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

2. 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

3. 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 99214 for 8 to 10 patients.

4. Group Visits Improve Metabolic Control in Type 2 Diabetes. Diabetes Care. 2001;24:995-1000 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

5. 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

6. Resources for Group Visits ► Family Medicine Digital Resource Library ► www.fmdrl.org and affiliated “Wiki’s” www.fmdrl.org ► (http://www.fmdrl.org/group/index.cfm?event=c.showWikiHome&wi kiId=15) http://www.fmdrl.org/group/index.cfm?event=c.showWikiHome&wi kiId=15http://www.fmdrl.org/group/index.cfm?event=c.showWikiHome&wi kiId=15 ► Starter kits, competency forms, sample progress notes, billing and coding ► Diabetes Master Clinician Program ► http://www.fafp.org/diabetes08.html http://www.fafp.org/diabetes08.html ► Links to ADA Standards of Care ► Patient Handouts on various topics ► Training Manuel for Group Visits

7. 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

8. 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

9. 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

10. 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: 99213 or 99214? Family Practice Management Coding and Billing the Group Visit

11. 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?

12. Video: Types of Group Medical Visits ► Link to video from website: ► http://www.impactbc.ca/practicesupport/ps pmodules/groupvisits http://www.impactbc.ca/practicesupport/ps pmodules/groupvisits http://www.impactbc.ca/practicesupport/ps pmodules/groupvisits Then Click on Group Medical visits (Watch video)

13. 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”?

14. 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

15. 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

16. 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

17. References 1. Group Visits Improve Metabolic Control in Type 2 Diabetes. Diabetes Care. 2001;24:995-1000 2. Group Visits: A Qualitative Review of Current Research. Jaber et all. JABFM 2006; 19:27-90 3. Further Evaluating the Acceptability of Group Visits in an Underinsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetics. The Diabetes Educator 2007;33:309-314 3.Further Evaluating the Acceptability of Group Visits in an Underinsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetics. The Diabetes Educator 2007;33:309-314 4. Diabetes Master Clinician Program, http://www.fafp.org/diabetes08.html http://www.fafp.org/diabetes08.html 5. Evaluating Group Visits in an Uninsured or Inadequately Insured Patient Population with Uncontrolled Type 2 Diabetes. The Diabetes Educator. 2003;29:292-302 6. 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;26:2032-2036 7. 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