Caring for seniors: making the most of 20-minute visits
By Phyllis Maguire
SAN DIEGO—How can you manage your Medicare patients' multiple medical problems while still sticking to 20-minute visit slots? Internists everywhere face this dilemma, but it's particularly acute for geriatricians like David B. Reuben, FACP.
Dr. Reuben, director of the geriatrics program at the David Geffen School of Medicine at the University of California, Los Angeles, said that full-time clinician educators at his facility are expected to see 300 patients a month. To make that mark, he said, physicians must limit most patient visits to only 20 minutes.
These time constraints can be particularly oppressive when patients are older and frail. Almost all of Dr. Reuben's patients, for example, are in their 80s or 90s. Most also have at least half a dozen medical conditions, and many take 10 or more different medications.
With time so scarce, he told a group of internists at Annual Session in April, it's easy to fall behind on screening for and managing geriatric conditions such as falls, urinary incontinence, cognitive impairment, and appetite and weight loss. Those conditions can increase morbidity or have a catastrophic effect on patients' quality of life.
Studies have shown that primary care physicians meet as many as 80% of quality indicators for treating common diseases such as hypertension and atrial fibrillation in Medicare patients, Dr. Reuben said. Only 40% of generalists, however, meet quality indicators for managing geriatric conditions.
"There is too much to do and too little time," Dr. Reuben added. "We grapple every day with how to get patients in and out of the office while still providing comprehensive care and being nice to them."
To make the most of the 20-minute office visit, his practice has come up with some innovative ways to save time and to access other resources to improve patient care. The strategies are inexpensive to implement, can be put in place with some help from staff—and can ensure that your oldest patients get the care they need.
Besides a lack of time, Dr. Reuben said, one of the biggest barriers to top-notch geriatric care is recognizing problems and symptoms. "If you don't know the patient has urinary incontinence," he said, "you won't be able to manage it."
To identify problems, his practice relies on a mix of pre-visit forms and simple screening techniques. Before initial visits, patients fill out a 10-page double-sided questionnaire that includes questions about geriatric conditions, patients' comprehensive medical history, advanced directives, nutrition, depressive symptoms and functional status. (This and other forms are available online.) The practice has about an 80% success rate getting patients to complete the questionnaire and bring it to the initial visit.
"We put a great deal of effort into ensuring that patients provide this information before they go into the examining room," Dr. Reuben said. Patients are first mailed the questionnaire, then called the day before the visit to remind them to fill it out. And patients who arrive without a completed form receive one in the waiting room before the visit.
The practice has also started using a one-page questionnaire for follow-up visits—another opportunity for patients to signal their concerns about geriatric problems. (According to Dr. Reuben, patients 65 and older visit their physician nine times a year on average.) Physicians give the form to patients when they check in. Patients complete the form while waiting to see their doctor.
The follow-up questionnaire asks patients to list the two most pressing topics or medical conditions they want to discuss during that next visit. It also asks about recent falls, shortness of breath, chest pain, weight loss and medications patients are taking.
Questionnaires and forms that your elderly patients fill out can quickly flag conditions that require follow up.
While forms help flag conditions that may require follow up, talking to the patient is just as important in the search for problems. Dr. Reuben said he asks patients at every visit about falls, incontinence, appetite and weight loss. (For a healthy geriatric population, he suggested asking about these issues once a year.)
During patients' initial visits—which last an hour—Dr. Reuben administers formal tests like the mini-mental state exam to assess cognitive impairment. He will then re-test patients about once a year by giving them short recall lists and asking them about current events.
He also gets important clues to problems during the minute or two he spends at the beginning of each visit chatting with patients about their families and interests. "A lot of times," Dr. Reuben said during a subsequent telephone interview, "that's when I get tipped off that something isn't right."
If your initial evaluation reveals evidence of several serious geriatric conditions, Dr. Reuben said a referral is sometimes the best way to go. "If patients fail on everything and it would take you two hours to figure out what's going on," he said, "it's probably more efficient to just send them for a comprehensive geriatric assessment."
But when you identify geriatric-related problems that you should manage, you face a new dilemma: How to fit management of those conditions in a 20-minute office visit while addressing underlying medical problems.
To help physicians manage an identified condition, Dr. Reuben and his colleagues have developed two other forms. One is called a "structured visit note" specific to that condition. Physicians fill out the examination and treatment plan portions of the note during the visit.
To save time, however, staff members fill out the history portion of the note before the patient sees the physician. For the structured visit note pertaining to falls, for instance, a nurse or medical assistant fills in the circumstances of patients' recent falls by checking boxes on the form.
Office staff also note if patients are using any devices to improve mobility or balance, and they give patients a brief eye exam. For patients with urinary incontinence, staff will enter dipstick results on the structured visit note for that condition and ask questions about symptoms.
Using structured visit notes and training staff to fill out portions are major time-savers, Dr. Reuben said. "The forms allow us to compress what I call the 'front half' of the visit-the history and some of the physical exam," he said. "That leaves a fair amount of time at the end of the visit to discuss other medical issues." Some physicians in his practice have been reluctant to delegate some history-taking to staff, Dr. Reuben said, while others are much more comfortable. Staff can at least make sure to put a structured visit note on top of the patient's chart once a condition is identified.
To also help track how well they are managing conditions, physicians at the practice have developed yet another form: a condition-specific follow-up questionnaire that patients fill out the day of their next appointment and bring with them.
The questionnaire asks about any problems the patient has had with the prescribed treatment for the condition (using a walker to prevent falls, for instance) and whether the condition has improved. The form also provides a list of condition-specific questions the patient might want to ask the physician during the next visit. Using the questionnaire helps physicians avoid an all-too-common problem when it comes to managing geriatric conditions: inadequate follow up.
"We identify a condition and try a therapy," Dr. Reuben explained, "but then the issue never resurfaces, even if the therapy didn't work."
In each 20-minute visit, Dr. Reuben said he typically addresses one of the patient's geriatric conditions, as well as two or three medical conditions. He will also briefly touch on other problems, although he usually saves in-depth discussion of other conditions for another visit.
"To be honest, you can't focus on more than two or three problems at a time, because that's more information than a patient can handle," he said. "Also, if you're changing medicines, you really don't want to change more than one medicine at a time, because you won't know the effect of that one change."
Dr. Reuben acknowledged that using so many forms sounds like a lot of work. But while training physicians to incorporate condition management techniques, he's found that managing each condition often takes no more than two minutes out of each visit. (For more information, see "Assessing balance problems in just two minutes.")
Changing your approach
Besides using forms to make the most of time spent with geriatric patients, Dr. Reuben said that physicians may have to modify their clinical approach.
"When dealing with geriatric patients, you need to develop a broader concept of what a therapeutic intervention can be," he said. "With almost all geriatric conditions, you have to address not only medical aspects of illness, but social and behavioral components as well."
While physicians are trained to write prescriptions and give injections, he explained, geriatric problems often require more community-based solutions. The patient who is prone to falls, for example, may need to be encouraged to join an exercise program rather than take a new medication.
To help patients access other resources, Dr. Reuben's practice provides patients a list it compiled of community contacts for each geriatric condition. His group's handout on community resources for falls, for instance, gives patients contact information for local agencies, senior centers, food and meal delivery programs, and transportation and durable medical equipment resources, as well as a complete list of local exercise programs including yoga and tai chi.
His practice also makes extensive use of patient educational materials. Dr. Reuben said the National Institute on Aging, for example, offers an excellent list of publications that can be customized with your group's name and logo. (For publications and ordering information, see www.nia.nih.gov/data/publist.asp.)
To save time during office visits, however, brochures and community resource lists have to be at your fingertips, he said. If you have to leave the exam room to fetch them, either you won't use them, he continued, or "someone will catch you in the hall and distract you." To keep materials readily available, his practice has outfitted every exam room with a rolling cart that staff re-stock at the end of each week.
Dr. Reuben recommended some other time-savers. Decision-support tools like "Geriatrics at Your Fingertips" and "The Tarascon Pocket Pharmacopoeia" are his favorites. He also said that using a handheld computer to check dosages and drug interactions for patients on multiple medications is "indispensable."
Dr. Reuben estimated that customizing forms, identifying condition-specific local community resources, and outfitting exam rooms with folders and shelves or rolling carts for patient information would cost about $300 per physician to implement in a practice with at least 300 patients age 75 or older.
His practice has also calculated that in a 10-physician group, it would take staff only about five additional minutes a day per physician to help fill out forms and make sure that patient education material is either with a patient's chart or in the exam room.
In return for that investment, Dr. Reuben said physicians have to spend less time during patient visits trying to convince patients to change. An even bigger payoff, however, comes in the form of more engaged and healthier patients.
"The bottom line," said Dr. Reuben, "is that an informed, activated patient and a proactive practice team lead to improved functional and clinical outcomes."
To evaluate balance problems in patients who are suffering falls (or afraid of falling), David B. Reuben, FACP, relies upon simple tests that add very little time to an office visit.
For the first test, patients hold three different stances that are progressively more difficult, each for about 10 seconds, said Dr. Reuben, a geriatrician at the David Geffen School of Medicine at the University of California, Los Angeles.
In the first stance, patients put their feet next to each other so they touch. Next, patients take a semi-tandem stance, touching the side of the heel of one foot to the side of the big toe of the other foot. For the third stance, the full tandem, patients place the heel of one foot directly in front of the other foot, touching the heel to the toes.
For patients who can hold the full-tandem stance, Dr. Reuben said, "I might recommend they join a community-based exercise program, but I basically tell them to keep doing what they're doing."
When patients have problems holding the semi-tandem stance, therapy depends on how long they were able to maintain the stance. "If it's just a little break at the end, you might refer them to tai chi classes or some balance training exercises," Dr. Reuben explained. If they break early on, however, "they're probably going to need a walker or a cane, and perhaps some physical therapy."
Patients who can't hold the side-by-side stance—the easiest—"will definitely need a walker and will often benefit from physical therapy," Dr. Reuben said. "I send them directly to the durable medical equipment supply house."
Following the three-stance exercise, Dr. Reuben also tests patients' quadricep strength by asking them to rise from a seated position without pushing on the chair arm rests with their arms. He then observes patients for bradykinesia and tests for rigidity-all elements he's prompted to do by a structured visit note for falls.
The cost in time? All told, the balance tests and observations take less than two minutes, Dr. Reuben said.
Geriatrician David B. Reuben, FACP, recently canvassed the physicians in his practice. He needed to conduct a quality improvement project and asked his colleagues what issue they wanted the project to explore.
Instead of asking to focus on reducing weekend call or streamlining the prescription refill process, most of his colleagues pointed to what they see as a much bigger problem: patient flow.
"They wanted to make sure that we see patients more promptly, within a few minutes of when their appointment is scheduled," said Dr. Reuben, who is director of the geriatrics program at the David Geffen School of Medicine at the University of California, Los Angeles. "They also wanted to leave the office when they were supposed to, not two or three hours later."
The practice kept a tally sheet for two weeks, tracking every single reason the practice's schedule was disrupted. At the end of the two weeks, the group identified four major patient-flow problems.
For one, physicians did not have all the information they needed-like lab results-in the chart. Also, patients often raised more issues than physicians could handle in a 20-minute office visit.
"On our follow-up visit questionnaire, we ask patients to identify their two most pressing problems," Dr. Reuben told the audience at his Annual Session presentation. "Now, our physicians are starting visits by asking, 'What two issues are we going to be talking about today?' If the patient wants to address more issues, we schedule another visit."
An even bigger patient-flow problem stemmed from the fact that geriatric patients need to use the bathroom frequently—and need a fair amount of time to do so.
But the major problem derailing patient flow, Dr. Reuben's group found, was even more basic: patients arriving late.
"When someone shows up 15 minutes late, every appointment afterwards gets backed up," he said. "You can try to make up a little time in subsequent appointments, but not much, especially if you're addressing issues like falls and urinary incontinence."
To solve the problem, Dr. Reuben's practice borrowed a tactic from the airlines: It now tells patients to arrive 15 minutes before they will actually see the physician. Staff tell a patient with a 4:00 p.m. appointment, for instance, to arrive at 3:45 to allow time for vital signs to be taken and to use restroom.
The practice also came up with another solution: Schedule patients who are chronically late only at the end of the day.
"If you schedule these patients early in the session and they are late," he said, "they push everyone else back for the rest of the day."
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