9/23/2015 Jackie F. Webb, DNP, FNP-BC Assistant Professor Linfield - - PDF document

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Jackie F. Webb, DNP, FNP-BC Assistant Professor Linfield College Participants will understand differences between traditional care vs. group care Participants will describe effective components

• f group care

Participants will describe barriers and facilitators to group care in primary care environments. Why should we be researching innovative health care delivery models?

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(Source: Wu, S & Green, A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000)

10 20 30 40 50 60 70 80 90 100

Conditions Chronic Pain Diabetes Cardiovascular Disease Cancer Stroke

100 million 26 million 16.3 million 12 million 7 million

Number of Patients

Medicaid Expansion will cover > 13 million uninsured Americans and another 24 million through the new federal an/or state health insurance exchanges. (CBO, 2014) Shortage and maldistribution of PCP’s impacting adequate access to care Dower & O’Neil, RBJ Found Synthesis Project, 2011; Lakhan & Laird, Int. Arch Med, 2009;

2(14); 1-4

Providers are looking for innovations in health care delivery to address:

Complex health care needs Access barriers to health care services.

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Better Care Better Health

Affordable Care Better Provider Satisfaction

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: care for the patient requires care of the provider. Annals

• f Fam Med (12)6.)

Patient driven focus and concerns A medical appointment attended by 4-10 patients, their caregivers, nurse, and other members of the health care team

Appointments may last from 60-90 minutes Medical care is delivered during visits

Different from the traditional 1:1 model of patient and provider Different from Support or Educational Groups

Group Care: Patient Centered Care Focus is on self- management skills

Support from

• ther patients

with similar condition

More time with provider Shared Learning

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With < 8-10 patients at a time With patients < 65 years of age With patients with similar diagnosis Patient led groups When providers are familiar with Group Care:

Group dynamics Communicate well Model Team Confidentiality is discussed

Self-management is a central tenet of most group care models Primary care clinics using group care model report:

Patients have greater knowledge of self-care skills Improvement in patient access to care Increased time spent with each patient Enhanced patient outcomes Decreased emergency room visits Increased patient and provider satisfaction

( Bendix & Brower, 2011; Bronson & Maxwell, 2004: Jaber et al, 2006; Kawasaki et al, 2007; Thacker, Maxwell)

Group care has been used with various chronic conditions:

Diabetes: Majority of research

Variables that have been researched:

Primary Physiological indicators: A1C, weight, BP, BMI, Peak flow levels Secondary indicators:

Hospitalization ER admissions Medication use Frequency of services Patient and provider satisfaction

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Cross-Sectional Survey for Providers: 23 Questions, Investigator designed Clinic Email: Survey Monkey link Sample size: 126 providers (MD, NP, PA, RN, LPN) 69 respondents or 55% response rate Focus Group for Patients: One time meeting: 5 questions 11 women ages 41-78 diagnosed with CNMP for > 1 year, average 21 years

Total # of Providers Female Respond. Male Respond Total #

Respondents

Average Practice Years Respondents MD

35 16 8 24 (69%)

16.40 (SD 17.1) NP/PA

33 14 2 16 (49%)

13.4 (SD 10.0) RN

58 12 3 15 (50%)

21.93 (SD 12.2) LPN n/a

12 1 13 1

14 (SD 11.5) Total

126 54 (79%) 14 (21%) 69 (55%)

Received Adequate Pain Educ. in school Wants more Pain education Benefit from Group Care for CNMP pt.'s Wants to learn about Group Care Want to participate in Group Care

Prescriber

(N=40)

Yes

9 (23%) 26 (65%) 26 (65%) 29 (73) 18 (45%)

No

29 (73%) 10 (25%) 1 (2.5%) 4 (10%) 8 (20%)

Not Sure

2 (5%) 4 (10%) 13 (33%) 6 (15%) 14 (35%)

Non-presc

(N=29)

Yes

12 (41%) 23 (79%) 21 (72%) 25 (86%) 15 (52%)

No

13 (45%) 4 (14%) 1 (3%) 5 (17%)

Not sure

4 (14%) 2 (7%) 7 (24%) 3 (10%) 9 (31%)

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10 20 30 40 Prescriber (MD, NP/PA) Non-prescriber (RN/LPN)

• Pt. willingness to participate
• Pt. knowledge of group care

Provider knowledge Practice setting Administrative Support Staff knowledge of group care

# of Providers

5 10 15 20 25 30

Prescriber (MD, NP/PA) Non-prescriber (RN, LPN)

Provider willingness to participate in Group Care Staff willingness to participate in Group Care Provider knowledge of Group Care Administrative Support

• Pt. willingness to participate in Group Care

Staff knowledge of Group Care

# of Providers

Barriers:

“A provider who doesn’t understand CNMP” “Confidentiality”

Facilitators:

“Providers that know CNMP and are up to date” “Learning from others” “Increased time with provider”

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• 1. Providers believe there is benefit from Group Care

Believe CNMP patients benefit from Group Care

• 2. Perceived Barriers:

Pt knowledge and willingness to participate

• 3. Perceived Facilitators:

Provider and staff willingness to participate

• 4. Patient’s concerns:

Provider knowledge of CNMP Confidentiality

Implementation of innovative health care delivery models requires: Pilot test strategy Practice site evaluation Education to increase knowledge & comfort (strategies for successfully preparing prescribers may be different from non-prescribers)

• NP education requires:

Curriculums to include Group Care skills More research to document effects of Group Care

Compensation:

Individual billing vs. group billing

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American Academy of Pain Medicine (2013). Incidence of Pain. Retrieved from http://www.painmed.org/patientcenter/facts-on-pain/#incidence Anderson, D., Wang, S., & Zlateva, I. (2012). Comprehensive assessment of chronic pain management in primary care: A first phase of a quality improvement initiative at a multisite community health center. Quality in Primary Care, 20(6), 421-433 Bendix, J., & Brower, A. (2011). The benefits of shared medical appointments. Medical Economics, (2), 68-76. Breuer, B., Cruciani, R., Portenoy, R.K. (2010). Pain management by primary care physicians, pain physician, chiropractors and acupuncturist: A national survey. Southern Medical Journal, 103(8), 738-747. Bronson, D.L., & Maxwell, R.A. (2004). Shared medical appointments: increasing access without increasing physician hours. Cleveland Clinic Journal of Medicine, 71, 369-377. Centers for Disease Control and Prevention (2011). National Health Interview Survey. Retrieved from http://www.cdc.gov/nchs/nhis.htm Edelman D., (2012). Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review. Veterans Administrations Evidence-based Synthesis Project #09- 010; 2012. Jaber, R., Braksmajer, A., & Trilling, J. (2006). Group visits for chronic illness care: Models, benefits and challenges. Family Practice Management, 13(1), 37-40. Kawasaki, L., Muntner, P., Hyre, A.D., Hampton, K., & DeSalvo, K.B. (2007). Willingness to attend group visits for hypertension treatment. The American Journal of Managed Care,13(5), 257-262. Noffsinger, E., & Scott, J.C. (2000). Understanding today’s group visit models. Group Practice Journal, (2), 46-58. Noffsinger, E.B. (2014, June 6). Re: What are group visits? Retrieved from http://www.groupvisits.com/what-are-group-visits.php Phillips, R.L., Bazemore, A.M., & Peterson, L.E. (2014). Effectiveness over efficiency: Underestimating the primary care physician shortage. Medical Care, 52(2), 97-98. Stannard, C., & Johnson, M. (2003). Chronic pain management, can we do better? An interview based survey in primary care. Current Medical Research and Opinion, 19, 703- 706 Wu, S., & Green, A. (2000, October). Projection of Chronic Illness Prevalence and Cost

• Inflation. In RAND Corporation.