patient Satisfaction surveys

Results Training and shadowing August-Oct 2012 180 Sessions with P2 s 35 Sessions with visit times monitored, 16 in geriatrics (9 test, 7 control) 42 MD diaries of pre-and post-session time (21 geriatrics) 125 Patients interviewed about satisfaction, 82 geriatric

Results: Time Series Data Collection MD/Patient Interaction MD Time (Minutes) Spent with Patient Control P² P-value Geriatrics 20.7 (N=55) 17.7 (N=79) 0.012 Based on a schedule of 12 slots of 20 minutes, an additional 1.5 patients could be accommodated without running over allocation.

Quality of Life (Pre and Post Session Times) Time (Minutes) Spent Before & After Clinic Session Control P² P-value Pre Session Geri (N=21) 31 14 0.0005 Post Session 76 18 0.0061

Results: Office Visit Survey Pre and Post Surveys for the Pilot MDs (GIM & Geri) PRE AVG (N=5) POST I spend too much time documenting the care that I provide. 4 2 Things I want to do for the patient don’t get done because I forget to order them. 3 1 I am doing tasks in the visit that office staff could be doing. Too much of the office visit is spent looking up things on the computer. Legend: 1=Rarely, 2=A little of the time, 3=Some of the time, 4=Most of the time, 5=Almost all of the time

Patient Perception Survey Geri: Control (N=31), P² (N=51) “The physician spent enough time with me” Strongly agree 81% control, 96% P2 (P <.0001) Felt uncomfortable having the P² in the room Agree 8% The P2 helped the visit run smoothly Agree 82% Geri: Control (N=31), P² (N=51) “The physician spent enough time with me” Strongly agree 81% control, 96% P2 (P <4E-07) Felt uncomfortable having the P² in the room Agree 8% (4 out of 50) The P2 helped the visit run smoothly Agree 82% (81.6%; 33 strongly agree, 7 agree out of 49)

Conclusions The use of P2s can: Shorten geriatric visit lengths Improve physician satisfaction with the office visit and reduce burnout Most patients feel that the P2s make the visit go smoother though a small minority feel uncomfortable with P2s in the room. If additional visits can be scheduled, the program may pay for itself.

Results: Maslach Burnout Inventory Pre and Post Surveys for the Pilot MDs (GIM & Geri) resulted in either the same or more positive answer. The questions listed below improved on average 1 point. PRE AVG Score (N=5) POST I feel used up at the end of the workday. 4 3 I feel I'm working too hard on my job. 2 Working with people all day is really a strain for me. 1 I worry that this job is hardening me emotionally. I feel like I'm at the end of my rope. Legend: 0=Never, 1=A few times a year or less, 2=Once a month or less, 3=A few times a month, 4=Once a week, 5=A few times a week, 6=Everyday

MD Quotes “I would see patients during my lunch break to keep this program going.” “Having the P2s gave me more time to actually take care of my patients, including those not in the office, and more importantly knowing that the P2s were supporting me with clear and accurate documentation made me feel energized and excited to see even more patients.” “Working with the physician partner has been valuable to my practice. They free up the office visit so that I can focus on the patient. I feel my visits are more enriching for both myself and the patients I see.” “They are like the extra brains and hands that I have always needed to ensure adequate documentation as well as completed forms, orders and patient instructions by the end of a visit!”

Patient Quotes “Having the physician partner in the room was terrific - she was quiet and respectful and I felt it helped moved the process along because she took notes while the doctor talked to me and examined me.” “Very pleasant and courteous. Allows doctor to focus on patient without waiting time to document.” “She seemed very nice and respectful. I did not feel any discomfort about her being in the room.” “It's like she wasn't there. Very quiet. Not in the way at all.”