What It Takes to Make Group Visits Work

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:

1. Administrative support. The New River program largely owes its success to Sally Hurst, a self-management outreach coordinator at Marshall University in nearby Huntington, W.Va., who helped set up the group visits, and to Linda Stein, a social worker who now coordinates the program, says Dan Doyle, MD, a primary care physician in the New River program. “It takes Linda's organization and advance planning for every visit to make this work,” he says.

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.

1. Customized patient groups. To promote bonding that keeps patients coming back, it helps to organize groups around demographic and disease similarities, notes Doyle. For example, New River offers a black lung group for retired miners, as well as women's health, chronic pain, and chronic disease groups.

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.”

1. Creative scheduling. Two-hour daytime visits are no problem for the many retirees and patients on disability at New River. But many of St. Peter's patients work during the day and don't want to spend 2–3 hours at a group visit, says Sawyer. He tinkered with the scheduling and found that more working patients would come for hour-long, smaller group visits during the day.

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.

1. Motivated patients. Group visits won't work for patients who want the quick, traditional doctor's visit, says Kevin Haughton, MD, residency program director at St. Peter. The group format should be a choice, not a mandate, he says, because it only works for the 30–40% of patients he estimates find it more motivating.

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.

1. Committed physicians. Finally, physician motivation is just as important to group-visit success as patient motivation, says Sawyer. Physicians who feel uneasy about losing the control of a one-on-one patient interaction probably should stick to traditional visits because group visits require physician buy-in, he advises.

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. ▪