Care of Patients in Groups: The New Model of Healthcare

Peter S. Bernstein, MD, MPH

Disclosures

April 19, 2006

When people idealize medical care, they picture the old-time family physician on a house call visiting a sick child in her bedroom, then sitting at the kitchen table discussing the child's condition with her worried parents over a cup of coffee. For better or worse, this model of care no longer exists, but still people imagine the epitome of healthcare to be personalized one-to-one care with the undivided attention of their provider.

But is the individual visit always the best way to deliver care? A conference, The Power of Connection: Group Health Care for the 21st Century, held March 26-28, 2006, in Chapel Hill, North Carolina, and sponsored by the Centering Pregnancy and Parenting Association (www.centeringpregnancy.com), has begun to lay the foundation to challenge this paradigm -- not just in the realm of prenatal care, but also for other areas of care. This conference provided an opportunity for providers from various areas of healthcare to describe how they have begun to use the group care model as a way to improve the delivery of medical care.

I have written before on the Centering Pregnancy model of group prenatal care[1] and how this model of care does a better job than traditional prenatal care of achieving the goals of prenatal care as put forth by the US Public Health Service Expert Panel on the Content of Prenatal Care in 1989. This model of care was a highlight at the conference. In fact, Jeanette Ickovics, PhD (Yale University, New Haven, Connecticut), began the meeting with a presentation of an as-yet unpublished randomized trial that compared Centering Pregnancy with traditional care. The study found that women who received their care according to the Centering model had a significantly lower rate of preterm delivery -- approximately one third fewer preterm deliveries. If this finding can be replicated in other studies, it will be a remarkable contribution to obstetrics, because nothing (with the possible exception of 17-alpha hydroxyprogesterone) has so reduced the rate of preterm delivery. Even if it cannot be replicated, however, the group model of care holds numerous other potential benefits that were elucidated by speakers at the conference.

With mounting pressures on physicians to see more and more patients, providers have been forced to reduce patient visits to approximately 15 minutes. Obtaining patient histories is now often done by means of a form patients complete in the waiting room to not waste time with the provider asking lots of questions. Once in the examination room, the provider need only ask a few questions, perform an examination, and quickly suggest some plan of care before moving on to the next patient. Often the plan of care is then cursorily reinforced by support staff in the office. Clearly, this is far removed from the idealized model of care described previously.

Providers who have moved to the group model of care, however, have found that it allows them to spend more time with their patients. Lucy Osborn, MD (University of Utah, Salt Late City), spoke about how she used groups for well-child care. She described how seeing groups of 6 children of similar age together allowed her to learn much more about her patients than she could in the typical well-child visit. She could observe their development, their interactions with their parents, and their interactions with the other children.

Dr. Osborn noted that traditional well-child care up to about 15 months of age has been built around immunizations and monitoring growth. And yet the goals of well-child care are much more. They include disease prevention, health promotion, developmental surveillance, family support, and assistance with parenting. All this cannot be done in the time allotted for a typical well-child visit.

But by using the group model of care, in addition to being able to observe the children and their parents over approximately 90 minutes, Dr. Osborn described how she was able to engage the parents in a discussion about their children's health. Parents could watch her and other parents' model behaviors in caring for their children. Parents had the time to ask any questions they could think of and to learn from the questions that other parents asked. Additionally, parents could observe developmental differences between children, and the variations between children could become normalized for them.

Dr. Osborn described how this group model of care translated in her practice into patients being less likely to change pediatric providers; in addition, parents were more likely to complete all their well-child visits, and there were fewer unscheduled visits to the emergency department at the hospital. She noted that parents became better informed about child safety recommendations. Finally, providers were more satisfied with their jobs and with the care they were providing.

The opportunity for increased patient compliance with care is impressive with this model of care. Ray Cox, MD (Prince George's Hospital, Cheverly, Maryland), focused on patient safety issues -- a hot-button issue for obstetrics in particular. He believes that the Centering model of prenatal care does a better job of improving communication with the patient because the model entails 20 hours of patient contact time during the pregnancy compared with the 2 hours on average that is provided with traditional care. The group visits improve communication and stimulate patients to become partners in their own care. Greater trust develops between provider and patient, and the woman and her family feel more of a sense of control over their healthcare.

The benefit of improved communication cannot be understated. Janet Ohene-Frempong (J O Frempong & Associates, Philadelphia, Pennsylvania), who is a consultant on health literacy and communications, gave a shocking talk about the low levels of literacy in the United States. She noted that 43% of adults read at very basic levels or lower. Therefore, many patients find it extremely difficult to follow what providers think are simple instructions as to how to manage their medical conditions. The more time an individual patient spends in a group visit may thus translate into better understanding of what that patient needs to do to comply with a plan of care.

Dawn Clancy, MD (Medical University of South Carolina, Charleston), spoke about using the group model with patients with diabetes. In one of the studies she conducted,[2] she found that compared with patients who had individual visits, patients enrolled in group care were more satisfied with their care, had greater trust in their providers, and achieved more of the quality indicators of diabetes care (eg, foot examinations, eye examinations, serum lipids management, and influenza immunizations). Patients who participated in the group visits also reported that their care was more culturally competent.

Nowhere were the benefits of group visits more evident than in the presentation by John Scott, MD (University of Colorado, Boulder), who discussed his use of the model of group healthcare for geriatric patients. He described seeing groups of between 15 and 20 seniors for 2.5 hours each every month. Ninety minutes were spent on group care and 60 minutes were spent on one-to-one visits. In a randomized study that compared group and traditional care with more than 300 chronically ill elderly patients, Scott and his coauthors found that patients randomized to group care were more satisfied with their care and had fewer visits to the emergency department or repeat admissions to the hospital.[3] Additionally, as we have seen elsewhere, providers were more satisfied with the group model of care. This study was conducted with HMO members, and the cost of care per member per month was also lower for the group patients.

Dr. Scott noted that patients seem to respond better to learning about their condition when they not only learn from the provider, but also from someone else who has the condition. This is a theme that was reiterated by all the presenters at the meeting. Group visits lead to improved self-efficacy among patients as a result of a better understanding of their conditions; patients with a given condition also feel less isolated. We have long known the power of support groups. These models of care harness that power into concrete indicators of improved outcomes of care.

Group care is clearly not just a gimmick. Patients like it more; providers like it more; and healthcare outcomes seem to be improved in all kinds of settings. Given the constraints on the provision of healthcare today, the individual visit may no longer be the ideal way to deliver healthcare. This conference suggests group care may be the way of the future.

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