Musculoskeletal Hand Pain Group Visits: An Adaptive Health Care Model

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.