Slide 1

Group Visits For Tobacco CessationGet Paid More to Produce Better Clinical Outcomes

This session is supported in part by a grant to the AAFP from the Smoking Cessation Leadership Center

Evidence-based recommendations:• All patients should be asked if they use tobacco

and should have their tobacco-use status documented on a regular basis. Evidence has shown that this significantly increases rates of clinician intervention. Strength of evidence: A

• Clinic screening systems such as expanding the vital signs to include tobacco-use status, or the use of other reminder systems such as chart stickers or computer prompts are essential for the consistent assessment, documentation, and intervention with tobacco use.

Strength of evidence: B

Agency for Healthcare Research and Quality Clinical Guidelines and Evidence Reports (AHRQ)

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.section.7838

Evidence-based recommendations:• All physicians should strongly advise every

patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. Strength of evidence: A

• All clinicians should strongly advise their patients who use tobacco to quit. Although studies have not independently addressed the impact of advice to quit by all types of nonphysician clinicians, it is reasonable to believe that such advice is effective in increasing their patients' long-term quit rates. Strength of evidence: B

Agency for Healthcare Research and Quality Clinical Guidelines and Evidence Reports (AHRQ)

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.section.7838

Question for audience:Do you currently offer group visits?

1. Yes – for tobacco cessation2. Yes – for conditions other than tobacco

use3. No

Outline1. What are group visits?2. Why should you offer group visits?3. What are the outcomes from using groups

visits?4. How do you organize and schedule a

group visit?5. How do you bill & document a group visit?6. How do you apply group visit techniques

to tobacco cessation?

“Skeptical scrutiny is the means...by which deep insights can be winnowed from deep nonsense.”

--Carl Sagan

What kinds of patients benefit most from group visits?

• High-risk patients:– Those patients who have an increased

risk for both high resource utilization and poor outcomes

– Tobacco users are certainly at high risk for both

High-risk groups• Diabetes• Tobacco users• Asthma• Cardiovascular disease (CVD)• Dyslipidemia• Depression• Total joint replacements• Frail elderly• HIV/AIDS

We can afford to focus on high-risk patients

• 1 percent of the population accounts for 20 to 30 percent of health care expenses

• 5 percent of the population accounts for 50 percent of total expenses

• Insurers are starting to fund and encourage group visits, even if they increase physician revenue

What Are Group Visits?

Shared medical visits that provide an effective way to manage high-risk cohorts

• Maximize educational time by working with 15 to 30 patients at a time

• Many patients prefer group visits• Group visits offer a billable service• Any medical provider can offer group visits

– Doctors, nurses, PAs, pharmacists, mental therapists, dieticians, etc. A physician and a dietician can even do a visit together

– Attendance drops if primary physician is not involved

Group visits can be annual, in a series, or longitudinal

• Annual visits share information and reach set targets for the group’s diagnosis (e.g., an osteoporosis visit or a single tobacco cessation group visit)

• Series group visits consist of 2 to 3 visits focused on tobacco cessation (e.g., initial and one 2 to 4 weeks later)

• Longitudinal group visits can substitute for many individual doctor visits (e.g., type 2 diabetes, but could also be used for patients with tobacco use and other related major health issues)

Difference between a group visit and a class:

• Class only provides information to a group• A group medical visit may include both

an individual E/M service and group education or individual E/M services observed by the group.

• The individual E/M service is a billable service. Group education may be billable.

• In a group visit you must spend one-on-one time to clarify the subjective, objective, assessment and plan for the visit.

Models for shared medical appointments

During the early 1990s, we had three models:1. Diagnosis-specific group visits (Masley)

Pick a diagnosis and invite those patients (e.g., tobacco abuse)

2. Cooperative clinics (Scott, Internist, Kaiser) Invite a group with different diagnoses to get their care together (frail

elderly)

3. DIGMAS: Drop-in Group Medical Appointments (Noffsinger, Psychologist, Kaiser & Private)

A system to help with access

Now, many models exist

Provider and Behaviorist Models• In the high-risk cohort model, I’ve done

visits with myself and a few medical assistants

• In the Cooperative Clinic and DIGMA models, you always invite a behaviorist to moderate the group

• Residents do well with a behaviorist present

• You don’t require a behaviorist; family physicians are great with people

Models for Group Visits• No “right model,” just the one that

works for you and your patients • The model you use is based upon

– The goals for your patients– Your patients’ diagnoses– Your reimbursement needs– Available office space

The model you choose should:• Improve clinical outcomes

• Increase your productivity by about 15 to 25 percent

• Improve both patient and provider satisfaction

• Lower total health care costs

Succeed in changing lifestyles with group visits

• Group visits help many patients succeed in making lifestyle changes, such as in quitting tobacco use

• Involve partners & family in changes• Groups visits have been shown to

improve dietary intake and activity levels; which help to address weight gain concerns related to tobacco cessation

Why should you offer group visits?

• Share more information in less time• Improve clinical outcomes• Improve patient satisfaction for many

patients• Save money on the cost of providing care• Increase productivity• Improve provider satisfaction• This is a rare Win-Win-Win opportunity

Outcome Data From Group Visit Studies

We need more data on Group Visits in particular

related to tobacco cessation

“Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing had happened.”

--Winston Churchill

Outcome Data• Data shows group visits improve quality of

clinical outcomes, patient satisfaction with care, cost data, & MD productivity

• This includes for diabetes, HTN, prenatal visits, asthma, etc.

• While group visits have been used for tobacco cessation programs, we don’t yet have data showing that the same intervention produces better results in groups than individually

Organizing & Scheduling Group Visits

“By doing just a little every day, I can gradually let the task completely overwhelm me.”

--Ashleigh Brilliant

How can you identify cohorts for group visits?

• Pull diagnosis codes from billing data – ICD code 305.1, Tobacco Cessation

• Create registries at patient visits– Empower your staff to enroll patients

• Review pharmacy prescription data • Create an Excel file or a Registry file

that you can update at scheduled intervals

Plan in advance• Schedule > 8 to12 weeks in advance

• Schedule 2 to 3 MA/LPN level providers for the first 15 to 30 minutes to collect data

• Reserve a room!

• Prepare overheads, handouts or choose reading material in advance

• Prepare chart note forms in advance

Group visit organization

• Organization brings order

• Disorganization produces chaos

• Some chaos will occur

“In science as in love, too much concentration on technique can often lead to impotence.”

--P.L. Berger

How much time do you need for a group visit? (one tested method)

4 hours for a group visit with 20 to 30 patients: 2 hours group time and 2 hours prep time (5 patients/hour of your time)– 1 hour to prepare didactic materials and to

coordinate with your staff – 1 hour for chart reviews prior to the visit– 1/2 hour for 2 to 3 nurses to collect data, and

for the provider to document specific plans– 1 hour to share information within the group – 1/2 hour for wrap-up

You can vary the time• Choose a group visit size that

reflects your style, patient population and group visit room

• You could see 10 patients during a total of 2 hours of physician time for a 1 hour group visit session

– Allow 30 minutes for chart review, 30 minutes to prepare materials and 1 hour for the session (again at least 5 pts/hour of MD time)

Selecting Patient Material• Select evidence-based objectives and targets,

and give them to your patients– A notebook for patients with current status and

targets– A book addressing lifestyle changes – AAFP patient education handouts:

www.familydoctor.org– 28-page AAFP Stop Smoking Guide:

http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/askact/guide.Par.0001.file.tmp/StopSmokingGuide2001.pdf

– Review the other tobacco cessation resources on www.askandact.org

How do you invite patients?• Willingness to enroll with the primary

physician is about 50% • Create a registry of patients with

tobacco use• Contact the tobacco users in your

practice (e-mail, mail, postcards)• Offer 2 to 3 group visits yearly for

tobacco cessation; have your staff market these sessions year round

How do you invite patients? (cont)• One month prior, write a letter to

tobacco users in your practice advertising dates for you next group visit (postal mail or e-mail)

• The letter encourages them to call and enroll for the group visit

• Have your receptionist call 1 week later to encourage enrollment.

Chart review before the group visit (ensures quality)

• Addresses key targets for the specific diagnosis

• If you have a registry of high-risk cohort patients, this is very easy

• If your charts lack cohort specific targets, the first review can be lengthy, but critically important

• Once a template is built for the chart review, a nurse/PA/MA can add data for physicians review

Registration• First visit, during registration

forms must be signed (I strongly recommend confidentiality and HIPAA forms), patients should be registered and fees collected

• Thereafter, register, collect co-payment or normal appointment fee, and begin data collection

Agreement to Participate Example

• I agree to meet with a group of patients and my doctor. I have the choice to be seen by my physician in this group or individually.

• Like any doctor’s appointment, I agree to be responsible for the bill or co-payment associated with this doctor’s visit.

Confidentiality Form • I agree to keep all information

regarding other patients at these visits private and agree not to disclose any information regarding other patients in these group visits.

• I will respect others’ privacy - ok to discuss what you have learned in these sessions, but don’t mention anyone’s name outside this group!

HIPAA Issues • Receptionist should mention this issue

when they register for the appointment• Signed HIPAA Disclosure Form

essential – Share with your HIPAA compliance

officer– Physicians should avoid sharing

personal health info about a patient without “additional consent” to do so

HIPAA Consent Example• During a Group Visit it is possible that

some of my personal health information will be disclosed. For example, at a Group Visit for Tobacco Cessation, it might be assumed that everyone attending uses tobacco. Discussions may occur regarding personal health information during a group visit. I have been notified of this potential disclosure and I wish to participate in a group medical visit. I realize that I have the option of being seen individually.

Room set-up• Horse-shoe shape works well• Back corners used for nurse evals

– Curtain for privacy optional

• Put handout materials by the entry/exit door

• Have a cart with blood pressure cuffs, charts, materials, extra pens, etc.

• Consider table for tea, healthy snacks, or for cooking demos

Room Layout

MD

Nurse

Nurse

Clip Board Screen Tea

Projector

Patient Role

1. Arrive on time2. Register3. Find a chair and complete

subjective aspect of the SOAP (subjective, objective, assessment, plan) note

4. Meet with the nurse5. Meet with the doctor6. Return to chair

Nurse Exam Stations (2 to 3)• Maximum 3 to 4 minutes/pt (sees 10 pts

/30 min)• Medical Record (EMR or paper)• New progress note completed. MD may have

already made comments from chart review• Scale, BP cuff, peak flow meter, etc• Review of systems, past history, vital

signs and peak flow may be completed here

• Physician will complete the note and sign the progress note

MD Role• Conduct preliminary 1-on-1, face to face

E/M with each patient– Signed HIPAA disclosure essential;– Clarify assessment with the patient (you

smoke, it is harmful and I advise you to stop using tobacco).

• Get permission to conduct balance of E/M service with group observing

– Might include starting a new medication and the risks and benefits of that Rx

– Put issues to address on the clip board– Private issues can be addressed at an

individual follow up visit (a recent headache)

MD location during documentation time

• Doctor’s station (table in the corner), or go from patient to patient (but you must have a HIPAA disclosure signed for this to work)

• Don’t leave the room

How does a preceptor mix with a resident-led group visit?

During the initial 30 minutes, while the patient has had data collected by the nurse, and when the provider (resident) speaks briefly with each individual, the preceptor should be available to observe and document “the key aspects of this appointment”

Prepare your chart note in advance• Have a typed, fill in the blank note for

your chart reviews (examples to follow)

• Fill in targets and recent labs prior with the chart review

• Choose targets you want to reach for the note

Prepare your chart note in advance• Nurse and patient may complete the

review of systems, past history, vital signs and peak flow measurement.

• You must document HPI, assessment and plan for each patient. The level of service is based on medically necessary key components provided to individual patient.

Documentation and Billing Examples

Group visits are only intended for established patients

New patients should initially be seen individually

Otherwise, the potential patient interactions and billing aspects may become very complicated

SAMPLE TOBACCO CESSATION PROGRESS NOTESAMPLE TOBACCO CESSATION PROGRESS NOTE

Name: _____________________Date: ____________ID #: ________________________________ HPI: Subjective (at least 4 questions)Years you have smoked? _____ Average cigarettes per day? _____ How many times have you tried to quit? _____Number Tobacco Pack Years? ____________ Hx recent heartburn? __ yes __ noHx smoker’s Coughing? __ yes __ noHx sinus problems? __ yes __ noAny specific issues you want addressed at this visit with the group? _____________________________________________________ ROS: (at least 2 questions)– Has your activity level been recently limited by breathing issues?–  Any chest pain with exercise?–  Any problems with insomnia? Past Med Hx: (See chart for details) Meds: (Include ASA qd; see flow sheet)

TOBACCO USE: PROGRESS NOTE, continuedTOBACCO USE: PROGRESS NOTE, continued

Objective  –    Wt __________ BP __________ BMI ________ RR ________–    Peakflow today ___________  Assessment (Tobacco abuse, 305.1); Other related diagnoses? _____________________ 

Plan–   Quit date planned–   Behavioral options to quit reviewed–   Medication options reviewed. Risks, benefits, and side effects discussed and questions answered. – Rx ________________________________________– Additional Plan _________________________________

 Billing: (circle one) 99212 99213 99214

Group Visit Details

Billing issues (key points)

• Do not rely upon time• Rely upon the complexity of the

diagnosis and your documentation• Consider the medically necessary

key components provided directly to the individual patient in determining the level of service to bill

• Include the diagnoses for comorbid conditions which were addressed in the visit

Pitfalls in offering group visits• Call coverage, especially inpatient and

obstetrical calls• Minimize patient no-shows with:

– Reminder calls 1-2 days prior, “Your MD expects you at this visit!”

– If the patient’s physician isn’t going to lead the group visit, a physician letter encouraging the session improves attendance

Choose a time that suits your audience

• Mid-afternoon for seniors

• Early evenings for working adults

• Tuesday, Wednesday and Thursday appear to be the most popular days

• Saturday mornings work for some groups (about 1/3 to 1/4 of those willing to participate in group visits)

Lifestyle issues to address during group visits

• Home environment• Developing new routines• Medication use• Stress management• Addressing cravings• Rewards

What would keep you from trying this?

• Space?

• Managed care environment?

• Staff support?

• Inertia?

Space Not all clinics are set-up to provide

group visits– Try using the waiting room– Hospitals, community clinics, and

religious centers will often provide space for free to a physician and their group to meet

Managed care

• You need an administrative champion– Offer to track your success as a pilot for other

clinicians

• Every group visit tracked to date has resulted in better satisfaction, lower cost to provide care, and better outcomes

• Many managed care companies encourage and promote group visits

Staff support • Organize your staff in advance

• Anticipate several people during the first 30 minutes, and one person to stay throughout the visit

• Teach your staff to encourage group visits

Inertia• This is a real factor

• It takes energy to save energy

• Are you fed up with the status quo yet?

• How dissatisfied to you need to become to be willing to make things better?– Why not make this better before things get even

worse?

Group visits are effective

Achieve efficiency in patient education: – Improve outcomes (proven for diabetes,

cardiovascular, etc issues)– Improve patient satisfaction– Reduce health care expenses– Enhance provider satisfaction

Questions?

Reporting CME for this event

http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/cme/webcasts/groupvisits.htm

Click on:• Members: Earn CME• Nonmembers: Activity Evaluation