Drop-In Group Medical
Appointments
Virginia Health Care Foundation
Nurse Practitioner Roundtable
April 16, 2010
Outline
• Shared Medical Appointments
• History
• Idealized DIGMA
• DIGMA Implementation
• Important Concerns
• Summary
• Resources
Shared Medical Appointments
• Shared Medical Appointments [SMA]
Multiple patients seen as a group for followup or routine care
• Created primarily to mitigate increasingly
constrained medical practice
Enhance practice efficiency
Increase patient access/satisfaction
Decrease negative health outcomes
SMA Sub-Types
• Drop-In Group Medical Appointment [DIGMA]
 Group model focused on patients in physician’s panel
• Cooperative Health Care Clinic [CHCC]
 Group model focused on patient utilization or
diagnosis
• Physicals Shared Medical Appointment [PMSA]
 Theoretically similar to DIGMA model; strong focus on
physical exams
History
Brief History
• Developed and established in 1996 by Dr.
Edward Noffsinger
 Psychologist at Kaiser Permanente
• Model designed with general intent
 Increase practice efficiency, patient health
outcomes, and provider/patient satisfaction
 Better manage practitioner workload
Brief History
• Development stimulated by confluence of three
general problem streams
1.Providers
 Decreased reimbursements, PCP shortages, increased
workloads
2.Patients
 Decreased face time with PCP, increased access to health
information, decreased patient satisfaction
3. Theory
 Increased understanding of need for holistic care, increased
understanding of the complexities of chronic disease
management
Brief History
• Dr. Noffsinger envisions use of DIGMA in
multiple realms of healthcare
Chronic disease management, ambulatory
care, psychiatric care, access issues, etc
• Use of model has been limited
Diabetes, psychiatric care, heart conditions
DIGMA
According to Noffsinger
Current Forms
• Exists in three forms
Homogenous Model
Patients grouped by diagnosis
Heterogeneous Model
All patients invited regardless of diagnosis
Mixed-Model
Meetings segmented based upon diagnostic
groupings
 Cardiopulmonary, weight management/diabetes, chronic
pain, gastrointestinal
Ideal DIGMA Sessions
• Intended to resemble series of individualized
office visits in a supportive group setting
• 10-20 patients
• ~ 90 minute runtime
• Physicians panel only
• Meets weekly
• Well-Staffed
 head provider [MD/NP/PA], 1-2 assistants, scheduler,
documenter and behaviorist
Provider Definitions
• Lead Provider
MD, NP, PA
• Medical Assistants
RN, LPN, CNA
• Behaviorist
Social worker, psychologist
• Documenter
Specially trained to take notes in “real-time”
Individualized
• Accomplished by incorporation of 5 core actions
in each session
1. Provider attends to patients sequentially
2. Provision of same medical services to each patient
3. Primary provider never leaves session
1. Exceptions: disrobing and private discussion occurs in
adjacent examination room
4. Comprehensive and individualized charts
5. Consistent focus on medical care throughout session
Group Atmosphere
• Room should be conducive to group discussion
 Brightly lit, central table/focus, attendees able to face
each other
• Patients informed that discussion should be
positive
• Behaviorist is key to facilitating discussion among
group
 Primary source of patient education within DIGMA is
derived from proper group discussion
 Guiding such discussion generally requires extensive
training
DIGMA Research
Current Research
• DIGMA specific research indicates
 Enhanced productivity, patient/provider satisfaction,
• Growing body of research concerning SMAs
provides general consensus of improved rates in
 Patient quality of life
 Health outcomes
 Quality of care
 Patient/Provider satisfaction
 Revenue streams
SMA Research
• Improvements in health outcomes
 Decreased HBA1C levels
 Improved blood glucose control
• Improvements in health indicators
 Decreased ER visits
 Increased Primary Care visits
• Improvements in health behaviors
 Increased fruit/vegetable intake
 Reduced consumption of high fat foods
SMA Research
• Improvements in patient satisfaction
Increased satisfaction of diabetic
management
Increased feeling of quality of care
Improved sense of trust in provider
• Improvements in health communication
Decrease in advice-seeking between site visits
Increased patient self-efficacy in providerpatient communication
DIGMA Implementation
Why use DIGMA
• Reasons for use of DIGMA vary widely
Location, budgets, PCP levels, MCO
• Common startup reasons
Overbooked or backlogged schedule
Reductions in PCPs
Similar patient bases
Repetition of advice
Better quality of care
Considerations Before Startup
• Facilities requirements
Room occupancy and availability
• Provider requirements
PCP, medical assistants, behaviorist,
documenter
• Billing/fiscal requirements
Billing is not always straight forward
Initial start-up funds will be necessary
however, should be made up in savings
Necessary for Start-up
• Leadership Support [“champion”]
 One individual serves as primary planner and
implementer of DIGMA program
• Patient buy-in
 Patients must understand and be convinced of
legitimacy of DIGMA
• Provider buy-in
 Concerns regarding model must be addressed
 Obtainment of behaviorist
The Champion
• Acts as lead for entire implementation
 Secures administrative support
Rooms, funds, approvals from higher administrative levels
 Secures providers
Engage potential providers, address provider concerns
 Customizes DIGMA model to practice
Patient base, location, reimbursement concerns
• Must possess thorough knowledge of DIGMA
theory and practice
Patient Buy-In
• Patients must be convinced of DIGMA legitimacy
 Radical change from standard one-on-one interaction
• Introduction of model should be addressed at
individual office visit
 Personal setting increases perceived legitimacy
 Model explanation should be three-step
Verbal explanation
Pamphlet/flyer
Personal invitation to attend
Provider Buy-in
• Providers are skeptics and must be shown
potential and legitimacy of DIGMA model
 Normally convinced by data, application to high-risk
patients, and case reports of previous uses
• Providers should not be ordered to conduct
DIGMA
 Drive for DIGMA must come from provider base
• Incentives can be used to support providers
 Increased flex-time on days of DIGMA conduction
• Selection of provider as champion can enhance
buy-in
Sample Session
• Room is prepped for patient arrival
 Refreshments, seating, quality of room
• Patients check-in
 Escorted to room; medical assistant can take vital
signs
• Providers welcome patients
• PCP examines patients individually
 Behaviorist promotes group discussion concerning
patients medical issues.
 Documenter follows PCP
• Termination of Session
Barriers to successful DIGMA
• Top-down dictation to providers
 Providers should not be ordered to conduct DIGMA
 Desire to conduct DIGMA must come from providers
• Inadequate space to conduct DIGMA
 DIGMA attendance and atmosphere requirements
necessitate adequate space planning
• Inadequate scheduling
 Scheduler greatly increases chances of reaching
necessary attendance
• Low attendance
 Productivity increases of DIGMA predicated on high
attendance rates
Important Issues
Confidentiality
• Primary source of confidentiality concerns
comes from providers
• Nature of DIGMA sessions inherently
address some confidentially issues
Patients who attend generally comfortable
with discussing personal health information in
group setting
• Issues of confidentiality may be addressed
using Noffsinger’s six-step guidelines
Noffsinger’s Six Steps
• Address confidentiality in promotional materials
 Clearly indicate group setting and the sharing of
medical information within group
• Train staff to properly refer patients
 Clearly indicate that session is group visit and not
extended individualized session
• Confidentiality agreement drafted by legal
professional
 DIGMA specific release should be created; Do not
borrow other release forms
Noffsinger’s Six Steps
• Signing of confidentiality release by attendees is
mandatory
 Signing of release form occurs before session.
 May eventually become unnecessary as time
progresses
• Discussion of confidentiality during session
 Behaviorist briefly discuses sharing of information and
maintenance of patient anonymity
• Placement of release in all patients charts
 Record keeping procedure; if using electronic medical
records then release can be scanned
Modifications to Idealized
DIGMA
• Use of original DIGMA form is ideal
however, real world constraints may
prevent such application
• Modifications to DIGMA can occur in a
variety of areas
Staff
Conduction of session
Census levels
Modifications to Idealized
DIGMA
• Staff
 Documenter can be eliminated
Primary provider can take notes
 Reduction in number of medical assistants
• Conduction of session
 Length of session time can be decreased
 Individual examinations can be entirely removed from
group; discussion of examination results upon return
to group
• Census levels
 Other clinics have done well on lower than ideal
census levels [4-6 patients per session]
Guides
• Improving Chronic Illness Care
 http://www.improvingchroniccare.org/downloads/gro
up_visit_starter_kit_copy1.doc
• ImpactBC
 http://www.impactbc.ca/files/documents/NHA_Group
_Medical_Appointments_Manual.pdf
• American Academy of Family Physicians
 http://www.aafp.org/online/en/home/practicemgt/qu
ality/qitools/pracredesign/january05.html
Resources
Resources
• Atkins, T., and E. Noffsinger. "Assessing a Group Medical Appointment
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Program: A Case Study at Sutter Medical Foundation." Group Practice Journal
50.April (2001): 42-49. Print.
Baurd, Stephanie, Todd Marcy, Becky Armor, Jennifer Chonlahan, and Paige
Beach. "Gropu Medical Visits at a Family Medicine Center: Analysis and
Resolution." Medscape: Medical News, Full-text Journal Articles & More. Web.
08 Apr. 2010. <http://www.medscape.com/viewarticle/541549_2>.
Bronson, David, and Richard Maxwell. "Shared Medical Appointments:
Increasing Patient Access without Increasing Physician Hours." Cleveland
Clinic Journal of Medicine 71.5 (2004): 369-77. Cleveland Clinic. Web. 8 Apr.
2010. <http://www.ccjm.org/content/71/5/369.full.pdf+html>.
Christianson, Jon B., and Louise H. Warrick. The Buisness Case for Drop-In
Group Medical Appointments: A Case Study of Luther Midelfort Mayo System.
Rep. Vol. 611. Commonwealth Fund, 2003. Print.
"Clinical Microsystems :: Toolkits : Shared Medical Appointments." Dartmouth
Medical School - DMS Home. Web. 08 Apr. 2010.
<http://dms.dartmouth.edu/cms/toolkits/shared_medical_appointments/>.
Group Health Research Institute. Rep. Group Health Research Institute. Web.
8 Apr. 2010.
<http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_co
py1.doc.>.
Resources
• "Harvard Vanguard - Shared Medical Appointments." Harvard Vanguard
Medical Associates, Delivering Comprehensive Healthcare in the Boston Metro
Area. Web. 08 Apr. 2010.
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<http://www.harvardvanguard.org/about/most/index.asp>.
ImpactBC. Confidentiality Agreement. Rep. ImpactBC. Print.
ImpactBC. Rep. ImpactBC. Web. 8 Apr. 2010.
<http://www.impactbc.ca/files/documents/NHA_Group_Medical_Appointment
s_Manual.pdf>.
Jaber, Raja, Amy Braksmajer, and Jeffrey Trilling. "Group Visits: A Qualitative
Review of Current Research." Journal of the American Board of Family
Medicine 19.3 (2006): 276-90. Print.
Harris, Marianne. "Shared Medical Appointments After Cardiac Surgery-The
Process of Implementing a Novel Pilot Paradigm to Enhance Comprehensive
Postdischarge Care." Journal of Cardiovascular Nursing 25.2 (2010): 124-29.
Journal of Cardiovascular Nursing. Web. 8 Apr. 2010.
<http://journals.lww.com/jcnjournal/Abstract/2010/03000/Shared_Medical_A
ppointments_After_Cardiac.7.aspx>.
• "Group Visits (Shared Medical Appointments) -- Clinical Quality Improvement
-- American Academy of Family Physicians." Home Page -- American Academy
of Family Physicians. Web. 08 Apr. 2010.
<http://www.aafp.org/online/en/home/practicemgt/quality/qitools/pracredesi
gn/january05.html
Resources
• Noffsinger, Edward B. Running Group Visits in Your Practice. New York ;
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Berlin: Springer, 2007. Print.
Noffsinger, Edward B. Running Group Visits in Your Practice. New York ;
Berlin: Springer, 2007. Print.
Noffsinger, Edward B. Running Group Visits in Your Practice. New York ;
Berlin: Springer, 2007. Print.
Noffsinger, Edward B. "Will Drop-In Group Medical Appointments (DIGMAs)
Work In Practice?" The Permanente Journal 3.3 (1999): 58-67. The
Permanente Journal. Web. 8 Apr. 2010.
<http://xnet.kp.org/permanentejournal/fall99pj/digma.html>.
Kirsh, Susan, Sharon Watts, Kristina Pascuzzi, Mary O'Day, David Davidson,
Gerarld Strauss, Elizabeth Kern, and David Aron. "Shared Medical
Appointments Based on the Chronic Care Model: a Quality Improvement
Project to Address the Challenges of Patients with Diabetes with High
Cardiovascular Risk." Quality and Safety in Health Care 16 (2007): 349-53.
BMJ. Web. 8 Apr. 2010. <http://qshc.bmj.com/content/16/5/349.abstract>.