The Ten-Week Pipeline

The ten-week pipeline for launching new DIGMAs and PSMAs was developed through the author’s extensive experience in personally launching over 500 DIGMAs and PSMAs with primary and specialty care providers both nationally and internationally. This pipeline presents a timeline as well as all key steps necessary to launch a successful DIGMA or PSMA program in 10 weeks (many of these steps apply to the CHCC model as well).

This pipeline is equally useful in individual practices, small group practices, mid-sized medical groups, and large integrated delivery systems. In large and mid-sized systems with a SMA champion and a program coordinator, the pipeline serves as an evolving SMA Department implementation tool that, through continuous process improvement, is constantly being refined through knowledge gained by launching evermore DIGMAs and PSMAs throughout the organization. It avoids having to reinvent the wheel time and time again, and enables the champion and program coordinator to efficiently launch numerous future DIGMAs and PSMAs throughout the entire system as easily and rapidly as possible. Ultimately unique to each integrated healthcare delivery system, the pipeline is designed to work within the culture, policies, and structure of that organization. It is meant to save time and money by systematizing and streamlining the entire implementation process for launching all new SMAs within the system.

Key Steps in the Ten-Week Pipeline

Table 4.1 presents the key steps in the ten-week pipeline to be taken whenever one is setting up a new group visit program in any system, regardless of whether it is a single physician, a small medical group, or a mid- to large size integrated delivery system. Each step depicted in Table 4.1 is a section or subsection in the following chapters of this manual, so the interested reader can easily examine what each step entails by flipping to the corresponding section. For example, this chapter will address the steps in weeks ten and nine prior to launching your new DIGMA or PSMA. Needless to say, there is flexibility in this pipeline to accommodate changes in timeframe and content that might better meet your needs. It is best to look at Table 4.1 as a helpful template that can be altered to best fit the specific needs of your SMA program and healthcare organization.

Table 4.1 Key steps in the ten-week pipeline
Full size table

Table 4.1 is broken down into several distinct timeframes:

  • Weeks ten and nine prior to launch

  • Weeks eight, seven, and six prior to launch

  • Weeks five, four, and three prior to launch

  • Weeks two and one prior to launch

  • Key steps during launch

  • Ongoing steps after the launch

The program coordinator will oversee most of these steps in larger systems, although the champion will need to be involved in several. Despite the fact that the champion and program coordinator will do everything possible to minimize the physician’s front-end time commitment to launching a new DIGMA or PSMA, it is critically important that the physician be directly involved in certain key steps of this pipeline. Having the program coordinator leverage the time of both the physician and SMA champion reflects a critically important tenet of DIGMAs and PSMAs: whenever possible and appropriate, delegate tasks to highly skilled and trained—but less costly—members of the SMA team.

Place SMA on the Schedules of Entire SMA Team

A new template of the physician’s master schedule (which includes all changes necessary to accommodate the SMA, including insertion of the computer code already selected for the DIGMA/PSMA) needs to be created by the program coordinator and given to the physician for approval. Once approved, it is submitted by the program coordinator to scheduling management for approval (and to update the provider’s master schedule to include the new DIGMA/PSMA). As soon as the SMA appears on the physician’s master schedule, the physician and support staff can begin personally inviting and scheduling patients into upcoming group visit sessions. In a similar manner, the program coordinator needs to place the DIGMA/PSMA on the master schedules of the behaviorist, nurse/MA(s), and documenter, beginning with the projected SMA start date and continuing on an ongoing basis thereafter.

Hold 2 h at First

For the physician, behaviorist, and documenter, schedule 2 h for the DIGMA/PSMA during the first 2 months. These initial sessions often finish late, and it is important to allow approximately 15 min for the physician and SMA treatment team to debrief after sessions for the first couple of months after launching the DIGMA/PSMA (sometimes with the assistance of the champion and program coordinator). However, after the first 2 months, when the group is finishing on time and debriefing sessions are no longer necessary, the master schedules of the physician and documenter should reserve only 90 min for all subsequent DIGMA/PSMA sessions.

Continue to Hold 2 h for the Behaviorist

The behaviorist will continue to block off 2 h for each DIGMA/PSMA session so she/he can arrive approximately 15 min early to greet patients, warm up the group, and begin writing patients’ health concerns down on the whiteboard—and then stay approximately 15 min after sessions to address any last minute nonmedical questions, tactfully clear the group room, and quickly straighten it up.

An important note: Since the physician will occasionally be at meetings, on vacation, on sabbatical, or out ill, it is likely that many SMA sessions will not be held during the year. The net result in one system was an average of only 36 weekly DIGMA/PSMA sessions being held per year. In order to keep the costs of the program down, consider hiring your behaviorist and documenter contractually—i.e., only for sessions actually held. If the behaviorist and/or documenter are employees of the healthcare system, then they need to be able to promptly backfill their schedules with other productive, chargeable activities during those weeks that the DIGMA/PSMA is not held so that the SMA program is not billed. This will be easier for physician activities that are typically planned far in advance (vacations, meetings, and sabbaticals); however, last minute cancellations due to illness of the physician can be more problematic.

Scheduling the Nurse/MA(s)

The master schedules of the nurse and MA are handled somewhat differently because their schedules are offset from other SMA team members. Although some physicians may only have either an MA or nurse available to them, whenever possible, I prefer using a nurse and an MA because: they tend to enjoy the companionship of a colleague; their duties can be divided according to interest, skill set, and scope of practice under licensure; and nursing duties can thereby be finished in approximately half the time.

In a DIGMA, the nurse and MA arrive approximately 20 min early and begin calling patients out from the group room individually, starting with those who arrive early. Usually, the MA escorts the patient from the group room to the exam room, where two stations are set up (one each for the MA and nurse), although two nearby exam rooms are sometimes used instead. The MA takes vital signs, updates routine health maintenance covers HEDIS/performance measures, and then hands the patient off to the nurse. The nurse gives necessary injections, performs any special duties requested by the physician, and escorts the patient back to the group room—writing key vital signs down alongside the patient’s name on the erasable whiteboard with grid lines. This process is repeated for all patients (except while the behaviorist is giving the introduction, so that all attendees can hear it), even after the session has started.

This entire process usually takes 45–60 min, at which time the nurse typically returns to normal clinic duties while the MA repeats taking blood pressure measurements on those patients in the group for whom it was initially high. (In addition to “white coat hypertension,” I have found that there appears to be some type of “group hypertension” that manifests in DIGMAs and PSMAs because several SMA patients typically have elevated blood pressures when their vital signs are initially taken but which frequently revert to normal levels later in the session.) The exception to the nurse returning to normal clinic duties would be the occasional physician who prefers to have the nurse join the DIGMA for the remainder of the session to help out in a variety of ways (most often, when it is the physician’s own nurse). After double checking high blood pressures (which can be done in the group or exam room, depending upon which is more expeditious and less disruptive of group process, although it is often done in the group room), the MA then becomes the care coordinator. When acting as care coordinator, the MA calls each patient out of the group room (after the physician has finished working with them and completed their SMA chart note), escorts them to the nearby exam room (or the nearby SMA registration area, if there is one), gives them an after visit summary (AVS), and schedules any referrals or follow-ups recommended by the physician.

Two MAs or nurses are required for the PSMA model. They arrive 20 min early and begin rooming patients who arrive early into each of the exam rooms (typically four rooms are used, but sometimes less). In this manner, four patients are typically roomed, gowned with vitals taken, and ready for their private physical examination by the time the physician arrives at the start of the PSMA. Although the workload is often divided between them such that each MA is responsible for two of the exam rooms (i.e., both rooming and cleaning up after patients in their two exam rooms), sometimes the two MAs prefer to divide the work up differently. Here, one MA escorts patients to the exam rooms, takes vitals, and gets patients gowned while the other MA escorts patients back to the group room and cleans up each exam room in turn after the exam has been completed. These are duties which the two MAs can then rotate between themselves on alternative PSMA sessions.

Arrange Clinic Coverage During SMA Sessions

In order to avoid unnecessary interruptions regarding clinic matters while running a DIGMA/PSMA, it is good to arrange well in advance for any needed clinic cross-coverage. Although there is always the possibility of an emergency interruption that will need to be handled by the physician during a SMA session, our goal is to keep all such interruptions to a minimum. Similarly, the entire SMA team will need to arrange for their own cross-coverage whenever they are unable to attend the DIGMA or PSMA (due to vacations, meetings, etc.). In the case of a last minute cancellation due to illness of a SMA team member, the program coordinator can help obtain appropriate substitute coverage for that SMA team member’s role in the group. Cross-coverage is the main reason I always recommend having at least two behaviorists and two documenters trained for each DIGMA and PSMA launched, even though only one will be the primary. The same holds true for SMA nursing personnel.

Train Provider to Best Word Personal Invitations

All providers interested in running a DIGMA or PSMA for their practice must agree to personally invite, in a positive manner, all appropriate patients seen during regular office visits. They must also actively involve their entire support staff (especially their reception, nursing, and scheduling staffs) in inviting, referring, and scheduling patients into the group visit. Nothing is more effective in getting a patient to attend a SMA than a positively worded, personal invitation from their own doctor. Even though the physician’s entire support staff can play a significant role in inviting and scheduling patients (as can the dedicated scheduler), experience has shown that even extreme efforts on their parts will not be able to adequately compensate for a physician who fails to consistently invite all appropriate patients seen during normal office visits.

From their earliest meetings together, the champion should model to the provider how to effectively invite patients into the SMA (i.e., by role playing several common scenarios that can occur while inviting patients). Since physicians are not used to taking a personal responsibility in filling their normal clinic schedule, they can easily forget to consistently invite all appropriate patients seen during regular office visits into their DIGMA or PSMA (a failure that could quickly result in inadequate census, thereby undermining the success of their group visit program). For this reason, providers unwilling to take 30–60 sec per office visit to personally and repeatedly invite all appropriate patients in their practice should not run a DIGMA or PSMA.

Of the hundreds of physicians I have worked with, one of the most successful at promoting his DIGMA and consistently filling sessions provides an example to emulate.

  1. 1.

    From the start, he had instructed his staff to refer all appropriate patients into his DIGMA. He told his staff: “If in doubt, invite them.” This physician also made a point to compliment his staff whenever his DIGMA sessions were filled. Equally important, he never demoralized his staff by complaining about patients they referred that he might have preferred to see individually (something which, when necessary, he instead handled very tactfully in an instructive manner on a one-on-one basis).

  2. 2.

    Wanting to do today’s work today, he instructed his staff to also offer his upcoming DIGMA session to all patients calling for an appointment when he was not able to see them individually that day or week. Thus, patients calling for a routine follow-up appointment were offered their choice of either his first available 15-min individual office visit (which was initially often weeks away, although his DIGMA quickly improved availability of individual appointments during the first couple of months of running it) or a 90-min DIGMA appointment that week, which his staff would briefly describe in positive terms and encourage them to attend.

  3. 3.

    When a patient called his office to speak with him about a non-emergent issue, he would have his staff offer the patient his 90-min DIGMA that week in lieu of a return phone call. His staff stressed that this would allow vital signs to be taken, injections and routine health maintenance to be updated, an exam to be conducted if necessary, and the necessary time to speak with the physician personally. They further explained that these visits were enjoyable and that patients often got answers not only to their own medical questions, but also to questions they might not have known to ask (because others do ask). This also offered the advantage of converting uncompensated phone calls into compensated DIGMA visits. In addition, since many of the physician’s return phone calls were made at the end of the day (when the physician would likely be tired and there might be insufficient information available about the patient), this approach could reduce the risk of making a mistake—and consequently, malpractice risk.

  4. 4.

    This physician was successful because he firmly believed in his DIGMA and challenged himself daily to invite every patient seen during regular office visits through a very positively worded personal invitation. Additionally, his personal invitation was quite strong and persuasive. For example, he would say: “Mary, you have diabetes and I think you should come back in 3 months for follow-up to see how you are doing. I would like to invite you to my new DIGMA program, as it is open only to my patients and was specifically designed for people like yourself. It will give us 90 min together, so I can go into more detail than I normally could during a rushed office visit—and I can even spend some time talking about the latest developments in the treatment of diabetes. It will give you an opportunity to meet some of my other patients dealing with similar issues, including some of my patients who have been successfully dealing with diabetes a lot longer than you have and may have some helpful tips to share with you. There is a strong focus on patient education and empowerment, so that my patients can learn to take the best possible care of themselves. You will probably get answers to medically important questions that you might not have known to ask. If you wish, you can also bring your spouse or a support person along with you, as they will likely also find it to be interesting. It’s lively, informative, and fun—heck, we even serve Starbucks coffee and some healthy snacks—so why not give it a try?” If the patient accepted the offer, he promptly scheduled them into the appropriate future DIGMA session.

  5. 5.

    When patients balked at his invitation or declined, he took an important and innovative extra step by asking: “Would you be willing to try it once for me, as I really believe it will help you?” Almost invariably, the patient would say something like: “Sure, if you feel that strongly about it, I’ll try it once and see.” Since patient satisfaction scores with DIGMAs and PSMAs are high, most patients are willing to return once they do attend—provided that they are invited to do so. Thus, the key to success lies in getting patients to try a SMA the first time, and then inviting them to return, when appropriate, for future appointments.

Physician Selects Snacks, Promotional Materials, and Handouts

The physician needs to specify precisely what snacks she or he wants to provide—preferably healthy snacks (especially those that are not messy), so as to model healthy lifestyle choices. When possible, it is a good idea to serve appropriate drinks and snacks like fruit, yogurt, power bars, decaffeinated coffee, tea, and bottled water. Patients appreciate it when even modest snacks and drinks (especially bottled water, coffee, and snack bars) are provided. Be careful not to serve inappropriate refreshments for the patient population that will be attending, such as caffeinated coffee for prenatal PSMAs in obstetrics, high caloric snacks at a weight management DIGMA, messy snacks (such as cookies, oranges, or potato chips) in a pediatrics SMA, or candy and soft drinks high in sugar content at an Endocrinology DIGMA for diabetes. Place drinks and snacks on a table in the corner or off to one side of the group room and make certain that they are readily accessible to all. During the behaviorist’s introduction, mention that snacks are available to all group members and that everyone should feel free to help themselves whenever they want to during the session. Additionally, if patients do not go over to get snacks during the session, it is a much appreciated gesture if the behaviorist puts several snacks and beverages on a tray and walks it around the group while offering it to all attendees—and does so a couple of times during the session.

Determine Target, Minimum, and Maximum Census Levels

Based on the physician’s current throughput, now is the time to decide:

  1. 1.

    The target census, or ideal group size, for this provider’s new DIGMA or PSMA

  2. 2.

    The maximum census, or biggest group the provider is willing to see

  3. 3.

    The minimum census, or least number of patients necessary for economic viability and adequate group dynamics

Determine Current Productivity

To do this, we must first determine the provider’s current level of productivity during normal clinic hours for similar types of appointments as will be seen in the DIGMA or PSMA (covering the previous 2–6 month period, if possible). Here, we need the average number of similar patients actually seen during 90 min of clinic time, rather than the number of patients scheduled (which often exceeds the patients seen due to no-shows, late cancels, open slots, and some possible downtime on the physician’s schedule). This discrepancy between “patients scheduled” and “patients actually seen” often causes physicians to believe that they see more patients each week than they actually do. Determining this lower number (the physician’s actual productivity during 90 min of clinic time that is devoted to seeing the types of appointments that the DIGMA or PSMA will replace) enables the percentage increase in the physician’s productivity gained through the DIGMA or PSMA to be accurately evaluated.

Set Target Census for DIGMAs

With DIGMAs and PSMAs, you will always want to preestablish your census targets—and then consistently meet them. Whenever possible, we want the DIGMA or PSMA to increase productivity by at least 300%, unless the provider is already exceptionally productive and only a 200% increase can be achieved. Experience has shown that physicians who use 15-min follow-up appointments schedule up to six patients in 90 min of clinic time, but typically only see an average of 3.9–4.7 patients during that amount of time (due to no shows, late cancels, some down time on the physician’s schedule, etc.). Serendipitously, tripling the productivity of such providers results in a range of between 11.7 and 14.1 patients, which is well within the ideal range of 10–16 patients for a DIGMA and, in most cases, a perfect target census to strive for.

Similarly, physicians with 20-min return office visits could schedule up to 4.5 patients during 90 min of clinic time, but experience has shown that they typically tend to only see approximately 3.3–4.0 patients (which, in order to triple productivity, would result in a DIGMA group size of between 9.9 and 12 patients—although I would generally recommend that DIGMAs not fall below 10 patients from both economic and psychodynamic perspectives). Likewise, physicians with 30-min follow-up appointments could schedule up to 3 patients, but would typically only see approximately 2.3–2.7 patients during 90 min of clinic time. Although tripling such provider’s productivity would result in a target census of between 6.9 and 8.1 patients (which could make for a small, boring group), I would nonetheless recommend a minimum DIGMA group census of 10 patients.

As can be seen, the longer the underlying individual appointment that the SMA is replacing, the easier it is to leverage a physician’s time by 300%. However, keeping DIGMAs within the ideal group size of 10–16 patients not only ensures economic viability, but also makes for a group that is more lively, interactive, productive, interesting, and fun.

Set Target Census for PSMAs

The ideal group size for a primary care PSMA is 6–8 female patients or 7–9 male patients. Primary care physicians who schedule 30 min of clinic time for a physical examination (and therefore schedule 3 patients during 90 min) typically only see between 2.3 and 2.7 patients. Tripling this level of physician productivity, as above, translates into between 6.9 and 8.1 patients being seen in the PSMA which, for the most part, is within the ideal group size range. On the other hand, primary care physicians scheduling 40-min individual physical exams would schedule 2.25 patients during 90 min of clinic time, but would typically only see between 1.8 and 2.0 patients. Tripling these numbers would result in a PSMA group size of only 5.4–6.0 patients, which is too small for adequate group interaction (so I would still recommend seeing a minimum of 6 women or 7 men in such primary care PSMAs so as to have a more lively, interactive, productive, and interesting group). Because the exam is often more limited and can be done quicker, the ideal PSMA group size in the case of many medical and surgical specialties (such as prenatal exams in obstetrics, full body skin exams in dermatology, or breast exams in plastic surgery) is often 10–13 patients.

One of the greatest benefits of group visits is that you can eliminate the vexing problem of physician downtime due to no-shows and late cancels by overbooking sessions according to the expected ­number of no-shows and late-cancels (less the number of drop-ins in the case of DIGMAs). By the time your DIGMA or PSMA has been operational for a few weeks, you will have a good idea as to how many scheduled patients will end up no-showing or late-canceling (and dropping in) to your group. Once that number is determined, overbook sessions (like an airline) by the number of patients who fail to keep their appointment, less the expected number of drop-ins. If the target census for a DIGMA is 12 patients and an average of 2 patients fail to show while one drops in, simply increase the target census from 12 to 13 patients to eliminate this costly source of physician downtime incurred during traditional individual office visits.

Determine Maximum and Minimum Census

Determining the minimum and maximum census levels for DIGMAs and PSMAs is relatively straightforward. The minimum census level is typically set to be the smallest number of patients that need to be seen during each session to ensure the group visit’s economic viability. Sometimes the minimum census is set to be 200% of the number of patients actually seen during regular office visits, as the first 100% would have been seen anyway during traditional office visits and the second 100% would more than pay for the cost of the SMA program. However, do not let the size of your DIGMA or PSMA get too small and always try to stay within recommended group sizes for the various SMA models, as group dynamics are as much of a consideration as economic viability. If a physician’s pre-DIGMA productivity is four patients actually seen during 90 min of clinic time, increasing productivity by 200% would translate into a minimum census of 8 patients, which is too small (as it is below the recommended range of 10–16 patients). In this example, I would recommend setting the minimum census at 10 patients (which would correspond to a 250% increase in productivity). I generally recommend setting your minimum census to be either a 200% increase in productivity or the low end of the ideal group size range for each SMA model—whichever is larger.

The maximum group census is simply the maximum number of patients that the physician is willing to actually see in her/his SMA. Be cautious about setting the maximum census too low—and ­consider not only the upper end of the ideal group size range of the SMA model you are using, but also the need to overbook sessions. As previously stated, the ideal group size ranges for the different types of SMAs are:

  • 10–16 patients for a DIGMA

  • 15–20 patients for a CHCC

  • 6–8 patients for a female primary care PSMA

  • 7–9 patients for a male primary care PSMA

  • 10–13 patients for a PSMA in many medical or surgical subspecialties

Consider setting your maximum census close to the top end of these ranges, but add the expected number of no-shows and late-cancels (less any anticipated drop-ins, in the case of DIGMAs). This sometimes initially scares physicians, but this is what experience has taught us and numbers do not lie. Always set your target, minimum, and maximum census levels to be sufficiently high to derive optimal benefit from your group visit program, making your group neither too small nor too large—so that it is fully enjoyable to physicians and patients alike.

How Far in Advance Should SMAs be Filled?

The program coordinator and dedicated scheduler should keep close tabs at all times on the number of patients scheduled for the next four DIGMA/PSMA sessions. The mark of a healthy DIGMA is to see the current week’s session completely full (and slightly overbooked), the next week’s session three-quarters full, the following week’s session half full, and the fourth week’s session a quarter full. If you always meet these criteria, you will never need to scramble to hurriedly top-off sessions not yet filled to targeted levels (an all too common occurrence).

For PSMAs, I like to see all sessions completely filled (including appropriate overbooking) approximately 2 weeks in advance of the actual PSMA session. This allows Patient Packets to be sent out far enough in advance so that health history forms and lab tests can be completed and returned to the office at least a couple of days prior to the session (and then duly entered by a staff member into each patient’s upcoming PSMA chart note comfortably in advance of the session). If these census requirements are not consistently being met for DIGMAs and PSMAs, the champion and program coordinator will need to provide additional training to the provider (as well as the provider’s scheduling, reception, and nursing staffs) on how to effectively invite and schedule patients into their SMA.

Order Wall Posters, and Then Have Them Framed and Mounted

Copies of the poster that has been developed for the system’s DIGMA and PSMA program are ordered for the provider’s lobby (approximately 30  ×  36 in.) and exam room (approximately 20  ×  24 in.) walls. The SMA poster is meant to create a trademark look for the SMA program throughout the organization (it can even contain the corporate colors) so that patients become familiar with the program and begin to view SMAs as a mainstream method of delivering care.

With its professional appearing and eye-catching graphics, the poster’s job is to create enough interest so that the patient gets up, goes over and reads it, then takes a program description flyer from the adjacent dispenser, and finally reads the flyer while waiting in the lobby or exam room. The poster is often generic (without the physician’s name or any unique details), so that the same poster can be used over and over for all DIGMA and PSMA programs—unless ­different photos are used in the generic posters for adult, pediatric, and ob–gyn SMAs. However, if it is a computerized template, all relevant information about any given provider’s SMA (and even the provider’s own SMA photos) can be entered with relative ease and included on the final wall posters. In this case, the downside is that a new poster will then need to be printed, framed, and wall mounted whenever any significant change occurs in the physician’s SMA—which can be both expensive and time consuming.

Most systems will want to frame the poster and mount it in a prominent location on the physician’s lobby and exam room walls (in a position that is both highly visible and readily accessible to patients). However, some organizations will prefer to either have them displayed in these areas on an easel or be self-standing by means of an attached cardboard stand on the back of the paster—both of which are less desirable options due to decreased visibility to patients and the limited number of flyers they can contain. As soon as copies of the posters are produced and delivered, the program coordinator needs to have them framed and mounted in prominent, accessible locations on the provider’s lobby and exam room walls (so as to provide maximum visual exposure to patients). The sooner that the wall posters go up, the sooner patients become familiar with the program and willing to attend.

Order Holders for the SMA Flyers

The program coordinator next needs to order the required number of attractive flyer holders for the provider’s lobby and exam room walls—dispensers capable of holding at least 100 (and preferably 200) copies of the program description flyer. Because they were solid, attractive, and cost about the same amount, I preferred to have my flyer holders custom-made by a local craftsman out of thick, clear plastic with rounded edges. I often did this rather than ordering standard holders out of a catalog since they so often were thin, flimsy, and breakable (and not a good fit to the flyers). Because the flyers are meant to form part of an appealing wall display that is graphically coordinated with the wall poster, this holder should support both sides of the upright flyers (and high enough up) so that they do not sag, droop over, or hang down. On the other hand, enough of the flyer needs to protrude above the front of the holder (i.e., between these two upright supports that contain the upper edges of the flyer) for patients to be able to easily retrieve them.

As soon as they are delivered, the program coordinator arranges (typically through the facilities department) for these holders to be mounted next to the framed wall posters. Together, posters and flyers should form a prominent, accessible, professional appearing, and eye-catching display. For those systems choosing to have posters that are either free standing or mounted on an easel, the flyer holder is typically mounted directly onto the poster. Such freestanding posters are problematic, however, because they are usually only capable of holding a relatively small number of SMA flyers, which often also need to be tri-folded to fit into the relatively small holder.

Select, Reserve, and Fully Equip Group and Exam Rooms

It is now time to select the group and exam rooms that are to be used in the SMA, and then to reserve and fully equip them.

Group Room

Try to avoid a cold, sterile, cluttered, or clinical appearance in the group room. Hang some pictures on the walls, bring in an artificial tree or two, and clear out the clutter. A group room can be decorated at little cost to provide a warm and comfortable ambiance. Ensure that the group room has good ventilation and is capable of comfortably seating 15–25 attendees in the case of a DIGMA or 10–15 for a PSMA. Because poor ventilation can cause a group room to quickly feel like a Turkish steam bath, inadequate ventilation—rather than insufficient group room size—is often the limiting factor as to how many patients can comfortably attend the DIGMA. Because group sizes are smaller, PSMAs do not require as large a group room as DIGMAs (often only half as large). This need for a smaller group room is further helped by spouses often not being invited to physical exams—especially in the case of primary care PSMAs, where group sessions are often divided by sex and age.

The group room should contain enough comfortable chairs, a desktop computer for the documenter, a laptop for the physician, and a telephone. In addition to installing computers, be sure to set up whatever type of computer desk configuration is most comfortable and convenient for the physician and documenter—who normally sits slightly behind, but to one side of, the physician in the group room. Also install a printer in the group room that is positioned in a convenient location for the physician, documenter, and behaviorist. I also find it helpful to have large wall clocks mounted on two or more walls of the group room so that the physician, behaviorist, and patients all remain cognizant of the time throughout the session. It is sometimes advisable to have a light box in the group room for the physician to examine X-rays (unless they are on EMR), some basic medical equipment (such as a stethoscope and a monofilament for diabetic foot exams), a couple of anatomical models, a few medical wall charts, and a selection of patient education handouts. I also like to have two 4  ×  6 foot erasable whiteboards installed at convenient locations on the walls of the group room (one with grid lines and one without)—mounted where the physician and documenter can clearly see them, and the behaviorist and nurse can easily get to them. The behaviorist can use the blank whiteboard to write down patients’ health concerns before the SMA starts, and the nurse/MA can write down lab results and vital signs on the whiteboard with grid lines (circling abnormal findings in red).

Many providers will want handouts to explain available internal and external resources such as nutritional classes, smoking cessation classes, depression and anxiety programs, community support groups, chronic illness groups, health education classes, or behavioral medicine programs. It is also helpful to have relevant educational handouts on issues as such as PSA, hormone replacement therapy, breast self-exams, good nutrition, exercise, diabetes, etc. Some providers prefer to have preprinted handouts that are alphabetically organized and stored in the drawers of a file cabinet, while others prefer to have them on their computer so that they can simply print out the desired number of copies in the group room on an as needed basis. Be certain to select handouts that are relevant to the patients in attendance and consistent with your own style of practice. For example, will you use a colorectal screening handout that recommends a fecal hemoccult screening test plus a flexible sigmoidoscopy or one that encourages periodic colonoscopies?

In DIGMAs and PSMAs, patients, support persons, the physician, and the behaviorist sit in a circular or elliptical seating arrangement. Try not to have tables or other obstructions in the midst of this seating arrangement. This enables the physician to easily walk over and examine a patient, hand them a prescription, or give them a handout. In addition, such impediments can create psychological barriers for patients to hide behind, which can interfere with active group participation (See Fig. 1.1 and Fig. 2.1). Ideally, the physician and behaviorist should sit next to each other with a small table between them—upon which handouts, forms, supplies, and any medical equipment that the physician might occasionally want to use in the group (such as a stethoscope, pulse oximeter, frozen nitrogen canister, tuning forks for simple hearing tests, monofilament for diabetic foot exams, etc.) are kept (See Fig. 1.1). For systems still using paper charts, patients’ medical charts could also be placed by the nurse/MA on this table as each patient is returned from the exam room to the group room. These medical charts would include today’s DIGMA chart note, which would be partially completed by the nurse/MA and paper clipped to the front cover (perhaps with the sections for vital signs, injections, performance measures, routine health maintenance, and reasons for today’s visit completed by the nurse/MA).

It is best for the physician and behaviorist to sit closest to the door leading to exam room, with their backs to the door, so the nurse/MA only needs to walk a short distance to get from the exam room to the group room in order to speak with the physician or place medical charts and partially completed referral forms as wall as chart notes on the table. This arrangement also enables the nurse to call patients out of the group room with minimal disturbance to the group. Furthermore, should the nurse or MA need to speak briefly to the physician about a patient they are working with, the physician is located in a convenient seating position within the group room to hear what the nurse has to say. Also, it is a good idea to leave some space (perhaps slightly less than the width of a chair) between the physician on one side (i.e., on the opposite side from the table) and the behaviorist on the other, lest the patient adjacent to the behaviorist (or the physician) incessantly keep leaning over to quietly speak with them throughout the ­session—which can be both distracting and annoying.

Exam Rooms

A DIGMA requires one properly equipped exam room located near to the group room, and sometimes two—i.e., in the event that both an MA and a nurse are utilized, and they each use a different exam room. In most cases where both a nurse and an MA are utilized, one nearby exam room is typically employed (one which contains two stations with desktop computers). Otherwise, if only one nurse or MA is utilized, a single station with a desktop computer is adequate. Since the MA will often use the exam room while acting as care coordinator during the last half of the DIGMA (or PSMA) session, it is also helpful to have a printer installed. On the other hand, a PSMA typically requires two to four exam rooms (most commonly four, especially in primary care). However, these four properly equipped exam rooms can be located in the physician’s office area rather than nearby the group room, although the nearer, the better. For physicians who might only have two exam rooms of their own, running a PSMA that utilizes four exam rooms usually necessitates holding the group session when another colleague (who also has two exam rooms, which are near to those of the PSMA physician) is consistently absent—provided that this arrangement is acceptable to the colleague.

Reserve Rooms on an Ongoing Basis

The group and exam rooms must be reserved on an ongoing basis as there is almost always a high demand for these facilities and we do not want competing resource demands to interfere with the SMA program. Having dedicated SMA group rooms is best because it avoids a whole host of potential scheduling conflicts that can so easily arise from a wide variety of sources within the system. If rooms are shared, highest priority must be given to the SMA program because it substantially leverages physicians’ time (plus, SMA groups are scheduled on a regular and ongoing basis). In fact, as discussed in the Savings explained section of Chap.  2, the DIGMA and PSMA models so dramatically ratchet up productivity that a single group room dedicated to them can create the equivalent of 2.5 physician FTEs out of existing resources.

Obtain List of Patients on Your Panel by Diagnosis

It is recommended that the program coordinator obtain a list of all appropriate patients identified as being on the physician’s patient panel—for example, all patients assigned to that provider or, if that is not available, perhaps all patients seen by that provider during the past 2 years. If possible, this list should be broken down by diagnosis and should also include each patient’s medical record number, address, phone number(s), and date of last visit. Although this list is for later use by the dedicated scheduler in an effort to top-off any future unfilled DIGMA or PSMA sessions, patients on this list must first be approved by the physician before they can be called by the dedicated scheduler.