SAN ANTONIO – Group visits aren’t just for diabetics.
At the Maine Medical Center in Portland, they also help – along with other measures – to keep recently discharged patients from being readmitted, according to Dr. Ann Skelton, chief of the center’s department of family medicine, who presented her findings at a conference on practice improvement sponsored by the Society of Teachers of Family Medicine.
Upon discharge from the Family Medicine Inpatient Service (FMIS) to the outpatient Family Medicine Center (FMC), patients are given the option of having their first follow-up visit with their primary care doctor, or in a group with other patients led by a team that includes an attending physician, a nurse, a social worker, pharmacist, and care manager, among others.
The slightly-more-than half who opt for the group find all of their hospital-to-home issues addressed at one time, in one place, and without delay.
If a patient has trouble getting through to a specialist, for instance, the social worker is there to help. If a patient needs home care, the care manager can set up an appointment, maybe for the same day. And there’s no need to go elsewhere for the physical exam – a physician does them during the meeting.
Patients also bring in their medications for the pharmacist to review. Sometimes the dosages are wrong; other times patients are taking the brand and generic versions of the same drug, or taking drugs that carry the risk of potential drug interactions – omeprazole and hydroxyzine, for example. COPD inhalers, warfarin, and allopurinol, among other drugs, often have had to be added to some patients’ regimens.
Overall, group visits are "a very effective way to do posthospital care. Bringing that team together makes it flow smoothly," Dr. Skelton said in an interview.
In a pilot project from June 2009 – shortly after the groups started – to November 2009, Dr. Skelton and her colleagues tracked outcomes for 175 patients admitted from the outpatient FMC to the inpatient FMIS, and then discharged back to the outpatient center.
The 30-day readmission rate among those who opted for the group was 2.4%; for those who opted for office follow-up, 9.4%. Overall, the 30-day readmission rate dropped from 14.2% to 12.6%, saving an estimated $158,884 on an annualized basis.
More recent data supports the trend. From June 2009 to September 2010, the 30-day readmission rate for those who opted for the group was 6.7%; Among all FMC patients, those who attended the group following discharge and those who did not, the 30-day readmissions rate was 8.9%.
It is not known whether the patients who opted for the group had lower readmission rates because they were less sick to begin with, or if other confounding variables contributed to the results; that analysis has not been done, Dr. Skelton said.
However, patients polled said that they understood their medications and care plans better after the group visit; virtually all said they’d recommend the group to recently discharged patients.
The 2-hour group visits are offered at the FMC every Wednesday morning, so patients who opt for them can attend within 7 days of discharge. Usually about 4, but sometimes up to 7, patients attend. The team knows who is coming and can prepare for the visits because the FMIS and FMC have improved how they track recently discharged patients. They share a common electronic registry of hospitalized patients; the system alerts staff on the outpatient side when a patient is admitted and discharged. Discharge summaries are almost always available within 24 hours. Nurses also call patients within 48 hours of discharge, making a note of any issues in the system.
The group visits and tracking upgrades are "catching things that used to fall through the cracks," one physician said in a poll.
The annual cost of the efforts, due mostly to the care team’s group visit time, is $30, 212. That’s offset by an annual gross revenue from the group visits of $30,368, billed under CPT code 99214, Dr. Skelton said at the conference, which was also sponsored by the American Academy of Family Physicians.
"As long as you have more than a couple patients in any week" so discharge group visits are cost-effective, they "make sense," she said.
There was no outside funding for the efforts, "just creative reallocation of human resources," said Dr. Skelton, who reported having no relevant conflicts of interests.