HSA Term Paper_ de La Rosa

7/25/2019 HSA Term Paper_ de La Rosa

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Healthcare Systems Improvement Analysis and Recommendations Report

Alexandra Giselle De la Rosa Berro

HSO Type: Primary are linic

Iss!e: "ana#ement o$ chronic conditions

Situation

hronic illnesses are de$ined as diseases that last a year or more and re%!ire on#oin#

medical attention& onditions s!ch as dia'etes( hypertension( cholesterol disorders( heart disease(

asthma( or arthritis are amon# the most common in the )nited States *D( +,,-.& The advances

in technolo#y o$ the last $e/ decades that have increased lon#evity and disease detection( this

alon# /ith an a#in# 'a'y 'oomer pop!lation( and an increase in 'ehavioral ris0 $actors have le$t

chronic conditions to 'e the central health need $or the American p!'lic *IO"( +,,1.&

Today( 123 million people in the )S have at least one chronic condition *Anderson(

+,1,.& This n!m'er contin!es to #ro/ at exceedin#ly rapid rate and 'y +,4, it is expected to

s!rpass 15, million people *Anderson( +,1,.& hronic diseases acco!nt $or 5,6 o$ all deaths in

the )&S *D( +,,-. and the leadin# ca!se o$ disa'ility( 'rin#in# severe activity limitations to a

%!arter o$ those /ho have them *Anderson( +,1,.& 7ot only is nearly hal$ o$ total pop!lation

chronically ill( 1 in 2 have m!ltiple chronic conditions& Amon# those 83 years and older( the

$astest #ro/in# sector o$ the )S pop!lation( that n!m'er is 4 in 2 *Anderson( +,1,.& These

alarmin# n!m'ers( not only ma#ni$y the need $or s!ita'le speci$ic disease mana#ement( '!t the

critical component o$ coordination o$ care across di$$erent care settin#s and specialties&


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9inancially( chronic conditions are 'y $ar( the 'i##est '!rden o$ the health care system&

!rrently 26 o$ all healthcare spendin# in the co!ntry is on chronic conditions( *"edical

;xpendit!re Panel S!rvey( +,,.& This is even more o$ a drain on p!'lic $!nds as --6 o$

"edicare and ,6 o$ "edicaid spendin# is on chronically ill persons *"edicare Standard

Analytic 9ile( +,,5.& The increased cost o$ m!ltiple chronic conditions is exponential *9i#!re 1.(

a sin#le chronic condition nearly triples the amo!nt o$ healthcare spendin#( and those that have

three conditions have more than seven times #reater spendin#& *"edical ;xpendit!re Panel

S!rvey( +,,8.& In $act( -36 on "edicare spendin# is $or those /ith more than one chronic

condition( 5-6 on people those /ith $ive or more( altho!#h this last #ro!p is only 1+6 o$ all

"edicare 'ene$iciaries *"edicare Standard Analytic 9ile( +,,5.& All this comes to a total o$ more

than


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Figure 1: Per capita healthcare spending by number of chronic conditions. Reprinted fromChronic care: Making the case for ongoing care by !. "nderson#$1$ Robert Wood

Johnson Foundation.

Background

Despite these technolo#y and costs o$ the American healthcare system( its c!rrent state is

no/here near 'ein# a'le to s!ccess$!lly mana#e chronic conditions& The healthcare system has

developed over the last cent!ry to primarily to treat ac!te=episodic illnesses and accidents& This

translates to a set>!p o$ short visits and $inancial compensation maximi?ed 'y individ!al

dia#nosis and treatment proced!res *@iela/s0i( +,,8.& Ho/ever( a completely di$$erent

approach is necessary to prevent the onset and complication o$ chronic conditions&

hronic care re%!ires a colla'orative( m!ltidisciplinary and lon#it!dinal process&

onditions rely on 'oth medical and sel$>mana#ement *e#: home 'lood #l!cose='lood press!re

meas!rement( ins!lin dosin# chan#es accordin# to meals( pea0 $lo/ meters $or asthmatics.( and

th!s( clinical pro'lems and plans m!st 'e de$ined and !nderstood e%!ally 'y patient and their

providers *IO"( +,,1.& Beca!se o$ the hi#h n!m'ers o$ m!ltiple conditions and de#rees o$

severity( 16 o$ chronically ill patients receive care $rom more than one doctor( !s!ally a series

o$ specialists( as /ell as a primary care provider *Anderson( +,1,.& I$ their conditions are

!nsta'le( they may also re%!ire advanced n!rsin# care and=or hospitali?ations( ma0in#

comm!nication and coordination 'et/een all these a#ents even more cr!cial *IO"( +,,1.&

et( the latest s!rveys $ind that an avera#e len#th o$ an o!tpatient clinic appointment is

14 to 18 min!tes *"edscape( +,11.( and 4 in 2 ad!lts report not havin# eno!#h time /ith their

doctor d!rin# appointments *Davis et al( +,,8.& 7ot s!rprisin#ly( only 486 o$ physicians are

satis$ied /ith the care they provide chronically ill patients( and 286 o$ the chronically ill report


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havin# !nmet needs in their care *Anderson( +,1,.& ;ven tho!#h s!'stantial evidence exists that

system level shi$ts a/ay $rom the ac!te model to/ards these aims /ill lo/er the disa'ility and

$inancial '!rden o$ chronic conditions in society the system( $or the most part( remains

!nchan#ed *@iela/s0i( +,,8.& )sin# the Instit!te o$ "edicine *IO".Cs six aims $or health care

system improvement *+,,1.( the c!rrent misC>mana#ement o$ chronic conditions can 'e

analy?ed 'y #aps in every sin#le one o$ these aspects:

Safety

IO" de$ines sa$ety as Eavoidin# inF!ries to the patients $rom the care that is intended to

help them *+,,1.& The precario!s h!rried manner in /hich chronic care is #iven in America

leaves a lot o$ possi'ility $or errors that leave patients at ris0 $or harm& In an international s!rvey

o$ sic0er ad!lts( 136 o$ American respondents 'elieved that there had 'een an error in their

medical care in the last t/o years( this /as the hi#hest percenta#e amon# the six ind!striali?ed

co!ntries s!rveyed *Davis et al( +,,8.& Bein# prescri'ed the /ron# medication or dose( receivin#

incorrect or delayed a'normal la' res!lts( or contradictin# dia#nosis 'y di$$erent providers(

amon# others( are all commonly reported errors 'y the chronically ill in the )&S *Davis et al(

+,,8 Anderson( +,1,.&

Effectiveness

;$$ectiveness or evidence>'ased care( re$ers to providin# care that is 'ac0ed 'y scienti$ic

0no/led#e to ens!re interventions *e: preventive screenin#( dia#nostic test( treatment. are

#iven to the appropriate people and are not !nder or over !tili?ed *IO"( +,,1.& In the $ee>per>

service str!ct!re o$ the American system( it is not !ncommon that over!tili?ation o$ interventions

is the norm $or a lot o$ health service or#ani?ations as reven!e relies !pon it& et( !nder!tili?ation


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o$ services is also an iss!e /hen h!rried providers do not have the opport!nity to do a thoro!#h

assessment o$ needs& 9or example( the American Heart Association( the American olle#e o$

ardiolo#y and the American "edical Association *+,11.( all recommend yearly cholesterol

screenin# $or all people /ith hypertension( yet 136 o$ patients report not havin# this re%!isite

met *Davis et al( +,,8.& Similarly( the American Dia'etes Association *+,12. recommends

ann!al cholesterol( $oot and eye exams and 'i>ann!al hemo#lo'in A1 meas!rements $or all

dia'etes( yet this re%!irement /as only met 'y 386 o$ American dia'etic respondents in the

Davis et al international s!rvey *+,,8.&

Patient-Centeredness

The aim o$ patient>centeredness( is a $oc!s on meetin# the individ!al patientCs needs and

respectin# their val!es and expressed pre$erences& It Eencompasses %!alities o$ compassion(

empathy at this time /hen technolo#y has #iven to patients 'ein# more in$ormed than ever on

their healthcare *IO"( +,,1.& It is not s!rprisin# that this satis$action is lac0in# $rom patients

/ith chronic conditions in the c!rrent expensive system o$ hastened enco!nters& Amon#

American respondents to the Davis et al s!rvey *+,,8.( hal$ report 'ein# o$$ered options and

as0ed $or their opinion in their treatment( 136 $eel their doctor doesnCt al/ays listen to their

concerns( and 1 in 2 have le$t an appointment /itho!t #ettin# an important %!estion ans/ered in

the past + years *Davis et al( +,,8.& This h!manistic aspect is an o$ten $or#otten one in disc!ssin#

%!ality at a systems level( '!t IO" ran0s it as important as all others& )ltimately( healthy people

are satis$ied people( and not simply ones that meet statistical #oals o$ clinical health o!tcomes&

Timeliness


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on# /aits $or short enco!nters is the norm $or patients in the c!rrent system& "ore

/orrisome( is harm$!l delays in #ettin# timely appointments o$ la'oratory res!lts& Delays in

receivin# la' res!lts is reported 'y a'o!t a %!arter o$ people *Davis et al( +,,8.& ario!s s!rveys

have $o!nd 'et/een a %!arter and a third o$ people reportin# di$$ic!lty #ainin# timely access to a

health provider /hen pro'lems occ!rred *Davis et al( +,,8 "!rray J Ber/ic0( +,,4 Kaiser

9amily 9o!ndation +,,1 +,,+.& "ore /orrisome is that the n!m'er o$ people reportin# these

delays has 'een and contin!es increasin# *A#ency $or Healthcare Research and L!ality( +,,.&

The m!ltiple providers most chronically ill people are 'ein# $ollo/ed /ith only compo!nds this

/aitin# time patients deal /ith F!st to 0eep !p /ith their care&

Efficiency

An e$$icient system is a cost>e$$ective one( one /here Ereso!rces are !sed to #et the 'est

val!e $or the money spent *IO"( +,,1.& Given all the a$orementioned it #oes /itho!t sayin#

that the c!rrent system co!ld not 'e $!rther a/ay $rom e$$icient on a national level& The /ei#ht

placed on 'oth individ!als and the system is very extensive $or s!ch little val!e& +86 o$ patients

report visitin# the emer#ency room $or an iss!e that co!ld have 'een addressed in an o!tpatient

'asis( that is more than any other co!ntry in the Davis et al st!dy *+,,8.( and ++6 report

receivin# d!plicate tests or proced!res *Anderson( +,1,.( also a meas!re ran0ed hi#hest in the

international s!rvey& On an individ!al level( chronically ill patients carry a si#ni$icant $inancial

'!rden $or their s!'par healthcare( /ith an avera#e o!t o$ poc0et cost o$


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+56 'orro/ $!nds $rom $amily=$riend( or 6 even declare 'an0r!ptcy F!st to $inance their

healthcare costs *Anderson( +,1,.&

Equitable

IO" de$ines an inte#ral p!rpose o$ the health system that it $!nction $or allpeople& They

de$ine e%!ity as critical 'oth in an individ!al level /ith e%!al treatment and respect( and at the

pop!lation level to red!ce health disparities and ens!re !niversal access to services *+,,1.& The

)nited States has 'y $ar( some o$ the /orst health disparities in the ind!striali?ed /orld *Davis et

al( +,,8.& There is s!'stantial di$$erences 'et/een races in F!st a'o!t very chronic condition( $or

example A$rican Americans have 136 hi#her rates o$ dia'etes( 2&3 times more visits to the ;R

$or asthma emer#encies( and do!'le the ris0 o$ stro0e than @hites *@ildin#( +,14.& Amon#

Hispanics there is nearly do!'le the rates o$ dia'etes *@ildin#( +,14.& At an individ!al level(

'oth these #ro!ps report not receivin# needed treatments $or their chronic conditions at hi#her

rate than @hites( 186 more A$rican Americans( +6 more Hispanics *Anderson( +,1,.& The

health disparities 'et/een socioeconomic classes are e%!ally da!ntin# /ith a +86 di$$erence

'et/een 'elo/ and a'ove avera#e incomes reportin# not visitin# their doctor or #ettin#

recommended treatment d!e to cost *Davis et al( +,,8.& The diversity o$ the American

pop!lation 'rin#s a lot o$ di$$ic!lty in the area o$ e%!ita'ility( '!t itCs a $!ndamental tenant o$ a

healthcare system( and it is a moral d!ty to contin!ally strive to achieve&

Opportunity for Improvement


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The #aps and tro!'les o$ c!rrent chronic care mana#ement are extensive and complex(

trans$ormations are necessary $rom the hi#hest levels in o!r systems to address many iss!es&

Primary care clinics are the Etrenches o$ chronic care mana#ement( trapped /ithin a $a!lty

system havin# to deliver lo/>%!ality care to an over/helmin# n!m'er o$ patients /ith

increasin#ly complex needs& onc!rrent /ith the rates o$ dia#nosis( almost hal$ o$ visits to

primary clinics are 'y those /ith chronic conditions( and that n!m'er has 'een sno/'allin# $or

years *Hin# J )ddin#( +,1,.& Ho/ever( despite the system>level #aps( there are potential

adF!stments at the clinic>level that co!ld address many o$ the di$$ic!lties $acin# chronic care&

Sa$ety( as al/ays( sho!ld 'e a n!m'er one priority o$ any healthcare system& et( the

!ncoordinated nat!re o$ care 'et/een primary and specialist providers in clinics( home care( and

possi'le inpatient care( leaves dan#ero!s holes $or medical errors& Primary care clinics are the

medical Ehome $or patients /ith chronic conditions navi#atin# the system( th!s( they hold the

hi#hest promise $or addressin# the iss!e $rontline 'y improvin# coordination e$$orts&

7evertheless( the r!shed arran#ement o$ o!tpatient clinics leave little time $or this to 'e done

e$$ectively and only $!rther increases possi'le errors& Primary care clinics m!st prioriti?e

red!cin# ris0 o$ error /ith e$$orts in colla'oration and time str!ct!res&

The $ra#mented and h!rried nat!re o$ o!tpatient chronic mana#ement also contri'!tes to

distancin# the most important part o$ the care p!??le( the patients& Patients over/helmin#ly

report their dissatis$action( and providers a#ree in their shortcomin#s to provide ade%!ate care

and meet all o$ patientsC needs *Anderson( +,1,.& The c!rrent hasten str!ct!re considera'ly limits

the time to spend on disease mana#ement( yet chronically ill patients tend to have m!ltiple

comor'idities and complex needs $or their condition*s.& The IO" /arned a#ainst care desi#ned


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aro!nd speci$ic conditions to avoid de$inin# patients 'y a sin#le condition or disease *+,,1.& It is

not !nreasona'le to descri'e the c!rrent ac!te>'ased system as one $oc!sed on sin#le conditions&

The limited time spent /ith patients simply does not allo/ $or the comprehensiveness necessary

$or the #ro/in# m!lti$aceted nat!re o$ chronic care&

astly( the matter o$ cost is a tremendo!s and disastro!s $actor $or care o$ the chronically

ill& ost is an iss!e at every level( $rom system>/ide spendin#( to the costs o$ physicians $or

or#ani?ations to treat so many( and the personal on#oin# $inancial '!rden $or patients& This $actor

can 'e easily shr!##ed 'y clinics as one to 'e addressed 'y lar#er political 'odies( yet( lo/erin#

costs o$ chronic disease mana#ement at the clinic>level is possi'le /ith s!ita'le chan#es and

primary investment $or lon#>term savin#s& @hile it is impossi'le to address every iss!e o$

chronic care at the or#ani?ational level( improvements in these 0ey $actors is achieva'le& There

exists optimal arran#ements that 'etter address the needs o$ patient( providers( and or#ani?ations(

i$ clinics are /illin# to remove themselves $rom traditional models&

Improvement Proposal

Root Cause Analysis

9actors o$ lo/>%!ality chronic care /hich can 'e addressed at the or#ani?ation>level can

'e #ro!ped into $o!r cate#ories& *1. )ncoordinated care( /hich a$$ects nearly every aspect o$

%!ality( /ea0enin# meas!res o$ sa$ety( e$$iciency( timeliness and e$$ectiveness& *+. o/ patient

satis$action and en#a#ement( essentially the a'sent patient>centeredness o$ ac!te>'ased care& *4.

Hi#h costs( the c!lprit o$ the systemCs lac0 o$ e$$iciency and ar#!a'ly( e%!ita'ility& astly( *2.

haste( /hich li0e $ra#mentation o$ care( a$$ects almost every aspect o$ %!ality( incl!din# sa$ety(

e$$iciency( e$$ectiveness and patient>centeredness&


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Policies

%Cumbersome recordrelase protocolse&en oralcommuncation

bet'een pro&iders% (nsurance limits

'here and 'hichpro&iders to be seenfor 'hich ser&ices

Procedures

%)cheduling apptsindependently foreachser&ice*pro&ider*clinic

%+imited coordiationbet'een inpatient

and follo',upoutpatient care.People

%Multiple carepro&iders andsupport sta- thatlook at diseasethrough di-erentand possiblycontradicting angles

%Family and*or homenurse also part ofcare pro&isionPlant/technology

%o /0R or

incompatible /0Rsbet'een pro&iders

%o features in /0Rfor inter, pro&idercommunication

%/0R lack of error,check for duplicateorders

Uncoordinated

Policies

%+o' pro&idereducation fonmanagement ofmultiple chronic

conditions% (nsurance limitations

and costs fortreatments

Procedures

%+imited time spent'ith pro&ider forpatients to ha&e1uestions andconcerns ans'ered

%o designated partof chart for patient

preferencesPeople

%Patients una'are ofho' to be moreacti&e in their care2+ack of healtheducation

%Pro&ider burn,outand lack of empathy*communication skills

Plant/technology

%3leak clinic

atmosphere%0assle of di-erent

locations fordi-erent ser&ices

%Patients ha&e limitedaccess to self,careresources

Low patientengagement

andsatisfaction

Policies

%3illing per ser&iceper &isit

% (nsurance*organi4ation

limitation on 'hatcan be done andbilled by 'ho resultsin need for multiplepro&iders

Procedures

%Physician care timethat could bepro&ided by otherless costly pro&iders

%o urgentscheduling option foroutpatient &isits2

unecessary /R usePeople

%Comple5 physicalsocial and emotionalneeds of chroniccondition6s7 re1uirelots of ser&ices forproper management

%Pro&ider speciali4e inonly one aspect ofchronic carePlant/technology

%Recurrent labs*

procedures fordi-erent pro&iders2possible duplication

%Costly at,homee1uipment optionso-ered or prescribedunecessarily

Costly


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Policies

%8rgani4ational goalsof producti&ity thatma5imi4e number ofpts to be seen

%Multiple careguidelines formultiple conditionsreuired to befollo'ed

Procedures

%"ppts scheduled inday hours, 'henmany pts ha&e otherresponsibilities

%Redundant aspectsof administrati&eintake and charting

reuired at e&ery&isitPeople

%Pressured pro&idersand support sta- tosee patients uickly

%Patients 'ithmultiple conditionsand comple5 needsto be met in short&isits

Plant/technology

%Clinic spaces not

designed tominimi4e tra&el timefor support sta- 9pro&iders

%+ack of /0R chartingfeatures like shorthand or auto,population of notesfrom labs 9 pre&ious&isitsHurried


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Problem Statements

1& The c!rrent system o$ mana#ement $or chronic condition involves many a#ents( res!ltin#

in !ncoordinated( sometimes d!plicated care $or patients and an increased ris0 $or

medical errors& In the next year( the clinic /ill 'e aim to decrease $ra#mentation and

red!ce d!plication /ith specialist provider*s.( red!cin# the n!m'er o$ medical errors over

the next $ive years&+& hronically ill patientsC individ!al needs and pre$erences are not 'ein# met 'y the c!rrent

system( leadin# to lo/ levels o$ satis$action and en#a#ement in their care& In the next

year( clinic>level e$$orts /ill 'e made to increase patient satis$action at every

appointment&4& The c!rrent demands o$ chronic condition mana#ement is costly $or the patient( clinic and

system& Over the next year( clinic>level chan#es /ill 'e made to !se reso!rces more

e$$iciently and lo/er costs $or the clinic over the next $ive years&4. !rrent demands o$ the system have shortened provider care time to a $e/ min!tes per

visit( re%!irin# a hasty approach to care that lo/ers satis$action $or 'oth patient and

provider (and increases the ris0 $or medical errors& Over the next six months( clinic

chan#es /ill allo/ $or services to have less a h!rried method that /ill increase patient

and provider satis$action( and red!ce the n!m'er o$ medical errors over the next $ive

years&

Improvement Plan

One o$ the most e$$ective tools that addresses all $o!r o$ the identi$ied #aps in chronic

care in the o!tpatient settin# is the !se o$ #ro!p visits *G.& Gs( also 0no/n as shared medical

appointmentsC are clinic visits that incl!de #ro!p ed!cation and interaction( alon# /ith the

critical elements o$ an individ!al patient visit *AA9P( +,12.& They com'ine the element o$ peer


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s!pport and individ!al appointment standards li0e history ta0in#( physical exam( and treatment

mana#ement& @hile these visits ta0e place instead o$ individ!al appointments( the latter are still

necessary in the clinic str!ct!re $or patients not eli#i'le or /illin# to participate in Gs or $or or

more intense individ!al mana#ement o$ those that do& In this model( the healthcare team *not F!st

the main provider. interacts /ith the patients in the periodic pro#ram o$ #ro!p visits( replacin#

the minim!m recommended n!m'er o$ visits( '!t not excl!din# patients $rom additional

individ!al appointments i$ necessary&

@hile Gs can 'e !sed $or mana#ement o$ sin#le diseases( the reality o$ chronic care in

America is m!ltiple comor'idities& Partic!larly( the most common( costly( and deathly ones:

dia'etes( hypertension and heart conditions incl!din# coronary artery disease and con#estive

heart $ail!re and stro0es *an D!sen( +,,.& The G model proposed /ill 'etter address the

!ncoordinated and costly nat!re identi$ied in the c!rrent system 'y $oc!sin# on those individ!als

a$$ected 'y m!ltiple chronic illnesses&

Plannin# $or Gs

It is recommended that plannin# $or Gs start no less than t/o months prior to the $irst

visit *Gro!p Health ooperative( +,,1.& Important tas0s d!rin# this phase incl!de *Ho!c0 et al(

+,,4 Gro!p Health ooperative( +,,1.:

;sta'lish G team( trainin# o$ all clinic sta$$ and /illin# providers in #ro!p visits

Orderin# or preparin# patient ed!cational materials or $acilitator #!ides

Determine /hether snac0s /ill 'e provided $or Gs at all or $or select visits

Sched!lin# o$ space( and i$ needed( appropriate adaptations or renovations

Decidin# /hich clinical( satis$action and $eed'ac0 meas!rement standards to !tili?e

$or pro#ram assessment Identi$yin# n!m'er o$ eli#i'le patients *Ta'le 1.


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9or a s!staina'le G str!ct!re( at least 4,6 o$ eli#i'le patients sho!ld enroll in the #ro!p

visit pro#ram *Gro!p Health ooperative( +,,1.& To 'est tac0le the a$orementioned pro'lems(

selected patients m!st 'e those /ith an increased '!rden on themselves and on the system& The

$ollo/in# eli#i'ility criteria 'e !sed:

Group Visit Program Eligibility

Dia#nosis o$ at least three o$ the $ollo/in# conditions:

> Type + dia'etes> Hypertension> on#estive heart $ail!re> oronary artery disease> ere'rovasc!lar disease> History o$ cardio or cere'rovasc!lar events *heart attac0 or stro0e.&

Hi#h>ris0=!ncontrolled stat!s o$ at least one condition

!rrently 'ein# seen at least every three months /ith #ood sho/>!p rates to

appointments

Desire or need $or health ed!cation *i&e&: pro'lems /ith adherence to treatments or sel$>

mana#ement #oals.

Table 1: Criteria for invitation to participate in group visit program.

Implementin# Gs

;li#i'le patients o$ the $acilitatin# providers sho!ld 'e invited and enco!ra#ed to attend

the G pro#ram *Appendix 1.( and 'e $amiliar /ith the #ro!p visit norms *Appendix +.(

partic!larly on the notion o$ con$identiality and attendance& Gs /ill 'e sched!led every three

months as esta'lished 'y the standard #!idelines $or hypertension( heart disease and dia'etes

care set 'y the American Heart Association( the American olle#e o$ ardiolo#y( the American

"edical Association *+,11. and the American Dia'etes Association *+,12.& To minimi?e the

h!rried pace o$ the clinic and ma0e attendance $easi'le $or participants( Gs /ill 'e sched!led at


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an evenin# or /ee0end time& isits last 'et/een 1&3 to + ho!rs and consist o$ a'o!t 1,>+,

patients&

The G>$ormat ma0es !se o$ the entire healthcare team *Ta'le +.& A G #enerally starts

/ith a 'rie$ chec0>in and #reetin# period /here re#istration( vitals and initial n!rse assessments

are done( as /ell as some individ!al con$erences 'y the provider( /ithin or o!tside #ro!p settin#(

as pre$erred 'y patient& This is $ollo/ed 'y a #eneral disc!ssion $acilitated 'y the provider

*Ho!c0 et al( +,,4.& The disc!ssion topic co!ld 'e on the tar#eted diseases( related health iss!es(

stress=social iss!es( n!trition( li$estyle interventions( or other patient>s!##ested concerns& The

topic*s. o$ the visit co!ld 'e determined either 'y a set c!rric!l!m team is trained in( or prepares

in visit plannin# meetin#s& ;ach disc!ssion portion o$ the G sho!ld incl!de ample time $or

patient concerns and s!##estions&

9ollo/in# the disc!ssion( the #ro!p ta0es a 'rea0( /hich can incl!de a clinic or patient>

provided snac0( or no snac0 at all& D!rin# this 'rea0( vitals or individ!al con$erences /ith

providers are cond!cted i$ they /ere not in the 'e#innin#& The #ro!p ret!rns $rom 'rea0 $or a

#eneral %!estion and ans/er session /ith the provider and #ood'yes& 9or patients that re%!ire

more thoro!#h or private assessment( practitioners co!ld provide one>on>one visits a$ter the

#ro!p session or sched!le the patient $or another time 'e$ore the next G&

In order $or Gs to r!n smoothly( there is time spent o!tside o$ the G to ens!re

preparation and s!ccess& The n!rse cond!cts chart revie/s $or patients 'e$ore each G(

hi#hli#htin# any 0ey areas( and completin# $orms $or dia#nostic test or la' /or0 'e$ore reportin#

res!lts to the provider& i0e/ise( a provider may spend additional time a$ter Gs to ens!re

proper doc!mentation $or each patient& This o!tside G time is critical $or ens!rin# coordination


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o$ the patientCs care( itCs d!rin# these chart revie/s that providers comm!nicate /ith $ello/

providers( ma0e re$errals and do!'le chec0 $or errors /itho!t the h!rried press!re o$ daily clinic&

Team Roles Group Visit ProgramTeam ember Prior to GV !ay of GV

7!rse or

medical

assistant

> Remind provider o$ !pcomin# Gs> Per$orm chart revie/( #ive res!lts to

provider

> Ta0e charts and s!pplies to room> Per$orm inta0e( vitals J imm!ni?ations> hartin# or data entry( i$ appropriate

Patient care

representativeand=or health

ed!cator

> Sched!le date and time $or visit and

coordinate /ith provider

> "a0e reminder phone calls $orsched!led patients

> ;ns!re room reservation and materials

are prepared

> hec0>in=re#ister patients( print la'els> Help set>!p and s!pport other team

mem'ers d!rin# visit

> Identi$y patients that need individ!alattention and ens!re itCs #iven> Dischar#e patients and sched!le $or

next G or individ!al appt( as

determined 'y provider

Provider *"D(

OD( AP7( PA.

> Participate in plannin# $or visit /ith

s!##estions $rom patients and team> Revie/ charts( identi$y individ!al

pro'lems> Prepare needed re$erral and treatment

paper/or0

> 9acilitate disc!ssion in #ro!p visit> ond!ct 1:1 assessment and

mana#ement d!rin# or a$ter G> Doc!ment visit

Table 2: Healthcare team roles in !s" adapted from #roup visit starter $it%" b& roupHealth Collaborative" 2''1

on#>term #oals o$ G pro#ram

The Plan>Do>St!dy>Act o$ the G pro#ram is seen in 9i#!re +& A $!ll initial co!rse o$ the

G pro#ram is one year in len#th *$o!r visits.( a$ter/ards the provider can contin!e the Gs

/ith the same #ro!p and=or start a ne/ #ro!p& A$ter year participation( patients are also $ree to

ret!rn to individ!al visits i$ they choose& A$ter the initial pilot year( $eed'ac0 $rom the team and

patients /ill 'e !sed to adopt and adapt $eat!res o$ the pro#ram& A second provider and=or a


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re #: P)" for group &isit implementation in clinic. "dapted from ;Plan,o,)tudy,"ct 6P)"7 /5amples http:**'

(dentify patients that meet !B criteria 6ab

second #ro!p $or the same provider /ill then 'e started $or another year cycle& By the start o$ the

second year 4,6 o$ eli#i'le patients o$ the participatin# provider sho!ld 'e enrolled in the G

pro#ram to ens!re s!staina'ility& O!tcomes $or the pro#ram /ill 'e eval!ated at the end o$ each

year cycle( /ith a thro!#h clinic>/ide assessment a$ter $ive years&

&

!alue of Investment Analysis


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The American Academy o$ 9amily Physicians concl!des that the research on Gs sho/s

them as a E/in>/in $or physicians and their patients *+,12.& In $act( the analyses o$ costs o$ G

in primary care $o!nd that it decreased the ann!al cost per patient 'y aro!nd


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Value of

Investment

Value

Reduced cost perpatient

(mpro&ed patient

satisfaction andcompliance

(mpro&ed clinicaloutcomes

Reduced pro&iderburnout and

disatisfaction

(ncreasedre&enue(nceased

producti&ity:more pts per hr

less calls tophysicans

More &isits

Investment

Craining costs

)ettingadaptation orreno&ation

Possible o&ertimepay for

e&enings*'kends

Materials: snacksfacilitation guides

or patient ed

Figure 2: !alue of investment anal&sis of group visits. (dapted from #Control and resourcmanagement)human resources and *scal management% +,o-er,oint slides" b& /. Wehbi" 2


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Recommendations

@ithin the next three months(

o Propose G pro#ram idea to clinic sta$$ and receive $eed'ac0=interest

o

9orm G committee to determine '!d#et and administrative lo#isticso Identi$y /illin# providers and $orm G healthcare team

@ithin next six months(

o ond!ct preliminary s!rvey o$ patient interest

o Determine /hich and complete G trainin# $or providers and sta$$

o Develop !ni%!e or adapt trainin# c!rric!l!m to patient pop!lation

@ithin nine months(

o ;sta'lish system $or identi$yin# eli#i'le patients

o Develop $ormat $or G data collection and=or extraction $rom ;HR

@ithin a year( 'e#in Gs

References

A#ency $or Healthcare Research and L!ality& *+,,.& Gro!p primary care visits improve

o!tcomes $or patients /ith chronic conditions&A"#R "ealt$ Care Innovations

E%c$an&e.


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Anderson( G& *+,1,.& hronic care: "a0in# the case $or on#oin# care&Robert 'ood (o$nson

)oundation&

American Academy o$ 9amily Physicians& *+,12.& Policies: shared medical appointments=#ro!p

visits&American Academy of )amily P$ysicians.

American Dia'etes Association& *+,12.& linical practice recommendations +,12&*iabetes

Care.

American Heart Association& *+,11.& A9=AHA=A"A>PPI +,11 Per$ormance meas!res $or

ad!lts /ith coronary artery disease and hypertension& Circulation. 1+2: +2>+5,&

enters $or Disease ontrol and Prevention& *+,,-.& hronic diseases& The po/er to prevent( the

call to control: At a Glance +,,-&+ational Center for C$ronic *isease Prevention and

"ealt$ Promotion&

Davis( K&( Schoen( &( Schoen'a!m( S&&( A!det( A>"&M&( Doty( "&"&( Holm#ren( A&( J Kriss(

M&& *+,,8.& "irror( mirror on the /all: An !pdate on the %!ality o$ American health care

thro!#h the patientCs lens& T$e Common,ealt$ )und.

Gro!p Health ooperative& *+,,1.& Gro!p visit starter 0it&

$ttp,,,.improvin&c$roniccare.or&inde%.p$pp/Critical0Tools1s/23.

Ho!c0( S&( Kilo( &( J Scott& M&& *+,,4.& Gro!p visits 1,1& )amily Practice 5ana&ement. 1,

*3.: 88>8&

Hin#( ;& J )ddin#( S& *+,1,.& isits to primary care delivery sites: )nited States( +,,& Centers

for *isease Control and Prevention.
http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162


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Instit!te o$ "edicine& *+,,1.& rossin# the %!ality chasm: A ne/ health system $or the +1 st

cent!ry& Committee on #uality of "ealt$ Care in America.

Ma'er( R&( Bra0smaFer( A&( Trillin#( M&S& *+,,8.& Gro!p visits: A %!alitative revie/ o$ c!rrent

research&(ournal of t$e American 6oard of )amily 5edicine. 1-*4.: +58>+-,&

Kaiser 9amily 9o!ndation& *+,,1.& 7ational s!rvey on cons!mer experiences /ith and attit!des

to/ards health plans: Key $indin#s&7aiser )amily )oundation.

Kaiser 9amily 9o!ndation& *+,,+.& @omenCs health in the )nited States: Health covera#e and

access to care&7aiser )amily )oundation.

KirshS&( @atts S&( Pasc!??i K&( ONDay "&;&( Davidson D&( Stra!ss G&( OCKern ;& J Aron D&&

*+,,5.& Shared medical appointments 'ased on the chronic care model: a %!ality

improvement proFect to address the challen#es o$ dia'etes /ith hi#h cardiovasc!lar ris0&

#uality 1 Safety in "ealt$ Care&1842--898

"edical ;xpendit!re Panel S!rvey& *+,,8.&A&ency for "ealt$care Researc$ and #uality.

"edical ;xpendit!re Panel S!rvey& *+,,.&A&ency for "ealt$care Researc$ and #uality.

"edicare Standard Analytic 9ile& *+,,5.& Centers for 5edicare 1 5edicaid Services.

"edscape& *+,11.& Physician ompensation Report +,11&5edscape.

"!rray( "& J Ber/ic0( D&"& *+,,4.& Advanced access: Red!cin# /aitin# and delays in primary

care&(ournal of t$e American 5edical Association. +-*4.: 1,43>2,&

Reid( R&M&( oleman( K&( Mohnson( ;&A&( 9ishman( P&A&( Hs!( &( Soman( "&P&( Trescott( &;&(

;ri0son( "& J arson( ;&B& *+,1,.& The Gro!p Health medical home at year t/o: cost


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savin#s( hi#her patient satis$action and less '!rno!t $or providers&"ealt$ Affairs. +-*3.:

43>24&

Scott( M& J Ro'ertosn( B& *1--8.& Kaiser oloradoCs cooperative health care clinic: A #ro!p

approach to patient care&5ana&ed Care #uarterly. 2*4. 21>23&

Spann( S&M *+,,2.& Report on $inancin# the ne/ model o$ $amily medicine& T$e Annals of )amily

5edicine. +*s!ppl 4.:S1>S+1&

an D!sen( A& *+,,.& AmericaCs most expensive medical conditions&)orbes 5a&a:ine.

@eh'i( 7& *+,12.& ontrol and reso!rces mana#ement>h!man reso!rces and $iscal mana#ement

Po/erPoint slides& Retrieved $rom )niversity o$ 7e'ras0a "edical enter PH 3,+:

Health Services Administration Blac0'oard: http:==my&!nmc&ed!

@iela/s0i( I&"& *+,,8.& Improvin# chronic illness care&Robert 'ood (o$nson )oundation.

@ildin#( "& *+,14.& Racial health disparities amon# people /ith chronic conditions in the )S:

9acts and statistics&"ealt$'or;s Collective.

"ppendi# $% Invitation to Group Visit Program

Reprinted from !roup &isits 1$1 by ). 0ouck C. Dilo 9 E.C )cott #$$? Famil& ,ractice

anagement.

"n Invitation &rom 'our !octor
http://my8.unmc.edu/http://my8.unmc.edu/http://my8.unmc.edu/


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o! are invited to Foin yo!r doctor and other patients in o!r practice $or a E#ro!p visit& ItCs anidea that other doctors aro!nd the co!ntry have $o!nd helps them care $or their patients in /aysthat cannot 'e accomplished d!rin# the !s!al 13> to +,>min!te o$$ice visit&

HereCs ho/ it /or0s: o!r doctor and one o$ o!r n!rses /ill visit /ith yo! and approximately 13to +, other patients $or a'o!t an ho!r and a hal$ in a con$erence room here at o!r o$$ice& D!rin#the visit( there /ill 'e time $or tal0in# /ith other patients as /ell as ed!cation a'o!t speci$ichealth pro'lems& Then( yo!r doctor /ill spend time tal0in# /ith each patient individ!ally a'o!thealth pro'lems and concerns& I$ yo! have additional health concerns that need to 'e addressed(there /ill also 'e time to meet alone /ith yo!r doctor a$ter the #ro!p visit& O$ co!rse( the visitsare completely vol!ntary&

The #ro!p visit pro#ram /as set !p to provide an additional opport!nity $or patients to meet /iththeir doctor on a re#!lar 'asis and to learn ho/ to deal /ith common health pro'lems& Gro!pvisits also #ive patients the opport!nity to learn $rom other patients /ho are dealin# /ith similar

health pro'lems and to #et their health needs met and their %!estions ans/ered& 9rom time totime other health pro$essionals( s!ch as pharmacists or health ed!cators( may Foin yo!r doctorand n!rse at the visits&

The date and time o$ the next #ro!p visit is listed at the 'ottom o$ this letter& I$ yo! are interestedin attendin#( please let yo!r physician or n!rse 0no/& o! are /elcome to 'rin# a $amily mem'eror $riend /ith yo!&

@hen yo! come in $or the #ro!p visit( simply chec0 in as !s!al /ith the $ront des0 and pay yo!r!s!al co>pay& The receptionist /ill direct yo! to o!r meetin# place&

@e /elcome yo!r possi'le interest in this ne/ opport!nity $or yo! to participate /ith yo!rphysician in yo!r health care& O$ co!rse( i$ yo! decide not to participate( yo!r doctor /illcontin!e to see yo! at the o$$ice as in the past&

Sincerely(o!r DoctorCs O$$ice

7ext #ro!p visit date and time: QQQQQQQQQQQQQQQQQQQQQQQQQQO!r phone n!m'er: QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ

"ppendi# (% Group Visit )orms

Reprinted from !roup &isit starter kit by !roup 0ealth Collaborati&e #$$1


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Group Visit Norms

e will!

"ncourage everyone to participate#

$tate our opinions openly and honestly#

%s& 'uestions if we don(t understand#

)reat one another with respect and &indness#

Listen carefully to others#

*espect information shared in con+dence#

)ry to attend every meeting#

,e prompt- so meetings can start and end on time#

HSA Term Paper_ de La Rosa

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