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From Cooper Medical School of Rowan University (Dr. Patel, Dr. Fuller) and Cooper University Hospital (Dr. Kaufman), Camden, NJ.
Abstract
- Objective: To describe an adaptive musculoskeletal hand clinic that offers accessible and economically viable musculoskeletal care for an underserved, urban population.
- Methods: Descriptive report.
- Results: An enhanced access group visit model was developed offering both nonsurgical and surgical care pathways for patients with musculoskeletal disorders of the hand. Both patient education and care were provided in the group environment. Staffing included an orthopedic surgeon, nurse practitioner, medical student, orthopedic technician, and medical assistant. Over a 12-month period, group visit efficiency improved to accommodate an equivalent number of patients as compared to the traditional model. Access (time to appointment) was improved in the group visit. The model allows for the addition of non-physician clinical staff to improve access and limit costs in a manner not feasible with traditional office visits.
- Conclusion: A group visit model may offer a sustainable process to increase patient access to musculoskeletal subspecialty care and accommodate care of greater numbers of patients while maintaining quality. The group model offers flexible staffing, enhanced access, and educational benefit.
Key words: Group medical visit, team-based care, hand pain, access, underserved populations.
Group visits are a relatively new health care delivery model [1–3]. The term is applied to a wide variety of visits designed for groups of patients, rather than individual patient-provider appointments. The group visit format has been used for various disease- or condition-specific populations. Group visits can increase access to care and have been associated with improved clinical outcomes [4].
The Urban Health Institute, a dedicated business unit at Cooper University Health System in Camden, NJ, was established to focus on care of the underserved. The business unit is working to reduce cost of care delivery, increase access, and improve quality through the use of workflow redesign, task shifting, dashboards, and other methods. With a large startup grant from the Nicholson Foundation, the Urban Health Institute launched the Cooper Advanced Care Center to provide the local under-served population with access to a collaborative practice of 23 medical and surgical specialties under one roof. The center incorporates traditional one-on-one provider visits with innovative models of care, including group visits. Multiple partners were required in the group visit design and implementation starting with buy-in from Cooper Health System’s leadership for existing space to be redesigned for the group visit activities.
The Cooper Advanced Care Center, which had high no-show rates of 30% to 40%, and low reimbursement for a primarily Medicaid and self-pay population, initially operated at a financial loss. Meanwhile, most physicians had extended lag time until their next available appointment. In a traditional patient–physician office visit, additional physician time is required to increase access to care. This costly solution is often not financially viable. Group visits were considered as a means of using an interdisciplinary team to increase access while controlling or decreasing the per-visit cost.
Musculoskeletal medicine was identified as an area of need in part due to limited access to care. Patients were waiting more than 2 months to see a musculoskeletal specialist and were being scheduled beyond capacity in our existing traditional weekly hand and knee/sports medicine clinics. Within musculoskeletal medicine, 4 areas of musculoskeletal medicine were considered for group visits: back pain, knee pain, hand pain, and foot and ankle disorders. The decision was made to focus the subspecialty musculoskeletal clinic on disorders of the hand and wrist to provide nonsurgical and surgical care options for atraumatic and traumatic disorders of the hand in a teaching environment at an urban hospital. The purpose of this article is to discuss the design and implementation of a hand pain group visit model to increase access to care without increasing cost.
Setting and Patients
Camden City, New Jersey, is a medically underserved, resource-poor community. The population is 48% African American and 47% Hispanic and nearly 40% of individuals live below the poverty level [5]. The group visit was intentionally set up as a means to provide access to the un- or underinsured. Patients attending the group visits were 33% African American, 33% Hispanic, and 30% Caucasian. Most patients had Medicaid insurance (67%) with the remaining patients covered by commercial insurance (15%), dual Medicare/Medicaid (11%), Medicare (5%), or self pay (2%).
Group Visit Staffing and Structure
In a traditional office visit, used nearly ubiquitously in outpatient medical offices, patients arrive at individual appointment times for a prescribed time encounter with the physician, are registered and roomed by support staff, and are then seen by a clinician for diagnosis and treatment. While assistants and trainees participate in the patient’s care with attending physician supervision, the majority of direct care falls to the physician. Access is coupled to physician availability; increasing access to care requires crowding the schedule with additional patients. We used this model as the benchmark for volume and scheduling against which to compare the group visit.
The group visit staffing was the same as for the traditional visit: hand surgeon, nurse practitioner, orthopedic technician, medical student, and medical assistant. However, each clinical session consists of four 1-hour, consecutive group visits scheduled once a month on a Monday morning. Up to 10 people could be scheduled for each 1-hour group visit. We continued to offer our traditional office visit clinic on the other 3 Mondays in the month.
The hand surgeon begins the group visit with a 10-minute educational session and group discussion held in a meeting room. He reviews common disorders of the hand, including carpal tunnel syndrome, trigger fingers, hand arthritis, cysts, sprains and fractures, how they are treated, and risks and benefits of treatments. Patients sign a confidentiality agreement at check-in. Time is allowed for questions and experiential sharing is encouraged. Expectations are set at the start of the visit to honor each patient’s input to provide a safe environment for asking questions and expressing concerns about their shared health condition to enhance the learning experience [6]. A medical assistant enters the chief complaint using an electronic standardized questionnaire into the EMR along with basic vital signs for each patient either prior to, during, or after the group presentation.
After the group educational session with the surgeon, patients transition to a large, open clinical room with 6 separate workstations, each consisting of a small table with 4 chairs and a laptop computer. Small procedures can be performed on the table (suture removal, dressing changes, injections) and the table is appropriately sized to accommodate a care provider, the patient, and their support person(s). Tables are spaced comfortably such that conversations do not carry much from one to the other. The clinical space has white noise speakers for sound dampening while patients receive individual history, vital signs, physical examination, and review of relevant studies. Patients may see the clinicians in a private exam room if they wish or require.
In a traditional office setting, workflow through the major tasks (check-in, data gathering, diagnosis, treatment) is often linear, as dictated by the configuration of individual patient rooms and the patient’s expectations of a traditional doctor’s visit. In the group visit, major tasks are performed simultaneously by the advance practice providers (nurse practitioners, physician assistants) in conjunction with supervision of the attending physician. The workstations (tables, chairs, laptops) in the open clinical room allows for greater efficiency; providers can easily transition to other tasks from one workstation to another during time that may have been spent waiting for other team members in the more linear, traditional clinic. For example, while waiting for the attending physician’s approval of a diagnosis and treatment plan for one patient, a nurse practitioner may be able to begin assessing and gathering data with a second patient until the physician becomes available.
Scheduling and Access
A primary aim of the group visit pilot was to develop a model of care delivery that allowed scheduling beyond capacity for the traditional office hand clinic. At the inception of the group visit, all patients were offered a visit in either the traditional office or group visit model by our scheduling secretaries based upon availability, with emphasis on scheduling a defined underserved population into the group visit.
In traditional 1:1 appointments, the number of people who can access care is dependent on physician availability. The team-based model uncouples the number of scheduled patients from the physician availability, allowing increased efficiency in the model and/or additional staff to increase the number of patients the group visit can accommodate. Thus, patients were essentially guaranteed an appointment in the next clinic because there was no cap on the number of patients that could be scheduled into the group visit. If the number of patients exceeded the limit of 10 per hour, a non-physician clinician was added to accommodate the patient demand. As our group visit matures, the ability to increase the staffing model enables patients to get care without adding more physician time.
Task Shifting
A central pillar of making the group visit a sustainable model for more accessible care is shifting tasks to non-physician health care workers. Adding specialist time enhances access but drives up the cost of care. Non-physician clinical staff members in subspecialty orthopedic offices with experience diagnosing and treating common conditions are capable of providing the standard of care for those conditions with variable physician oversight [7].
In the group visit, there is a deliberate assignment of patients to clinical staff by the physician based on anticipated level of care required. Given the attending physician’s experience with the most common disorders related to hand pain, it is possible to anticipate the approximate complexity of care required for each patient based on the nature and duration of the presenting complaint. With some degree of clinical supervision by the physician, members of the team operate maximally independently to assist patients. The nurse practitioner can operate largely autonomously in the group visit. The overall goal is to encourage all team members to function at the top of their licenses and abilities. Task shifting in this manner increases the productivity of all members of the team and minimizes redundancy. Despite more autonomy of mid-level providers and support staff in the group visit, there is still direct supervision of care by the attending physician.
The current body of literature in task shifting to non-physician health care workers has mostly concerned low-income countries with marked physician and provider shortages [8]. However, given the increased patient volume already seen with the Affordable Care Act and further expected increases, the health care system is likely to see provider shortages, especially in primary care [9–11]. This will necessitate the adoption of strategies to increase access, maintain quality care, and decrease systemic cost. Task shifting provides one such strategy.
Patient Satisfaction
One concern with shifting clinical duties to non-physician clinical staff is patient satisfaction. An abbreviated interaction with physicians can make patients dissatisfied with medical care independent of eventual clinical outcome [12]. However, it has also been demonstrated in an outpatient hand surgery clinic that quality of time spent with the physician may have a greater impact on satisfaction than quantity of time [13].
Our group visit is structured to allow high physician-patient visibility and interaction. The introductory remarks by the physician engage patients with the physician early in the visit and establish a group and individual rapport. The physician introduces the clinical team and the idea of patients being seen by other clinical staff up front, which establishes comfort for later patient–staff interaction. This is also an important time for patient education, which has been shown as a significant determinant of patient satisfaction in the outpatient setting [14]. The patient education at the beginning of the visit answers questions by one person that another person may not have considered, and generates patient questions to be addressed individually with a clinician. One common example is when a person considering carpal tunnel surgery hears from a person who has recently completed the procedure and can talk about their operative experience.
In the group room, the physician and staff can move between patients quickly and efficiently without waiting for turnover of rooms and resources. The structure of the visit allows staff to dedicate more time to patient care by bypassing the extra time required when patients are roomed individually. The group/communal structure also allows patients to see the staff at work, as compared to time spent waiting alone in an exam room in the traditional office. This enables patients to appreciate the efforts of the clinical staff and avoids giving the impression that the physician is inattentive or cursory in patient interaction.
Medical Education
An important consideration at any academic medical center is education. However, education often introduces redundancies and inefficiency into the medical care visit. The work a trainee does is either extensively overseen or the clinical questions are repeated by a supervising provider. However, it is possible to increase efficiency and utility of trainees in the group visit setting while maintaining educational value.
Given the relatively narrow scope and the nature of conditions encountered in the hand clinic, medical decision making for many patients is limited to a “straightforward” or “low complexity” level. These designations assume a limited number of diagnoses, management options, and amount and complexity of diagnostic workup. Most importantly, risk of complications or morbidity/mortality at these levels is minimal to low. For these conditions, a supervising physician can allow a trainee more independence to practice employing simple treatment and management guidelines and progress to working independently when addressing simpler conditions as the trainee’s experience grows. As independence grows, trainees can build confidence in medical management as well as focus on other core educational competencies once they are comfortable with the evaluation and management of a limited scope of conditions. Conditions such as trigger fingers, hand arthritis, ganglion cysts, and carpal tunnel are those the trainee is likely to encounter in a primary care practice. While there may be a decrease in direct physician teaching, the trainee gains clinical autonomy and experience in educational core competencies such as patient communication, patient education, systems-based practice, procedural skill, cultural competency, and interdisciplinary teamwork [15,16].
Lessons Learned
The success of the group visit required buy-in from hospital and physician leadership, the clinical team, and multiple partners in the hospital system. The hospital administration supported group visits as an integral component of the Urban Health Institute. Buy-in from key hospital leadership ensured resources and dedicated space for the group visit program. Grant support allowed additional programmatic support to acquire the necessary assistance from information services, EMR support, legal, and marketing. Physician buy-in was the most significant piece to the success of an individual group visit. Accepting the movement away from physician autonomy to team-based care is challenging for many providers. Physician willingness to start a high-demand group visit, recognition of the start-up inefficiencies, and working with the administrative and clinical team on program improvement strategies has succeeded in launching a sustaining group visit model.
Conclusion
There is a need for an adaptive and economically viable model of patient care to meet increasing demand, as well as provide care for indigent populations in a way that is more economically sustainable than providing care through the emergency department. The development and implementation of an urban hand group visit at our institution has demonstrated that such a model, based on group visit models more commonly seen in primary care, can be effectively implemented in a subspecialty care setting. This model is capable of increasing patient access to care and effectively handling increased patient volume with room for cost-effective growth in the future, all while maintaining quality of care. We anticipate further subspecialty clinics within hand pain to emerge, such as a group visit dedicated specifically to carpal tunnel syndrome or hand arthritis. This will allow each group to be more focused and will streamline education and mutual support among the patients.
Corresponding author: Steven Kaufman, MD, 3 Cooper Plaza, Suite 211, Camden, NJ 08103, kaufman-steven@cooperhealth.edu.
Funding/support: The Nicholson Foundation.
Financial disclosures: None reported.
1. Gardiner P, Dresner D, Barnett KG, et al. Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic. Glob Adv Health Med 2014;3:20–6.
2. Remick RA, Remick AK. Do patients really prefer individual outpatient follow-up visits, compared with group medical visits?. Can J Psychiatry 2014;59:50–3.
3. Thompson C, Meeuwisse I, Dahlke R, Drummond N. Group medical visits in primary care for patients with diabetes and low socioeconomic status: users’ perspectives and lessons for practitioners. Can J Diabetes 2014;38:198–204.
4. Eisenstat S, Lipps SA, Carlson K, Ulman K. Putting group visits into practice: a practical overview to preparation, implementation, and maintenance of group visits at Massachusetts General Hospital. Women’s Health Associates, The John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital; January 2012.
5. U.S. Census Bureau. State and city Quickfacts: Camden (city), New Jersey. Accessed 29 Sep 2015 at http://quickfacts.census.gov/qfd/states/34/3410000.html.
6. Slocum YS. A survey of expectations about group therapy among clinical and nonclinical populations. Int J Group Psychother 1987;37:39–54.
7. Newhouse RP, Stanik-hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ 2011;29:230–50.
8. Joshi R, Alim M, Kengne AP, et al. Task shifting for non-communicable disease management in low and middle income countries--a systematic review. PLoS ONE 2014;9:e103754.
9. Hofer AN, Abraham JM, Moscovice I. Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. Milbank Q 2011;89:69–89.
10. Kushnir T, Greenberg D, Madjar N, et al. Is burnout associated with referral rates among primary care physicians in community clinics?. Fam Pract 2014;31:44–50.
11. Calfee RP, Shah CM, Canham CD, et al. The influence of insurance status on access to and utilization of a tertiary hand surgery referral center. J Bone Joint Surg Am 2012;94:2177–84.
12. Lin CT, Albertson GA, Schilling LM, et al. Is patients’ perception of time spent with the physician a determinant of ambulatory patient satisfaction?. Arch Intern Med 2001;161:1437–42.
13. Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand surgeon is not associated with patient satisfaction. Clin Orthop Relat Res 2014.
14. Murdock A, Griffin B. How is patient education linked to patient satisfaction?. Nursing 2013;43:43–5.
15. Accreditation Council for Graduate Medical Education. Common program requirements. Approved 2014. Available at www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_07012016.pdf.
16. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. [updated June 2013]. Available at www.lcme.org/publications/functions.pdf.
17. Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf 2011;20:46–51.
From Cooper Medical School of Rowan University (Dr. Patel, Dr. Fuller) and Cooper University Hospital (Dr. Kaufman), Camden, NJ.
Abstract
- Objective: To describe an adaptive musculoskeletal hand clinic that offers accessible and economically viable musculoskeletal care for an underserved, urban population.
- Methods: Descriptive report.
- Results: An enhanced access group visit model was developed offering both nonsurgical and surgical care pathways for patients with musculoskeletal disorders of the hand. Both patient education and care were provided in the group environment. Staffing included an orthopedic surgeon, nurse practitioner, medical student, orthopedic technician, and medical assistant. Over a 12-month period, group visit efficiency improved to accommodate an equivalent number of patients as compared to the traditional model. Access (time to appointment) was improved in the group visit. The model allows for the addition of non-physician clinical staff to improve access and limit costs in a manner not feasible with traditional office visits.
- Conclusion: A group visit model may offer a sustainable process to increase patient access to musculoskeletal subspecialty care and accommodate care of greater numbers of patients while maintaining quality. The group model offers flexible staffing, enhanced access, and educational benefit.
Key words: Group medical visit, team-based care, hand pain, access, underserved populations.
Group visits are a relatively new health care delivery model [1–3]. The term is applied to a wide variety of visits designed for groups of patients, rather than individual patient-provider appointments. The group visit format has been used for various disease- or condition-specific populations. Group visits can increase access to care and have been associated with improved clinical outcomes [4].
The Urban Health Institute, a dedicated business unit at Cooper University Health System in Camden, NJ, was established to focus on care of the underserved. The business unit is working to reduce cost of care delivery, increase access, and improve quality through the use of workflow redesign, task shifting, dashboards, and other methods. With a large startup grant from the Nicholson Foundation, the Urban Health Institute launched the Cooper Advanced Care Center to provide the local under-served population with access to a collaborative practice of 23 medical and surgical specialties under one roof. The center incorporates traditional one-on-one provider visits with innovative models of care, including group visits. Multiple partners were required in the group visit design and implementation starting with buy-in from Cooper Health System’s leadership for existing space to be redesigned for the group visit activities.
The Cooper Advanced Care Center, which had high no-show rates of 30% to 40%, and low reimbursement for a primarily Medicaid and self-pay population, initially operated at a financial loss. Meanwhile, most physicians had extended lag time until their next available appointment. In a traditional patient–physician office visit, additional physician time is required to increase access to care. This costly solution is often not financially viable. Group visits were considered as a means of using an interdisciplinary team to increase access while controlling or decreasing the per-visit cost.
Musculoskeletal medicine was identified as an area of need in part due to limited access to care. Patients were waiting more than 2 months to see a musculoskeletal specialist and were being scheduled beyond capacity in our existing traditional weekly hand and knee/sports medicine clinics. Within musculoskeletal medicine, 4 areas of musculoskeletal medicine were considered for group visits: back pain, knee pain, hand pain, and foot and ankle disorders. The decision was made to focus the subspecialty musculoskeletal clinic on disorders of the hand and wrist to provide nonsurgical and surgical care options for atraumatic and traumatic disorders of the hand in a teaching environment at an urban hospital. The purpose of this article is to discuss the design and implementation of a hand pain group visit model to increase access to care without increasing cost.
Setting and Patients
Camden City, New Jersey, is a medically underserved, resource-poor community. The population is 48% African American and 47% Hispanic and nearly 40% of individuals live below the poverty level [5]. The group visit was intentionally set up as a means to provide access to the un- or underinsured. Patients attending the group visits were 33% African American, 33% Hispanic, and 30% Caucasian. Most patients had Medicaid insurance (67%) with the remaining patients covered by commercial insurance (15%), dual Medicare/Medicaid (11%), Medicare (5%), or self pay (2%).
Group Visit Staffing and Structure
In a traditional office visit, used nearly ubiquitously in outpatient medical offices, patients arrive at individual appointment times for a prescribed time encounter with the physician, are registered and roomed by support staff, and are then seen by a clinician for diagnosis and treatment. While assistants and trainees participate in the patient’s care with attending physician supervision, the majority of direct care falls to the physician. Access is coupled to physician availability; increasing access to care requires crowding the schedule with additional patients. We used this model as the benchmark for volume and scheduling against which to compare the group visit.
The group visit staffing was the same as for the traditional visit: hand surgeon, nurse practitioner, orthopedic technician, medical student, and medical assistant. However, each clinical session consists of four 1-hour, consecutive group visits scheduled once a month on a Monday morning. Up to 10 people could be scheduled for each 1-hour group visit. We continued to offer our traditional office visit clinic on the other 3 Mondays in the month.
The hand surgeon begins the group visit with a 10-minute educational session and group discussion held in a meeting room. He reviews common disorders of the hand, including carpal tunnel syndrome, trigger fingers, hand arthritis, cysts, sprains and fractures, how they are treated, and risks and benefits of treatments. Patients sign a confidentiality agreement at check-in. Time is allowed for questions and experiential sharing is encouraged. Expectations are set at the start of the visit to honor each patient’s input to provide a safe environment for asking questions and expressing concerns about their shared health condition to enhance the learning experience [6]. A medical assistant enters the chief complaint using an electronic standardized questionnaire into the EMR along with basic vital signs for each patient either prior to, during, or after the group presentation.
After the group educational session with the surgeon, patients transition to a large, open clinical room with 6 separate workstations, each consisting of a small table with 4 chairs and a laptop computer. Small procedures can be performed on the table (suture removal, dressing changes, injections) and the table is appropriately sized to accommodate a care provider, the patient, and their support person(s). Tables are spaced comfortably such that conversations do not carry much from one to the other. The clinical space has white noise speakers for sound dampening while patients receive individual history, vital signs, physical examination, and review of relevant studies. Patients may see the clinicians in a private exam room if they wish or require.
In a traditional office setting, workflow through the major tasks (check-in, data gathering, diagnosis, treatment) is often linear, as dictated by the configuration of individual patient rooms and the patient’s expectations of a traditional doctor’s visit. In the group visit, major tasks are performed simultaneously by the advance practice providers (nurse practitioners, physician assistants) in conjunction with supervision of the attending physician. The workstations (tables, chairs, laptops) in the open clinical room allows for greater efficiency; providers can easily transition to other tasks from one workstation to another during time that may have been spent waiting for other team members in the more linear, traditional clinic. For example, while waiting for the attending physician’s approval of a diagnosis and treatment plan for one patient, a nurse practitioner may be able to begin assessing and gathering data with a second patient until the physician becomes available.
Scheduling and Access
A primary aim of the group visit pilot was to develop a model of care delivery that allowed scheduling beyond capacity for the traditional office hand clinic. At the inception of the group visit, all patients were offered a visit in either the traditional office or group visit model by our scheduling secretaries based upon availability, with emphasis on scheduling a defined underserved population into the group visit.
In traditional 1:1 appointments, the number of people who can access care is dependent on physician availability. The team-based model uncouples the number of scheduled patients from the physician availability, allowing increased efficiency in the model and/or additional staff to increase the number of patients the group visit can accommodate. Thus, patients were essentially guaranteed an appointment in the next clinic because there was no cap on the number of patients that could be scheduled into the group visit. If the number of patients exceeded the limit of 10 per hour, a non-physician clinician was added to accommodate the patient demand. As our group visit matures, the ability to increase the staffing model enables patients to get care without adding more physician time.
Task Shifting
A central pillar of making the group visit a sustainable model for more accessible care is shifting tasks to non-physician health care workers. Adding specialist time enhances access but drives up the cost of care. Non-physician clinical staff members in subspecialty orthopedic offices with experience diagnosing and treating common conditions are capable of providing the standard of care for those conditions with variable physician oversight [7].
In the group visit, there is a deliberate assignment of patients to clinical staff by the physician based on anticipated level of care required. Given the attending physician’s experience with the most common disorders related to hand pain, it is possible to anticipate the approximate complexity of care required for each patient based on the nature and duration of the presenting complaint. With some degree of clinical supervision by the physician, members of the team operate maximally independently to assist patients. The nurse practitioner can operate largely autonomously in the group visit. The overall goal is to encourage all team members to function at the top of their licenses and abilities. Task shifting in this manner increases the productivity of all members of the team and minimizes redundancy. Despite more autonomy of mid-level providers and support staff in the group visit, there is still direct supervision of care by the attending physician.
The current body of literature in task shifting to non-physician health care workers has mostly concerned low-income countries with marked physician and provider shortages [8]. However, given the increased patient volume already seen with the Affordable Care Act and further expected increases, the health care system is likely to see provider shortages, especially in primary care [9–11]. This will necessitate the adoption of strategies to increase access, maintain quality care, and decrease systemic cost. Task shifting provides one such strategy.
Patient Satisfaction
One concern with shifting clinical duties to non-physician clinical staff is patient satisfaction. An abbreviated interaction with physicians can make patients dissatisfied with medical care independent of eventual clinical outcome [12]. However, it has also been demonstrated in an outpatient hand surgery clinic that quality of time spent with the physician may have a greater impact on satisfaction than quantity of time [13].
Our group visit is structured to allow high physician-patient visibility and interaction. The introductory remarks by the physician engage patients with the physician early in the visit and establish a group and individual rapport. The physician introduces the clinical team and the idea of patients being seen by other clinical staff up front, which establishes comfort for later patient–staff interaction. This is also an important time for patient education, which has been shown as a significant determinant of patient satisfaction in the outpatient setting [14]. The patient education at the beginning of the visit answers questions by one person that another person may not have considered, and generates patient questions to be addressed individually with a clinician. One common example is when a person considering carpal tunnel surgery hears from a person who has recently completed the procedure and can talk about their operative experience.
In the group room, the physician and staff can move between patients quickly and efficiently without waiting for turnover of rooms and resources. The structure of the visit allows staff to dedicate more time to patient care by bypassing the extra time required when patients are roomed individually. The group/communal structure also allows patients to see the staff at work, as compared to time spent waiting alone in an exam room in the traditional office. This enables patients to appreciate the efforts of the clinical staff and avoids giving the impression that the physician is inattentive or cursory in patient interaction.
Medical Education
An important consideration at any academic medical center is education. However, education often introduces redundancies and inefficiency into the medical care visit. The work a trainee does is either extensively overseen or the clinical questions are repeated by a supervising provider. However, it is possible to increase efficiency and utility of trainees in the group visit setting while maintaining educational value.
Given the relatively narrow scope and the nature of conditions encountered in the hand clinic, medical decision making for many patients is limited to a “straightforward” or “low complexity” level. These designations assume a limited number of diagnoses, management options, and amount and complexity of diagnostic workup. Most importantly, risk of complications or morbidity/mortality at these levels is minimal to low. For these conditions, a supervising physician can allow a trainee more independence to practice employing simple treatment and management guidelines and progress to working independently when addressing simpler conditions as the trainee’s experience grows. As independence grows, trainees can build confidence in medical management as well as focus on other core educational competencies once they are comfortable with the evaluation and management of a limited scope of conditions. Conditions such as trigger fingers, hand arthritis, ganglion cysts, and carpal tunnel are those the trainee is likely to encounter in a primary care practice. While there may be a decrease in direct physician teaching, the trainee gains clinical autonomy and experience in educational core competencies such as patient communication, patient education, systems-based practice, procedural skill, cultural competency, and interdisciplinary teamwork [15,16].
Lessons Learned
The success of the group visit required buy-in from hospital and physician leadership, the clinical team, and multiple partners in the hospital system. The hospital administration supported group visits as an integral component of the Urban Health Institute. Buy-in from key hospital leadership ensured resources and dedicated space for the group visit program. Grant support allowed additional programmatic support to acquire the necessary assistance from information services, EMR support, legal, and marketing. Physician buy-in was the most significant piece to the success of an individual group visit. Accepting the movement away from physician autonomy to team-based care is challenging for many providers. Physician willingness to start a high-demand group visit, recognition of the start-up inefficiencies, and working with the administrative and clinical team on program improvement strategies has succeeded in launching a sustaining group visit model.
Conclusion
There is a need for an adaptive and economically viable model of patient care to meet increasing demand, as well as provide care for indigent populations in a way that is more economically sustainable than providing care through the emergency department. The development and implementation of an urban hand group visit at our institution has demonstrated that such a model, based on group visit models more commonly seen in primary care, can be effectively implemented in a subspecialty care setting. This model is capable of increasing patient access to care and effectively handling increased patient volume with room for cost-effective growth in the future, all while maintaining quality of care. We anticipate further subspecialty clinics within hand pain to emerge, such as a group visit dedicated specifically to carpal tunnel syndrome or hand arthritis. This will allow each group to be more focused and will streamline education and mutual support among the patients.
Corresponding author: Steven Kaufman, MD, 3 Cooper Plaza, Suite 211, Camden, NJ 08103, kaufman-steven@cooperhealth.edu.
Funding/support: The Nicholson Foundation.
Financial disclosures: None reported.
From Cooper Medical School of Rowan University (Dr. Patel, Dr. Fuller) and Cooper University Hospital (Dr. Kaufman), Camden, NJ.
Abstract
- Objective: To describe an adaptive musculoskeletal hand clinic that offers accessible and economically viable musculoskeletal care for an underserved, urban population.
- Methods: Descriptive report.
- Results: An enhanced access group visit model was developed offering both nonsurgical and surgical care pathways for patients with musculoskeletal disorders of the hand. Both patient education and care were provided in the group environment. Staffing included an orthopedic surgeon, nurse practitioner, medical student, orthopedic technician, and medical assistant. Over a 12-month period, group visit efficiency improved to accommodate an equivalent number of patients as compared to the traditional model. Access (time to appointment) was improved in the group visit. The model allows for the addition of non-physician clinical staff to improve access and limit costs in a manner not feasible with traditional office visits.
- Conclusion: A group visit model may offer a sustainable process to increase patient access to musculoskeletal subspecialty care and accommodate care of greater numbers of patients while maintaining quality. The group model offers flexible staffing, enhanced access, and educational benefit.
Key words: Group medical visit, team-based care, hand pain, access, underserved populations.
Group visits are a relatively new health care delivery model [1–3]. The term is applied to a wide variety of visits designed for groups of patients, rather than individual patient-provider appointments. The group visit format has been used for various disease- or condition-specific populations. Group visits can increase access to care and have been associated with improved clinical outcomes [4].
The Urban Health Institute, a dedicated business unit at Cooper University Health System in Camden, NJ, was established to focus on care of the underserved. The business unit is working to reduce cost of care delivery, increase access, and improve quality through the use of workflow redesign, task shifting, dashboards, and other methods. With a large startup grant from the Nicholson Foundation, the Urban Health Institute launched the Cooper Advanced Care Center to provide the local under-served population with access to a collaborative practice of 23 medical and surgical specialties under one roof. The center incorporates traditional one-on-one provider visits with innovative models of care, including group visits. Multiple partners were required in the group visit design and implementation starting with buy-in from Cooper Health System’s leadership for existing space to be redesigned for the group visit activities.
The Cooper Advanced Care Center, which had high no-show rates of 30% to 40%, and low reimbursement for a primarily Medicaid and self-pay population, initially operated at a financial loss. Meanwhile, most physicians had extended lag time until their next available appointment. In a traditional patient–physician office visit, additional physician time is required to increase access to care. This costly solution is often not financially viable. Group visits were considered as a means of using an interdisciplinary team to increase access while controlling or decreasing the per-visit cost.
Musculoskeletal medicine was identified as an area of need in part due to limited access to care. Patients were waiting more than 2 months to see a musculoskeletal specialist and were being scheduled beyond capacity in our existing traditional weekly hand and knee/sports medicine clinics. Within musculoskeletal medicine, 4 areas of musculoskeletal medicine were considered for group visits: back pain, knee pain, hand pain, and foot and ankle disorders. The decision was made to focus the subspecialty musculoskeletal clinic on disorders of the hand and wrist to provide nonsurgical and surgical care options for atraumatic and traumatic disorders of the hand in a teaching environment at an urban hospital. The purpose of this article is to discuss the design and implementation of a hand pain group visit model to increase access to care without increasing cost.
Setting and Patients
Camden City, New Jersey, is a medically underserved, resource-poor community. The population is 48% African American and 47% Hispanic and nearly 40% of individuals live below the poverty level [5]. The group visit was intentionally set up as a means to provide access to the un- or underinsured. Patients attending the group visits were 33% African American, 33% Hispanic, and 30% Caucasian. Most patients had Medicaid insurance (67%) with the remaining patients covered by commercial insurance (15%), dual Medicare/Medicaid (11%), Medicare (5%), or self pay (2%).
Group Visit Staffing and Structure
In a traditional office visit, used nearly ubiquitously in outpatient medical offices, patients arrive at individual appointment times for a prescribed time encounter with the physician, are registered and roomed by support staff, and are then seen by a clinician for diagnosis and treatment. While assistants and trainees participate in the patient’s care with attending physician supervision, the majority of direct care falls to the physician. Access is coupled to physician availability; increasing access to care requires crowding the schedule with additional patients. We used this model as the benchmark for volume and scheduling against which to compare the group visit.
The group visit staffing was the same as for the traditional visit: hand surgeon, nurse practitioner, orthopedic technician, medical student, and medical assistant. However, each clinical session consists of four 1-hour, consecutive group visits scheduled once a month on a Monday morning. Up to 10 people could be scheduled for each 1-hour group visit. We continued to offer our traditional office visit clinic on the other 3 Mondays in the month.
The hand surgeon begins the group visit with a 10-minute educational session and group discussion held in a meeting room. He reviews common disorders of the hand, including carpal tunnel syndrome, trigger fingers, hand arthritis, cysts, sprains and fractures, how they are treated, and risks and benefits of treatments. Patients sign a confidentiality agreement at check-in. Time is allowed for questions and experiential sharing is encouraged. Expectations are set at the start of the visit to honor each patient’s input to provide a safe environment for asking questions and expressing concerns about their shared health condition to enhance the learning experience [6]. A medical assistant enters the chief complaint using an electronic standardized questionnaire into the EMR along with basic vital signs for each patient either prior to, during, or after the group presentation.
After the group educational session with the surgeon, patients transition to a large, open clinical room with 6 separate workstations, each consisting of a small table with 4 chairs and a laptop computer. Small procedures can be performed on the table (suture removal, dressing changes, injections) and the table is appropriately sized to accommodate a care provider, the patient, and their support person(s). Tables are spaced comfortably such that conversations do not carry much from one to the other. The clinical space has white noise speakers for sound dampening while patients receive individual history, vital signs, physical examination, and review of relevant studies. Patients may see the clinicians in a private exam room if they wish or require.
In a traditional office setting, workflow through the major tasks (check-in, data gathering, diagnosis, treatment) is often linear, as dictated by the configuration of individual patient rooms and the patient’s expectations of a traditional doctor’s visit. In the group visit, major tasks are performed simultaneously by the advance practice providers (nurse practitioners, physician assistants) in conjunction with supervision of the attending physician. The workstations (tables, chairs, laptops) in the open clinical room allows for greater efficiency; providers can easily transition to other tasks from one workstation to another during time that may have been spent waiting for other team members in the more linear, traditional clinic. For example, while waiting for the attending physician’s approval of a diagnosis and treatment plan for one patient, a nurse practitioner may be able to begin assessing and gathering data with a second patient until the physician becomes available.
Scheduling and Access
A primary aim of the group visit pilot was to develop a model of care delivery that allowed scheduling beyond capacity for the traditional office hand clinic. At the inception of the group visit, all patients were offered a visit in either the traditional office or group visit model by our scheduling secretaries based upon availability, with emphasis on scheduling a defined underserved population into the group visit.
In traditional 1:1 appointments, the number of people who can access care is dependent on physician availability. The team-based model uncouples the number of scheduled patients from the physician availability, allowing increased efficiency in the model and/or additional staff to increase the number of patients the group visit can accommodate. Thus, patients were essentially guaranteed an appointment in the next clinic because there was no cap on the number of patients that could be scheduled into the group visit. If the number of patients exceeded the limit of 10 per hour, a non-physician clinician was added to accommodate the patient demand. As our group visit matures, the ability to increase the staffing model enables patients to get care without adding more physician time.
Task Shifting
A central pillar of making the group visit a sustainable model for more accessible care is shifting tasks to non-physician health care workers. Adding specialist time enhances access but drives up the cost of care. Non-physician clinical staff members in subspecialty orthopedic offices with experience diagnosing and treating common conditions are capable of providing the standard of care for those conditions with variable physician oversight [7].
In the group visit, there is a deliberate assignment of patients to clinical staff by the physician based on anticipated level of care required. Given the attending physician’s experience with the most common disorders related to hand pain, it is possible to anticipate the approximate complexity of care required for each patient based on the nature and duration of the presenting complaint. With some degree of clinical supervision by the physician, members of the team operate maximally independently to assist patients. The nurse practitioner can operate largely autonomously in the group visit. The overall goal is to encourage all team members to function at the top of their licenses and abilities. Task shifting in this manner increases the productivity of all members of the team and minimizes redundancy. Despite more autonomy of mid-level providers and support staff in the group visit, there is still direct supervision of care by the attending physician.
The current body of literature in task shifting to non-physician health care workers has mostly concerned low-income countries with marked physician and provider shortages [8]. However, given the increased patient volume already seen with the Affordable Care Act and further expected increases, the health care system is likely to see provider shortages, especially in primary care [9–11]. This will necessitate the adoption of strategies to increase access, maintain quality care, and decrease systemic cost. Task shifting provides one such strategy.
Patient Satisfaction
One concern with shifting clinical duties to non-physician clinical staff is patient satisfaction. An abbreviated interaction with physicians can make patients dissatisfied with medical care independent of eventual clinical outcome [12]. However, it has also been demonstrated in an outpatient hand surgery clinic that quality of time spent with the physician may have a greater impact on satisfaction than quantity of time [13].
Our group visit is structured to allow high physician-patient visibility and interaction. The introductory remarks by the physician engage patients with the physician early in the visit and establish a group and individual rapport. The physician introduces the clinical team and the idea of patients being seen by other clinical staff up front, which establishes comfort for later patient–staff interaction. This is also an important time for patient education, which has been shown as a significant determinant of patient satisfaction in the outpatient setting [14]. The patient education at the beginning of the visit answers questions by one person that another person may not have considered, and generates patient questions to be addressed individually with a clinician. One common example is when a person considering carpal tunnel surgery hears from a person who has recently completed the procedure and can talk about their operative experience.
In the group room, the physician and staff can move between patients quickly and efficiently without waiting for turnover of rooms and resources. The structure of the visit allows staff to dedicate more time to patient care by bypassing the extra time required when patients are roomed individually. The group/communal structure also allows patients to see the staff at work, as compared to time spent waiting alone in an exam room in the traditional office. This enables patients to appreciate the efforts of the clinical staff and avoids giving the impression that the physician is inattentive or cursory in patient interaction.
Medical Education
An important consideration at any academic medical center is education. However, education often introduces redundancies and inefficiency into the medical care visit. The work a trainee does is either extensively overseen or the clinical questions are repeated by a supervising provider. However, it is possible to increase efficiency and utility of trainees in the group visit setting while maintaining educational value.
Given the relatively narrow scope and the nature of conditions encountered in the hand clinic, medical decision making for many patients is limited to a “straightforward” or “low complexity” level. These designations assume a limited number of diagnoses, management options, and amount and complexity of diagnostic workup. Most importantly, risk of complications or morbidity/mortality at these levels is minimal to low. For these conditions, a supervising physician can allow a trainee more independence to practice employing simple treatment and management guidelines and progress to working independently when addressing simpler conditions as the trainee’s experience grows. As independence grows, trainees can build confidence in medical management as well as focus on other core educational competencies once they are comfortable with the evaluation and management of a limited scope of conditions. Conditions such as trigger fingers, hand arthritis, ganglion cysts, and carpal tunnel are those the trainee is likely to encounter in a primary care practice. While there may be a decrease in direct physician teaching, the trainee gains clinical autonomy and experience in educational core competencies such as patient communication, patient education, systems-based practice, procedural skill, cultural competency, and interdisciplinary teamwork [15,16].
Lessons Learned
The success of the group visit required buy-in from hospital and physician leadership, the clinical team, and multiple partners in the hospital system. The hospital administration supported group visits as an integral component of the Urban Health Institute. Buy-in from key hospital leadership ensured resources and dedicated space for the group visit program. Grant support allowed additional programmatic support to acquire the necessary assistance from information services, EMR support, legal, and marketing. Physician buy-in was the most significant piece to the success of an individual group visit. Accepting the movement away from physician autonomy to team-based care is challenging for many providers. Physician willingness to start a high-demand group visit, recognition of the start-up inefficiencies, and working with the administrative and clinical team on program improvement strategies has succeeded in launching a sustaining group visit model.
Conclusion
There is a need for an adaptive and economically viable model of patient care to meet increasing demand, as well as provide care for indigent populations in a way that is more economically sustainable than providing care through the emergency department. The development and implementation of an urban hand group visit at our institution has demonstrated that such a model, based on group visit models more commonly seen in primary care, can be effectively implemented in a subspecialty care setting. This model is capable of increasing patient access to care and effectively handling increased patient volume with room for cost-effective growth in the future, all while maintaining quality of care. We anticipate further subspecialty clinics within hand pain to emerge, such as a group visit dedicated specifically to carpal tunnel syndrome or hand arthritis. This will allow each group to be more focused and will streamline education and mutual support among the patients.
Corresponding author: Steven Kaufman, MD, 3 Cooper Plaza, Suite 211, Camden, NJ 08103, kaufman-steven@cooperhealth.edu.
Funding/support: The Nicholson Foundation.
Financial disclosures: None reported.
1. Gardiner P, Dresner D, Barnett KG, et al. Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic. Glob Adv Health Med 2014;3:20–6.
2. Remick RA, Remick AK. Do patients really prefer individual outpatient follow-up visits, compared with group medical visits?. Can J Psychiatry 2014;59:50–3.
3. Thompson C, Meeuwisse I, Dahlke R, Drummond N. Group medical visits in primary care for patients with diabetes and low socioeconomic status: users’ perspectives and lessons for practitioners. Can J Diabetes 2014;38:198–204.
4. Eisenstat S, Lipps SA, Carlson K, Ulman K. Putting group visits into practice: a practical overview to preparation, implementation, and maintenance of group visits at Massachusetts General Hospital. Women’s Health Associates, The John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital; January 2012.
5. U.S. Census Bureau. State and city Quickfacts: Camden (city), New Jersey. Accessed 29 Sep 2015 at http://quickfacts.census.gov/qfd/states/34/3410000.html.
6. Slocum YS. A survey of expectations about group therapy among clinical and nonclinical populations. Int J Group Psychother 1987;37:39–54.
7. Newhouse RP, Stanik-hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ 2011;29:230–50.
8. Joshi R, Alim M, Kengne AP, et al. Task shifting for non-communicable disease management in low and middle income countries--a systematic review. PLoS ONE 2014;9:e103754.
9. Hofer AN, Abraham JM, Moscovice I. Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. Milbank Q 2011;89:69–89.
10. Kushnir T, Greenberg D, Madjar N, et al. Is burnout associated with referral rates among primary care physicians in community clinics?. Fam Pract 2014;31:44–50.
11. Calfee RP, Shah CM, Canham CD, et al. The influence of insurance status on access to and utilization of a tertiary hand surgery referral center. J Bone Joint Surg Am 2012;94:2177–84.
12. Lin CT, Albertson GA, Schilling LM, et al. Is patients’ perception of time spent with the physician a determinant of ambulatory patient satisfaction?. Arch Intern Med 2001;161:1437–42.
13. Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand surgeon is not associated with patient satisfaction. Clin Orthop Relat Res 2014.
14. Murdock A, Griffin B. How is patient education linked to patient satisfaction?. Nursing 2013;43:43–5.
15. Accreditation Council for Graduate Medical Education. Common program requirements. Approved 2014. Available at www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_07012016.pdf.
16. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. [updated June 2013]. Available at www.lcme.org/publications/functions.pdf.
17. Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf 2011;20:46–51.
1. Gardiner P, Dresner D, Barnett KG, et al. Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic. Glob Adv Health Med 2014;3:20–6.
2. Remick RA, Remick AK. Do patients really prefer individual outpatient follow-up visits, compared with group medical visits?. Can J Psychiatry 2014;59:50–3.
3. Thompson C, Meeuwisse I, Dahlke R, Drummond N. Group medical visits in primary care for patients with diabetes and low socioeconomic status: users’ perspectives and lessons for practitioners. Can J Diabetes 2014;38:198–204.
4. Eisenstat S, Lipps SA, Carlson K, Ulman K. Putting group visits into practice: a practical overview to preparation, implementation, and maintenance of group visits at Massachusetts General Hospital. Women’s Health Associates, The John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital; January 2012.
5. U.S. Census Bureau. State and city Quickfacts: Camden (city), New Jersey. Accessed 29 Sep 2015 at http://quickfacts.census.gov/qfd/states/34/3410000.html.
6. Slocum YS. A survey of expectations about group therapy among clinical and nonclinical populations. Int J Group Psychother 1987;37:39–54.
7. Newhouse RP, Stanik-hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ 2011;29:230–50.
8. Joshi R, Alim M, Kengne AP, et al. Task shifting for non-communicable disease management in low and middle income countries--a systematic review. PLoS ONE 2014;9:e103754.
9. Hofer AN, Abraham JM, Moscovice I. Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. Milbank Q 2011;89:69–89.
10. Kushnir T, Greenberg D, Madjar N, et al. Is burnout associated with referral rates among primary care physicians in community clinics?. Fam Pract 2014;31:44–50.
11. Calfee RP, Shah CM, Canham CD, et al. The influence of insurance status on access to and utilization of a tertiary hand surgery referral center. J Bone Joint Surg Am 2012;94:2177–84.
12. Lin CT, Albertson GA, Schilling LM, et al. Is patients’ perception of time spent with the physician a determinant of ambulatory patient satisfaction?. Arch Intern Med 2001;161:1437–42.
13. Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand surgeon is not associated with patient satisfaction. Clin Orthop Relat Res 2014.
14. Murdock A, Griffin B. How is patient education linked to patient satisfaction?. Nursing 2013;43:43–5.
15. Accreditation Council for Graduate Medical Education. Common program requirements. Approved 2014. Available at www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_07012016.pdf.
16. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. [updated June 2013]. Available at www.lcme.org/publications/functions.pdf.
17. Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf 2011;20:46–51.