Use of Drop-In Group Medical Appointments (DIGMAs) at our San
Jose Medical Center has substantially leveraged physician time;
improved accessibility at both the individual physician and the
departmental levels; increased quality of care by better addressing
patients' mind-body needs and improving follow-up care; achieved
high levels of patient and physician professional satisfaction;
and reduced cost to the organization by leveraging existing staffing
resources. This article discusses the DIGMA model and suggests
how it can be usefully implemented at other health care facilities.
Introduction
In this era of cost containment and managed care, specialists
and primary care providers encounter everincreasing pressure to
efficiently see more patients in less time while simultaneously
meeting competitive market demands for service and quality care.
Optimal value, service, and quality of care will be achieved in
today's fastpaced health care environment only by providing the
best possible mix of cost-effective group appointments and traditional
individual appointments.
Because they are specifically designed to improve specialty and
primary care access through use of existing resources, DropIn
Group Medical Appointments (DIGMAs)1-11 enable physicians
to "work smarter, not harder." DIGMAs enable physicians
to see dramatically more patients in the same amount of time but
in a way that increases patients' satisfaction with their health
care and physicians' professional satisfaction while improving
service and quality of care. DIGMAs offer an extended medical
appointment with the patient's own doctor in a group visit setting
that enhances the patient's care experience. The increased efficiency
that DIGMAs provide can be used both to enable physicians to better
manage their large practices and to improve the customer focus
of the organization. Although still quite new, the DIGMA concept
is already beginning to gain attention and recognition.12,13
While incorporating most aspects of a traditional individual
medical appointment, DIGMAs provide more integrated or holistic
care by also dealing with patients' psychological and behavioral
health needs--needs which drive a large proportion of medical
visits14-16 and which typically cannot be adequately
addressed during the brief time span of an individual appointment.
Origin and need for the DIGMA concept
In 1996, I transferred to the Kaiser Permanente (KP) San Jose
Medical Center from the KP Santa Clara Medical Center, where I
had been Director of Oncology Counseling and Chronic Illness Services
for more than a decade. At KP Santa Clara, I had specialized in
designing and implementing large multidisciplinary group treatment
programs for high-risk medical patients and their families. During
my 23 years at KP Santa Clara, I worked closely with primary and
specialty care physicians to provide integrated mindbody care
to more than 10,000 medical patients. Through this work, I became
familiar with the growing workload and the challenges that increasingly
large patient panels presented to our physicians. I also encountered
the demands of a rapidly changing health care environment where,
increasingly, more must be done with less.
As a senior health psychologist in the Psychiatry Department
put on long-term loan to the Division of Behavioral Medicine at
the KP San Jose Medical Center, I had the responsibility of expanding
the small Behavioral Medicine Department into the major medical
illness arena by establishing such large integrated interdepartmental
group programs as Cancer, Stroke, Major Medical Illness, Caregivers,
Bereavement, Extra Care Group (for inappropriately high utilizers),
etc. I also participated regionally and locally to help primary
care and assist in the rollout of KP's Adult Primary Care Redesign.
All these activities caused me to reflect on how I might help
specialty and primary care physicians to better manage their large
and expanding practices.
Thus, my first priority at KP San Jose was to conduct a thorough
primary care needs assessment by personally meeting with more
than 50 internists, family practitioners, and administrators.
Physicians at KP San Jose were struggling with many of the same
problems as at KP Santa Clara: deteriorating access, substantially
increased workloads, growing patient demands and expectations,
morale issues, and managing increasingly large patient panels.
Physicians felt that they scarcely had enough time during routine
office visits to attend adequately to patients' physical medical
needs. Little if any time remained, either for dealing with the
psychosocial needs of medical patients or for enriching the physician-patient
relationship which, like physician professional satisfaction,
was suffering as a result of these systemwide stresses.
Clearly, the system did not have sufficient resources--money
or physicians--to solve these access and panel management problems
solely by traditional means, ie, by simply increasing the total
number of individual office visits available. A tool was needed
that would work equally well in primary and specialty care settings
to enable physicians to see dramatically more patients in the
same amount of time, but do this in such a way that both patient
and physician professional satisfaction were improved while access,
service, and quality of care were simultaneously increased. On
the surface, these objectives seemed mutually exclusive. It appeared
to be impossible to simultaneously satisfy organizational needs
(improved access, increased efficiency, and enhanced productivity
by utilizing existing resources alone), patients' needs (better
access and more time with their doctor, increased quality of care,
and improved patient satisfaction), and physicians' needs (increased
professional satisfaction and better management of large patient
panels).
Of these three sets of needs, physician professional satisfaction
seemed to present the greatest challenge, given the economic reality
and rapid pace of change in today's health care environment. During
these early months, many models of care were conceptualized that
would leverage physician time and increase productivity while
simultaneously increasing patient satisfaction; however, the challenge
was to achieve this while also increasing physician professional
satisfaction. In 1996, the DIGMA model began to take shape and
emerge as a viable means of meeting these seemingly conflicting
demands of patients, physicians, and the organization and of providing
a "win-win-win" situation for all three.
Structure and Types of DIGMAs
DIGMAs may be defined as group-setting medical visits which give
patients an extended medical appointment with their own physician
and the more relaxed pace of an effective support group with the
behavioral health professional and other patients experiencing
similar issues. To date, more than 8000 DIGMA patient visits have
been made in 12 different specialty and primary care DIGMAs which
I have co-led during the past two years in oncology, nephrology,
endocrinology, rheumatology, neurology, and primary care at the
KP San Jose Medical Center. Customized with heterogeneous, homogeneous,
and mixed designs,1 DIGMAs are structured to respond
to the particular needs, practice style, and patient panel constituency
of the individual physician. DIGMAs are open to the physician's
entire patient panel, may be attended only by the physician's
own patients (and their support persons), and are typically held
weekly for 90 minutes (Figure 1). They are coled by the specialty
or primary care provider and a specifically trained behaviorist
(eg, psychologist, social worker, health educator, nurse) and
are typically supported by a medical assistant and a scheduler.
 |
| Figure 1. Drop-In Group Medical Appointment in progress |
The group typically consists of 10 to 20 patients, three to six
family members or other caregivers, the behaviorist, and the physician.
Patients who are directly booked into the DIGMA in lieu of an
individual visit enter from three sources: 1) by physician invitation
during routine office visits to have their next visit be a DIGMA
visit; 2) by the scheduler telephoning appropriate patients each
week from the physician's panel or waiting list and inviting them
to attend; and 3) by patients attending the group on an unscheduled
basis (often instead of scheduling an individual office visit
or telephoning) when they have a medical need or question. Just
as no one would expect a physician's individual appointment schedule
for the day to be fully booked without patients having been called
and scheduled beforehand, a preassigned scheduler with adequate
time dedicated for telephoning patients each week needs to be
attached to most DIGMAs.
Much of the economic and productivity gain of DIGMAs arises from
the direct booking component: appropriately selected patients
who agree to attend are scheduled directly into a DIGMA session
instead of being scheduled into an individual office visit. However,
much of the continuity of DIGMAs, as well as their warm and caring
side, is provided by their spontaneous "dropin" component.
A great amount of medical care can be provided during a DIGMA
visit: vitals signs can be measured; medical charts can be reviewed
and progress notes entered on each patient; questions can be answered;
treatment options and medication side effects can be discussed;
prescriptions can be changed or refilled; tests can be ordered
and test results discussed; and brief private physical examinations
or private discussions can be provided as needed during the last
10 to 20 minutes of group time in an adjacent examination room
while the behaviorist leads the group, focusing on psychosocial,
emotional, and healthy lifestyle issues of common interest to
group members.
DIGMAs enable physicians to address in detail many issues of
mutual interest to patients in a warm and supportive group setting
where all can listen and learn--eg, the information and misinformation
that patients glean from the media, Internet, friends, and direct
advertising by pharmaceutical companies. Instead of repeating
the same information to different patients with similar conditions--as
is done during individual office visits--physicians can address
an entire DIGMA group at once, often in greater detail because
of the increased amount of time available. Similarly, the entire
group can benefit simultaneously from the physician's answer to
one patient's medical question, and further discussion is often
stimulated. Patients often remark that in group they often get
answers to important questions that they did not even know to
ask. Patients clearly support one another and enjoy learning from
each other's experiences. Patients help other patients in group
by sharing helpful information, encouragement, support, effective
coping strategies, and disease self-management skills. Everyone
leaves the group with the realization that things could be worse
and that they are not alone.
Unique Features of the DIGMA Model
DIGMAs differ from other group visit models such as the CHCC model
and the CHCC Specialty model developed by Dr. John Scott and his
colleagues at the Cooperative Health Care Clinic (CHCC) of the
Kaiser Permanente Colorado Medical Group.17,18 Both
CHCC models focus on patient populations, either by utilization
behavior (eg, the CHCC model for high-utilizing geriatric patients)
or by diagnosis (eg, the CHCC Specialty model for high-risk patient
populations with conditions such as hypertension, diabetes, hyperlipidemia,
asthma, congestive heart failure, irritable bowel syndrome, depression,
anxiety, and fibromyalgia).
In contrast, the DIGMA model focuses not on patient populations
(either by diagnosis or by utilization behavior) but on the entire
patient panel of the individual physician. This conceptual difference
results in benefits specific to the DIGMA model. Because DIGMAs
focus on improving access and helping physicians to better manage
their entire large patient panels, physicians and their patients
are the ones who directly benefit from DIGMAs. DIGMAs win physicians
over out of self-interest, which ultimately leads to a high level
of physician ownership and acceptance of the model.
How Patients Benefit from Participating in
a DIGMA
Patient Satisfaction is High
Patients have accepted DIGMAs well and have consistently been
highly satisfied with them. Many patients report that they actually
prefer DIGMAs to traditional office visits. DIGMAs empower patients
by giving them choice while giving assurance that individual appointments
can also be scheduled as before.
Surveys have shown that patient satisfaction with DIGMAs is extremely
high because the model gives patients what they most want: prompt
access to high-quality care that attends to mind as well as body
needs and gives patients more time with their own doctor. DIGMAs
also release patients from the isolation of the individual office
visit by having the help and support of other patients become
an integral part of their medical care. These benefits of DIGMAs
have inspired some patients to describe DIGMAs as "Dr Welby
Care."
Patients Help Other Patients
Patients attending the DIGMA provide encouragement and information
to one another and are a source of realistic hope. Patients feel
less isolated with their illness and gain a more balanced perspective
about their situation because of the information and emotional
support provided by other patients, including many who are seen
as being worse off. Patients enjoy closer followup care because
they can simply drop into the DIGMA any week they have a question
or medical need and spend a great deal of time with their own
doctor (which enhances the physicianpatient relationship) and
other patients. Patients often remark that the presence of others
in the group lets them feel safe enough to ask questions they
were not comfortable asking during routine individual office visits.
The greater amount of time available--together with the presence
of the behavioral health professional, the physician, and other
group members--enables mind as well as body needs to be attended
to. The emotional support and occasional confrontation from other
patients who have already undergone the recommended treatment
regimen with benefit or who have been dealing for a longer time
with the same illness that the patient has can be extremely helpful
in increasing medical compliance. Patients also benefit from presence
of family members and other caregivers at the DIGMA and from their
issues also being addressed.
In addition, because of the prompt, barrier-free access that
DIGMAs offer, patients who otherwise might not have bothered to
schedule an individual office visit (especially patients who deny
or minimize the severity of their symptoms) sometimes drop into
a DIGMA session where their medical condition--which might even
be lifethreatening--can be detected and appropriate care delivered
(including referral to the emergency department in severe cases).
Discussion of specific benefits that DIGMAs offer to patients
is more fully developed elsewhere.3
Even patients who chose not to participate in a DIGMA can benefit
from the fact that their physician has a DIGMA program for his
or her practice. This indirect benefit is improved access: by
converting many individual visits appropriately into DIGMA group
visits, DIGMAs increase the availability of individual office
visits for patients needing or preferring them.
Essential Steps for Developing a Successful
DIGMA Program
As is the case for all group visit programs, DIGMAs have certain
specific requirements that must be met. Although these demands
are reasonable and small compared with the multiple benefits that
DIGMAs can offer, they are nonetheless real and critical to success.
Failure to fulfill these nominal requirements will jeopardize
the entire DIGMA program. Although this question is more fully
developed elsewhere,4,8,9 I will summarize the essential
steps here.
Securing Administrative Support
Formation of a successful DIGMA program requires early and adequate
administrative support. For larger group practices, where multiple
DIGMAs are to be established, the right person must be carefully
selected to be the DIGMA champion. The champion, who must be very
knowledgeable about all aspects of the DIGMA model, assumes primary
responsibility for the entire DIGMA program, including its development
and implementation throughout the medical facility.4
The champion serves as "point person" for attending
to the myriad details necessary to ensure success. The champion
must also inform physicians about the DIGMA model1
and its many benefits,3 address physicians' questions
and concerns,2 and encourage physicians to start a
DIGMA for their practice. The champion customizes the structure
and design of the DIGMA around the particular needs, goals, practice
style, and patient panel constituency of each individual physician
who chooses to add a DIGMA to their medical practice.
Securing Patient Buy-In
Formation of a successful DIGMA program requires support from
patients. Because patients have grown to expect a traditional
oneonone office visit with their doctor, successful introduction
of this radically different concept of group medical care has
certain requirements for marketing the program. For example, all
marketing materials directed at introducing patients to the DIGMA
concept (eg, wall posters, fliers, announcements, followup letters
to patients) must have a professional appearance that accurately
portrays the high-quality medical care DIGMAs provide. In addition,
physicians will need to take 15 to 30 seconds during every office
visit to briefly explain some of the benefits that the DIGMA offers
to patients, to hand patients a flier describing their DIGMA group,
and to personally invite patients (as appropriate) to have their
next visit be a DIGMA visit.
Securing Physician Buy-In
The DIGMA program must be allowed to evolve and develop among
physicians at the grassroots level. Indeed, critical to the ultimate
success of any DIGMA program is physician acceptance and buyin,
which can only be achieved by promptly and thoroughly addressing
the concerns physicians raise. Resolution of these concerns will
greatly facilitate physicians' willingness to start a DIGMA for
their own practice. I discussed elsewhere2 some common
concerns expressed by physicians about DIGMAs: "It won't
work for my practice"; "I'm too busy to start a DIGMA";
"I'm not comfortable delivering medical care in a group";
"I still need individual appointments with my patients";
"What if I lose control of the group?"; "Is this
increased quality of care or just more HMO cost-cutting?";
"It's 'meat market' care"; "Groups strip away my
easiest patients"; "I have some ethical concerns";
and "I'm concerned about confidentiality." The DIGMA
model addresses these concerns very well, so that they can either
be resolved promptly or soon after the DIGMA is started.
Physicians who are concerned about confidentiality may wish to
use a brief disclosure or informed consent form to be signed by
all patients at the beginning of each DIGMA visit. I initially
did this myself. However, it has been my experience that concerns
about confidentiality have rarely, if ever, been expressed by
patients attending DIGMAs and that any initial concerns regarding
patients' needs for confidentiality and possible unwillingness
to discuss their medical issues in a group setting have proved
unfounded. In general, patients feel safe and comfortable in a
well-run DIGMA group and are surprisingly open and candid--a finding
also reported elsewhere.17
One concern in particular is frequently expressed by physicians:
"Why should I start a DIGMA for my practice if the net longterm
effect will only be 1000 more patients added to my panel?"
This physician concern is the only one the DIGMA model itself
does not solve, and the potential for longterm abuse in this area
is real. Physicians are concerned that running DIGMAs for their
practices will only produce a substantial net longterm increase
in patient panel size that would completely nullify any net gain
in efficiency the DIGMA would otherwise provide.
To create a "winwinwin" situation, physicians too (ie,
not only patients and the organization) must derive substantial
net longterm benefit from the increased efficiency provided by
their DIGMAs. Physicians view this matter as one of fairness and
trust. Managed care organizations that seek to capitalize on the
many patient, physician, and organizational benefits offered by
DIGMAs must adopt long-term business policies that build physicians'
trust and provide benefits to them as well as to patients and
to the organization. Physicians need reassurance from administrators
that, as a result of implementing a DIGMA for their practice,
some meaningful net benefit will accrue to them. Physicians must
be assured that any future increase in panel size based on the
increased efficiency that DIGMAs provide will be reasonable, so
that they will be left with a substantial net gain for their efforts.
Assigning a Scheduler and Medical Assistant
to the DIGMA
In most cases, a medical assistant and a scheduler must both be
assigned to the DIGMA group. The scheduler must have enough dedicated
time each week to telephone patients from the physician's panel
or waiting list (who have been approved by the physician as appropriate
for the DIGMA) to invite them to attend the next DIGMA session.
The scheduler must be trained regarding the scripted telephone
message to be used for inviting patients to the next DIGMA session
and in how to answer patient questions about the DIGMA program.
The scheduler must also be trained to send the personalized, computer-generated
followup letter that includes all necessary information about
the DIGMA and that incorporates the physician's signature. The
scheduler's function is a clerical one that represents one of
the least expensive personnel resources in the medical center;
nonetheless, this function is a predictable, important expense
that planners must include in the DIGMA budget.
The medical assistant assigned to the group must be trained to
work with the increased patient volume that DIGMAs involve and
the expanded responsibilities of this role, which includes not
only taking vital signs but also performing many special duties,
such as obtaining fingerstick blood glucose measurements for diabetic
patients. Other special duties include reviewing all prompters
on the registration forms for tests and medical services due,
retrieving referral and testing forms, and completing as much
patient information as possible before attaching the forms to
the medical charts and returning them to the group, where the
physician can efficiently order indicated tests and referrals
during group time.
All personnel associated with the DIGMA--from the receptionists,
medical assistant, and scheduler to the physician and behavioral
health provider--must be well-trained, empathetic, and courteous.
Accordingly, the medical assistant attached to the DIGMA should
be selected on the basis of skill, pleasantness with patients,
and a willingness to work hard and welcome the expanded role and
responsibility that the DIGMA offers to medical assistants. Any
medical assistant who complains about the workload and pace of
care would be a poor choice for the DIGMA program. Try to select
a medical assistant who is motivated to work with the DIGMA and
perceives the added responsibility as an opportunity to gain experience
and develop professionally.
Choosing the Right DIGMA Champion
Thoughtful, careful selection of the DIGMA champion is an important
step for developing a successful DIGMA program. The champion's
clinical skills and knowledge of the DIGMA model are the foundation
on which rests the success of the entire program, especially in
its early stages. The champion must not only be skilled and experienced
in working closely with both medical patients and physicians but
also must engender a high level of physician confidence and respect--so
much so that physicians will be willing, by working with the champion,
to entrust delivery of medical care in the dramatically different
format of a DIGMA group visit.
Physicians need much help from the champion when starting their
DIGMA. The champion is responsible for implementing the entire
DIGMA program at the facility. The champion should be a behavioral
health professional who has adequate dedicated time and detailed
knowledge about starting and running a successful DIGMA program;
is comfortable working closely with physicians and hospital administrators;
has experience in handling group dynamics and in leading large
group programs; is compassionate toward the medically ill and
is aware of their psychosocial needs; and can train other behavioral
health professionals to lead DIGMAs which the champion has established--after
which, the champion moves on to starting other DIGMAs with other
physicians.
In addition to helping the physician to customize the design
of the DIGMA to best meet the physician's needs, the champion
helps to develop the program description fliers and progress note
(which is mostly preprinted in checklist form for quick charting)
and takes the lead in getting the DIGMA program started. Whenever
possible, the champion should start the DIGMA program with the
physician and then remain with the group for a couple of months
until it is running smoothly, all system problems (eg, medical
charts not arriving on time) are solved, and the physician has
become comfortable with the DIGMA model. The champion may also
help the physician to learn how best to select and invite patients
seen during routine office visits to have their next visit be
a DIGMA visit. The champion can also advise physicians on how
to best use DIGMAs to meet their stated goals and objectives,
which continuously evolve as needs change.
The champion must also train different behavioral health professionals
as replacements to assume the champion's coleadership of all DIGMAs
established by the champion. Because they will be working closely
together and need to be compatible, considerable care must be
taken in selecting the best behavioral health professional for
each DIGMA in order to ensure that this replacement is well matched
to both the physician and the group.
Choosing a Behavioral Health Professional for the DIGMA
The behavioral health professional must be selected on the basis
of skill set, scope of practice under licensure, and being well
matched to the group and the physician (and not simply on the
basis of lowest personnel expense). A poor choice of behaviorist
is likely to reduce the productivity of the DIGMA and may even
cause the group to fail.
The behavioral health provider introduces the group, manages
group dynamics, addresses emotional and psychosocial issues, provides
behavioral health evaluations and interventions, responds to any
psychiatric emergencies, and helps to keep the DIGMA running smoothly
and on time. In addition, the behaviorist helps the physician
to resolve patient hostility or other negative emotions and leads
the group alone (focusing on psychosocial issues) when the physician
leaves the room to conduct brief private examinations or is otherwise
absent. This arrangement enables physicians to focus on delivering
quality medical care instead of worrying about group dynamic and
psychosocial issues that require special expertise.
The behavioral health professional must be skilled in running
groups; compassionate toward the chronically ill; knowledgeable
about the psychosocial needs of medical patients; and have sufficient
experience, training, and scope of practice under their license
to handle all of the responsibilities that are likely to occur
in the DIGMA. It is for these reasons that I particularly recommend
using health psychologists in nephrology, oncology, and rheumatology
DIGMAs, where anxiety, depression, and suicide are more likely
to be major issues.
Developing Effective Promotional Tools
Well-designed wall posters (for the physician's lobby and
examination rooms) and descriptive fliers about the DIGMA program
represent an important but relatively small, one-time expense
incurred at the beginning of each DIGMA program. Although small,
considerable lead time should be allocated to this expense, which
must be built into the DIGMA budget. Failure to obtain these important
promotional tools will negatively impact the entire program.
Maintaining Predetermined Minimum Census Levels
I cannot overstate the importance of establishing and consistently
maintaining a minimum patient census level for each DIGMA: Adequate
census is the key to leveraging physician time and to attaining
the levels of increased productivity and efficiency that well-run
DIGMAs can achieve. Failure to consistently meet minimum census
requirements would not only reduce efficiency and productivity,
but could also jeopardize the entire DIGMA program.
Moreover, in contrast to the way the DIGMA model swiftly resolves
most concerns, the concern around establishing and maintaining
a minimum level of census is as real and important after a year
or two as it was at the first DIGMA session. The minimum census
level must be set high enough to meet the targeted goals for increasing
physician productivity; at the same time, the minimum census level
must not be set so high as to create an onerous workload or to
reduce patient bonding. Experience has shown that the ideal census
for most DIGMAs is between 10 and 16 patients plus an additional
three to six family members and caregivers.
Maintaining census is critical to the success of each DIGMA and
requires continuous vigilance. In addition, not only must a certain
number of patients attend group each week; they must be the right
patients (ie, patients whom the physician has specifically selected
for inclusion and especially those who attend the DIGMA in lieu
of an individual visit). Maintaining census converts individual
visits into group visits, leverages physician time, improves accessibility,
and achieves the goals for which the DIGMA model was originally
designed.
The behavioral health professional has the responsibility of
monitoring the group census each week and of notifying both the
physician and the scheduler if census starts to drop or fails
to meet the established minimum census level so that they can
increase their efforts for inviting patients. In this way, the
DIGMA census can be fine-tuned and maintained so that the DIGMA
program's desired objectives continue to be met.
Implementing DIGMAs Throughout the Organization
Larger group practices and managed care organizations may wish
to first establish and evaluate the effectiveness of DIGMAs at
a pilot site before disseminating the DIGMA model to facilities
throughout the organization. Ultimately, full-scale implementation
in both primary and specialty care settings is likely to be the
organizational goal; this process is discussed in detail elsewhere,4
as are important keys to success8--and pitfalls
to avoid9--when developing a DIGMA program throughout
the organization.
Barriers to Development of a Successful DIGMA
Program
The difficulties that I faced as DIGMA champion at the KP San
Jose Medical Center should serve as a lesson for others and can
be prevented by following the steps described in this article.
Initially, primary care physicians were not easily convinced to
try DIGMAs for their practices; I therefore started with specialists,
and interest soon evolved among primary care practitioners. I
also had difficulty obtaining funding for the three sets of framed
wall posters and accompanying DIGMA program description fliers
for the physicians' lobby and for two examination rooms. In addition,
there were sometimes difficulties reserving a group room that
was adequately sized, comfortable, and with a well-stocked examination
room nearby. Overcoming these difficulties often required improvisation,
ingenuity, and persistence.
Due to lack of funding, we did not have a scheduler assigned
to most DIGMAs with sufficient time dedicated each week (as much
as four hours were needed in some weeks) to telephone patients
and send follow-up letters. As a result, the census
was sometimes below targeted levels, and the degree to which productivity
was increased was correspondingly less than optimal.
Any perception by frontline physicians that the DIGMA model is
being dictated "from the top down" is likely to engender
physician resistance and resentment. Instead, managed care organizations
should recognize that DIGMAs have the remarkable ability to win
physicians over at the grassroots level out of selfinterest and
through wordofmouth recommendations from colleagues already successfully
running DIGMAs for their practices. By thus achieving high levels
of physician "buyin," DIGMAs can create for HMOs, group
practices, and managed care organizations a special opportunity
to initiate system reform that increases physicians' productivity
from the "bottom up" rather than being imposed "top
down." Instead, it is recommended that administrators simply
provide the necessary support, carefully select the best possible
candidate to be the DIGMA champion, and then allow the DIGMA program
to develop and evolve among primary and specialty care physicians.
Why Physicians Like DIGMAs
Physician professional satisfaction has been
consistently shown to increase with DIGMAs as a result of
reduced backlogs and waiting lists, fewer patient phone calls
and force bookings, less complaints about access, and more
rewarding interactions with patients and their support persons.
Physicians report that DIGMAs enable them to regain a sense
of control over their practice by better managing their burgeoning
panel sizes, delivering a more satisfying level of care, and
enjoying improved physician-patient relationships. DIGMAs
also offer physicians other benefits:
- A regular reprieve from the fastpaced
treadmill of individual care;
- More time with the patient so that
mind as well as body care can be provided, including addressing
the psychosocial and behavioral health issues known to
drive a large percentage of all medical visits;14-16
- An opportunity to try something new
and different that provides an interesting learning experience;
- Improved access and a way to "work
smarter, not harder";
- Less need to repeat information;
- Collegial interaction with the behavioral
health professional;
- More compliant patients;
- A way to get back on schedule, even
if the physician enters the group late;
- The ability to respond effectively
to angry or demanding patients;
- The benefit of helpful assistance
from both the behavioral health professional and the group
itself.
|
Conclusions
DIGMAs Help to Optimize Value
The DIGMA model offers an exciting new dimension to costeffective
delivery of highquality health care. The extraordinary national
response I have received to my published articles on the DIGMA model1-5
shows that the model is attractive to administrators and physicians
alike. Because DIGMAs strike an optimal balance between economy
and the needs of patients, physicians, and health care organizations,
DIGMAs provide a "winwinwin" situation and can be expected
to play an increasingly important role in the future of health care
delivery.
Group Visits Complement Traditional Office Visits
DIGMAs work well in conjunction with the judicious complementary
use of individual appointments. Both types of appointments have
an important role in today's health care environment; each has
its own advantages and disadvantages, and neither is best for
everyone in every situation. Physicians who use DIGMAs effectively
can achieve tremendous results in their practices. DIGMAs excel
at containing costs by making individual appointments more available
for patients who need them most, by leveraging physicians' time,
by using existing staff resources more efficiently, by reducing
return patient backlogs, and by increasing accessibility and therefore
service. By addressing mind as well as body needs and by providing
better follow-up care, DIGMAs enhance quality of care while improving
patients' and physicians' satisfaction with the total health care
experience.
DIGMAs function most effectively when used to replace or supplement
routine return appointments for relatively stable chronic illnesses,
the worried well, patients with extensive informational and psychosocial
needs, and patients who require much contact with their physician
and a lot of professional handholding. Individual appointments
are best used for initial evaluations, lengthy individual examinations,
one-time consultations, most medical procedures, acute illnesses,
urgent medical situations, and for patients who refuse to try
group visits.
DIGMAs Increase Access to Care
DIGMAs have been demonstrated to be extremely effective in solving
individual physician6 as well as departmental7
access problems by converting many individual visits into more
efficient, costeffective group visits. DIGMAs work especially
well for patients who are noncompliant, anxious, depressed, angry,
distrustful of medical care, or have extensive psychosocial needs
that require much time and emotional support. Physicians consistently
remark how much easier it is to gain trust and medical compliance,
even among resistant and noncompliant patients, when their treatment
recommendations are reinforced by other patients in the group
who have already received benefit from the recommended treatment.
Will DIGMAs Work in Practice?
See Sidebar
Would the DIGMA model work in actual practice? After three
years of development, over 8000 DIGMA patient visits, and
experience with 12 specialty and primary care DIGMAs in three
different phases, I can unequivocally answer this question
in the affirmative: Carefully designed, properly run, and
adequately supported DIGMAs can consistently work well in
actual practice to achieve all of the goals for which the
DIGMA model was originally designed. All 12 DIGMAs implemented
to date have successfully met the goals for which they were
designed. |
DIGMAs excel in addressing the behavioral health, emotional, and
psychosocial needs that are known to drive a large percentage of
all medical visits,
14,15,16 and this result can substantially
reduce the demand for individual visits. Because DIGMAs can so effectively
meet the medical needs of the relatively stable chronically ill,
the worried well, and the psychologically needy, they can free up
numerous individual office visits for rapidly evolving medical conditions,
procedures, lengthy examinations, and patients truly needing an
individual appointment.
DIGMAs Increase Patient and Physician Satisfaction
As important as any other benefit provided by DIGMAs, this model
of health care delivery has been shown to increase the satisfaction
of patients as well as physicians. DIGMAs reduce or eliminate
appointment waiting lists and extra appointments force booked
into already full schedules, decrease the need for patients to
phone physicians' offices, increase access to medical care, and
facilitate more rewarding interactions between physicians, patients,
and patients' support persons.
Acknowledgments: I would like to thank the Medical
Editing Department at Kaiser Foundation Research Institute for
providing excellent editorial assistance. I also acknowledge the
many hours spent by my wife, Janet M. Noffsinger, BA, son, Michael
E. Noffsinger, and daughter, Angela M. Noffsinger, in word processing
and proofreading this article.
Most especially, I would like to give a heartfelt
thanks to the physicians who have run DIGMAs for their practices
at the Kaiser Permanente San Jose Medical Center in San Jose,
California with the assistance of the author. Without their commitment
and cooperation, this entire effort would not have been possible.
Oncology: Joseph Mason, Jr., MD; Joseph Ramek,
MD
Nephrology: William Peters, MD (assisted by Christopher DiMaio,
MD, psychiatrist)
Neurology: Rajan Bhandari, MD; Jai Cho, MD; C. Gregory Culberson,
MD
Endocrinology: Lynn Dowdell, MD; Patricia Kan, MD
Rheumatology: Thomas Abel, MD; David Granovetter, MD
Primary Care: Monica Donovan, MD (Family Practice)
I would also like to thank Administration at the
Kaiser Permanente San Jose Medical Center for their support.
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