Group Visits to Family Physicians Result in Improved Outcomes

Terry Hartnett

September 28, 2006

September 28, 2006 (Washington) — Faced with the challenge of an aging population with complex medical needs and a payment system that pays for procedures rather than outcomes, family practice physicians are looking for ways to enhance their medical practice that provide more patient-centered care.

One way that more personal care can be given to patients is by using a group visit model, John Scott, MD, a geriatrician at the University of Colorado Health Sciences Center, Denver, CO, said here at the annual scientific assembly of the American Academy of Family Physicians (AAFP).

"Originally, physicians didn't like the idea of a group visit," said Dr. Scott. "What we have found is that the relationship between doctor and patient is completely different in this model and much more personal," he said. "Patients are satisfied because they are involved in their own personal care, [and] have the ability to ask questions that they often forget in a short office visit. Physicians find this model efficient and it puts the joy back into their practice."

In the early 1990s, Dr. Scott developed a group visit model. The primary goal of the Cooperative Health Care Clinic (CHCC) at Kaiser Permanente in Denver, Colorado, was to increase the quality of care to geriatric patients. This model currently is being used by physicians at the Cleveland Clinic, Group Health Cooperative, Puget Sound, Washington, as well as a number of group practices, including Kaiser Permanente sites in California and Colorado.

The group visit is a monthly standing office visit for 12 to 15 patients ideally. Patients are invited by the physician to participate in this group setting. Participation is voluntary and the same patients generally attend each session. Patients are encouraged to commit to regularly scheduled visits. The physician practice sets aside a specific amount of time — usually 2 to 2.5 hours — on a routine basis. The group visit can be held monthly, quarterly, or just once depending on the circumstances. Any lab work (eg, HbA1c) is completed a week prior to the visit. During the group visit, patients are seated together. Also at the meeting are the physician(s), nurse facilitator, and other healthcare providers as appropriate.

The first 10 to 15 minutes are what Marlene McKenzie, RN, MN, group medical appointment consultant, described to session attendees as a "cornerstone of the program's success." The warm-up session allows for personal time for everyone in the group including the healthcare providers. Education is interactive between the healthcare professionals and patients and is tailored to the group.

The nurse makes rounds in the room taking initial blood pressures or other routine screening measurements. The physician meets one-on-one with each patient. This can be done in the group setting or in a separate meeting between the physician and patient in an adjacent office, Ms. McKenzie said. If the patient prefers, or if it is medically necessary, the patient may be seen in a regular office visit after the group visit. The final portion of the visit is dedicated to group planning of the next visit.

Dr. Scott noted that the group concept works best for follow-up visits and routine care. Examples include groups for patients with diabetes, hypertension, or even well-baby visits. Some physicians have used this model to handle preoperative physicals.

"I do not recommend the use of this model for new patients," Dr. Scott added. He noted that this model is attractive to all ages. The number of patients in each group and the time set aside for the group visit can vary depending on the individual physician practice.

Ms. McKenzie, who coaches physicians in using this model, said satisfaction is high among patients and physicians. "We create a personal medical care notebook for each patient," she explained. The group visit also covers issues like advance directives, durable medical equipment, and routine health maintenance.

This group visit model of care has proven successful in many ways, Dr. Scott said. Several randomized controlled trials conducted by Kaiser Permanente in 1991 and 1995 demonstrated fewer emergency department visits and fewer repeat hospitalizations. A 2005 Kaiser study of diabetes patients who attended group visits showed improved clinical outcomes (lower HbA1c levels, lower low-density lipoprotein cholesterol levels) and physician adherence to the use of clinical practice guidelines.

Dr. Scott described a second type of group visit called the "drop-in group medical appointment" (DIGMA). In contrast to the CHCC model, the goal of the DIGMA is to provide access to physicians and reduce costs, said Dr. Scott. A group practice sets aside 90 minutes each week for clinical-only visits with 10 to 15 patients or fewer. The DIGMA model usually is set up according to disease state. "Productivity increases dramatically in this model," said Dr. Scott. Generally, the physician can see twice as many patients in the same time period.

Physicians who choose to try a group visit model should be aware of 2 key issues, the presenters said. HIPAA rules and Centers for Medicare and Medicaid Services (CMS) and insurer payments. Regarding HIPAA restrictions, patients must sign a privacy waiver before the session begins. CMS currently will not pay for group visits unless the physician does one-to-one private care with the patient. In some cases, the provider may obtain permission through the Medicare fiscal intermediary.

Georgetta Lupold, MD, a family practice physician from Valley View, Pennsylvania, employed by the Penn State Geisinger Health System, said there is a great deal of interest in the group model among her colleagues. After attending the session, she said she is likely to develop a CHCC model for diabetes patients. "Some days I see 6 patients with diabetes in a row and repeat the same information. This model will let us do a lot more teaching," she said.

AAFP 2006 Scientific Assembly: Group Visits: New Models for Health Care Delivery. Presented September 27, 2006.

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