slides for kutob, hekler, thomson

The Only Prescription with Unlimited Refills

Every Patient, Every Visit, Every Treatment Plan

Saturday, March 10, 20127:00 AM - 4:30 PM

DoubleTree by Hilton Hotels



Made possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. The

trademark Exercise is Medicine is used by permission from the

American College of Sports Medicine.

Promoting Healthy Lifestyles in Real World Clinical Settings: Moving Beyond the Barriers.

Randa M. Kutob, MD, MPHExercise is Medicine ConferenceMarch 10, 2012Department of Family and Community MedicineUniversity of Arizona, College of [email protected]

mailto:[email protected]

http://www.fcm.arizona.edu/

Disclosures

• I have no financial or other conflicts of interest to disclose.

What Are We Here For?

• Review data on obesity, physical activity, and diabetes in the U.S.

• Explore provider barriers to lifestyle counseling

• Examine the evidence for what works• Share ways to put more lifestyle change

into our practices

What I Hope You Will Get Out of It

Just one idea to implement in your practice to promote physical activity and lifestyle change.

But First… A Quiz

http://hp2010.nhlbihin.net/portion/

http://hp2010.nhlbihin.net/portion/

Do You Know How Food Portions Have Changed in 20 Years?

National Heart, Lung, and Blood Institute

Obesity Education Initiative

COFFEE 20 Years Ago

Coffee(with whole milk and sugar)

Today

Mocha Coffee(with steamed whole milk and

mocha syrup)

45 calories 8 ounces

How many calories are in today's coffee?

COFFEE 20 Years Ago

Coffee(with whole milk and sugar)

Today

Mocha Coffee(with steamed whole milk and

mocha syrup)

45 calories 8 ounces

350 calories16 ounces

Calorie Difference: 305 calories

How long will you have to walk in order to burn those extra 305

calories?*

*Based on 130-pound person

Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out

If you walk 1 hour and 20 minutes, you will burn approximately 305 calories.*


Calories In = Calories Out

320 calories How many calories are in today’s turkey sandwich?

TURKEY SANDWICH20 Years Ago Today

Calorie Difference: 500 calories

820 calories 320 calories

TURKEY SANDWICH20 Years Ago Today

How long will you have to ride a bike in order

to burn those extra calories?*




If you ride a bike for 1 hour and 25 minutes,you will burn approximately 500 calories.*


Scope of the Problem

Obesity Trends* Among U.S. Adults, BRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx

.

http://apps.nccd.cdc.gov/DDTSTRS/default.aspx


Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 0%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

www.cdc.gov/diabetes

County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2008

Age-adjusted ranks based on age-adjusted percent of diabetesAbove median rank

Below median rank

Not above median rank or below median rank

www.cdc.gov/diabetes

County-level Estimates of Leisure-time Physical Inactivity among Adults aged ≥ 20 years: United States 2008

Age-adjusted percentQuartiles

0 - 23.2

23.3 - 26.2

26.3 - 29.1

> 29.2

FRENCH FRIES 20 Years Ago Today

210 Calories

2.4 ounces How many calories are intoday’s portion of fries?

610 Calories6.9 ounces

Calorie Difference: 400 Calories

FRENCH FRIES 20 Years Ago Today

210 Calories

2.4 ounces

How long will you have to walk leisurely in order to burn those extra 400 calories?*




If you walk leisurely for 1 hour and 10 minutes you will burn approximately 400 calories.*


Walking in the U.S.

• U.S. Men-5,340 steps• U.S. Women-4,912 steps (Bassett, 2010)

• Amish men-18,425 steps• Amish women-14,196 steps (Bassett, 2004)

Obesity, Diabetes, and Physical Inactivity in the U.S., Arizona, and Pima County

United States

Arizona Pima County

Obesity 33.8 % (2008)

24.3 % (2010)

23.8 % (2010)

Diabetes 8.3 % (2011)

8.1 % (2010)

7.0 % (2008)

Physical Inactivity

25.0 % (2008)

22.9 % (2010)

19.7 % (2008)

Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx

.



Scope of the Problem

Diabetes and Prediabetes 18.8 million with diabetes 7.0 million undiagnosed +79.0 million w/prediabetes______________________= 104.8 million!!!!

Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.

Diagnosed DiabetesUndiagnosed Di-abetesPrediabetesThose Unaffected

BUT…

Only 1/3 of those with prediabetes received provider advise about it in the past year! (Geiss, 2010)

What are Practicing Docs/Providers Doing? A Survey of Our Practice

(n=62)

Gordon JS, Thomson C, Kutob R, Burns KD, Byron D, Marquis A, & Cunningham J. Practices, attitudes, self-efficacy, and perceived barriers for preventing and treating obesity in the primary care clinic. Poster presented at the Research Frontiers in Nutritional Sciences Conference, February 29 – March 1, 2012, Tucson, AZ.

What Does the Literature Say?

• Time• Lack of materials• Lack of resources• Lack of confidence in counseling skills• Reimbursement• Concerns about effectiveness

(Kushner 1995, Kolasa 2010)

So What Can We Do?

If primary care physicians did all the preventive services recommended by the USPSTF, we would spend 7.4 hours out of an 8-hour day doing them! (Yarnall 2003)

Exercise Matching Game

Activity• Walking• Yoga/stretching• Bicycling• Jumping Rope• Yard Work• Weight Training• Swimming • Basketball• Jogging

Calories Burned in 30 minutes

• a. 140 calories• b. 220 calories• c. 295 calories• d. 145 calories• e. 165 calories• f. 90 calories• g. 110 calories• h. 255 calories• i. 325 calories

Table 2. From the Surgeon General’s Vision for a Healthy and Fit Nation52.

Kolasa K M , Rickett K Nutr Clin Pract 2010;25:502-509

Copyright © by The American Society for Parenteral and Enteral Nutrition

Training, Effectiveness, and Confidence: Know What Works

• High intensity (face to face at least once a month for 3 months)

• Frequent contact• Self-monitoring (keeping food diaries and

activity records)• Nutrition education and meal planning (portion

size and not skipping meals)• Control of the stimuli that activate eating• Goal setting• Social support• Increasing physical activity

More Is Better

At 2 years:

• Usual Care: minus 1.7 kg• Brief Lifestyle Counseling: minus 2.9

kg• Brief Lifestyle Counseling plus Meal

Replacement: minus 4.6 kg (Wadden, 2011)

Think About How to Deliver the Message: Eliciting Explanatory

Models• “How do you feel about your weight?”• “How do you feel your weight affects your

health?”• Think about Stages of Change• Use Motivational Interviewing techniques• Help your patient set realistic, specific goals• Ask about barriers• Telling patients to exercise without a

specific intervention does not work!

Time and Teams: Don’t Do It All Yourself

• Registered Dieticians• Medical Assistants• Nurses• Promotoras• Referrals to community programs

The UA Health Network’s Clinical Weight Loss Program

Community Resources

• YMCA’s: up to 100% financial assistance available• Diabetes Prevention: YMCA and United Healthcare• Community Centers:

– E.g., Kino, Drexel Heights, Catalina, JCC, Ellie Townes Flowing Wells, John Valenzuela Youth Center, Littletown, Robles Ranch

• Parks and Recreation• City Pools

(Byron, UA Family Medicine Residency Program, 2011)

Reimbursement

• If you can, collect data to show key stake holders the value of what you do

• Or share with the data that already exists

24.7 Billion Dollars!!!! (Ormand, 2011)

Don’t Do It In the Same Way:Families United:Familias Unidas

Group Office Visits for Diabetes Prevention• Twelve, 2-hour sessions • Adults, ages 18-70, with any diabetes risk factor (e.g., hypertension, hypertriglyceridemia, etc.) were eligible

• Participants identified one support person, age 14-70, to accompany them

Have Fun Doing It !Have Fun Doing It!

The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:

Advisory Board:

Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community Health Continuum

Taz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education Institute

Maureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.

Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.

Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.

Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.

Pima County Medical Society - Steve Nash, JD, Executive Director.

University of Arizona Section of Endocrinology, Diabetes and Hypertension- Craig Stump, M.D., PhD, Professor.

University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.

University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Center for Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.

Creative Team:

Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.

M2Design: Graphic Design - Michael Drabousky.

Dupont Videography: Video Recording & Editing - John Dupont.

Sonora Communications: Computing, Networking, Internet Services Gene Cooper.

TECHNOLOGY PRACTICE APPLICATIONS

Eric Hekler, Ph.D.Assistant Professor

School of Nutrition and Health Promotion

Arizona State University

Outline

My background

State of technology

State of the science

Promising commercial technologies

Coming soon…

My background Clinical Health Psychologist, Rutgers

Postdoc – Stanford University

Focus: The use of technologies for health behavior change

ACSM Committees:SHI-Behavioral Health CommitteeEIM Family Website developmentEIM Committee member for identifying evidence-based

practices

Technology-focused projects

Mobile Interventions for Lifestyle Eating and Exercise at Stanford (MILES) study

Exploring the influence of intentions when playing Exergames

The CHAT Trial - Focused on promoting physical activity by telephone delivered either by a human or automated counselor

The Stanford Healthy Neighborhood Discovery Tool

CHART-2: Intervention to increase physical activity using PDAs

Disclaimer

I will be discussing many different technologies. I am in no way affiliated with any of the corporations mentioned and I am NOT endorsing them in any way. I use them more as illustrative examples.

Outline

My background

State of technology



Coming soon…

What has changed?

Technology offers opportunities for behavior change that were near impossible10 years ago

Key playersWidespread use of cell phones (and smartphones)“Cloud” computingCheap wireless sensors with APIsAlgorithmsInformation development modelsSocial Networking

http://thenextweb.com/mobile/2011/02/02/the-shocking-numbers-behind-cellphone-usage-infographic/

http://thenextweb.com/mobile/2011/02/02/the-shocking-numbers-behind-cellphone-usage-infographic/

What is the cloud?

Algorithms

Powerful data analytic techniquesMachine learning, data mining, system

identification Used in a variety of contexts

Focused Search (i.e., Google)Activity classification“Recommender” systemsPersuasion ProfilesMood classification via voice, writing style, etc.

“2024”“2014”

Development Models

Expert-sourcedContent generated by

“experts”

Information evaluated by experts

Rigorous but slow

www.britannica.com

Crowd-sourcedContent generated by

“crowd”

Information evaluated by crowd

Fast but inaccurate?

www.wikipedia.org

http://www.britannica.com/

http://www.wikipedia.org/

Wired, July 2009, Quantified Self

Outline

My background

State of technology



Coming soon…

Technology delivery channels

Exergames Text messaging (SMS) Web pages Interactive voice response systems Wearable sensors Smartphones Social media

Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Brassington, Hekler, et al. in press

Exergames

ExergamesCan promote light to moderate intensity PA

Much less work on sustained use

Some research exploring best practices

Barnett, Cerin, Baranowski, 2011; Chen, Hekler, King, under review

Text messaging

Some efficacy for general health promotion Less work on PA in particular, but promising

Most used SMS as just one component

Work best if appropriately timed

Fjeldsoe, B. et al. 2009; Franklin, et al. 2006; Norman, Kolodziejczyk, Hekler, & Ramirez, under review

Web pages

“Small but statistically significant effects”

Efficacious interventions tended to:Compared to wait-list controlFocused on shorter-timeline

Key problemSustained adherence

Cugelman, Thelwall, & Dawes, 2011; Webb, Joseph, Yardley, & Michie, 2010; Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Neve, Collins, et al. 2010

Interactive voice response Very few studies, but very promising results

Comparable to human intervention

Even for promoting 18m maintenance

Norman, Kolodziejczyk, Hekler, & Ramirez, under review; AC King, et al. 2007; King, Hekler, et al. under review

Wearable sensors

Lots of devices out there, with some evidence starting to be collected

Pedometers (particularly accelerometer-based such as Omron’s devices)

BodyMedia best evidence for weight loss Others just starting to be researched

Fitbit, Phillips Direct Life


Smartphones

Very limited evidence but popular topic

Will be reporting some preliminary efficacy


Social media

Very limited evidence, very popular topic Research finds health advice given One study, StepMatron, used Facebook

app and pedometer to motivate PAResults found increased check-ins on steps

when using Facebook compared to not Much more work is needed

Norman, Kolodziejczyk, Hekler, & Ramirez, under review; J. A. Greene, Choudhry, Kilabuk, & Shrank, 2011; Foster, Linehan, Kirman, Lawson, & James, 2010

Outline My background

State of technology



Coming soon…

Happtique

Healthcare-APP-bouTIQUE

Focused on categorizing health apps

Exploring ways to build evidence into apps practice

Popular Smartphone apps RunKeeper iMapMyFitness Nike+GPS Hundred PushUps All in Yoga HD Monumental

Lots of new devices

Nike Fuelband

Striiv

Jawbone UP

Outline

My background

State of technology



Coming soon…

Lots of new stuff being tested

Many health researchersUCSD- Smart Trial

Human Computer InteractionsCHI ConferencePersonalinformatics.org

Introduction Mobile Interventions for Lifestyle Exercise and Eating at

Stanford (MILES)

NHLBI-funded Challenge Grant (10/09 – 08/12) PI- King, 1RC1HL099340-01

Status: Ran preliminary pilot with 36 older adults; iterated on design and now running second trial

Collaborators: Abby King, Tom Robinson, Matt Buman, Lauren Grieco, Frank Chen, Jesse Cirimele, Beth Mezias, Banny Banerjee, Martin Alonso

Purpose

Develop theoretically meaningful smartphone apps for midlife & older adults

Physical activity & sedentary behavior

Passively assess PA & SB

Provide just-in-time feedback for behavior change

Activity Algorithm Validation

Hekler et al, 2010, November

N=15, Men & Women, Mean Age=55 12 laboratory-based activities 3-4 min each Hip- and pocket-worn Android phones Compared to Actigraph & Zephyr Bioharness

Results

Hekler et al, 2010, November

0 2000 4000 6000 8000 10000 120000

200

400

600

800

1000

f(x) = 0.0896939917730109 x + 55.075461392382R² = 0.825752545985109

Comparison of Phone to Actigraph "Counts"

Minute-level "counts" Linear (Minute-level "counts")

Actigraph "counts"

Ph

on

e A

UC

m/s

3

The “Apps”

mTrack mSmiles mConnect

King, Hekler, et al. April, 2012, Hekler et al. 2011

Control: Calorific

Very Preliminary Results

King, Hekler, et al. April, 2012

mSmiles mConnect mTrack0

10

20

30

40

50

60

70

80

90

Difference in LMPA across the intervention compared to control

min

/day

of

Lig

ht/

Mo

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ate

Ph

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ical

Act

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y D

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Co

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**

**

ns

EIM initiatives in the works EIM Family-focused website

EIM evidence-based practices

Thank you for inviting me!

Eric Hekler

[email protected]

Designing Health Lab @ASU

Twitter: @ehekler

mailto:[email protected]

References Barnett, A., Cerin, E., & Baranowski, T. (2011). Active video games for youth: a

systematic review. Journal of Physical Activity & Health, 8(5), 724-737. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy1.lib.asu.edu/pubmed/21734319

Brassington, G., Hekler, E. B., Cohen, Z., & King, A. C. (2011). Health Enhancing Physical Activity. Handbook of Health Psychology. Mahwah, New Jersey: Lawrence Erlbaum Associates Publishers.

Chen, F. X., Hekler, E. B., & King, A. C. (2012). Designing Health Messages: Framing Exergames for Exercise Improves Duration of Use. submitted for publication2.

Cugelman, B., Thelwall, M., & Dawes, P. (2011). Online Interventions for Social Marketing Health Behavior Change Campaigns: A Meta-Analysis of Psychological Architectures and Adherence Factors. Journal of Medical Internet Research, 13(1), 84-107. doi:e17 10.2196/jmir.1367

Fjeldsoe, B. S., Marshall, A. L., & Miller, Y. D. (2009). Behavior change interventions delivered by mobile telephone short-message service. American journal of preventive medicine, 36(2), 165-73. American Journal of Preventive Medicine. doi:10.1016/j.amepre.2008.09.040

Foster, D., Linehan, C., & Kirman, B. (2010). Motivating physical activity at work: using persuasive social media for competitive step counting. Proceedings of the 14th …. Retrieved from http://dl.acm.org.ezproxy1.lib.asu.edu/citation.cfm?id=1930510

References Franklin, V. L., Waller, A., Pagliari, C., & Greene, S. A. (2006). A randomized controlled trial

of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine, 23(12), 1332-1338.

Hekler, E B, Buman, M. P., Haskell, W. L., Rosenberger, M., & King, A. C. (n.d.). Validity of Android-Based Mobile Phones as Assessment Devices of Physical Activity. mHealth Summit. Washington, DC.

King, A C, Friedman, R., Marcus, B., Castro, C., Napolitano, M., Alm, D., & Baker, L. (2007). Ongoing physical activity advice by humans versus computers: The community health advice by telephone (CHAT) trial. Health Psychology, 26(6), 718-727. doi:10.1037/0278-6133.26.6.718

Neve, M. J., Collins, C. E., & Morgan, P. J. (2010). Dropout, Nonusage Attrition, and Pretreatment Predictors of Nonusage Attrition in a Commercial Web-Based Weight Loss Program. Journal of Medical Internet Research, 12(4), 81-96. doi:e69 10.2196/jmir.1640

Neve, M., Morgan, P. J., Jones, P. R., & Collins, C. E. (2010). Effectiveness of web-based interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: a systematic review with meta-analysis. Obesity Reviews, 11(4), 306-321. doi:10.1111/j.1467-789X.2009.00646.x

Webb, T. L., Joseph, J., Yardley, L., & Michie, S. (2010). Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. Journal of Medical Internet Research, 12(1). doi:e4 10.2196/jmir.1376


Advisory Board:











Creative Team:





Tool-Kit: Putting Prevention into Action in Your Clinic

Cynthia Thomson, PhD, RDDirector

Canyon Ranch Center for Prevention and Health Promotion

Exercise is Medicine Planning Committee

fittucson.org

1 Great Plate® Magnets

USDA MyPlate Poster

USDA MyPlate Placemat Tablet

Energy In/Energy Out Poster Set

Bodies Built Here Poster

MyHealthy Prescription Pads

Let’s eat for the health of it

EiM A Clinician’s Guide to Exercise Prescription

EiM Health Care Providers’ Action Guide

EiM Exercise Prescription and Referral Form

EiM Physical Activity Clearance Form

EiM Physical Activity Readiness Questionnaire

EiM Starting an Exercise Program

Food and Activity Log

Guide to Group Visits

Starting the ConversationGet Active

Starting the ConversationHealthy Eating

32 local restaurants Minimum 3 menu

items meeting “healthy” criteria

< 700 calories <1000 mg sodium < 15 grams fat

NutritionHub

Smart Choices for Healthy Dining

Healthy Dining Guide Insert

Materials without Implementation = Trash

Post information in a visible location◦ Place strategically:

Shared with key staff in your office◦ Personal wellness◦ Wellness ambassadors

Write scripts for healthy behaviors Follow-up, monitor and reward progress Visit fittucson.org


Advisory Board:











Creative Team:





Group Visits forChronic Conditions Affectedby Overweight and Obesity

Tucson, March 10, 2012

Talk Outline1. What are group visits?2. How do you organize and schedule a group visit?3. How do you bill & document a group visit?4. Apply group visit techniques to exercise

What Kinds of Patients Benefit Most from Group Visits?

High Risk Patients, Namely◦ Those patients who have an increased risk for “both” high

resource utilization and poor outcomes◦ Obese patients are certainly at high risk for both

High Risk Groups Diabetes Obesity Tobacco users Asthma Cardiovascular disease (CVD) Dyslipidemia Depression Total joint replacements Frail elderly HIV/AIDS

What Are Group Visits?

Maximize educational time by working with 6-30 patients at a time

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

◦ Doctors, nurses, PA, pharmacists, mental therapists, dieticians, etc.-- a physician and a dietician can even do a visit together

◦ Attendance drops if the primary physician is not involved

Shared Medical Visits Provide an Effective Way to Manage High Risk Cohorts

Annual visits share information and reach set targets for the group’s diagnosis (Lipids, BP)

A series of 2-4 visits focused upon weight loss or tobacco cessation

Longitudinal group visits can substitute many individual doctor visits (e.g., type 2 diabetes over 6-10 visits)

Group Visits can be Annual, a Series, or Longitudinal

Class provides information to a group Group visit must gather information and

document it in the patient record, label an assessment, and note a plan

Group visit is a billable service, a class usually is NOT a billable service◦ Billing information will follow◦ You must spend a moment of one-on-one time to clarify

the subjective, objective, assessment, and plan for the visit. 60-90 seconds will suffice

Difference Between a Group Visit and a Class

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◦Office space you have available

Many Models Exist for Group Visits

Improve clinical outcomes Increase your productivity by about 15% to 25% Improve both patient and provider satisfaction Lower total health care costs

Premise: The Model You Choose Should

Group visits help many patients succeed in making lifestyle changes:◦Quitting tobacco use◦Food monitoring improves diet

compliance◦Monitoring and promoting activity

encourages exercise

Succeed in Changing Lifestyles with 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 Enhance reimbursement (~20%) Improve provider satisfaction This is a rare Win/Win/Win/Win/Win opportunity

Why Should You Offer Group Visits?

Organizing & Scheduling Group Visits

(This section is addressed in your handout in detail)

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

--Ashleigh Brilliant

Schedule a session 8-12 weeks in advance

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

Reserve a room! Prepare material in advance Prepare chart note forms in advance

Plan in Advance for Group Visits

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

Allow 4 hrs total time for a group visit with 20-30 patients/session: 2 hrs group time & 2 hrs prep time (5 pts/hr 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 2-3 nurses to collect data and for the

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

How Much Time Do You Need For a Group Visit? (one tested method)

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

Vary the Time with the Size of Your Group

30 minutes to collect patient data, meet individually, and complete medical record notes

15 minutes for the group to address their concerns to me and each other

45 minutes to introduce didactic material and interact

30 minutes to answer questions, plus time to write prescriptions, and meet individual needs

Actual physician time varies; I encourage you to finish on time!

How Do I Organize My Time During the 2-Hour Group Visit Session?

4-6 weeks prior, mail/e-mail a letter to selected patients in your practice advertising dates for you next group visit (See sample letter)

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

Have your receptionist call 1 week later to encourage enrollment (See sample phone call script)

Anticipate 40-50% enrollment (if the primary physician invites own patients to attend; 5-15% enrollment if primary writes the letter, and another provider offers the group visit)

How to Recruit Patients for a Group Visit?

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, nurse/MA can add data for physicians review

Chart Review Before the Group Visit (ensures quality)

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

Be prepared for a wave all arriving at once◦ You can’t have them line up like a usual visit

Registration

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

Signature: ___________________

Agreement to Participate

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!

Signature: _________________

Confidentiality Form

Receptionist should mention this issue when they register for the appointment

Signed HIPAA Disclosure Form Essential ◦ Share with your HIPAA compliance officer (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.

Signature___________________

HIPAA Issues

Arrive on time Register Find a chair and complete subjective aspect of the

SOAP note Then meet with the nurse Next meet with the doctor Return to chair

Patient Role

Maximum 3-4 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, monofilament for foot exam, peak flow

meter, etc, etc Subjective and objective part of the note completed at

this station Physician will complete the note and sign the progress

note

Nurse Exam Stations (2-3)

Maximum 45-90 seconds one-on-one, face-to-face ◦ Signed HIPAA disclosure essential◦ Clarify assessment with the patient, (You smoke, it

is harmful, & I advise you to stop using tobacco)◦ Get permission to share questions and answers

with the group◦ Might include starting a new medication and the

risks/ benefits with that Rx◦ Put issues to address on the clip board◦ Private issues can be addressed at an individual

follow up visit (a recent headache)

Physician/PA/NP Role

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 Leave subjective and objective data for a nurse

to collect, let your patients fill out the subjective part of the chart

Your chart note documentation determines your billing level

Prepare Your Chart Note In Advance

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 CVD Progress Note HPI: Subjective

Any new angina. Any new signs CHF (SOB, edema, wt increase?)

ROS: Recent activity level◦ No activity◦ Moderate 2-3 times / wk◦ Moderate 4-6 times / wk * vigorous <4 times

/wk vigorous 4 or more x/ wk

Recent type fat intake◦ Most common fat intake

Produce serving intake◦ Less than 2 cups daily◦ 2-3 cups daily◦ 4 or more cups daily

Past Med Hx: (See chart)

Meds: (See med chart)

Tobacco Use:

Objective◦ Wt, BP, recent lipid profile,

FBS or HbgA1C Assessment

◦ CAD; At target? Yes/No Plan

◦ Treat and follow lipids◦ ASA daily (or other Rx)◦ Encourage activity and healthy

diet◦ Review med options: risks,

benefits, effects◦ Mange HTN & glycemia◦ >50% of this 90-minute visit in

counseling

99213, with 4 parts to the history, a brief exam, and decision making regarding a complex problem, with a stable patient and no therapy changes for a diagnosis of CAD

99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a CAD patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change

Billing for a CVD Group Visit

SAMPLE DIABETES PROGRESS NOTE

HPI: SubjectiveRecent hypoglycemia? (shaky, jittery, light-headed)Fatigue? Freq urination?

ROS: Activity Level◦ No activity◦ Moderate 2-3 times / wk◦ Moderate 4-6 times / wk vigorous <4

times / wk vigorous 4 or more x / wk

Produce servings intake◦ Less than 2 cups daily◦ 2-4 cups daily◦ 5 or more cups daily

Past Med Hx: (See chart)Meds: (Include ASA qd; see flow sheet)Tobacco Use:

Objective (dated)◦ Wt, BP, recent HbgA1C, lipids, urinary

microalbumin, creatinine◦ Foot and eye exams

Assessment◦ Type 2 Diabetes

(controlled/uncontrolled) Plan

◦ HgbA1C Rx reviewed◦ ASA daily◦ Encourage activity◦ Encourage healthy diet◦ Review med options: risks, benefits, side

effects (Including ace-inhib.)◦ Manage lipids, HTN, proteinuria, feet,

retina◦ >50% of this 90-minute visit in counseling

99213, with 4 parts to the history, a brief exam, and decision making regarding a complex problem, with a stable patient and no therapy changes for a diagnosis of TYPE 2 DIABETES

99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a TYPE 2 DIABETIC patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change

Billing For A Group Diabetic Visit

SAMPLE OSTEOPOROSIS PROGRESS NOTE Name: ____________________________________________ Date: ____________ID #: ____________________________________________ HPI: Subjective History severe spinal pain? yes noAny fracture during the last year? yes noTroubles tolerating medications for osteoporosis? yes noConstipation with calcium supplements? yes noTaking Vit D and magnesium with their calcium? yes noAny specific issue you want addressed at this session? __________________________________________________ ROS: Current weight bearing activity level: No activity, moderate 2-3 times / wk, moderate 4-6 times / wk, vigorous <4 times / wk, vigorous 4 or more x / wk Strength training sessions per week (circle one)None 1 session/wk 2 sessions/wk 3 sessions/wk >3 sessions/wk

How many mg of calcium intake do you get per day (diet plus supplements) _______(See handout to calculate calcium intake) Past Med Hx: (See chart for details) Meds: (Include; see flow sheet)Current Tobacco Use: yes no

OSTEOPOROSIS PROGRESS NOTE (cont)Objective

– Wt __________ BP __________ BMI ________ Hand Grip Strength ______kg (____

%)

– Last DEXA Completed ______ Lumbar BMD, _____ gm/cm Total Hip BMD ______ gm/cm

AssessmentOsteoporosis, responding to therapy

Osteoporosis, not responding to therapy

Other diagnoses: __________, _____________, ______________, ____________

Plan– Clarify next DEXA date

– Reviewed calcium, magnesium, and Vitamin D therapy recommendations– Encouraged activity, including weight bearing and strength training

– Moderate salt, animal protein, caffeine, and Vitamin A intake– AAFP osteoporosis patient handouts reviewed (3)

(http://search.aafp.org/htdigsearch/htsearch?words=osteoporosis)– > 50% of this 90 minute visit was spent on counseling

Billing: 99213 99214

http://search.aafp.org/htdigsearch/htsearch?words=osteoporosis

SAMPLE 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 cough/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 (cont)

Objective: – Wt __________ BP __________ BMI ________ RR ________– Peak flow 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) 99213 99214

Tobacco Abuse Visit Billing Options 99213, stable patient with tobacco abuse, evaluation

includes a history with 4 questions and ROS with two questions (may or may not include a brief exam), and decision making regarding a complex problem, receiving education, updated information

99214, Tobacco abuse with other complicated medical problems and in addition to the above, you address a treatment plan that entails some risk and benefit regarding the additional problems ◦ Usually a patient requiring a change in therapy with

documentation of a risk benefit discussion related to that therapy change in addition to tobacco cessation, such as a change in blood pressure therapy during this same visit

You are not limited to taking insurance An example, I offer a Ten Years Younger Group Visit Course

◦4-12 group sessions◦Body composition measures taken pre & post◦Initial nutrition evaluation◦Individual fitness evaluation pre & post◦They have the option of weekly trainer sessions

at a gym and get a 8-12 week gym membership◦Price varies from $500-1200 mostly depending

upon amount of trainer time

CASH GROUP VISITS

Group Visit Details

Do not rely upon time Rely upon the complexity of the diagnosis and

your documentation Spend a few moments of individual time with each

patient, briefly review the data collected, their diagnosis, and ensure their individual questions are addressed with the group

Adding extra diagnoses beyond overweight will help for insurance coverage of this visit

Insurance Billing Issues (Key points)

Call coverage, especially inpatient and obstetrical call

Minimize patient “NO SHOWS” with: ◦ Reminder calls 1-2 days prior “Your MD expects you at

this visit!”◦ Advertise guest speakers or cooking demonstrations◦ If the patient’s physician isn’t going to lead the group

visit a physician letter encouraging the session improves attendance

Pitfalls in Offering Group Visits

Mid afternoon for seniors Early evenings for working adults Tuesday, Wednesday, and Thursdays

appear the most popular days Saturday mornings work for some groups

(about 1/3-1/4 of those willing to participate in group visits)

Choose A Time That Suits Your Audience

Exercise topics Weight loss Tobacco cessation Food choices (Adding foods, increase fiber

intake, changing type fat intake, reducing fat intake)

Medications and supplements Lab testing topics Shopping, dining, and cooking skills Understanding lipid levels and targets Stress management

Get Paid to Address Lifestyle Issues During Group Visits

Space? Managed care environment? Staff support? Inertia?

What Would Keep You From Trying This?

Not all clinics are set-up to provide group visits with a lecture hall room

Try using the waiting room, works for smaller groups

Hospitals, community clinics, and religious centers will often provide space for free to a physician and their group to meet

Space

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 Set-Up

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

Managed Care

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

Staff Support

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

???

Inertia

Finally, you can get paid to educate your patients during a group visit and: ◦Improve outcomes◦Improve patient satisfaction◦Reduce health care expenses◦Enhance provider satisfaction and

provider compensation

Group Visits Are Effective


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Health & Medicine