Bringing patients together can help them and you
Model works well for chronically ill, worried well
If your practice has a huge backlog of patients waiting for appointments, many of whom are chronically ill and need reassurance, professional hand-holding, and follow-up care, you might try what some California physicians have found to be a successful solution: See your patients in a group.
Drop-in group medical appointments (DIGMAs) are the brainchild of Edward B. Noffsinger, PhD, a Santa Cruz, CA, consultant who retired recently after 26 years as a health psychologist for the Permanente Medical Group. He developed the DIGMA model at Kaiser Permanente Medical Center in San Jose, CA.
"Access to care is a huge problem nationally in both primary and specialty care. The DIGMA model offers a new cost-effective tool that can allow primary and specialty care physicians to solve the access problem without hiring additional staff," he says. Much of the same medical care that normally is provided during routine office visits can be provided during a DIGMA, he says.
If your practice is capitated or otherwise at risk for patient care, you may be able to realize financial savings with DIGMAS while handling your backlog and improving patient care. (For tips on how to adjust the DIGMA model when your reimbursement is largely fee for service, see p. 166.)
Under Noffsinger’s model, 10 to 20 patients and their friends or loved ones attend a weekly 90-minute session led by their physician and a behavioral health professional. The behaviorist may be a psychologist, social worker, nurse, or health educator.
Most of the physicians with whom Noffsinger has worked have one 90-minute DIGMA a week, usually during office hours.
Physicians who have started DIGMAs report that their backlog of patients has decreased, the number of phone calls from patients has dropped, patient complaints about accessibility have been reduced, and they feel like they are better able to manage their large practices and deliver better care.
"The DIGMAs enabled me to get a lot done in a short time without feeling like I was going through a revolving door from one room to the next," comments Lynn A. Dowdell, MD, an endocrinologist with Kaiser Permanente Medi cal Center in San Jose.
When she started her weekly DIGMA, Dowdell was able to get through a very large backlog of patients, who often had to wait two to three months or more for an appointment.
Because of staffing changes in Dowdell’s office, her DIGMAs are on hold at present, but she hopes to start them again soon. "The patients miss the group," she says.
DIGMAs address psychosocial issues
The group appointment model works best for relatively stable chronically ill patients, the worried well, or other patients who typically take a lot of the physician’s time and require a lot of professional hand-holding, Noffsinger adds.
"Patients with significant behavioral health and psychosocial issues are overutilizers," says Noffsinger. He adds that research has shown that 40% to 60% of all medical visits are driven by behavioral health and psychosocial issues rather than medical need.
Joseph E. Mason Jr., MD, an oncologist with Kaiser Permanente Medical Center in San Jose, holds a weekly DIGMA that is usually attended by 12 to 15 cancer patients and their family members.
Most of the people who come to Mason’s DIGMAs are people who have recently been diagnosed, who have had a change in condition, or who need ongoing support.
"I don’t have any hard statistics, but I have a sense that it has decreased the number of phone calls my office receives. I know that it is an enormous patient satisfier. It really increases people’s approval of the care they’re receiving," Mason says.
Today’s physicians are under so many productivity and time constraints that they barely have enough time to deal with a patient’s physical needs, much less their psychosocial needs or the patient-physician relationship, he adds.
Noffsinger doesn’t recommend the model for initial evaluations, one-time consults, most procedures, or for patients with acute illnesses or rapidly evolving medical conditions. However, the concept does work well for patients who are fearful about their medical condition. For instance, diabetics who require insulin but fear needles or patients who are facing dialysis are reassured by others in the group who feel better as a result of the treatment.
In a DIGMA, the physician has the additional help of the behavioral health professional and the group itself for dealing with noncompliant patients.
"There’s nothing more helpful in persuading noncompliant patients to comply than another patient who has the same condition, didn’t comply, and got into trouble," Noffsinger says. "They always advise the patient to comply and avoid making the same mistakes."
Dowdell found DIGMAs useful when patients needed a follow-up appointment for a test or procedure, or when a patient started on insulin or a new medication and needed a short-term follow-up. Seeing the patient during her regularly scheduled DIGMA worked better than trying to fit an individual appointment into her busy schedule, she adds.
Occasionally, Dowdell wouldn’t be able to answer a patient’s questions, but others in the group could. For instance, when one diabetic asked where he could get special shoes, several patients gave him useful suggestions.
Another time, a patient expressed concern about taking a treadmill test for her cardiac symptoms. "Another patient who had been through the test explained what it was like and was reassuring, so the patient was willing to comply," Dowdell says.
Because physicians are concerned about confidentiality, Noffsinger suggests that participating patients sign a confidentiality release form when appropriate. But confidentiality is rarely a problem, he adds.
"In reality, I’ve participated in more than 8,000 DIGMA patient visits, and I’ve never had a problem in this area," he says.
Instead, patients often feel free to discuss their individual test results and conditions. DIGMAs give the physicians an opportunity to discuss areas of common interest one time and in greater detail instead of repeating the same information over and over during individual office visits.
"Doctors are working too long and too hard. They need to find a tool to leverage their time so they can manage their practices and still have a life. This model enables them to improve access, increase productivity, manage large groups of patients, improve quality of care, provide better follow-up care, and do it all with existing resources," Noffsinger says.
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