Diabetes Group Visits Relationships and Education and SelfManagement
Diabetes Group Visits: Relationships, and Education, and Self-Management… Oh My! Sameer Ohri, MD Tracy R. Juliao, Ph. D Doctors Hospital of Michigan Pontiac, MI STFM/AAFP Conference on Practice Improvement December 5, 2008
Disclosures w Neither presenter has any disclosures Ohri & Juliao, 2008
How Do Group Medical Visits Relate to the Patient-Centered Medical Home? w PCMH emphasizes: w Physician-Patient Relationship w Physician Directed Medical Care w Whole Person Orientation w Coordinated/Integrated Care w Quality and Safety w Enhanced Access w Payment for Performance (AAFP, AAP, ACP, AOA: Joint Principles of the Patient-Centered Medical Home, 2007) Ohri & Juliao, 2008
Why Group Medical Visits? Research Favors Group Interventions: w More efficient use of resources w Improved access w Use of group dynamics to: w motivate behavior change w improve outcomes (American Diabetes Association's Scientific Sessions, 2004) Ohri & Juliao, 2008
Research: Group Visits Improve Metabolic Control for DM-II Patients w At the end of 2 years: w Patients participating in group visits, as compared to controls. . . (Kimura, Dasilva, & Marshall, 2008) w Hb. A 1 c levels lower w HDL cholesterol levels increased w BMI lower w Triglyceride level lower w Improved knowledge of diabetes w Increased appropriate health behaviors w Improved quality of life Ohri & Juliao, 2008
Research: Group Visits Improve Metabolic Control for DM-II Patients w At the end of 2 years (cont. ): w Physicians’ experience: w Spent less time seeing 9 -10 patients as a group, than if each was seen individually w Patients’ experience: w Spent more time and had more interaction with physician within a group, than if he/she were seen individually (Kimura, Dasilva, & Marshall, 2008) Ohri & Juliao, 2008
Research: Group Visits and Reduction of Health Care Costs w Underserved/underinsured patients: w Replaced non-indicated specialty visits with the group medical visits w Reduced outpatient medical care costs for patients (Clancy, Dismuke, Magruder, Simpson, & Bradford, 2008) Ohri & Juliao, 2008
Our Setting / Challenges w Community Hospital w Family Medicine Residency (6 -6 -6) w Residents’ office days vary monthly according to rotation w Continuity and number of patient visits “matter” w Underserved & underinsured patient population Ohri & Juliao, 2008
Our Planning Process w Determine goals w Improved patient care/patient outcomes w Increased satisfaction of patients and resident physicians w Resident education w Determine personnel needs w w w Resident Physician(s) Attending Physician(s) Behavioral Scientist Diabetes Educator Medical Assistant(s) Administrative (Office Manager & Biller) Ohri & Juliao, 2008
Our Planning Process w Determine accreditation and billing needs/issues w Is ADA Education Recognition necessary? w If billing as medical visit, can we also bill for diabetes educator and/or psychologist? w Determine group structure w w Open vs. Closed Regular dates (e. g. 3 rd Monday of the month) Vitals and Physical Exam What happens when personnel change? Ohri & Juliao, 2008
Our Planning Process w Plan educational itinerary for 8 group medical visit model w Identify diabetic patient population w Identify sample of population w Ascertain patient interest w Obtain written consent to discuss medical information in group w Determine documentation needs w Same as individual visit or unique to group medical visit? Ohri & Juliao, 2008
Our Planning Process w Logistics w w How to schedule (antiquated system)? Who confirms appointments with patient? Who reminds patients the day prior? Check-in process (co-pays, vitals)? w Rollout the group medical visits w Post-visit documentation and data gathering w Quality Improvement Research? ? ? Ohri & Juliao, 2008
Educational Curriculum 1. Diabetes Disease Process w w w 2. Types of diabetes Signs and Symptoms High and low blood glucose; actions to take Possible complications Lifestyle changes Monitoring w w Goals Glycoslated Hemoglobin (Hb. A 1 c) Schedule and recording Demonstration of glucometer use (Developed by Cheryl Wilson, RN, CDE, 2008) Ohri & Juliao, 2008
Educational Curriculum 3. Medications w w w 4. Medication schedule Purpose and possible side effects to report Demonstrate insulin technique and site rotation Healthy Eating w w w w Body Mass Index (BMI) Making better food choices Reducing portion sizes Following a meal plan Reading a food label Counting calories and carbohydrates Reduction of sodium and saturated fats (Developed by Cheryl Wilson, RN, CDE, 2008) Ohri & Juliao, 2008
Educational Curriculum 5. Being Active w w w 6. Exercise benefits Exercise contraindications Exercise longer and more often Types of exercise Adjusting pre-mail insulin for activity Carbohydrates needed per hour of activity Reducing Risks w w w Risk factors for diabetes Risk factors you can control and cannot control Stop smoking Self-care activities Regular medical follow-up (Developed by Cheryl Wilson, RN, CDE, 2008) Ohri & Juliao, 2008
Educational Curriculum 7. Problem Solving w w 8. Plan problem situation treatment Prevent problem situations Healthy Coping w w w Cope with diagnosis of diabetes Adapt to lifestyle changes Community resources and support groups (Developed by Cheryl Wilson, RN, CDE, 2008) Ohri & Juliao, 2008
Educational Curriculum Led by Resident Physician w Goals and Targets w w Health Maintenance Issues w w Nutrition (ELMO) Activity Levels (Exercise) Foot Care Importance of Specialty Care w w Example - Bull’s Eye Podiatry Opthamology Myth busting Consequences of non-adherence Ohri & Juliao, 2008
Identifying Our Diabetic Population w Chose one resident’s patients w Seen in past 6 months w ICD-9 codes 250. x (x = 0, 4, 5, 7, 8, 9) w Resident Physician w Contacted patients by phone w Introduced the concept of diabetic group medical visits w Ascertained patient interest w Invited patients to diabetic group medical visit Ohri & Juliao, 2008
Develop Outcome Measures w Diabetes Targets w w Hemoglobin A 1 c Blood Pressure LDL levels Urine Microalbumin/Cr ratio w Health Maintenance targets w w BMI ASA use Pneumovax/Flu Vaccinations Foot/Eye Exams Ohri & Juliao, 2008
Group Medical Visit Preparation: In Advance w Arrange mutually convenient time for group visit for all providers w Schedule space w Near office preferable w Large enough for group w Not too formal w Notify patients of meeting time w Resident physician calls patients to confirm appointment Ohri & Juliao, 2008
Group Medical Visit Preparation: Day of Visit w Generate Billing/Encounter Forms w Transport the following to the meeting room: w Patient charts w Blank group progress notes w Blood pressure cuff w Glucose monitor w “Set up” room to facilitate interaction Ohri & Juliao, 2008
Group Medical Visit Logistics w w Patients check-in and pay co-pay Patients escorted to group room by Medical Assistant takes patients’ vitals (15 min) Behavioral Scientist conducts an ice breaker activity with group members (15 min) w Diabetic Educator provides education and answers patients’ questions (30 min) w Resident Physician conducts group medical visit (60 -90 min); Attending Physician supervises and participates as needed w Discusses each patient’s medical information w Provides education as related to issues raised w Facilitates interaction between group members w Behavioral Scientist - throughout group medical visit w Monitors time w Facilitates individual goal identification and assessment Ohri & Juliao, 2008
Group Medical Visit Agenda 1: 30 - 1: 45 pm Patients arrive; taken to room; vitals taken 1: 45 - 2: 00 pm Ice Breaker 2: 00 - 2: 30 pm Diabetic Educator works with group; individualizes education when possible 2: 30 - 3: 45 pm 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: 00 pm Goals reviewed; final questions; wrap-up Ohri & Juliao, 2008
Documentation Items: Occurs During Group Medical Visit w Vitals w Physical Exam w Heart w Lungs w Foot exam w Random Blood Sugar w Blood sugar log checked w Health maintenance notes w Compliance w Hypoglycemic episodes w Side effects w w Prescriptions needed/provided Labs needed Time spent on education Lifestyle/Behavior Change Goals Ohri & Juliao, 2008
Diabetes Group Medical Visit Documentation: Goal Setting w Self-Care Behaviors w Healthy Eating w Activity Levels w Monitoring glucose levels w Medication Adherence w Problem-Solving (identification, planning, and preparation) w Coping Skills/Resources w Reducing Risk (American Association of Diabetes Educators, 2004) Ohri & Juliao, 2008
Diabetes Group Medical Visit Outcomes w. No data generation as yet w. Obstacles to obtaining data w Patient Attendance w Insurance coverage/loss w Reminder phone calls (personnel) w High co-pay balances w “open” group model w Hospital closure/re-opening Ohri & Juliao, 2008
A Little About Billing w Group Medical Visits = “medical visits” w Patients pay their usual co-pay w Billed with E&M codes: Level-3 (99213) or Level-4 (99214) w w w (Medicare Reimbursement Rates, 2008) Review of systems Physical exam Focused detailing of multiple health issues Time Reimbursement = $75. 00 ($57. 96) - 99213 Reimbursement = $113. 00 ($87. 28) - 99214 Ohri & Juliao, 2008
Other Billing Options w 99354 - prolonged physician service; timebased (30 -74 minutes) w Add on to E&M codes w Reimbursement = $142. 00 ($88. 27) w 99355 - prolonged physician service; timebased (75 -104 minutes) w Add on to E&M codes w Reimbursement = $141. 00 ($86. 73) (Medicare Reimbursement Rates, 2008) Ohri & Juliao, 2008
Other Billing Options w 99078 - group education by physician w Used in place of E&M codes w Reimbursement = unable to locate w 96153 - health & behavior by physicians & non-physicians; time-based (15 minute increments); can be used more than once w Used in conjunction with E&M codes w Reimbursement = $8. 00 ($4. 97) (Medicare Reimbursement Rates, 2008) Ohri & Juliao, 2008
Other Billing Options w 97804 - medical nutrition treatment by non-physician w Used in conjunction with E&M codes w Requires standardized curriculum w Reimbursement = $23. 00 ($13. 43) w 90857 - interactive group therapy by psychologist, master-level counselor, or social worker (AKA: licensed therapist) w Used in conjunction with E&M codes w Reimbursement = $56. 00 ($33. 03) (Medicare Reimbursement Rates, 2008) Ohri & Juliao, 2008
Other Billing Options w 98961 - education & training for patient self-management by non-physician; 2 -4 group members w Used in conjunction with E&M codes w Reimbursement = unable to locate w 98962 - education & training for patient self-management by non-physician; 5 -8 group members w Used in conjunction with E&M codes w Reimbursement = unable to locate (Medicare Reimbursement Rates, 2008) Ohri & Juliao, 2008
Diabetic Group Medical Visits Summary: Challenges & Benefits w Challenges w Collaboration of multiple providers w Billing for / Payment of multiple providers w Coordination of patient scheduling, reminders, etc. w Benefits w w w Improve outcomes (possibly!) Financially feasible, with appropriate documentation (? ) Promotes patient knowledge & understanding High patient satisfaction rates More efficient office visits Decreased health care costs (possibly!) Ohri & Juliao, 2008
Thank You! w These slides are available on the Family Medicine Digital Resource Library (FMDRL), along with: w DGMV Progress Note Samples w Patient Action Plan Samples Ohri & Juliao, 2008
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