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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
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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
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Share Your Experience…
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Group Medical Visits Shared office visit, 12 - 20 patients
Chronic disease management Multidisciplinary team approach
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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
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“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
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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
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Nuts and Bolts 6 monthly sessions per group
1 hour 15 minutes per session Facilitators Resident Faculty physician Behavioral science faculty Guest educator
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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
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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
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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
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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
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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.
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Implementation Strategy
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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
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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
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2 Months Prior Resident training sessions Patient recruitment
Chronic Care Model Diabetes core measures Group facilitation skills Motivational interviewing Patient recruitment FMC staff preparation
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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
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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?
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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
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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%
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(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 % 5. Was an hour and 15 minutes adequate enough time to successfully conduct your MGV? Yes %
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(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
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(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 % 10. How likely would you say you are to actually implementing group medical visits in your future practice? (1-5)
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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
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Questions / Discussion
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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:
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