Sep 10, 2016
Weary of trying to manage complex diseases in 15-minute increments, many primary care physicians are trying group visits as a way to spend more time with their patients and potentially improve outcomes. The group visit model has gained traction in recent years as physicians look for ways to improve care without jeopardizing the financial health of their practices
“In today’s healthcare environment, it’s challenging to simultaneously maintain access, engage patients and improve quality of care,” says Marianne Sumego, MD, an internist and director of shared medical appointments at Cleveland Clinic in Cleveland, Ohio. “Group visits can help us address all three of those challenges.”
Group visits typically include about a dozen patients who share the same chronic condition, such as diabetes or heart disease, but physicians have also been using the visits to address other issues, such as advance care planning and weight loss. The meetings typically start in the same way as a typical office visit, with clinicians taking vital signs and adjusting medications privately, then move into group presentations on disease-related topics, social interaction and support, and assistance with disease self-management.
Besides improving care, group visits can make good financial sense, because they enable physicians to see multiple patients at once. Physicians can use the same Current Procedural Terminology (CPT) codes for reimbursement as they would for a one-on-one office visit.
“You need a setting where you can host a group and there’s a lot of prep work involved on the front end,” says Dennis Saver, MD, part of a 12-physician group practice in Vero Beach, Florida, who has been holding diabetes group sessions for the past decade. “But once it’s up and running, it becomes easier to keep it going.”
Patients thrive in groups
Several recent studies suggest that group visits, also known as shared medical appointments, can have a direct impact on improved patient outcomes. They’ve also been shown to increase patient satisfaction and patient engagement in self-managing their diseases.
“I used to try to squeeze a discussion about low or high blood sugar into five minutes during individual visits with each of my diabetes patients,” says Saver. “With group visits, I can spend more time on important topics, and less time repeating myself.”
The Diabetes Master Clinician Program, a web-based registry and training program, has documented a similarly positive trend. Saver, who uses the registry in his practice, says that his diabetes patients who take part in the group visits have 0.4% -0.6% lower HbA1c levels than those who do not.
At Cleveland Clinic’s chronic disease group sessions, there have been many cases of the group positively affecting patient decisions, says Sumego.
In one case, a woman with a family history of colon cancer expressed reluctance to schedule a follow-up appointment after her screening test showed a precancerous polyp. However, she decided to proceed with the follow-up after another participant described how a routine screening test had detected her cancer early enough to be treated.
“There’s value in patients encouraging each other that we as physicians are not able to capture when we see them one-on-one,” says Sumego. “This case was a really important lesson to me that one of the main benefits of shared medical appointments is to leverage the value of sharing experiences among peers.”
Group visits can take a variety of forms and it’s up to each physician to determine the format and content. However, Saver advises seeking out support from professional groups or other physicians before getting started. In his own practice, Saver relied on the training manual produced by the Master Diabetes Clinician Group, which offers a step-by-step guide to preparing for a successful first session.
One of the first hurdles is establishing a venue for the visits, says Saver, who hosts meetings in his office’s employee lunchroom. To protect patient privacy and ensure that they don’t run afoul of Health Insurance Portability and Accountability Act (HIPAA) regulations, some physicians have patients sign confidentiality and HIPAA disclosure forms. By signing such forms, patients confirm that their participation in the group is voluntary and promise to keep all information discussed during the visit confidential.
It’s also important to get everyone on staff involved in the planning process, says Sumego.
“Your team is critical and should be included in developing the workflow and the implementation plan from the beginning,” she says. “Talk with everyone about what it will take to check in 12 patients at once.”
The Master Diabetes Clinician Group guide recommends starting with a full staff meeting to explain how group visits are different from support groups in that they provide medical evaluation, medication adjustment, and care coordination in addition to support for self-management. Physicians should also explain that the group visit replaces some of the routine one-on-one office visits.
At the same time, it’s essential to identify someone in the practice—whether it’s the physician or another clinical staff member—who can act as facilitator and has the skills to lead and manage interactive group discussions, says Saver. “Group visits are not meant to be lectures,” he notes. “The process should be fun and useful and encourage patients to share their personal experiences and insights with others.”
Group visits usually focus on one chronic illness but can encompass several. Jean Antonucci, MD, a primary care physician with a solo practice in Farmington, Maine, conducted group visits for about two years with a small group of patients. Participants had various chronic diseases, including diabetes and depression, and were drawn together by the need for support.
Antonucci says the meetings improved overall care but she stopped offering them because they were too difficult to manage on her own. She had to hold the sessions after business hours in order to use a waiting room she shares with another physician, and without support staff to help, she got bogged down in documentation.
“The patients loved it but it ended up being too much work for me,” she says. “You really need someone to help with charting so you can focus on leading the meeting.”
To determine the best size for the group, double the number of patients that would normally be seen in the approximate two-hour block reserved for the visit, says Sumego. That number should be small enough to facilitate group discussions but large enough to be financially beneficial for the practice.
Always plan for less than 100% turnout, the Master Clinician Group guide advises. As a general rule, about 30% of those invited will not come and, of those that do attend, only 70% will return for another visit.
Finally, develop an agenda with a series of planned topics and speakers, says Saver. He divides his meetings into two parts: A topical issue such as diabetes and eye disease or foot care takes up the first hour, followed by a refreshment break. The second hour focuses on disease management issues, such as HbA1C measurements, recognizing symptoms of high or low blood sugar, and sharing tips or experiences among patients.
Saver often invites specialists to speak at the meetings on diabetes-related topics. For example, an ophthalmologist might give a presentation about eye disease or a dietician might talk about food and nutrition issues.
The key is to tailor the content to the needs of the group, says Antonoucci.
“I picked people who had very high needs and were not likely to have social support,” she says. “I dealt with general issues around health confidence and problem solving because that’s what many of these patients have the most trouble with.”