Practicing Physicians Curriculum Document: Focus on DiabetesLast updated at 08/27/2007 10:36:05 AM EST by Traci Nolte
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Group Visits (focus on diabetes)
Practicing Physician Curriculum Document
Ed Shahady MD
Introduction
Group visits are an innovative way to help patients achieve reaching diabetes goals (10-17). Group visits are not a substitution for diabetes educators. Diabetes educators play a major role in educating patients and empowering them to better care for themselves. The educators are usually located at diabetes centers, the offices of endocrinologists and hospitals. Diabetes classes can be very effective for some patients. Additional strategies are needed in order to reach a larger number of patients. Group visits are therefore complementary to teaching by diabetes educators. Some patients will require both and some will prefer one or the other.
In the past diabetes education has been based on providing information though lectures. Knowledge changes behavior has been the belief of most medical education. Unfortunately knowledge alone does not provide the needed fuel to change behavior (2). Patient’s experiences with their own diabetes mold their behavior. These experiences are based on the emotion and feelings that accompany diabetes. Group visits are not lectures. The visits provide a setting where patients feel safe asking questions and expressing their concerns about their diabetes. Being able to express feelings in a supportive environment is therapeutic. Group visits have the advantage of being conducted by a clinician and nurse/MA team that have an established a relationship with the patient. Once the practice team learns the skills of facilitating group visits their prior trusting relationship makes it easier to conduct group visits.
Diabetes knowledge is still conveyed but not in the traditional way. Each group visit may have a focus like diet or exercise but instead of starting with the usual lecture the visit starts with asking the patients for their questions and concerns about the topic. Not all clinicians and nurses are comfortable with this method of teaching and different teachers implement it differently. The key is to remember that knowledge alone does not change behavior. Teachers can learn a lot about the effectiveness of their session by asking patients what was most helpful about the session. They will usually find that the knowledge that was shared after a patient’s specific question or comment is what is most remembered.
Barriers to effective diabetes care
When I visit the practices associated with the project and share their % achievement for quality diabetes goals the first response I hear is “patient non-compliance”. This defensive posture is understandable as this is the first time many of them have seen how well they are doing compared to their peers and national standards. They are surprised and disappointed with their levels of goal achievement. They think they are good clinicians and have done everything possible so blame has to be with the non compliant non adherent patient.
Unfortunately being defensive and looking for blame is a part of the culture of medicine. Words like adherence and compliance have grown out of this culture. Anderson and Funnell, two respected diabetes educators (2), believe that compliance and adherence are dysfunctional concepts in diabetes care . A review of the literature on adherence and compliance identifies providers, systems, and treatment regimens in addition to patients as contributing factors to not achieving desired outcomes (3-9). Barriers to care seems like a more acceptable term as it does not necessarily imply blame, seems less inflammatory and does not tend to incite a defensive response. Table 1 lists several of these barriers.
Table 1-Barriers
Patient related
Lack of trust in physician and office staff
Lack of understanding of treatment regimen
Costs and side effects greater than benefit
Lack of transportation
Inability to pay for medication
Depression
Other emotional issues consume patient’s energy
Regimen related
Complex treatment regimen
Not offering cost-savings strategies
Provider related
Lack of time
Lack of system support
Lack of reimbursement for counseling
Major focus on acute medical problems
Lack of counseling skills
Provider not explaining prescribed regimen
Provider incorrectly assumes patient adherence
Not trained to deal with chronic disease
Not trained to deal with cultural and literacy issues
System related
High co-payment
Frequent refill requirements
Frequent staff turnover
Established policies not promoting treatment to goal
Limited staff for patient teaching
System does not facilitate addressing barriers
Current Medical Education system may promote barriers
The traditional approach to the care of diabetes (based on the acute care model) may fuel and promote non compliance and non adherence (13). Physicians and other clinicians receive the most exciting and most memorable part of their training in the acute care model where the patient is a passive recipient of care. The patient is many times bed bound and or the illness short lived. The clinician writes orders and multiple individuals carry out the orders. The objective of care is cure and return to pre-illness state of health. The results of treatment are measurable and obtained in a short period of time. The acute care experience provides immediate gratification that is directly linked to the clinician’s decisions. Decisions in acute care are based on in depth knowledge of pathophysiology and pharmacology and the skill to use the knowledge. The acute care model is of extreme importance and saves many lives acutely but does not provide an effective base for chronic care. Unfortunately the feeling of immediate gratification has become the standard for comparing all future medical experiences.
Chronic disease is different (8). Cure is usually not possible; results are measured by different standards, and gratification is delayed sometimes for years. Patients are not passive recipients of care but active equal partners in chronic diseases like diabetes. Expertise is defined differently. The patient is the expert in the illness. The clinician is the expert in the disease. Patients are the main manager of their diabetes and do so based on values and experiences gained from family, culture, religion, gender, socioeconomic status, and past experience with illness. Chronic care decision making requires skillfully combining patient values and experiences with the pathophysiology and pharmacology appropriate for that disease. The chronic care experience does not provide immediate gratification and if the standards of acute care gratification are used the clinician will experience significant frustration. They express their frustration with labels like non-compliant, non-adherent, gomers, train wrecks etc. Younger physicians, especially those still in training, have the most difficulty adapting to the chronic care model because their training is weighted towards being taught by acute care physicians in acute care models.
The DMCP has as its core value the chronic disease model. It provides clinicians and trainees the tools to recognize and address the above barriers and understand the rewards of chronic disease care.
Patient evaluations
Approximately 350 patients from these practices have attended group visits and patient questionnaires indicate a high level of satisfaction. On a scale of 1 to 5 with 5 being the highest rating patients gave an average rating of 4.7. The advantages of group visits according to many patients is the opportunity to share information with other diabetics and also have more time with their family physician than a hurried 15 minute visit. The patient report card is considered a real positive.
The following comments were made by patients evaluating the group visits.
I like the group visits because you learn so much from other people with diabetes
Report card is great. I now remember my numbers and goals. I put it on my refrigerator to motivate me.
I really appreciated the open air environment for discussion and the education on the disease
I really appreciate the report card. In the past I forgot the numbers but now I can remember them and remind myself to be good.
Relaxed atmosphere. I got to know the people present in the group.
Learn from others some of the things you can do.
The fellowship of the group education is very helpful
I like that personal visit with my Dr.
The group interaction helps me to see myself in a different perspective .
Discussing the type of food and drinks to eat; and when to check your sugar
Liked group discussions, good materials, helpful information
I won't feel alone with this condition.
The group idea is absolutely great. It was very informative.
Group participation was very informative. I am still trying to make the necessary
adjustments for my diabetic situation and appreciate the group participation.
I like it when everybody talks about their own diabetes
Group visits and discussing emotions.
Negative emotions play a significant role in each patient’s perception of diabetes. Clinicians have been trained to be logical and rationale. Not trained to be comfortable discussing patient’s emotions. Negative emotions are not pleasant for the untrained ear. Clinicians feel they have to fix or change the feeling so they are reluctant to encourage expression of something they can not change or fix. More experienced clinicians approach negative emotion by providing a safe non judgmental environment for the patient to express negative feelings and facilitate patient and peer solutions for the negative emotion. Group visits are ideal settings for dealing with negative emotions. Patients are anxious to express their emotions in the presence of other patients with similar problems. They benefit from hearing the stories of other diabetics by learning they are not the only ones who are experiencing emotional struggles. They also benefit by reflecting on what they have learned about themselves and others The skills of the clinician are now changed to listening, facilitating discussion and encouraging reflection (not fixing the problem). It is challenging for many clinicians to accept this new role because solutions are not always obvious or immediate. The patient’s problem solving skills exceed the clinicians problem solving skills because patient derived solutions have a greater chance of success.
Group visit coding and charging (CPT and ICD 9 codes)
Documentation is the key and most established patients qualify for a 99214 if they are properly documented.
99213 documentation
A 99213 requires a CC, 1 to 3 questions about their diabetes (frequency and values of self monitored blood sugars, vision, feet, exercise, diet etc), 1 ROS question, and low complexity care of diabetes, an assessment of controlled diabetes, and a plan that deals with the diabetes. Use a controlled diabetes ICD 9 code like 250.00 for type 2 controlled or 250.01 for type 1 controlled. The fifth digit indicates control and the fourth digit indicates complications. (See summary )If they are controlled but the complication like renal disease is not controlled you should be able to code a 99214. You do not need to do any exam but document the above items like the CC, usual diabetes questions, etc. The patient questionnaire documents the answers. Document any significant answers.
99214 documentation
Most of your patients in a group visit should be the ones that are the most difficult to control and have HBA1C’s of >6.5, LDL >100, or B/P greater than 130/80. The ICD 9 fifth digit would be 2 or 3 if one of these values is not controlled. Remember to document all of these values. The fourth digit indicates complications. An example would be diabetic neuropathy (fourth digit of 6) in a type 2 in control would be 250.60. If the patient is not controlled (HBA1C is >6.5 ) the ICD 9 code would be 250.62.
A 99214 requires four questions related to their diabetes, 2 ROS questions, and one question about either past med history and or social history. Include in the documentation evidence that the patient is an uncontrolled diabetic not at target and how you will be attempting to bring the patient into control. Documenting the attempt to bring the patient into control satisfies the moderate complexity requirement. ( Other documentation that indicates uncontrolled and moderate complexity includes some of the following:
Numbers that are out of control i.e. A1C, LDL B/P
Patient not obtaining eye consult or other consults
Complications are present like retinopathy (dilated eye exam positive), neuropathy (monofilament or vibratory sense decreased), nephropathy (creatinine increased), angina, TIA, stroke, chest pain, MI, hypertension
Modifications in their care like more exercise, diet, eye exam, urine testing etc.
Increasing a medication dosage or starting a new med, or suggestions for increased adherence to medications or lifestyle.
Discussion of side effects of medications like statins, review of drug interactions (note where you found the information i.e. Epocrates)
Advise and discussion of how to adhere to lifestyle changes
For group visits you do not need to do any exam other than vital signs to code a 99213 or 99214 for established patients as long as you have satisfied the history and level of complexity requirements as indicated above. Be sure your ICD 9 code reflects the level of control, type of diabetes and any complications
Summary ICD- 9 code in diabetes
5th digit 250.XX indicates the type of diabetes and level of control
a. 250.X0 indicates Type 2 controlled
b. 250.X1 indicates Type 1 controlled
c. 250.X2 indicates Type 2 not controlled
d. 250.X3 indicates Type 1 not controlled
4th digit 250.XX indicates the complications
e. 250.0X indicates no complications
f. 250.4X indicates renal complications
g. 250.5X indicates eye complications
h. 250.6X indicates neurological complications
CPT code summary
Documentation requirements for established patient visits at group visits
Adapted from Coding "Routine" Office Visits: 99213 or 99214? Family Practice Management September 2005
Group visits planning conducting, recruiting
Preparing your office staff for group visits
Have a meeting with everyone in your office to explain that these are visits not support groups that are optional. Let them know that the group visit will replace some of the routine diabetes visits that the patient makes and the group vists help you better care for chronic disease.
They should be aware that not every patient wants to come to group visits, some only come to one visit and of those that come about 70% like them and will come back.
The staff are critical to your success needs to talk it up and encourage patients.
Who to invite.
The group visit will have the most benefit for the patients who are not well controlled. Try to also involve a few patients who are well controlled so they can offer advice to the not well controlled patients. About 10 patients is a good number for a group visit. More than 10 to 12 individuals in a group session promotes the chances of less interaction and the session being more like a lecture. Patients should feel free to bring family members.
Date and time of the visit
Set date far enough in advance to avoid conflicts. Time of the visit can vary depending on the ability of availability of space, staff and clinician schedules.
Frequency of Meetings– Usually range from every month to every three months with the same group of patients.
Length of Meeting– Inform the patients the entire session will take about 2.5 hours. The initial 15 to 30 minutes is used for vital signs and completing questionnaires. The first hour is with the staff person and the second is with both the staff person and the clinician. After the meeting an additional 15 to 30 minutes are needed to complete the paper work.
Invitations:
Use combination of letters, phone calls, posters and invitations at the time of other visits
SAMPLE INVITATION LETTER
Dear Patient
I would like to invite you come to a new and better way to care for your sugar diabetes. This new program is called group visits. We think this is a good way to help you better care for your diabetes.
These group visits will replace some of your routine visits for your diabetes. You will be charged for these visits like a regular visit to the Doctor.
Our first meeting will be held on (date) at (time) in (place). The visit will last 2.5 hours and go from x to y time. This gives you a lot of time with your Doctor and nurse. You will learn a lot about how to better care for your diabetes and prevent problems like blindness, kidney failure, stroke and heart attack.
Please call to confirm that you will be able to attend. Remember this is an appointment with the Doctor and Dr. ______________ has set all this time aside for you.
If you have any questions, please call _____________ coordinator, at _________________.
Sincerely,
Other items
Prepare a handout explaining why you want to start these group visits
Put up a poster in the office informing patients
A week before the visit clinician and clinician associate sit down to plan agenda for the visit
Day before the visit (nurse/MA)
Phone call reminders-have ½ patients scheduled 15 mins earlier than others to facilitate more timely obtaining vital sign and questionnaire.
Pull charts-staff person to help
Review charts to be sure all labs etc entered
Print out patient report card and chart flow sheet and put both in the chart. If you see anything really out of line mention it to the clinician. Have an extra copy of the patient record flow sheet to give to the clinician before the groups visit starts.
Review the curriculum that will be used for visit
Remind clinician of the agenda and curriculum and ask him/her to reinforce what you will be saying. E.g. if exercise is the topic clinician should devote at least 5 minutes to asking patients questions about exercise. .
Day of the visit (staff)
Review charts to be sure all information is included
Look at room make sure it is set up correctly.
Set up tables/chairs according to group size. Circle or horseshoe facilitates group discussion.
Make sure all teaching materials in the room.
First visit make sure all the permission slips are there
Prepare coffee/refreshments 20/30 minutes before meeting.
On flip Chart or Blackboard: Write information pertaining to meeting, future meeting dates, and names of staff members, etc.
Pay special attention to acoustics, signage, visibility, and climate for needs of disabled and elderly patients
The Visit
ROLES
Nurse(s) or Medical Assistant(s)
The first hour of the meeting will be conducted by the nurse /MA. The nurse(s) or medical assistant(s) take vital signs provides triage and management of patient needs before and during the meeting. Establishing an environment that encourages open discussion and participation by all members is an important role. There is no formal curriculum but topics for discussion. Start with a brief introduction of the topic and then ask patients questions about how the topic relates to them. Your questions will generate additional need for information and clarification about the topic. Topics for discussion may include the following
Nutrition
Exercise
Review of diabetes report cards.
Foot Care
Hypertension
Lipids
General pointers
Explain the purpose of group visit emphasizing that the GROUP VISIT is an alternative
way for a patient to receive care that works.
Some will not like them and that is OK.
Clear definition of expectations of participants
A sharing of group norms and setting guidelines.
Do not have to share any information if you do not want to do so.
Emphasize the value of helping each other care for diabetes. One patient may have
suggestions that can help another diabetic
Make sure they understand that this is like a regular office visits and there is a charge or
co-pay
First hour
Staff person obtains B/P, Wt, on each patient and gives them their report card and
questionnaire and sends them to the group visit room. May have a healthy snack in the
room. May need help from another nurse/MA for the first part 30 mins for check in.
For first time visit- sign permission slip and HIPPA form.
See if meds need refilled and have prescriptions written for clinician to sign.
Make sure patients have completed questionnaires. May discover literacy problems if patients have difficulty completing questionnaires. 30 to 40 minutes interactive educational session- -do not lecture more than 8 minutes at a time without asking for feedback and seeing what they are learning. Make sure they have their homework books and are using them at every visit
Stay on track with diabetes-parking lot sheet available for other issues. Some good questions about other health issues like mammograms and colon cancer screening may come up. Remind patient of purpose of session and place question on parking lot list for potential discussion and move on. Placing the question on the parking lot sheet permits continued focus on diabetes without discounting the patient’s question. There may be time later for the question when it does not disrupt the focus on diabetesMay want to show all of them how to examine their feet at least once for each group
Second hour
Clinician comes in and welcomes the group Clinician looks at parking lot issues and decides when and what to address being sure to thank the patient for the questions.. If the questions are about other health related issues that are not acute remind patient they still have their yearly evaluation where these items are handled. May need to see a patient after the visit or schedule another visit. Remember primary goal of group visit is diabetes related
Clinician reinforces the curriculum point for the day. E.g importance of exercise or A1C.A nice way to get the group talking is to ask the participants to share something about their diabetes. Clinician strives to be a facilitator and not the answer to all questions. When someone asks you a question find out what the others think the answer might be before giving your opinion.
Create and atmosphere of trust and a feeling that “you can do it”. Most patients don’t feel they can control their diabetes and our job is to help them feel empowered to take control. You are the coach and they are the players
Tips for survival
Make sure everyone in the office knows about the Group Visit schedule
Charts ready
Name tags (large ones)
Refreshments
Consider room
Handouts
Comfortable temperature
Pens, markers, flip chart, pencils, Kleenex, etc.
Start on time – end on time
After the Meeting
Complete progress notes
Take down meeting signs
“Show or no show” attendance noted in chart
Book appointments after meeting
Review who needs labs or other tests and make reminder list.
Schedule patients for next meeting (order charts, send reminders)
Return completed charts
Spend 10 minutes evaluating the meeting
Sample consent form to attend a group visit
Dear Patient
Signing this form indicates you have voluntarily consented to participate in a “Diabetes Group Medical Visit”. During this visit you and other patients may share personal health information only if you agree to do so. This information will be used to help teach you and other members of the group about various health topics that help improve diabetes care.
The diabetes group visit will consist of discussions of the importance of exercise, diet and medications in the care of diabetes. The visit also may include your being examined in the group for blood pressure reading, and a foot exam.. If you wish to have these parts of the exam done in a private examining room just let us know
The group visit is like a regular office visit and you will be charged for the visit.
The group visit may replace some of your routine visits for diabetes but you will still have some privately scheduled appointments with me.
You of course have the option not come to the group visits. If you have questions about this process please discuss with me.
Name
Signature (Clinician)
If after reading the above and you wish to attend group visits please print and sign your name. Your signature indicates that you have read the above, understand what it says and agree to attend group visit
Name (Printed) _______________
Signature__________________ Date ____________
CONFIDENTIALITY STATEMENT
The practice of Dr________________is committed to maintaining the highest standard of confidentiality for our patients. We believes that all medical, financial and personal information is confidential and is to be protected from unauthorized viewing, discussion and disclosure. We believe that all patients have the right of confidentiality regarding their medical record.
I understand that in order to assure and protect confidentiality, I will not discuss any other patient’s medical information or personal business that I may be privileged to during the the group visits (I may discuss what I learned but never disclose any information about an individual patient in our group).
I understand that I do not need to discuss any information concerning myself unless I choose to do so.
Patient’s name (printed ____________________________________________________
Patient’s signature ________________________________________________________
Date _____________________________________________
This form borrowed from St Vincent’s Family Practice Residency with permission
CONSENT TO ATTEND A GROUP VISIT
I, hereby voluntarily consent to participate in a “Diabetes Group Medical Visit” in which I and other patients may share personal health information, if they wish on a purely voluntary basis. This information will be used to help educate the group about various health topics and which may help improve my care. There may be publications written describing the group visits and their ability to improve diabetes care but your name will not be mentioned.
The group meeting will consist of discussions of current medical conditions, pertinent educational information, and open discussions with other patients on diabetes and other subjects of interest to the group.
To the extent needed I may be examined in the group for blood pressure reading, foot exam or other areas. If you wish to have these parts of the exam done in a private examining room just let us know.
The group visit may replace some of your routine visits for diabetes but you will still have some privately scheduled appointments needed with your doctor in the future. You of course have the option to not come to the group visits.
I have read the above, understand what it says and agree to attend group visits.
Name (Printed) ___________________________________________
Signature ________________________________________________
Today’s Date __________________________________
Diabetes Group Visit Progress Note (Shahady)
Patient to complete this sheet
Name: ___________________________ Date______________________
How many times daily do you check your blood sugar? _____ What is the usual value?_______
What is your current activity level?
____ Not very Activity ___ Moderate ( 2-4 times weekly) ___ Vigorous (5 or more times weekly)
If you are not very active what is the reason?
____ Arthritis ____Afraid I will hurt myself _____Do not like to exercise
How many times a week do you eat any of the following foods? (ham, pork, hamburgers, hot dogs, fried fish. fried chicken or other fried foods)
____One time a week __Three times a week __ Five or more times a week
How many times a week do you eat any of the following foods? (lean ground beef, chicken, fish or turkey that is broiled or baked)
_____ One time a week ___Three times a week __ Five or more times a week
How many times a week do you eat vegetables? (for example green beans, cauliflower, other beans, broccoli, peas)
_____ One time a week ___Three times a week ____ Five or more times a week
How many times a week do you eat fruit? (for example bananas, apples, berries, peaches)
_____ One time a week __Three times a week ____ Five or more times a week
Tobacco Use: _____Current _____ Quit _____Never
When was the last time you saw an eye doctor (Ophthalmologist or Optometrist)? ______
Please list any questions you would like addressed today
Staff to complete
Date: _________
Wt: ________ Ht._______ Pulse:_______ BP:________
HBA1C_____ LDL______ HDL______ Triglycerides_______
Medications Name Dose Number of Refills (write scripts and attach)
Clinician to complete
Comments
Assessment: _____________________________
250.00 Type 2 controlled no complications 250.01 Type 1 controlled no complications
250.02 Type 2 not controlled no complications 250.03 Type 1 not controlled no complications
4th digit 250.X indicates the complications, 0 is no complications, 4 is renal complications, 5 is eye complications and 6 is neurological complications like neuropathy.
Plan:
Discussed targets and management of HbA1c.
Discussed targets and management of lipids
Discussed targets and management of Blood pressure
Recommended ASA daily.
Discussed and encouraged activity.
Discussed and encouraged diet.
Reviewed Medication options; risks, benefits and side effects
Reviewed Foot Care
Spent more than 50 percent of visit counseling re: therapy options and management of diabetes.
Charge Code 99213 99214 99215
Signed:____________________________________________ Date:__________________________
Type 2 Diabetes Progress Note for Group Visits
St Vincent’s Family Practice Residency
Date: _________ Doctor:_________________
HPI: Visit to follow diabetes and rhypertension / rhyperlipidemia /
Please answer the following questions:
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