|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||
Polly Workman, 34, knew her type 2 diabetes was out of control when her glycated hemoglobin (A1C) shot up to 12.5%. Post-divorce depression had broken her self-management stride, so she sought help through group medical visits recommended by her primary care physician, Devin Sawyer, MD.
|
During these visits, several patients gather with their medical providers to review recent lab results and set disease self-management goals.1 They also learn from each other's difficulties and successes—the type of guidance it turned out Workman needed to begin regaining control of her diabetes. Her A1C is now down to 8.8%, she says. (The American Diabetes Association recommends that diabetes patients aim for an A1C <7%.)
|
"I don't feel alone any more," says Workman of the group visits. "The other patients share what medications and diets do and don't work for them. They help me out."
|
This buoying, group-huddle effect is exactly what Sawyer had in mind when he brought group visits to the St. Peter Family Medicine Residency Program, based in Olympia, Wash., in 1999.
|
"You can be sure a patient with a broken leg will come back with a cast on, but the odds aren't so good that a patient with diabetes will stay on a medication or diet regimen," explains Sawyer, director of St. Peter's group-visit project. "You need something more—the motivation of other people."
|
Something of a group-visit missionary, Sawyer secured a 45-month, $740,000 Robert Wood Johnson Foundation (RWJF) grant to grow his program in 2003. So did another group-visit program at New River Health Association in rural Scarbro, W.Va. Both used a portion of grant monies to encourage the establishment of permanent group-visit programs as part of the RWJF Diabetes Initiative, an effort to bolster self-care and community support for diabetes patients (see sidebar, "Augmented Diabetes Help in Primary Care," page 10).
A 3-year review of St. Peter's patient records reveals almost half of group-visit participants kept their A1Cs <7%. They also showed significant reductions in LDL cholesterol and increases in health goal-setting. Meanwhile, anecdotal data on New River's patients suggest they control their diabetes better after participating in group visits, which squares with past research findings.2–5
An obvious follow-up question might be, "Yes, but how do you get paid for services?" According to administrators at both sites, payment is actually comparable: Providers bill the same medical-management codes used for regular visits (Current Procedural Terminology code 99213). Administrators emphasize, however, that it takes several key ingredients to make group visits work: ongoing administrative support, customized patient groups, creative scheduling, motivated patients, and last but not least, committed, well-prepared physicians.
GROUP-VISIT RATIONALE
The group-visit model emerged in the 1990s with Kaiser Permanente's efforts to serve a growing load of chronic-disease patients receiving less face time with physicians.6,7 The thinking was these patients need extra support because they deliver most of their own health care at home.
Kaiser's answer was monthly group medical visits for 20–25 patients.6 St. Peter and New River have tweaked that model, lengthening the time between visits to 3 months and reducing patient numbers (see chart, "Group-Visit Snapshots"). St. Peter limits its provision of clinical services to groups of 3; larger groups of 7–12 patients attend "open-office" visits focused solely on discussion. New River's group visits are bigger still, serving 10–15 patients at a time.
Visits at both sites include foot checks, seasonal shots, prescription refills, and referrals. Before visits, participants undergo testing of kidney function, lipids, A1Cs, and the like, then discuss the results with the group. All patients sign Health Insurance Portability and Accountability Act forms to keep each other's health information confidential. In addition, each patient devises a self-management plan to work on between visits.
WHAT IT TAKES
Through the RWJF grants, sites have gleaned insights on what makes group visits work. After all, critics question if they can be cost- and time-effective and if physicians and patients can relinquish their traditional one-on-one roles.
Administrators at St. Peter and New River say these new approaches can work, but require the following:
Stein recruits patients for the sessions—a key function because the sessions require at least 10 patients each to break even financially, says Doyle. Stein also ensures that patients undergo previsit lab testing and provides the results to physicians for pregroup review. At St. Peter, medical assistant Shari Gioimo performs a similar coordination role.
Extra financial support—like that provided by RWJF—also helps launch group visits, say Doyle and Sawyer. New River receives additional funding as a Federally Qualified Health Center.
While many of New River's patients are older and retired, St. Peter's patients are more diverse. Accordingly, administrators there try to group younger patients who share similar workplace and childrearing challenges together; likewise with older retirees facing compounding physical problems, says Sawyer. "You don't want to put someone who wants to discuss resisting donuts at the office with someone who wants talk about getting around on weak knees."
Hence, the three-person "mini-group visit" was born. Meanwhile St. Peter holds larger, open-office visits 4–6 p.m., attracting older patients who enjoy the socializing and some younger patients who arrive late after work.
"We've modified the standard group-visit model to fit the needs of our staff and patients," explains Sawyer.
For a patient like St. Peter's Polly Workman, the biggest motivator is moral support. She found individual doctor's visits weren't working because she felt so alone trying to manage her type 2 diabetes.
By joining a mini-group, she enlisted others' support to help regain control of her disease. In fact, her father was recently diagnosed with type 2 as well, and has since joined her group. (Patients' family members are encouraged to attend group visits at both New River and St. Peter.)
For other patients, education is the main motivation. As a newly diagnosed type 2 diabetes patient, Mary "Ginny" Coleman of New River wondered how to change her diet and choose from an array of medical equipment. Group members have since enlightened her about insulin pumps and cooking with olive oil instead of fatback.
For many older patients, the motivation is largely social, says New River's Doyle. "Yesterday's group visit sounded like a prayer meeting," he says.
To make the visits work, physicians must supply energy and preparation, adds Doyle. For example, he takes an hour to read through patient charts before a visit. That front-end time is offset by the time saved seeing multiple patients. With the help of his group-visit team, he's actually able to serve more patients than usual. "In one session I hit 12 targets with one arrow, instead of one by one, over and over," says Doyle. "I see and help more patients on group visit days than on any other."
More important, he says, he sees group-visit patients' health improving.
"Patients do better and that's what really helps my productivity,"
Doyle says. 
Footnotes
To view a video about group medical visits at St. Peter Family Medicine Residency Program, go to www.rwjf.org/newsroom/profiledetail.jsp?id=21097&typeid=150 and click on "view this interactive."
More information about group visits at St. Peter and the New River Health Association is available on the Robert Wood Johnson Foundation Diabetes Initiative Web site at http://diabetesnpo.im.wustl.edu/programs/documents/GranteeBooklet-ALLPAGES_000.pdf.
To find out about lessons learned by the 14 grantees of the Diabetes Initiative, go to http://diabetesnpo.im.wustl.edu/lessons/summarySheets.html.
References
2. Trento M, Passera P, Tomalino M, et al.: Group visits improve
metabolic control in type 2 diabetes: A 2-year follow-up. Diabetes
Care 24:995–1000, 2001.
3. Trento M, Passara P, Borgo E, et al.: A 5-year randomized
controlled study of learning, problem solving ability, and quality of life
modifications in people with type 2 diabetes managed by group care.
Diabetes Care 27:670–675, 2004.
4. Clancy DE, Cope DW, Magruder KM, et al.: Evaluating group visits in
an uninsured or inadequately insured patient population with uncontrolled type
2 diabetes. Diabetes Educ 29:292–302, 2003.
5. Coleman EA, Eilertsen TB, Kramer AM, et al.: Reducing emergency visits in older adults with chronic illness: A randomized, controlled trial of group visits. Eff Clin Prac 4:49–57, 2001.[Medline]
6. Noffsinger EB, Scott JC: Understanding today's group visit models. The Permanente Journal 4:99–112, 2000.
7. Sadur CN, Moline N, Costa M, et al.: Diabetes management in a
health maintenance organization. Diabetes Care 22: 2011–2017, 1999.
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Related Article:
| ||||||||||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
