Teaching Residents to Lead Mini-Group Medical Visits: Overcoming Challenges and Evaluating Successes Arnold Goldberg, MD Kim Salloway Rickler, MSW Jerome McMurray, MA Garrett Sullivan, BA Melissa Nothnagle, MD

Overview What is a mini-group visit? Nuts and bolts of the visit Role play of mini-group visit Implementation of mini-group visits Evaluation of educational and patient outcomes

Share Your Experience…

Group Medical Visits Shared office visit, 12 - 20 patients Chronic disease management Multidisciplinary team approach

Unique Features Integrates medical management, nutritional guidelines, behavioral change Promotes self-management strategies Supportive group context Benefits of group visits: ↑ Patient access ↓ ED visits ↑ Provider satisfaction ↓ specialists referrals ↑ Patient satisfaction ↑ immunization rates ↓ HgbA1C

“Mini-Group Visit” (MGV) Goal: Teach residents to plan and conduct group medical visits 3 - 4 patients from one resident’s panel Target learners: PGY-3’s

Brown Family Medicine Residency MEMORIAL HOSPITAL OF RHODE ISLAND Urban community hospital 13 residents per year 2nd year class particularly diverse 50% US graduates 50% international medical graduates 7

Nuts and Bolts 6 monthly sessions per group 1 hour 15 minutes per session Facilitators Resident Faculty physician Behavioral science faculty Guest educator

Preparation for Visit Resident and faculty physician Coordinator Review charts Problem list Medications Flow sheet (core measures) Coordinator Confirm guest educator Gather evaluation forms Receptionist Confirm patient appointments

Structure of the Visit Vitals (by LPN/CNA) Introductions: 15 minutes Sign HIPAA forms, discuss confidentiality Patients review their own chart printouts Patients identify and report progress on self-management goals Educational program: 20 minutes Medical exam: 20 minutes Wrap up: 5 minutes

Educational Topics by Session Core Diabetic Measures Self Management Goals, Motivational Interviewing Nutrition Medications for Diabetes Exercise and Weight Loss Wrap-up and Next Steps

Post Visit Immediate debriefing (15 minutes) Resident completes charts Verbal feedback to resident Agree on follow-up plans if needed Resident completes charts Faculty completes rating tool

Role Play Patients: Milo is a 63-year-old former chef who now works in environmental services who has had diabetes for 15 years. Rachel is a 60-year-old single mother of a physically disabled 29-year-old daughter who lives with her. Patient has known about her diabetes for 6 years. She is afraid to use needles. Peter is a 53-year-old who has had diabetes for 4 years. He worked as a chemist but his company closed. He is now studying to be an LPN. He is recently remarried. Jessie is a 60-year-old married woman who has had diabetes for 11 years. She is concerned about her health. She has a supportive husband. She is a teacher.

Implementation Strategy

12 Months Prior Assemble team Develop goals/objectives Faculty physician behavioral scientist group visit coordinator Develop goals/objectives Plan implementation # visits, interval, personnel, timing, location, orientation for learners Plan evaluation

4 Months Prior Finalize evaluation tools Orient target learners Evening session with dinner Encourage learners to express concerns Identify target patients From each resident’s panel Negotiate scheduling Education coordinator, residency leadership

2 Months Prior Resident training sessions Patient recruitment Chronic Care Model Diabetes core measures Group facilitation skills Motivational interviewing Patient recruitment FMC staff preparation

Challenges: Foreseen and Unforeseen Resident resistance ANOTHER required activity?!! Last minute panic: I am not prepared!! Success of first resident (chief) helped Staff resistance Less of a problem Faculty time commitment Scheduled in 1st part of precepting session

Challenges: Foreseen and Unforeseen Recruiting and retention Recruit 6-8 patients to yield 3-4 Scheduling: very complex Series of meetings with residency administration Scheduling far in advance ideal What would you foresee in your setting?

Evaluation Methods Tracking patient participation Faculty assessments of residents Resident evaluation of curriculum Patient evaluation of visits Changes in core measures of DM Alumni surveys re: implementation of group visits

Preliminary Evaluation Results 12 residents completed 71 visits 5-6 visits per resident Analysis of 26 patients Mean HgbA1C: pre 8.45; post 8.59 Systolic BP: pre 129; post 124 Diastolic BP: pre 73; post 72 LDL: pre 102; post 90 mg%

(unless otherwise noted) Program Evaluation by Residents Question Median (unless otherwise noted) Range 1. How helpful were the training sessions in preparing you to run a Mini Group Visit (MGV)? 3.5 (2-5) 2. In your opinion, how important is a team approach in conducting a mini group visit? 5.0 (3-5) 3. How efficient and smooth was the patient flow? 3.0 4. Was the physical space adequate for conducting the MGV? Yes - 83.3% 5. Was an hour and 15 minutes adequate enough time to successfully conduct your MGV? Yes - 91.7%

(unless otherwise noted) Program Evaluation by Residents Question Median (unless otherwise noted) Range 6a. How satisfied were you with the education sessions during the MGVs? - Core Measures 5.0 (3-5) 6b. How satisfied were you with the education sessions during the MGVs? - Behavioral 4.0 6c. How satisfied were you with the education sessions during the MGVs? - Nutrition 6d. How satisfied were you with the education sessions during the MGVs? - Pharmacist (2-5) 6e. How satisfied were you with the education sessions during the MGVs? - Physical Therapy (1-5) 6f. How satisfied were you with the education sessions during the MGVs? - Wrap Up

(unless otherwise noted) Program Evaluation by Residents Question Median (unless otherwise noted) Range 7a. How satisfied were you with the facilitation by the Core Faculty Team? - Arnold Goldberg 5.0 (4-5) 7b. How satisfied were you with the facilitation by the Core Faculty Team? - Kim Rickler 4.0 (3-5) 7c. How satisfied were you with the facilitation by the Core Faculty Team? - Jerry McMurray 4.5 8. How satisfied were you with the MGV program overall? 3.5 9. Do you feel adequately prepared to conduct Group Medical Visits in your future practice? Yes - 91.7% 10. How likely would you say you are to actually implementing group medical visits in your future practice? (1-5)

Next Steps… Resident interviews Alumni surveys Feedback on curriculum Intent to provide group visits Alumni surveys Provision of group medical visits In the midst of Year #2 with new 3rd years Streamlining faculty time commitment

Questions / Discussion

Take Home Message… Mini-group visits are a feasible and fun way to teach the group medical visit model to residents For more information contact: Arnold_Goldberg@mhri.org