Dr. Noffsinger, the Pioneer of Group Medical Appointments   

by  Tricia McMahon

Shared medical appointments are a creative and tested approach to enhancing patient care that was pioneered by Dr. Noffsinger in the mid 1990s.

The general term "group visit" is applied to a variety of models designed for groups of patients, rather than the traditional individual patient-provider appointments. Two primary models: DIGMA and PSMA are the result of Dr. Noffsinger's personal experience and professional expertise and are used extensively nationwide. To date, DIGMAs have been implemented in more than fifty clinics, including leading medical organizations.    

DIGMA, the acronym for Drop In Group Medical Appointment, is an innovative and collaborative way of caring for patients while also making the work of the primary care physicians immensely effective and efficient.  DIGMA is a multidisciplinary team-based approach to care that typically involves weekly 90-minute sessions with a doctor, behaviorist, medical assistant (and/or nurse), and medical recorder. In a DIGMA, medical care is sequentially delivered by the physician individually to each of the 10 to 16 patients in attendance. Primarily for follow-up visits, DIGMAs are best envisioned as a series of individual office visits with observers, with the exact same care being delivered (and often more) as during traditional individual office visits.

In a DIGMA, patients have their medical needs and health questions addressed, but in a supportive group setting while others present are able to listen, learn and interact-so that patients learn both from the physician and from other patients in this supportive environment. Whenever needed, private exams or personal issues may be addressed privately in a nearby exam room. On the other hand, Dr. Noffsinger's Physicals Shared Medical Appointment (PSMA) model is used not for follow-up visits, but rather for private physical examinations in primary care and the various medical subspecialties.    

Currently, Dr. Noffsinger is bringing his experience and knowledge to Harvard Vanguard Medical Associates/Atrius Health as their Vice President of Shared Medical Appointments and Group-Based Disease Management. His book Running Group Visits In Your Practice, due to be published June 2009, will not only be a definitive treatise on group visits, but also a self-contained 'how-to' manual including DVDs and examples of the various forms one would want to customize for their own practice.

Dr. Noffsinger's previous work included more than 26 years as Director of Oncology Counseling and Chronic Illness Services at Kaiser Permanente, where he expanded his work into the development of the DIGMA model in the mid-1990s.

After taking an early retirement package from Kaiser in 1999, he became Director of Clinical Access Improvement at Palo Alto Medical Foundation, where he subsequently developed his second shared medical appointment (or PSMA) model. Dr. Noffsinger is now widely regarded as the pioneer and expert on shared medical appointments, having personally conducted, as behaviorist and SMA Champion, more than 20,000 patient visits nationally and internationally in these 2 group visit models to date-i.e., with more than 450 primary and specialty care providers in all types of health care systems.

Through a series of 18 articles, his work has been featured in Group Practice Journal, a publication of the American Medical Group Association, as well as in the national media-such as Time and Newsweek, The Wall Street Journal and Boston Globe, CNN and PBS, NPR and other radio networks.

Dr. Noffsinger received PhDs in counseling psychology from the University of California at Berkeley and in psychology with a certificate in psychoanalysis from the California Graduate Institute in Westwood. He received his MA in psychology from California State University in San Jose, and MS and BS degrees in physics from the University of Illinois at Urbana. He is a member of the American Psychological Association and the California State Psychological Association.

How the DIGMA Model Came About

Seriously ill from 1988-1992, Dr. Noffsinger was frustrated at how healthcare was being delivered and was convinced that there had to be a better way.

Dr. Noffsinger realized:

• The need for patients to have PROMPT ACCESS to their medical professional
• The need for more TIME with their doctor once granted an appointment; a way to slow down the pace of care
• The need for support from other patients
• The value of a multi-disciplinary experience
• The need to alter the disparity in the power of the doctor vs. power of the patient
• Eventually, he became intimately familiar with lifestyle medicine, especially after being invited to speak at the Lifestyle Center of America. Enthralled with the concept and service of LCA, he and his wife returned as patients and were most impressed with the fine work in lifestyle management being conducted there-especially for diabetes.

Intended for follow-up visits, DIGMAs are used for a wide variety of practices from internal medicine to family medicine to a multitude of specialties. Valuable to both patient and provider, patients are given prompt access, more time with their provider, greater patient education, and the help and support of both a multidisciplinary care delivery team and other patients. They can also allow for some individual appointments to be allocated to the underserved and those who most need them.  DIGMAs enable the provider's time to be used most efficiently, and the patients to gain both greater access to their provider and the multiple benefits of the group experience.

Team Approach Medical Appointment

First and foremost, DIGMAs are medical visits-not classes, health education programs, psychotherapy groups, or support groups. Extensive medical care is provided during each DIGMA, which includes many of the same medical services that physicians deliver during routine individual office visits.

Typically only open to the physician's own patients and including most or all of his or her patient panel, a DIGMA is co-led by the physician and a behavioral health professional, such as a psychologist or social worker (although nurses or diabetes nurse educators are also often used as behaviorists). The patients and clinicians are present throughout the group session, which is typically held for 90 minutes at the same time, place and day of the week. Because patients attend only when they have medical needs, the group varies with each session.

Phone calls are made prior to the group meeting time:

• to confirm appointments (less 'no shows' and less 'overbooking to compensate for 'no shows)
• to do a complete medication reconciliation while the patient is at home and can look at each prescription to avoid any guesswork/errors
• to ensure that all pre-visit labs have been completed
• to confirm that the patient's health history form (which is frequently used for PSMAs) is completed and returned to the office prior to the group meeting.

At the DIGMA, a medical assistant and/or nurse calls patients out of the group room individually to take vital signs on the 10 to 16 patients gathered in the comfortable group room. The behaviorist, skilled in group dynamics, and addressing psychosocial needs, helps the physician pace the session and leads discussions about disease management, lifestyle changes, and self-help techniques. Throughout the entire session, the physician addresses the medical needs of one patient at a time in the supportive group setting, delivering the same types of care (and sometimes more) as for traditional office visits-history, exam, medical decision-making, counseling, risk assessment, etc.

Immediately after working with each patient in turn, the physician temporarily steps over to the documenter to review and modify the chart note that has been created on that patient.  It is during this time that the behaviorist temporarily takes over the group, focusing upon behavioral health or nursing issue of interest to the group and fostering group interaction. By having the chart note done for them, the physician is able to look and focus upon the patient without the distraction of constantly looking at the computer to draft the chart note themselves.

Patients In Need

The DIGMA is particularly effective for chronically ill patients who often have a greater need to talk about their illness and get support and reassurance from others. "Many physicians running DIGMAs tell me for the first time they're able to adequately address the psychosocial needs of their patients," says Noffsinger. "Unmet psychosocial needs are often why chronically ill patients make appointments." DIGMAs are not appropriate for extensive private physical exams (for this, use the PSMA model), for patients with rapidly deteriorating medical conditions, or for complex medical procedures.

DIGMAs can be disease specific (homogeneous DIGMAs) or address a wide variety of health issues within one group (heterogeneous DIGMAs). Surprisingly, mixed-diagnosis DIGMAs are more popular than single diagnosis DIGMAs for better managing busy backlogged practices, according to Noffsinger. "Often DIGMAs that start out as homogeneous or mixed designs eventually become heterogeneous over time," he says. The reason for this is that if one were to design a homogeneous DIGMA for your own patients, many of those patients would come into the group with a host of additional issues not related to diabetes that they want addressed (carpal tunnel, hypertension, tennis elbow, sprained ankle, GERD, etc).  By dealing with these issues in the group, the DIGMA gradually becomes more heterogeneous.

Confidentiality

With so many people partaking of one another's personal story, one might think that confidentiality could be an issue. Every patient signs a confidentiality agreement, but in truth it is each one's  commitment to the welfare of all--individually and collectively--that makes such group privacy possible.

Dr. Noffsinger is in awe at the extent of the group sharing: "In considering the group model, you might wonder about patients talking in front of others about their health issue. I find it quite amazing just how open and honest participants are."  The DIGMA model makes valuable connections possible-newfound realizations within themselves and with each other that is broader and deeper in scope than what typically happens in the traditional doctor/patient appointment.

Getting Paid

Because they are run from start to finish like a series of one doctor-one patient encounters with observers,  DIGMAs and PSMAs are typically billed according to the level of care delivered and documented using existing E&M. codes This results from DIGMAs and PSMAs being unique amongst group visits by being run throughout as a series of individual office visits with observers. Medicare has no specific CPT code for group visits; however, existing CPT codes say nothing about how many observers can be present or in what settings care can be delivered, so many clinics bill for the level of care provided and documented during the group visit.

Billing for "individual appointments with observers present," patients are charged a copay and documentation is entered into each patient's medical record. "Most systems only bill for time spent on individual history, exam, risk-assessment, and decision making; however, they do not bill for counseling time as several patients could be benefiting from the same counseling and it would be fraudulent to bill several times over for the same block of counseling time," explains Dr. Noffsinger.

Physician and Patient Satisfaction

Due to the efficiency and productivity gains of DIGMAs and PSMAs, access to the physician occurs more rapidly than with typical scheduling approaches. Both patients and physicians feel less rushed than in a traditional medical visit, and there is more time available to address a wide range of medical and preventive care issues in a single visit.

"When I've implemented group patient visits in the past, both patient and physician satisfaction improved dramatically," says Dr. Noffsinger. "These appointments increase a patient's access to their physician, give the patient more time with the physician, and engage patients in a broader range of health education topics, while also providing doctors with a much more manageable work schedule." Lower blood glucose levels, better blood pressure control, better compliance monitoring of their own glucose levels, and greater likelihood of managing their diet and scheduling recommended eye exams are potential examples of the positive outcomes from DIGMA patient care.

The increase in the number of patients the doctor can see in a DIGMA or PSMA, coupled with their being comprehensive visits that attend to mind as well as body needs, reduces patient demand, provides a greater chance to serve the underserved and un-insured, offers tremendous patient education, offers the help and support of the other patients, and increases both physician and patient satisfaction.

Even though the issues that other patients bring up might not relate exactly to them, other patients are nonetheless likely to be interested because it helps to take better care of themselves in the event that they get it, or perhaps it happens to relate to loved ones or friends. In any case, many describe a DIGMA as being like a mini-medical class taught by their own doctor, and the breadth of education that transpires is valuable for all.

PSMA--Physicals Shared Medical Appointment.              

In 2002 Dr. Noffsinger published his work outlining the Physicals Shared Medical Appointment (or PSMA) group visit model that is specifically designed to double, triple, or more the productivity of delivering complete physical examinations-but doing so while overbooking for no-shows and delivering high levels of patient and physician professional satisfaction. Realizing that the exam itself takes the least amount of time, this model of group visit is utilized when a private physical exam is required-and when a great deal of patient education is desired.

Upcoming Book:  
Dr. Noffsinger's book entitled "Running Group Visits In Your Practice", to be published by Springer, is due out this June. (2009)

 
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