DM and Chronic Care
Group clinics fold elder care into new model
They combine clinical and psychosocial care
The Cooperative Health Care Clinic (CHCC) started in 1991 when a group of Kaiser Permanente-Colorado physicians discussed how to do a better job of taking care of their elderly patients. "It’s the same old knowledge base, delivered in a way that’s more effective for the older person," explains one of the CHCC originators, John Scott, MD, staff internist and geriatrician with Kaiser Permanente in Westminster, CO.
The CHCCs replace routine office visits for approximately 32 groups of older Kaiser HMO members in the Denver metropolitan area. Each group consists of 20 to 25 participants. For continuity, the same patients attend each month. "These are people we’ve known for 10 years or more," Scott says.
Unlike standard individual office visits in which providers do something to their patients, the group model allows providers to do something with their patients. Patient and provider satisfaction is enormous. CHCC participants use the emergency room 20% less and the hospital 24% less. Individual office appointments are still an option, and utilization has actually increased slightly for the CHCC members. Detailed outcomes data are withheld pending journal publication.
Here’s the monthly CHCC agenda:
1. Activity — socialization (15 minutes). The original purpose was to enable members to form a cohesive group in which they felt safe enough to exchange information about their health problems.
Outcome — "It may be the most important aspect of the program," Scott says. "People tell us they’re more comfortable in the group than with their own families because the group members understand their problems more deeply than their families can."
2. Activity — education (30 minutes). Topics cover advance directives, symptom management, health maintenance, and coping skills. The style is interactive. The physician sits in the middle of a horseshoe-shaped seating arrangement, "with no power symbols like the white coat or stethoscope," Scott says. Participants share their opinions on subjects of common interest, such as how it feels to have a heart attack, or a health feature on last night’s news. The physician validates opinions and fills in the information gaps.
Outcome — Participants come to regard each other as credible sources of information on living with a chronic disease. For example, after a discussion about arthritis, one woman in the back of the room said, "You mean I’m going to have to live with this the rest of my life?" The woman next to her, with claw-like hands from rheumatoid arthritis, nudged her and said, "Honey, see me during the break and I’ll tell you how to live with it." Scott says, "No rheumatologist could give such practical advice unless he or she had rheumatoid arthritis."
3. Activity — break (20 minutes). The physician and nurse go from one person to the next checking blood pressure, validating parking stickers, giving flu shots, or answering individual questions. Participants take turns furnishing treats for meetings.
Outcome — The activity takes care of forgotten issues that often pop up at the end of individual appointments. The interactive care component replaces many individual appointments. Partici-pants have further opportunities to share information, enjoy mutual friendships, and compli- ment the cook of the month.
4. Activity — question and answer (25 minutes). Wide-ranging discussions go from the benefits of a new drug to childhood sexual abuse.
Outcome — "Patients tell us they feel more comfort and openness with this kind of provider relationship than when they sit naked under a piece of paper on an exam table," Scott notes.
5. Activity — one-to-one (60 minutes). This is the time when approximately seven participants can confer with the doctor or nurse, in a private space, on individual issues. The clinicians choose an additional seven patients for such things as diabetes monitoring or medication checks.
Outcome — This hour is incredibly efficient, Scott explains. "I can do a heart exam on a man in two minutes or a complete physical on a woman in seven."
Overall outcomes and results
• Patient and physician satisfaction is "hugely increased" over the individual office visit model, according to Scott.
• This form of intervention slows the decline in an elder’s ability to perform activities of daily living and reduces hospital use. "We see hospitalization as a failure when we’re treating the frail elderly," Scott notes, "because even one day of bed rest is a significant debilitator."
• It’s incredibly cost-efficient, Scott says, although that was not the original intent. Plans are under way to start 20 more groups this year.
• Focus groups identify the most potent elements of the model: Patients feel freer to talk about what’s on their minds in a relaxed group environment. The social setting is not a threat to confidentiality. In fact, the multiple inputs help members understand what to worry about and what not to worry about. One man observed, "I don’t feel very good, but when I come here, I see it could be a lot worse."
Further application of the model
Younger adults with hypertension have used the model. Groups meet at 7 a.m. so they can get to work on time. Feedback indicates that once they try the CHCC model, they would not opt for individual visits. Experiments are under way for parents of chronically ill children, and orthopedic pre-surgical groups, as well as patients with fibromyalgia and functional bowel problems.
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