Managing Your Practice

The Value of Group Visits


 

As with so many things, I had heard about group medical visits long before I offered them. I had not remotely thought of offering them. Then that mother of invention, necessity, pushed her way into my office.

I had been struggling to help my most difficult patients. These were the patients with multiple problems. Many were obese with diabetes and chronic pain. In addition to their disease burden, many faced chaotic lives. They were living in poverty and lacked support at home.

Although they had frequent office visits, I was not succeeding in getting them to clinical goals. I felt like a nag when I tried to help them make changes. It wasn't good for them or me. And that was when I remembered I had a tool I was not using.

In October 2006, I began to offer group visits to patients with overlapping problems. We meet in my waiting room once a month from 5 p.m. to 6:30 p.m. The goal is to have the group work together on problem-solving skills and common problems.

Before each group meeting, I assess the patients' charts to see who needs refills or labs and what issues need to be addressed. I start each group off on a topic. Sometimes I give them a lighthearted quiz.

I am careful not to run the sessions as a class. The goal is for the patients to interact and solve problems with one another. I am there as a guide. I use an easel and markers to write down key words as they come up, to help define and reinforce take-home points. These are not group therapy sessions. The groups focus on medical issues such as accepting the need to take daily meds, affording care, and forming strategies for managing pain and achieving good nutrition despite the constraints of family and finances.

One of the most rewarding topics focuses on assertiveness skills. More than any other aspect, helping patients with this skill helps them feel more confident in managing their stress and their medical care. Another recurring topic is how to deal with setting goals and managing setbacks.

The ideal group size is from four to seven patients. This seems to be the magic number that allows everyone some airtime and prevents any one person from dominating the conversation.

During the group visits, I meet very briefly with each patient individually to check weight and vital signs and discuss any particular issues.

I bill the same way as with an individual visit. However, the evaluation and management (E/M) codes do tend to be less robust in this setting.

Privacy is important to address from the outset. From the beginning, I have made it clear that no one need reveal anything he or she does not wish to reveal. I wrote down a list of problems that many of my patients share and asked each person to think about which ones applied to him or her. Inevitably, the participants do reveal details about themselves as they become comfortable. In addition, when I communicate with participants via e-mail to remind them of group dates, I make sure that messages are sent individually to safeguard privacy.

Group visits are efficient. The work we all do with patients is repetitive, and it is more efficient to do it once for five people than five separate times. I run an individual medical practice, so my panel is small. Nevertheless, the group allows four to seven people to be seen in the duration of time I would have needed to see three patients during one-on-one office visits.

The bottom line is that my patients have benefited. The beauty is that when they solve problems with the support of their peers, they are more likely to set manageable goals. And when they achieve goals, there is a lovely positive feedback cycle that begins. This grows confidence.

Confidence is an undermeasured tool in our practices. Confident patients are more compliant and achieve better outcomes.

As a physician who is seeking to help motivate healthy behaviors, I find the synergistic value of group visits both humbling and rewarding.

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