Reports From the Field

Musculoskeletal Hand Pain Group Visits: An Adaptive Health Care Model

Journal of Clinical Outcomes Management. 2017 February;24(2)

References

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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.

Since the inception of the group visit, appointments as measured on a per-hour basis increased, equaling the traditional office setting’s hourly capacity at the end of the 1-year study period. When group visits began, the number of patients scheduled was intentionally kept below what we believed our maximum capacity might be so that we could identify any inefficiencies or issues with a smaller number of patients. As each month went by, we confidently added more patients to the groups. Care providers began to understand the flow of patients and mechanisms of interaction with both the patients and each other to smooth the process. The Figure reflects the growing volume of patients scheduled into the group clinic as well as the increasing number of patients being served through the group model.

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].