10/6/2017. Obesity Management Through Shared Medical Appointments. Goals. Background. Eric J. MacEvoy MD/MBA

Transcription

1 Obesity Management Through Shared Medical Appointments Eric J. MacEvoy MD/MBA Goals To provide a background on the problems with obesity management Describe a viable model of group visits in the primary care setting Discuss the impact on primary care providers in terms of performance metrics, QOL, and finances Background Estimated 190 Billion dollars spent for obesity related costs per year Associated with myriad disease processes and poorer prognosis in chronic conditions as well as surgical interventions Correlated with reduced work force productivity 1

2 Background ~20% of those who attempt diet based weight loss succeed in maintaining a 10% reduction at 1 year Average of 1/3 of weight returns within 1 year Most weight returns within 3-5 years following loss Why do Patients Fail Change is hard Lack of knowledge or direction Provider doesn t address or doesn t seem to make it a priority No plan Chronic illnesses and/or mental health The human brain is wired such that the desire for short-term pleasures will almost always overrule the fear of long-term consequences. The default condition is to eat food that is delicious and avoid excess exercise. Prevention of chronic disease turns out to be a very poor incentive for patients ~Michael Dansinger MD 2

3 Adherence Over ½ of patients placed on a medication are not adherent 40-50% of diabetics and hypertensive patients do not follow their medication regimens Weight loss adherence is even worse with less than 1/3 of patients maintaining adherence Addressing adherence takes time and in our current productivity system time is RVUs for clinicians Psychological Factors of Adherence Adherence increases as patients understand more about their condition When the treatment makes sense, adherence improves Anxiety, depression, and poor mental health adversely effect adherence Contact time greatly increases adherence Adherence The less investment the patient has personally, the lower the rate of adherence to a plan A study by Johns Hopkins showed that adherence doubled when education was combined with behavior modification strategies and emotional support Same meta-analysis shows group visits outperform other interventions and innately incorporate the above factors 3

4 Adherence Study by Jean Mayer from USDA Human Nutrition Research Center on Aging at Tufts Medical Center > Atkins diet, Ornish, Weight Watchers, Zone, etc, all lost similar amounts of weight regardless of regimen > ONLY success marker was continuation Patient perspective > If a provider doesn t take a direct role in a condition, it is viewed as being less important/urgent to address Provider Limitations Time > Visits ~20 minutes and often need to cover multiple medical issues > Obesity pts often present with multiple other comorbidities, demanding more time > Education for a patient, depending on their background, is time consuming Productivity > Many physicians are measured based on productivity per FTE > Expectation to see ~18 patients per day and produce ~20-22 RVUs per day A Possible Solution: Group Visit Model Provider or team based Patients are collaborators and resources Time is set aside at the beginning and end for 1 on 1 time with individual patients Curriculum > I have favored a certain set curriculum and floating lectures with occasional guest speakers Utilize alumni for both motivation as well as for helping them maintain changes 4

5 What We Do to Prepare Identify patients and time availabilities It starts with the initial phone call > Phone from the wait list > Describe course, visit schedule, adherence and attendance If using the team approach, identify roles and goals Prepare materials for patients, ie handouts, notebook, tools Dry run and time the rooming process Prepare a dossier on patients, medications, medical problems, and any concerns you may have to refer to on day of class Group Visit Model: Day of Patients need to show up early for appointment to start on time All patients sign a HIPPA form for confidentiality Have an activity lined up to keep people from waiting idle Provider listens to hearts, lungs, and brief exam along with simple questions and brief ROS while pt is getting their intake vitals and measurements from the MA. Round table roles and goals for patients and staff Intro lecture Q&A and meet patients 1:1 class Chart using a template and use normal E&M coding Total time 2:40 PM 5:00 PM Aftermath Provider audit the class for improvement Patient evaluation done and and verbal feedback elicited with provider at end of classes Look at measures and re-evaluate areas to improve and grow 5

6 Benefits Time with patient > Pt spends ~90 minutes in the presence of provider and can ask questions > Questions and answers are heard by all and only need to be repeated once > patients can be seen at a time > Patient adherence increased > Our surveys report very high patient satisfaction In studies correlated to feeling that provider and medical team care and with time spent with patient Financial > Each visit can be billed with traditional E&M coding, ie visits of leading to productivity of RVUs for provider time of 2 hours > Quality score increase leading to institution and provider reaching benchmarks in A1c and in the future other health goals Quality Of Life > Physician satisfaction Results: Grouped averages bp 230 weight a1c Results: Grouped averages weight a1c

7 Insights Ideal group size for scheduling > First group to make sure the system works 8-10, ward, larger groups of > Attrition the first and second group visits is roughly 20-25% > In order to validate the team approach and account for the time of others, group size needs to be at least 8 people Consistency of provider presence important, even if not leading the class Follow up calls in between visits have proven invaluable in directing classes and making patients feel heard Need speaker who is comfortable with public speaking and group dynamics Thank you! 7