1. Facilitative Leadership and Group Medical Visits STFM, 2009 Julie M. Schirmer, LCSW Ed Shahady, MD Carmen Strickland, MD Mary Talen, PhD

2. Objectives Identify key strategies and methods of successful group facilitation Describe the experience of facilitating a group medical visit Describe multiple strategies to manage common difficult processes in group medical visits Identify resources within and outside the clinical arena to conduct group medical visits

3. Introductions Experience? Hopes/expectations for the workshop? Facilitation IQ

4. Facilitation Group Visit Agenda Introduce selves Icebreaker (s) Experience and learning about group medical visits or group facilitating (from self-assessment) Facilitative Leadership – Carmen & Mary Individual action plans

5. Facilitative Leadership for Group Visits 2009 STFM Carmen Strickland

6. Group Care: What It’s NOT Social Club Class Support Group

7. Group Care vs. Traditional Care Focus on the GROUP Provider is no longer in control but rather GUIDES the care Patients are EMPOWERED  Decision-making  Action Plans  Get support from the group

8. Group Facilitation A cooperative partnership between provider/facilitator and group members All members to share in the responsibility of making the group workLISTENING… IS A MAGNETIC AND STRANGE THING, A CREATIVE FORCE… - BRENDA UELAND

9. Facilitator Goals Time management Coordinate effective clinical assessment/care Guide discussion to provide useful information Provide opportunity for socialization Optimize the power of the group

10. From Teaching to listening... “Instead of projecting your own autobiography and assuming thoughts, feelings, motives and interpretation, you’re dealing with the reality inside another person’s head and heart. You’re focused on receiving the deep communication of another human soul.” S. Covey, 7 Habits of Highly Effective People, p. 241.

11. Basic Group Values Each person has an opportunity to share but may choose not to at any given moment Each person is responsible for her/his own behavior and sharing Each group works together to achieve mutual goals Involvement = Investment = Ownership

12. Qualities of Facilitative Leaders Affirming of others Interested in each group member Good listener Stays focused Organized but flexible

13. Qualities…. Appropriately shares expertise Hooks information to structure Open to new ideas Organized but flexible

14. The facilitator sets the tone for the group by... Body posture Facial expressions Choice of seat General attitude

15. Strategies for Group Facilitation Organize the session Openings and Closings Every group member participates Games/Activities  Interactive- engaging  Physically Active- increase energy Use reflective exercises  Self assessment  Homework/Action Plans Break- socialize/snack

16. The Facilitative Process Acknowledge the concern of the member Refer the concern to the group for processing Return to the member to see if the concern has been met

17. The facilitative process … “I hear that…is a concern for you and perhaps for others…” “What do the rest of you think?” “How are you feeling about our discussion..?”

18. The Facilitator ‘Centers’ by… Watching Observe the group, both the verbal and non-verbal cues Waiting Give it time. See who has something to contribute Wondering Be continually curious… ”I wonder what will happen next..” adapted from Nancy Cohen, Infant Mental Health, 35: Winter 2002-03.

19. Challenges to Facilitation Lack of training re: group care Difficulty giving up control Lack of trust in the group process Insufficient organization

20. Facilitative Behavior Summary Acknowledge each other as equals Stay curious about each other Recognize that we need help from others to become better listeners Slow down…take time to think Conversation is the natural way for us to think together Expect it to be messy at times! From M. Wheatley, Turning to One Another

21. Facilitative Behavior Summary And above all else…. Learn to trust the group!

22. CenteringParenting®CenteringPregnancy®

23. Break time Reconvene at 4:00pm

24. Presenters Experience The best of times and the worst of times

25. Mock Group Visits Each person begin counting 1-6 There will be as many groups as there are sextuplets Group leadership will be coached by presenters and include groups on:  Pregnancy  Diabetes  Weight Loss  Other

26. Large group debriefing…..

27. Why do GMV or Shared Medical Appointments?

28. Patient Empowerment

29. Improved Outcomes Diabetes – 1) Trento: 5 year f/up 2) FM multi-residency study: 12 mo. f/up Cardiac – Schirmer/Goldberg: 6 mo f/up Prenatal – Ickovics: birth weight greater for infants of GMV mothers at public clinics (Centering Pregnancy Program)

30. Patient Satisfaction 350 patients from DMCP (Florida) On a satisfaction scale of 1 to 5 with 5 being the highest-average rating was 4.7 Comments  “ I loved the chance to hear from others with diabetes”  “The report cards are great. I no longer forget my numbers like I did before. I like terms like lousy and happy.”  “I like the extra time with my Dr. & Nurse”

31. Provider Satisfaction (n=18): reporting increased quality of care (4.8-5 pt. scale) provider satisfaction (3.8-5 pt. scale) patient education (89%) patient satisfaction (73%) healthy life-style ed (72%) productivity (3.4- 5 pt. scale)

32. Opportunities for population-based QI studies FMEC Diabetes Study MMC study If you want to share data: IRB, HIPAA and confidentiality agreements needed

33. Reduced Costs Beck: $14.79 per person per month (pppm) Masley: gvm decreased costs by 6%  ed utilization of ERs, specialist visits, hospitalization rates, CT scans

34. Improved Health Behaviors Masley:  ed fruits & veggies Trento:  ed knowledge & behaviors CDSM:  ed exercise (strength training & cardio),  ed pt-doctor communication

35. Quality of Care Trento: HEDIS measures Trento: flu & pneumonia vaccines Schirmer: pt.self management plans on charts

36. Reimbursement Break-even point: 10-12 patients Billing:  99213, with 4 parts to the history & decision making regarding a complex problem, with a stable patient and no therapy changes  99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a pt. requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change  99499 AAFP recommendation (unlisted E/M)

37. National Support “The AAFP believes that group visits are a proven, effective method of treating chronic conditions, increasing patient satisfaction, and imporving outcomes.” “Group visits are one component of the patient centered model of care.”

39. Talen, Schirmer, Shahady Survey http://www.surveymonkey.com/s.aspx?sm=LxHdj_2b MijN8G80pGYACMNA_3d_3d

40. CenteringPregnancy: The State of the Art Carmen Strickland, MD, MPH STFM May 2, 2009

41. Effects of Group Prenatal Care: Randomized Control Trial National Institute of Mental Health #MH 61175, 2001-2006 Ickovics, et al. (2007)Obstetrics & Gynecology. 110(2): 3230-39.

42. RANDOMIZED STUDY SAMPLE, SELECT CHARACTERISTICS GROUP (n=653) INDIV (n=394) AGE, years (range 14-25)20.320.6 EDUCATION, years (26% drop out) 11.411.3 GA STUDY ENTRY, weeks18.018.4 NULLIPAROUS62%61% SMOKE, current21%20% Hx STI52%50% RACE * African American Latina 81% 11% 74% 17% Hx PRETERM BIRTH * 4.0%7.1% PRENATAL DISTRESS, mean * 15.213.7

43. METHODS CONDITIONS - RANDOMIZED 1. Standard individual prenatal care (Control) 2. Centering Pregnancy (CP) 3. Enhanced Centering Pregnancy (CP+) bundled HIV/STI prevention DATA COLLECTION (A-CASI)  Trimester 2 (16-20 wks GA) & 3 (34-38 wks GA), 6 & 12 months post-partum STUDY SAMPLE (N=1,047)  14-25 years, HIV-, English/Spanish, public clinics in New Haven and Atlanta

44. Preterm Delivery, Stratified by Study Condition Note: All analyses controlled for study site, factors that were different by study condition despite randomization (race, prior preterm delivery prenatal distress) and clinical risk factors assoc with birth outcomes (smoking, prior miscarriage/stillbirth). Ickovics, et al. (2007)Obstetrics & Gynecology. 110(2): 3230-39. OR=.67, (.44-.99) OR=.59 (.31-.92) 33% 41% Per 1000 women in group, 40 preterm deliveries averted; 60 per 1000 for African American women

45. BREAST FEEDING Planned contrast CP+/CP vs control, for short-term (0-6 months, solid) OR=1.65, P=.001, and long-term (6-12 months, striped) OR=1.48, P=.05. Ickovics, et al. (2007)Obstetrics & Gynecology. 110(2): 3230-39.

46. PRENATAL CARE ATTENDANCE, SATISFACTION & COST 78% average attendance Less than adequate care (Kotelchuck):  26% vs 33%, OR =0.68 (.50-.91) Women in group care had greater satisfaction with care, F=27.2, p<.001 No difference antenatal or delivery costs (p>0.69)

47. GROUP PRENATAL CARE IMPROVES PERINATAL KNOWLEDGE, ATTITUDES Prenatal knowledge p<.001 Readiness for labor & deliveryp<.001 Readiness for baby carep=.056 Planned contrast CP+/CP vs control; measured post-intervention Ickovics, et al. (2007) Obstetrics & Gynecology. 110(2): 3230- 39.

48. Centering Developments… Over 300 sites in almost every state, involving community health centers, public health and hospital clinics, birth centers and private offices Several large research studies Content module development in teen pregnancy, oral health, sexual health, mental health, diabetes, and chronic care.

50. International Work Active sites in Australia, Canada, and the UK with interest in Africa and South America.

51. Q & A Panel Discussion

52. Wrap up Facilitation skills can be learned, practiced and honed The groups eventually run themselves, if you develop the group process Patients and providers will be rewarded on multiple levels

53. Talen, Schirmer, and Shahady Study N-107 52% conducted 48% not  55% practicing docs  18% physician faculty  24% behavioral medicine faculty  28% private group  26% FQHC  18% hospital-based practice  14% solo practice  13% university-based practice

54. Why not conduct GMVs? Uncertain what to do (49%) Not enough staff (49%) Not enough preparatory time (45%) Lack of patient interest (22%) Loss of revenue (32%) Afraid of audits (9%) Confidentiality (8%)

55. Coding 99214 (54%) 99214 (41%) Group education (8%) Nutrition (3%) Health and Behavior Codes (8%)

56. Benefits Scale of 1-5, from not at all, to very beneficial Patient education (4.4; very beneficial – 56%) Adherence (3.7; moderately beneficial – 37%) Provider satisfaction (3.8; beneficial – 36%) Patient satisfaction (4.1; beneficial and very beneficial – 39%)

57. Barriers Scale=1-5, significant to no barriers Patient attendance – 2.8 Lack of skills – 3.8 Lack of reimbursement for time – 3.2 Not enough time – 3.2 Requires to much preparation – 3.3