HomeWhat's NewStories of ChangeCarondelet Medical Group - Tucson, AZ

Stories of Change:
Group Medical Appointments Improve Access and Patient Satisfaction at Carondelet Medical Group

by Rhondda Francis

In the waiting room on the north side of Carondelet Medical Group, Southwest art adorns the walls and unassuming blue chairs are arranged in six rows of three, facing the curved, adobe-pink front-desk. A large TV in the corner is tuned to a CNN health channel. Framed signs announce: "Innovative Care… Outstanding Medicine. Carondelet is proud to announce Group Medical Appointments." Smaller print explains that this is a great way to spend a whole hour with your physician and learn from other patients.

While the set up of the room might dismay an interior decorator or a feng shui aficionado, Carondelet's set up of their waiting room reflects a clear-eyed thoughtfulness. It is quite simply a conscious effort to maximize their space. The layout not only enables patients to sit while they wait to speak with check-in and referral staff, it also allows the addition of an inexpensive room divider from World Market and the quick and easy repositioning of a minimal number of chairs to transform the room into to two separate spaces— one of which is used for group visits, or as the staff and providers at Carondelet call them, Group Medical Appointments or GMA.

A proud history of Access to Care

Established in 1995, Carondelet Medical Group (CMG) in Tucson, Arizona, now grown to 17 family medicine practices, is affiliated with Carondelet Health Network (CHN).  In 2002, CHN merged with Ascension health, the largest faith-based health care system in the United States. Carondelet was a self-directed participant in TransforMED's National Demonstration Project, which ended in April 2008.

The practice consists of 21 staff members and 6 clinicians located near St. Joseph's in two nearly mirror-image buildings — "the north side" and "the south side" — stuffed full of staff and stuff. Providers on the north side included (at the time of this writing) Dr. Edward Schwager, Dr Shelley Dotson and NP Steve Walls. On the south are Dr. Dustin Morris, Dr. Christian Moher and Dr. Moira Wristen. Griselda Kovrig, MBA is the practice manager for this CMG office.

The Carondelet practice takes the ideas of "do today’s work today" and "open access" very seriously. Not only does the practice do same-day scheduling, but 40% of this clinic’s patients are enrolled in Medicaid and the physicians' panels are always open to accept patients in need.

Access to "My Doctor" at issue

At 8:00 am each business day, Carondelet Medical Group's staff open the 22 phone lines and, as Dr. Schwager likes to say, "let 'er rip."  By 8:30 am every provider's schedule is full for the day. Demand is vastly greater than supply at CMG.

"Every year," says Practice Manager Griselda, Kovrig, "we conduct general patient satisfaction surveys and although our scores have been better than national averages, ease of getting an appointment was usually our lowest score. Our CEO, Mr. Walter Davis, has experience with group appointments and had been inquiring about group medical appointments as a different means for providing our patient population with access to services and generating revenue for the physicians (in a time where physicians have to work extra hard to stay afloat due to increasing expenses and Medicare cuts). Our office, in particular Dr. Schwager, saw this as an opportunity to try something new and also to assist with our ongoing patient demand for appointments and answer our number one patient complaint of not being able to be seen."

In hopes that it might improve access for patients as well as increase revenue, Carondelet leadership decided to give group medical appointments a try.

The Carondelet GMA pilot project begins

The first step the practice took was to engage an expert. "We received training and guidance from our GMA consultant, DeeAnn Schmucker," says Kovrig. Initially the consultant met with the Carondelet Medical Group CEO and Kovrig to review all aspects of GMA implementation, including staffing needs and billing. While staffing and back-office elements were being prepared and implemented, the consultant met with the interested providers and gave them a general overview of GMA. 

Each of Carondelet's providers had different needs and wants, so in follow-up meetings the consultant helped each provider decide how to structure their groups. Together they also identified the days and times as well as the number of available appointment slots for each group. She provided sample letters informing patients of the new group medical appointments and these were customized for each physician. Finally, the consultant met with all the physicians and staff to discuss the group visit philosophy and answer questions. 

With all the pieces in place, Carondelet Medical Group was ready for its first "demo" Group Medical Appointments, which the consultant facilitated for participating providers. Two of the practice's MAs who had been selected to become facilitators were present at these initial visits so they observed first hand how the consultant facilitated the groups. "Office staff — scheduling staff in particular — also attended these initial group visits in order to familiarize them with this new method of caring for patients and thus provide better insight to our patients as we tried to 'sell' these visits," says Kovrig. The overwhelmingly busy office was even closed for half a day in order to give everyone in the practice the opportunity to get comfortable with the process.

"Group Medical Appointments are a foreign concept to us all — physicians, support staff and patients.  It will take education, experience and time for all the various participants to understand, accept and encourage their use," says Dr. Schwager.

Carondelet took off the training wheels and began offering group medical appointments facilitated by their own staff in mid-August 2007. Of the five providers that began the pilot, two providers ended the pilot program. Today three providers at Carondelet offer GMA in two to three sessions per week.

A group visits model "mash-up" is just what the doctor ordered

Carondelet's group visits are a hybrid of the Drop-in Group Medical Appointments (DIGMA) and Cooperative Health Care Clinic models. Although their Intergy Electronic Health Record has population analysis capability, group visits aren't oriented around specific chronic diseases, conditions or lifestyle needs, but rather are used as a way to increase access — ideally, but not necessarily, access to one's own personal physician.

Because the program is oriented around providing better access to the patient's doctor, it is the providers who lead the "recruiting" effort by recommending GMAs to their patients, reinforced by the schedulers, constantly offering these appointments. Says Kovrig, "Scheduling of these appointments is very much physician-driven. According to our guidelines, physicians need to tell patients about GMA and recommend patients schedule a follow-up appointment preferably during a GMA. Physicians hand out GMA information flyers to their patients as they leave the exam room." Kovrig emphasizes, "I am convinced that in order for patients to accept the GMA, physicians need to inform and ask patients to schedule a group appointment. A recommendation coming from the physician has more weight than the recommendation of a staff member."

Anatomy of a Group Medical Appointment at Carondelet

"The 'team' for Group Medical Appointments comprises the physician, a medical assistant and a group facilitator —  ideally someone with behavioral or counseling skills," explains Dr. Schwager.  "We do not do physicals in group, so we find Group Medical Appointments work for nearly all types of visits."

Kovrig provides more detail as to how a typical visit unfolds: "The medical assistant makes sure all patients are roomed and vitals taken prior to entering the group session area.  The facilitator welcomes the group members and provides them with a brief description of how the visit is going to be structured.  Once the group is ready to start, the facilitator will, one by one, ask the patients the reason for visit. While the facilitator is asking the initial questions, the physician is reviewing the patient's electronic record and may begin documenting the progress note, begin writing prescriptions and/or requesting lab orders from the MA."

"The providers and MAs use tablet PCs as their main tool to conduct patient visits," Kovrig continues. "For example as the facilitator is asking patients general questions as to the condition, symptoms, etc, the provider reviews the patient's electronic record and begins documenting patient's electronic progress note.  Once the facilitator is done asking the questions, the provider then takes additional history and conducts assessment, etc. If the provider is ordering any referrals and/or labs, he requests these by sending an electronic task to MA or referral clerk. By the time group is over, the patient picks up the lab from the MA and the referral from the referral clerk."

Skepticism largely transformed into success

Although CMG leadership saw group visits as the right medicine, not everyone on the team agreed. Certified Medical Assistant Sarah Severson who conducts Dr. Dotson's group says, "I must admit I didn't think it would be a successful program. I was skeptical, but not anymore! People really do learn from each other and then they take that learning back to their family and friends. So it isn't just patient education...Without your even knowing it, community education about health and wellness is happening!"

And even after good-faith efforts to make it work, two of the five providers decided GMAs weren't right for them. Kovrig recalls that one of the providers who stopped conducting group visits couldn't adapt habits of care delivery to the longer time frame and had a hard time keeping the proceedings organized and on track. Another provider who bowed out began having feelings of anxiety on group visit days. The provider would "look at the patients' reason for visit and records and would come and tell me... 'John Doe is scheduled for group and I don't think he is a good candidate for a GMA...'  — even though the patient had already agreed to take part in the group visit!" says Kovrig.

CMA Severson has seen that group visits can work and takes a broad view: "It's not a good fit for some providers. For others, I think it may actually work better than 'regular' appointments — especially for certain types of diagnoses, for example, fibromyalgia. There are so many ways to treat that. There's no one single treatment. So it's really great for people in the group to be able to say 'here's what I do' and for patients who have just received that diagnosis to get a number of different perspectives — what's working for different people."

Some patients initially looked askance at the new GMA program as well, but patient satisfaction survey results have shown improvement and anecdotal feedback is positive. Overall survey results for all providers have averaged 4.5 — between Excellent and Very Good — on a scale of 1-5.

Looking over her patient satisfaction surveys Griselda Kovrig chuckles, "The irony of these results is that what our patients initially identified as their main concern, their main reason for NOT wanting to attend a group session (sharing detailed medical information in front of other patients), was in the end, the thing that the majority of patients find that they most like!  Patients like the fact that they can learn from other patients' medical issues."

Certified Medical Assistant Lauri Morales, who conducts groups for both NP Steve Walls and Dr. Schwager, says. "I find that patients who have never attended a group medical appointment do tend to be resistant to the idea. They think it's going to be something like group therapy. But once someone's actually been to one, they like the warm, supportive setting and they realize that they've learned a lot by learning from each other, by hearing the real-life experiences of other people."

Sarah Severson agrees: "Sitting in a room full of people. Strangers. It's intimidating. No matter how well 'how this works' is explained in advance. Patients were almost always skeptical the first time, but willing to give it a try. But we were prepared for that. Our consultant gave us the heads up that people would have an aversion to it — if for no other reason than that it's new!"

"But for certain patients it's a really good fit," she continues. "And it's surprising how people will open up about things that you and I might think would be too personal. As I said before, I was skeptical, but I learned that we don't know our patients as well as we think we do. Patients are good at recognizing what's good for them. People are pretty smart."

Dr. Schwager, is very pleased with the success of the group visits innovation at Carondelet and sees benefits to patient care beyond just improving access. Outcomes can be improved as well. "This 'new doctoring' allows me to tap other members of the group to reinforce advice —  especially around lifestyle recommendations and chronic disease monitoring. This group reinforcement seems to be more powerful than my recommendations alone."

At the end of the day, the providers, patients and staff at Carondelet are enthusiastic about GMAs and the positive impact they've had on the practice and the patients. "What stands out in my mind," says Kovrig, "is the positive feedback that comes back from the patients after they have attended a group session. One of the recurring comments patient make in the surveys is how much they learned from the visit and how relaxed and informative the appointment was for them.  Over half of the patients state they would return or recommend group visits to a friend or relative."

Author's note: At the time of publication, Griselda Kovrig had been promoted to Regional Operations Manager and Dr. Edward Schwager had become the only Carondelet provider conducting GMA, due to physician transfers and departures.

PRACTICE WEBSITE: www.carondelet.org/cmg