Transcript GROUP VISIT - Cross Cultural Health Care Conference

GROUP MEDICAL VISITS FOR
THE TREAMENT OF ASIAN
PACIFIC ISLANDERS WITH
CHRONIC DISEASES
Ritabelle Fernandes, MD, MPH
Maricel Abad, RN
Patsy Uehara, RD
Riano Nazareth, AS
Ann Jimenez McMillan, MPH
Objectives
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Explain the different models of Group
Visits
Understand the delivery of care using
multidisciplinary approach within a
group visit setting
Improve provide productivity using
group visits
Why Group Visits?
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Increases patient satisfaction
Support and empowerment from peers
Improves access to care
Education about disease
Improves outcomes
Increases productivity
Trento et al. Lifestyle intervention by group care prevents deterioration of
type 2 diabetes: a 4 year Randomized control trial. Diabetologia
2002;45:1231-1239
Different Models for Group
Visits
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DIGMA – Drop In Group Medical
Appointment
CCHC – Cooperative Health Care Clinics
Continuing Care Clinic
Cluster Visits for Diabetes Care
CDSMP - Chronic Disease Self
Management Program
Support Groups
Studies - Diabetes Group Visits
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Sadur et al. study of Diabetes Cooperative Care Clinics providing
cluster visits multidisciplinary care model for patients with diabetes
in a HMO setting has shown improvement in HbA1Cand increased
confidence in self management behaviors
Wagner et al. conducted a system wide randomized control trial of
chronic care clinics for diabetes in a HMO setting and found
increased preventative procedures among attendees
Clancy et al. found group visits excellent for promoting
concordance with ADA guidelines in uninsured and underserved
populations improving the quality of care
Kokua Kalihi Valley &
Kalihi-Palama Health Center
Chronic Disease Group Visits
Kokua Kalihi Valley
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Gulick Elder Center
(monthly)
- Memory clinic
Kuhio Park Terrace
(bi monthly)
- Diabetes
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Main Clinic
- Diabetes (monthly)
- Kidney Disease
(bi monthly)
Kalihi Palama Health
Center
- Asthma/COPD
(monthly)
- Diabetes
(weekly cycles)
Mail Invitations
-REMINDERFor:
Come and join us for our
DIABETES CLASS
It is held at the
Conference Room
2nd floor of KKV Health Center
every 1st Wednesday of the month
We will learn more on how to
control and manage our diabetes.
We will have FREE healthy meals
cooked by our great nutritionists.
We will also have some PRIZES!!
HOPE TO SEE YOU THERE!!
Reminder calls
Transportation
Waiting Room
Lunch Room/Reading Room
Group Visit Format
8.30
8.45
9.15
9.30
10.30
-
8.45
9.15
9.30
10.30
11.00
11.00 - 11.30
11.45 - 12.00
Check In
Vital signs and history taking
Participants introduction/sharing
Educational presentation
Break
One on one with physician
Lunch with nutritional counseling
End
Follow up appointments given
Wellington M. Stanford health partners: Rationale and early experience in
Establishing physician group visits and chronic disease self –management
workshops. J Ambulatory Care Manage 2000; 24(3):10-16
Sign In
Vital Signs
Taking History
Introductions
Topics
Facilitative Teaching Style
Presentation - Glucometer
Teaching
Incentives
Break - Medication Refill
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Samples
Patient Assistance
340 B
Prescriptions
Immunizations
Meet with Doctor
Healthy Lunch
How to get started?
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COLLABORATION
Partner with existing education/support
groups
Frequency
Reserve Room
Delegate duties
Team - Standing Orders
SUSTAINABILITY
Patient Selection, Recruitment,
Retention
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Group visits by Language/ethnicity
Limited to individual provider’s panel
Open access to all providers
Community Health Workers
Work close proximity to health maintenance
group, day care
Food, Incentives are key
Challenges – Language barriers, dementia or
psychiatric issues, time constraints
Staffing
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Medical Students, Residents, Fellows
Public Health Nurses
Guest speakers
Interpreters
Medical Assistants
Nutritionist
Behavioral Health
Eligibility
Tobacco Cessation Specialist
Pharmacy
Advantages of Provider Presence
CARE COMPONENT IN ADDITION TO
EDUCATION COMPONENT
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Medications can be ordered/refilled
Symptom management
Phlebotomy, Immunizations, tests can be
ordered
Referrals made to specialists
Time for Q & A
FEE TICKET
LABEL
ARRIVAL TIME:____________
INSURANCE:_______________
EFF DATE WITH KKV:______
INTAKE INITIAL:___________
CHART REVIEW:___________
REFERRING PCP:_________________
UPIN #:__________________________
CODE
DIAGNOSIS
CODE
DIAGNOSIS
CODE
New Patient 10 min
99201
Abdominal pain, site:______
789.0_
Counseling, health education
V65.40
New Patient 20 min
99202
Abnormal EKG
794.31
CVA/stroke, acute
436
New Patient 30 min
99203
Agitation
308.2
Delirium
293.0
New Patient 40 min
99204
Allergy, unspecified
995.3
Dementia, Alzheimer’s
331.0
Established Patient 5 min
99211
Alcohol Dependence
303.90
Dementia, Multi-infarct
290.40
Established Patient 10 min
99212
Anemia, Iron Deficiency
280.9
Dementia, Parkinsonism
331.82
Established Patient 15 min
99213
Anemia, unspecified
281.9
Dementia, nos
290.0
Established Patient 25 min
99214
Angina Pectoris, unspecified
413.9
Diabetes Screening
V77.1
Established Patient 40 min
99215
Anorexia
783.0
DM1, controlled
250.01
Medical disability evaluate
99455
Anxiety disorder, generalized
300.02
DM1, uncontrolled
250.03
Arthralgia, unspecified
719.40
DM2, controlled
250.00
OFFICE VISIT
CONSULTATION
New Pt Focused H/E
99241
Asthma, acute exacerbation
493.92
DM2, uncontrolled
250.02
New Pt Expanded H/E
99242
Atrial Fibrillation
427.31
DM2 with circulatory compl
250.70
New Pt Detailed H/E
99243
Back Pain, unspecified
724.5
DM2 with neuro compli
250.60
New Pt Comp H/E
99244
Back Pain, lumbago
724.2
DM2 with opthal compli
250.50
Increase Revenue and
Productivity
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Physician – 99212 or 99213
Certified Diabetes Educator (ADA
certified site) – G0108, G0109
Smoking Cessation – G 0375 or 99406
Reimbursed for In-House laboratory
eg. Point of Care Testing, Spirometry
UDS numbers – interpreter and other
enabling services
Preliminary Data 2006 – KKV
Diabetes Group A, B, Cs
Variable
Group visit Attendees >3
visits N = 31
Diabetes Clinic
Population N = 451
HbA1C
7.8
8.5
Blood Pressure
(SBP)
129.4
127
Blood Pressure
(DBP)
76
74
LDL Cholesterol
99.9
107.8
Flu Vaccine
100%
73.2%
Pneumococcal
Vaccine
91%
82%
Eye Exam
95%
39.7%
Foot Exam
100%
62.7%
Preliminary Data 2007 – KKV
Diabetes Group A, B, Cs
Variable
Group visit Attendees >3
visits N = 30
Diabetes Clinic
Population N = 521
HbA1C
7.9
8.7
Blood Pressure
(SBP)
125
125
Blood Pressure
(DBP)
70.9
73
LDL Cholesterol
101
110.4
Flu Vaccine
98%
58.4%
Pneumococcal
Vaccine
100%
78.7%
Eye Exam
95%
47.8%
Foot Exam
100%
70.4%
2007 Self Efficacy Data
Stanford diabetes self efficacy scale
Self-Efficacy for Diabetes N = 30
Variable
Mean
Preventing low blood sugar
9.2
Knowing what to do when sugar drops
8.9
Control of diabetes
8.9
Judging changes in illness mean should visit the doctor
8.8
Following diet when preparing or sharing food
8.3
Exercising 15 – 30 minutes
8.3
Eat meals 4-5 hours everyday
7.9
Choosing appropriate food to eat
7.1
2007 Diabetes Quality of Life
Diabetes Quality of Life (DQOL) N = 30
Variable
Satisfied (3)
Neutral (2)
Dissatisfied (1)
Mean
Diabetes Treatment
28
0
2
2.9
Time to manage diabetes
27
2
1
2.9
Time for exercise
29
0
1
2.9
Time for checkups
28
1
1
2.9
Knowledge about diabetes
29
0
1
2.9
Time for glucometer
25
3
2
2.8
Burden on family
21
7
2
2.6
Sex life
7
21
2
2.2
Variable
Seldom
Sometimes
Often
Mean
Worry about missing work
27
3
0
2.9
Limitation to career
26
3
1
2.8
Pain due to treatment
23
6
1
2.7
Physically ill
24
3
3
2.7
Worry about passing out
20
8
2
2.6
Eat something/hide illness
10
19
1
2.3
Bad night’s sleep
13
13
4
2.3
Satisfaction Survey 2008
(N=19)
Variable
Mean*
1. I learned new information at this group.
4.68
2. The session reinforced what I already knew.
4.68
3. This session increased my confidence in managing my
diabetes.
4.58
4. I will change the way I manage my diabetes.
4.53
5. The presence of an interpreter was helpful.
(respondents = 13)
4.85
6. The doctor gave me treatment and medicines that I needed.
4.79
7. The nurses were helping in caring for me.
4.47
8. The cooking instruction will help me cook and eat healthier
foods at home.
4.42
9. These diabetes group visits are a quick and easy way for me
to get care for my diabetes.
4.63
* Based on a 1-5 Likert scale 1 = strongly disagree to 5 = strongly agree
Comments
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I come every time we have a diabetes
class because I learned everything
regarding diabetes and trying to apply
at home
I thankful this program. So I know what
kinds of food I eat. It good to my
diabetic
I really like this group because I learn a
lot about my diabetic this group is good
for every patient has diabetic
Public Health Nurse’s Role
Diabetes Group Visits
HEALTH EDUCATION
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MANAGING DIABETES
CHECK BLOOD GLUCOSE
MEDICATION and INSULIN
• GENERAL HEALTH INFORMATION
HEALTHY EATING
HEALTH EDUCATION
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PREVENTING COMPLICATIONS
FOOT CARE
HYPERLYCEMIA/ HYPOGLYCEMIA
HEALTH EDUCATION
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EASY TO UNDERSTAND
BASED ON GROUPS NEED
UTILIZE DIFFERENT METHODS OF
TEACHING
ENCOURAGE PARTICIPATION
Creative, Interactive and Fun
GROUP FACILITATOR
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Facilitative Leadership Style
Encouraging Discussions
Learning through each other’s
experiences
Goal Setting
COORDINATE ACTIVITIES
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COLLABORATING WITH OTHERS
HAVING GUEST SPEAKERS
SET CURRICULUM
BEING FLEXIBLE
ENCOURAGING STAFF
DEVELOPMENT
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ALLOWING STAFF TO
PARTICIPATE IN GROUP
SESSIONS
MOTIVATING STAFF
MEMBERS
TRAINING THROUGH
MODELING
OPPORTUNITY FOR STAFF
TO INTERACT WITH CLIENTS
INCORPORATING CULTURE
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PARTICIPANTS ARE OF DIFFERENT
CULTURES
SHARING CULTURAL BACKGROUND
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FOOD
BELIEFS
OPPORTUNITIES FOR FAMILIAR
HEALTHY CULTURAL ACTIVITIES
ALLOWING PARTICIPANTS TO SPEAK IN
THEIR LANGUAGE
USE OF INTERPRETERS WHEN NEEDED
Cultural Adaptations - Music
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Dance
Exercise, stretching
Exercise
HOOULU ‘AINA
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KKV ROOTS PROJECT
PROMOTING HEALTH
THROUGH (CINRTR:
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CONNECTING TO THE
LAND and the FOOD
GROWN
CONNECTING WITH
EACH OTHER and
LEARNING ABOUT EACH
OTHERS CULTURE
SENSE OF COMMUNITY
APPRECIATING HEALTHY
CULTURAL FOODS
Role of Nutritionist
• Recommend typical plate
size about 8” in diameter
• Party plate size range
from 12 to 20” or larger
20”
Plate Method for Portion Control
Using Cultural Local Foods
Making Fish Palusami
Using the Taro Leaf
Fish Palusami
Pineapple Salsa
Boiled Banana
Food Demonstration
•Chicken Divan
•Brown Rice
•Strawberries and Banana
Recipes
Produce from Ho’olu Aina
Bok Choy
Fiddlehead Fern
Mint
Kabocha
Collard Greens
Swiss Chard
Basil
ROLE OF MEDICAL ASSISTANT
AND CASE MANAGER
Chart Review
DIABETES GROUP VISIT NOTE
Name: _______________________________________________
Date: _________________
Subjective:
Daily Meal Patterns
[ ] 3 meals + snacks [ ] 3 meals[ ] 1-2 meals + snacks
Unhealthy carbohydrate [ ] 1-2 /month
[ ] < 1/week
Current exercise
[ ] > 3/week
[ ] 2/week
Glucometer
[ ] Yes
[ ] No
Hypoglycemia past year [ ] No
Past Medical history:
Hospital/ ER visit past year
Immunizations
Medications
Social history:
Tobacco use
DOB: _________
[ ] 3-5 /week
[ ] 1/week
SMBG
[ ] 1-2 meals
[ ] Daily
[ ] None
[ ] No ] Yes How often ?__
[ ] Yes_______________________________
[ ] None
[ ] Up to date
[ ] See flow sheet
[ ] Poor compliance
[ ] Yes Where/Why?_________
[ ] Needs ___________________
[ ] Refill?___________________
__________________________
[ ] No
[ ] Yes How many ___________
KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
2239 NORTH SCHOOL STREET HONOLULU, HAWAII 96819
PHONE: 791-9400/FAX: 847-6051 (Revised September 1, 2005)
GROUP VISIT - VITALS RECORD
No.
Name
Date of Visit _________________________
Wt
Lbs
Ht
cms
BMI
Temp
F
BP
mm
Hg
Pulse
/min
Sugar
1.
[ ] FBS
[ ] RBS
2.
[ ] FBS
[ ] RBS
3.
[ ] FBS
[ ] RBS
4.
[ ] FBS
[ ] RBS
5.
[ ] FBS
[ ] RBS
6.
[ ] FBS
[ ] RBS
Blood Test Station
Date of
Birth:
Name
Date
Diagnosis
Cholesterol CPT-83718
ALT CPT-84460
AST CPT-84450
HgbA1C CPT-83036
0
Urine Dipstick
CPT-82043
Microalbum
in
Provider
Staff
Initial
KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
2239 NORTH SCHOOL STREET HONOLULU, HAWAII 96819
PHONE: 791-9400/FAX: 847-6051 (Revised September 1, 2005)
GROUP VISIT - FOLLOW UP APPOINTMENT
No.
1.
2.
3.
4.
5.
Name
Date of Visit ________________
Doctor
Location
Sch/Gul/KPT
F/U
Date/Time
Referrals
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Opthalmology
Podiatry
Community resources
Transportation
Translations
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Interpretation
Translation of
handouts
Asthma/COPD group at KPHC
Asthma Ed/ Tobacco Spec
 Practitioner Style & Philisophy:
Empathy for patients, healthy living & quality of life
Understand group process, support grps, pts learn
from each other, family involvement
Create fun, safe, relax, interactive milieu for pts & family
Elicit pts suggestions; encourage f/u w/provider
 Skills:
Evaluate grp intervention to improve/ expand/ evolve program
Prj Dir developed “Chuukese Smoking & Spit/Chew Tobacco
Cessation & Secondhand Smoke Brochure”
Collaboration w/ external agencies, Asthma Initiative, Coalition Tobacco
Free HI, Amer Lung Assoc, COPD Coalition, CHCs, UHSPH, DOH, etc
Final Chuukese Smoke & Chew/Spit Tobacco Cessation
Plus Secondhand Smoke 6-Panel Brochure
Inside Flap Panel
Back Panel
Front Panel
Kalihi-Palama Health Center
Smoke-Free Families Program
808.848.1438
Kalihi-Palama Health Center
Smoke-Free Families Program
Fori Om Apoinmen
Ifa Usun Om Kopwe Wes
Me Supa/Nunu Snaf/Atuf
808.848.1438
Kalihi-Palama Staff Cultural Review Committee
Sia awora ach angangen aninis ren om
kopwe kouno om unumi me mongo
supwa. Ika en mi mochen kouno.
Fos ngeni ekkei chon aninis ika noum
Sousafei kokkori 791-6329
ren tichikin poraus.
Cultural Review Committee:
Kalihi-Palama Staff External
Chiquitita Enlet, AA Nia Aitaoto, MPH
Millie Phillip, AS
Nerleb Likisap, MDiv
Haruo Sippa
Robert Lorin
Marumina Soyon, BA Selynda Selifis, AA
Illustrations by: Lieliena Loynaz, BA
Project Director:
Ana Jimenez McMillan, MPH, CTTS
Language: Chuukese
Kalihi-Palama Health Center
Smoke-Free Families Program
915 N. King Street, Honolulu, HI 96817
808.848.1438 www.kphc.org
Final Chuukese Smoke & Chew/Spit Tobacco Cessation Plus
Secondhand Smoke 6-Panel Brochure Continued
Left Inside Panel
Efeiengawan Om
Nunu Snaf!
Middle Inside Panel
Right Inside Panel
Ka Mochen Kouno Ne
Nunu Supwa?
Ka Mochen Kouno
Ne Unumi Supwa?
Tumunu noum moni fanitan
osupwangen famini.
Semerit me famini resap
nom non otuotun supwa.
Unumi supwa a efeiengawa
me awosupwangwa ewe inis
pun a tongeni fis semwenin
kanser, ngasangas, mano
epek inisum, semwenin
emun, ika mano.
Epwe efeiengawa, tinnawom
cheen mongoom, pwan ekkoch
kanserin awom, nukom me
semwenin ngasangas, a afisata
samau me mano.
Nunu supwa fiti ekkewe puu a
esenipa an epwe wor semwen
ika mano.
Tumunu noum moni fanitan
osupwangen famini.
Semerit me famini resap poputa
nunu/atuf/eaea snaf.
Role in Asthma/COPD Group
Intervention
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Logistics – room set up, name tags, create
fliers
Introductions
Education
Invite guest speakers
Tobacco cessation counseling
Second Hand Smoke exposure education
Data collections, surveys
Self Assessment –
Asthma Control Test
Asthma Ed/ Tobacco Spec
 TREATMENT SRVCS INTEGRATION BENEFITS PATIENTS
Pts more comfortable & familiar w/staff; more adapt to ask for help/ quests
Provide brief/ intermediate cessation counseling; remind about other appts
Pts realize they're not alone in coping/living/managing Asthma/COPD cond
Other providers/m assistants can meet briefly w/pts for other tx issues/meds
Less visits to clinic; support of the group; consistency
Increase patients treatment compliance and understanding of Asthma/COPD
Increase pts understanding of tobacco use/ 2ndhandsmoke exposure as relates to
Asthma/COPD cond
 BILLING
Tobacco Cessation Tx not a billable service; however, counted & documented as
enabling service – montly sign-in sheet
Designed EHRecs Assessment and Progress Note forms for Tobacco Tx
Developed matrix for Health Plans Coverage for Tobacco Tx & Pharmacotherapy
Kalihi-Palama Health Center, Smoke-Free Families Program
KPHC ID #_____________
Progress Note (Only for Patients w/Completed Assessment Form )
Tobacco Cessation Counseling INTERMEDIATE (3 – 10 Mins)
Tobacco Cessation Counseling INTENSIVE (10+ Mins)
Patient Name: ____________________________________ Date of Birth: __________
1. Do you currently use tobacco in any form? YES
NO
2. Are you a former tobacco user? YES
(If Yes #1 is NO)
NO
If Yes,
Quit Date:
__________
3. How many cigarettes/cigars/chews per day do you use?
Cigarettes/Cigars/day
4. What is your readiness to quit tobacco?
Chews/day
Does not
Apply
Quit _________(Number of Days/Mos/Yrs)
Ready to Quit in 30 Days Quit Date________
Ready to Quit within 6 Months
Ready to quit in 6+ Months
5. Strategies Provided: Motivators___ Reduction Plan___ Smoking Diary___ Triggers___
Activities to Distract/Avoid Tobacco Use___ Withdrawal Symptoms___ *Exercise___ *Eat More Fruits/Vegetables___
Support System___ Calendar/Dots___
Counseling Notes:
______________________________________________________________________
Kalihi-Palama Health Center
Tobacco Education Post Survey
1. How would you rate the tobacco education presentation?
Excellent
Good
Fair
Poor
2. Did you learn about health effects from tobacco smoke?
YES
NO
3. If current/former tobacco user did tobacco education presentation help you think about
quitting or avoid starting tobacco use again?
YES
NO
NEVER SMOKED/DOES NOT APPLY
4. Would you tell a family member or friend to come to this presentation? YES NO
5. Please provide ideas to improve tobacco education presentation? _________________
______________________________________________________________________
______________________________________________________________________
KPHC SFFP Asthma/COPD
OTHER TOBACCO PRODUCTS
WHAT ARE OTHER TOBACCO PRODUCTS?
● Electronic-Cigarettes ● Smokeless Tobacco ● Tobacco Lozenges ● Dissolvable Tobacco
► Not Safer Than Smoking Tobacco Cigarettes, Cigars or Pipes
► Affects Health – Causes Cancers & Heart Diseases
► Leads to Higher & Faster Nicotine Addiction
► Not Approved by USA Food & Drug Administration as Medicine to Help
Quit Tobacco Smoking or Reduce Tobacco Use
E-Cigarettes or Non-Nicotine E-Cigs or Personal Vaporizer – battery powered device provides
inhaled doses of nicotine with vaporized solution:
● heats solution of nicotine in propylene glycol producing fine mist that’s inhaled
Diabetes Education, Kalihi-Palama Health Center 2010
Food – low allergenic
Expert Patient Training –
Dr Ron Sanderson
TEAM
T = Together
E = Everyone
A = Achieves
M = More
Questions?