The 20-minute Medicare Visit

1. The 20-minute Medicare Visit David B. Reuben, MD David Geffen School of Medicine at UCLA

2. Overview of Next 90 Minutes • General background • Individual approaches • Approach to redesigning practice to manage geriatric conditions (eg, falls, incontinence) • An example of how this might work • Costs of implementing change

3. Slides and Supporting Materials http://www.geronet.ucla.edu/centers/acove/index.htm What’s inside • Slides and reprints • Office forms • Physician education • Patient education

4. Ground rules (assumptions) • Follow-up visit cannot take more than 20 minutes • General medical care cannot be compromised • No electronic medical record • Office staff can provide some help

5. Goal: comprehensive care of older personsThe problem: too much to do, too little time • Aggravating factors: two separate, sometimes competing agendas -the patient’s and the physician’s • Inadequate resources - office staff and other professionals • Business as usual

6. Background • Assessing Care of the Vulnerable Elderly (ACOVE) project • identified vulnerable elders, • created a a set of quality indicators based on literature review and expert panel for 22 conditions that affect older persons • examined the process of care (by chart review and structured interview) for each condition

7. Background-II • ACOVE findings • Overall, 54% of QIs met • High numbers of QIs met for common diseases in older persons (e.g., hypertension, diabetes) • Low numbers ( 29-41%) of QIs met for geriatrics conditions (e.g., urinary incontinence)

8. Background-III • Previous research has identified barriers to effective management of geriatric conditions • Inadequate case recognition • Lack of physician knowledge • Poor patient adherence to treatment plan • Inadequate follow-up • Lack of time and resources to address issues

9. Individual Approaches • Advantages • One person can initiate • Doesn’t take much time to get going • Can borrow or adapt existing instruments • Disadvantage: • Only a partial step

10. Strategies for Saving Time in Clinical Practice 1) Delegate data collection

11. Physician-Patient Encounter $$$$ Out-of-Office Preparation Office Visit $$ $ • Reduce time but increase effectiveness/efficiency of the inner circle • Always push to outermost possible circle whenever possible

12. Pre-visit Questionnaire 1. Past medical history- Current medications- Drug allergies- Surgical & medical hospitalization- Social history (habits, sociodemographics)- Preventive services, including lifestyle 2. Home safety checklist 3. Advance Directives

13. Pre-Visit Questionnaire • Specific questions on: • Vision • Hearing • Dentition • Falls • Urinary incontinence • Nutrition • Depressive symptoms • Functional status

14. Efficiency of Geriatric Case Finding in a Private Practitioner’s Office • Methods • Design: Case-series • Setting: Family practitioner’s office • Participants: 104 Subjects >69 years of age • Intervention: Brief case-finding by office assistant using standardized instruments

15. Targeted Problems and Case Finding Instruments Used, with References and Average Performance Time

16. Targeted Problems and Case Finding Instruments Used, with References & Average Performance Time

17. Efficiency of Geriatric Case Finding in a Private Practitioner’s Office • Results • Time required for case finding: 21.8 minutes • 72% had at least 1 target abnormality • 55% of those abnormalities were previously unrecognized or resulted in enhanced treatment J Am Geriatr Soc 1995:533-537

18. Efficiency of Geriatric Case Finding in a Private Practitioner’s Office • Results (continued) • Most common underdiagnosed and undertreated were: • hearing loss • urinary incontinence • depression • vision problems • sexual dysfunction • Cost effectiveness ranged from <$1/case (for hearing loss and urinary incontinence) to $68/case if patient had no abnormalities J Am Geriatr Soc 1995:533-537

19. Multidimensional Office Staff-Administered Screen Problem Screening Measure Memory loss 3-item recall Depression “Do you often feel sad or depressed?” Leg mobility Modified timed “Up & Go” test Nutrition/ “Have you lost 10 lbs. over the past weight loss 6 months without trying to do so?” Weight Hearing Audioscope impairment

20. Multidimensional Office Staff-Administered Screen (continued) Problem Screening Measure Vision “Do you have difficulty driving or watching television, or doing any of your daily activities because of your eyesight?” If yes, Snellen Eye Chart Urinary “In the last year, have you ever incontinence lost your urine and gotten wet?” If yes, “Have you lost urine on at least 6 separate days?” Physical disability 6 questions

21. Multidimensional Office Staff-Administered Screen (continued) • Time needed to complete screen: 10 minutes • Inter-rater reliability: 77-100% • Problem prevalences: 21-72% • Positive Predictive values: 0.60-0.91 • Negative Predictive values: 0.77-0.96 • Cost per screen: $1-$7 Am J Med 1996;100:438-443

22. Obstacles to Delegating Screening/Case-finding to Office Staff • Cost • Training • Capability of acting on results

23. Strategies for Saving Time in Clinical Practice • ) Delegate data collection • ) Minimize data recording time • Dictation • Templates • Word processing programs • Computerized medical records

26. Strategies for Savings Time in Clinical Practice • ) Delegate data collection • ) Minimize data recording time • ) Keep information needed for decision- making readily available • Pocket guides • PDA programs • Useful books • Computer retrieval system

27. Strategies for Savings Time in Clinical Practice • ) Delegate data collection • ) Minimize data recording time • ) Keep information needed for decision- making readily available • ) Delegate plan execution • Network of health professionals • Health educators

28. The Bottom Line • Individual approaches: • can improve efficiency in recognizing geriatric problems • may not do much for managing detected conditions • are a start in the right direction

29. The Next Step • To improve care, change must focus on three key levels • patient • provider • practice • Does not need to be expensive • Should follow the Chronic Care Model

31. Redesigning Care for Chronic Geriatric Conditions • Fundamentally changes the office visit • Consistent with Chronic Care Model • Draws upon many resources (office, community, patients, families) • Can address both recognition and management • Principles can be adapted to many conditions

32. Redesigning Care for Chronic Geriatric Conditions-II • Identify a target population (e.g.,outpatients 75+ years) • Case-finding for untreated conditions • urinary incontinence • falls • Standardized multi-component intervention

33. Multi-component Intervention-I • Efficient collection of condition-specific clinical data, including information collected by non-physicians and automatic orders for simple procedures • Medical record prompts to encourage performance of essential care processes

34. Multi-component Intervention-II • Patient education materials and active patient role in follow-up • Physician decision support and education

35. So, how does this work?(an example)

36. The ACOVE-2 Intervention • Recently implemented in two group practices in California • Real doctors, real patients • Evaluated as part of a clinical trial

37. Case Finding • Brief screening questions to patient or proxy to identify bothersome incontinence, cognitive impairment/dementia,and falls or fear of falling • Questions administered by office staff (in person or by telephone) prior to visit • Patient (or proxy) responses are given to provider at clinic appointment

38. Case-finding Questions-I • Bothersome incontinence • Had a problem with losing your urine that is bothersome enough that youwould like to know more about how it could be treated

39. Case-finding Questions-II • Memory loss • 3-item recall • Recently had more trouble than in the past with memory for day-to-day happenings around the house, such as remembering where he/she put things, recalling recent events, forgetting what you told him/her, or what he/she told you, remembering plans, appointments or phone calls? (surrogate)

40. Case-finding Questions-III • Falls or fear of falling • Fallen 2 or more times? • Fallen 1 time and hurt yourself or needed to see a doctor because of the fall? • Been afraid that you would fall because of balance or walking problems?

41. Initiating the Intervention • If case-finding is positive, condition-specific materials are attached to the chart • Structured visit note (or sticker) • Visit follow-up sheet • Physician can also initiate the intervention • If multiple conditions are triggered, may need to schedule a “planned” visit

42. Structured Visit Note (or sticker) • History items and simple procedures (completed by the intake office staff) • More detailed historical and exam elements, and ordering diagnostic tests (completed by physician) • Impression and plan (completed by physician)

44. Patient educational materials • Assembled for each condition • Include community resources • Readily available to the clinician to facilitate treatment • Include follow-up visit sheet

45. Visit follow-up sheet • Condition-specific • Prompts the patient to: • monitor the response to treatment • report problems or complications (including inability to adhere to the recommended treatment) to the clinician • Patients are encouraged to bring follow-up sheet to appointment to stimulate discussion

46. Decision Support-Physician Education • Small group educational sessions aimed at practical approaches to each of the four conditions within the context of a busy practice (1 initial, 1 follow-up) • Written decision support briefs that describe the management of the condition (http://www.geriatricsatyourfingertips.org/) and community resources to help in management

47. Flexibility • Intervention group practices must address all conditions using all components of the intervention • Flexibility in how the components are administered and the content of components • Decide how much of the intervention is performed by office staff rather than physicians • Can modify content and supporting materials

48. So, you can do this. Does it work?

49. Quality Scores after Interventionfor Dementia, Falls & Incontinence * p<0.001 for difference in QIs passed between I and C groups.

50. Scores for Falls Care