Reports From the Field

Musculoskeletal Hand Pain Group Visits: An Adaptive Health Care Model

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

Author(s):

References

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.