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A pilot program recently launched in the Denver area seeks not only to improve patient satisfaction but also to improve the quality of careers for the health care professionals who administer it. The program is built around drop-in group medical appointments (DIGMAs). DIGMAs involve a group-setting medical visit, which gives patients an extended medical appointment with their physician. The group sessions, co-led by a physician and a behavioral health specialist, typically involve between 10 and 16 patients and last 90 minutes.
"We decided to try DIGMAs mainly to improve access," notes Scott K. Cunningham, MD, an internist with an internal medicine and family practice at the Colorado Permanente Medical Group in Denver. "It had really been a problem in our region; routine access has typically been out to eight weeks at times, and we wanted to reign that in in a cost-effective way," he adds.
In 1996, DIGMAs were originated at the Kaiser Permanente San Jose (CA) Medical Center by Edward Noffsinger, PhD. However, quality improvement was not measured. "So, from a quality perspective, we actually don’t know the exact role of DIGMA programs," Cunningham admits. "To Noffsinger, DIGMAs were the possible answer to an access problem, and he did find that access improved dramatically. My intuition would tell me that quality would probably be either neutral or slightly improved. In our region, quality is already one of Kaiser’s highest nationally, so we don’t expect quality of care to go up dramatically. What we’re aiming for is to improve quality of service."
Cunningham notes that he’s also seeking to boost career quality. "As a physician, when I hear patients complain day after day that they have to wait too long for their next appointment, it has a negative impact on my quality of career," he asserts. "We needed to have a place to put these people."
The pilot program, which began in January, involves four Kaiser Permanente primary care practices — Cunningham’s; one at the Skyline medical office; and two at the Highline medical office. "I was the first to go up, in mid-January," he recalls. "The last two started in mid-March." Cunningham’s practice handcrafted a flier that he would hand out to patients at the end of their visit, saying he’d like to see them for a follow-up and explaining the new program.
The groups meet each Tuesday morning from 10 to 11:30. "We have had an average of 10 patients, generally with chronic illnesses: diabetes, a lot of blood pressure rechecks, high cholesterol, some skin problems. We have even had an alcoholic," Cunningham notes.
The sessions begin with the behavior health specialist giving a brief summary of the DIGMA concept and setting ground rules for the meeting. Then, in brief, round-robin fashion, each patient tells what he or she needs that day. The behavioral health specialist generates a handwritten list of names and problems, which she reviews with Cunningham, who is sitting at a computer.
"We prioritize how to go about performing the agenda," says Cunningham. "All records are computerized. I may take Mrs. Smith’ first, and go over her blood pressure medicine, perhaps changing the dosage and telling her to come back again in two months. Then, I head to the computer to do my charting, and meanwhile, the behaviorist is directing a discussion about some of the things we can do to help lower our blood pressure. In essence, it’s a light mental health intervention."
Other patients don’t mind waiting their turn, says Cunningham, because they actually rally together to help each other. "Sometimes that even happens before the group starts; they mentor each other. It’s a little instant community," he observes.
Patient response to date has been positive, Cunningham reports. "We are measuring patient satisfaction with an instrument that gives us a good idea of how things are going," he notes. "So far, we seem to be scoring all 4s and 5s, which is agree’ and strongly agree.’"
And how have the DIGMAs impacted his quality of career? "I love it," Cunningham says. "I knew I’d love it, because I’ve done other types of group appointments. I’ve wanted do this ever since I found out about it."
Cunningham is convinced the DIGMA model can be applied in a wide variety of settings. "It definitely can be done in a panel practice sort of environment," he asserts. "If you had a large, unified organization that was on a fee-for-service or cash-for-service basis, it could still be done; you’d just need to pay close attention to price. But you pretty much know how much time you should allot for each patient."
Above all, Cunningham remains convinced that the dual focus on patient satisfaction and career satisfaction is the right way to go. "These are two of the three or four issues our organization had identified from the top levels as chief predictors of our success in the next decade," he concludes.