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Friday, May 7, 2010

Group visits

A number of practices in the TransforMed National Demonstration Project (NDP) implemented group visits.  Several practices did diabetes visits, and some did prenatal visits. The practices agreed that group visits greatly improved care outcomes and peer-to-peer support and learning for patients. They did, however, find group visits time-consuming. One practice estimated spending 60 staff hours in preparation for a 2 hour diabetes visit – probably far above the average, but something to think about.

Several years ago, before the NDP, I had experimented with group visits.  I was disturbed by how many of my female patients weighed over 200 pounds.  These were women under 6 feet, so none of them should have weighed that much.  From an EHR search of my 3000+ patients (of whom 75 percent are women), I found that 600 of them weighed over 200 pounds and 200 of them weighed over 300 pounds!  This fact was very distressing.  I felt that my 15 minute face-to-face encounters were not doing the job.  And, to be honest, counseling during occasional 15-minute visits alone is not the best way to help a patient lose weight and learn to eat better.

My office manager and I visited several exercise facilities in the area and were able to secure discount coupons for patients who attended our planned weight-loss group visits. We obtained dietary information handouts from a dietitian friend and BMI calculators from a pharmaceutical rep.  (For the record, my office manager and I spent about 10-12 hours combined to prepare, not 60!)  I then solicited patients for interest based upon office visit content.  I soon had a list of 12 interested patients. We scheduled the visit for a Friday afternoon when the clinic was usually closed.  Three of the 12 who had signed up actually came.  For the second group visit, I charged a “holding fee” of $10, and five of 10 signed up showed up.

I conducted the group as the only provider.  We calculated caloric requirements for weight loss for each person and reviewed general dietary principles, deciding as a group to follow a low-carbohydrate diet. Beginning weights were recorded, and two of the members formed a “walking group,” planning to walk together daily. The group had one follow-up visit, with modest weight losses of 3-4 pounds per member over 1 week.  The group decided they did not want to continue to meet and thought they could maintain the program on their own. I did not bill insurance companies, since weight loss counseling is a “never-covered” service.

The patients paid $10 for a 1 hour group visit.  In retrospect, this was a very low fee, and perhaps we would have had more participation if the fee had been higher.  We did not find this format to be any more successful in helping with weight loss than normal visits.  Most weight loss groups do work by accountability and money committed but charge much higher fees and have more intensive programming.

I have no current plans to schedule more group visits, although I might if I were to measure some clinical outcome that told me that individual visits weren't doing the job in helping patients live with asthma, diabetes, or some other chronic condition.

Though my experiment was not very successful, NDP practices collectively have a wealth of experience with group visits, and I'll benefit from that if I do decide to try again. Diabetes has been the most popular disease state around which to construct a group visit.  Peer education in patients with diabetes is powerful in encouraging adherence to lifestyle changes and therefore in promoting improved control of diabetes.  Group visits can work for a variety of different patient types, however.  Moreover, physicians can get paid for their work in a group visit as long as the visit incorporates one-on-one time with each patient and documentation supports the level of E&M code billed. 

The group visit set-up can provide a change in the daily routine of visit after visit.  The practice works more as a team, pulling in other staff members to do teaching and evaluation.  Many practices in the NDP networked with community providers, bringing in dietitians, dentists, or pharmacists as guest lecturers. If you think you might want to try a group visit, it's easy to learn more. The TransforMed web site provides a list of resources on group visits, the AAFP offers advice on implementing group visits, and Family Practice Management has published several relevant articles and tools, which you'll find in the "Access to care and information" section of the FPM's collection of Patient-Centered Medical Home Resources.

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About the Author

Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.

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Real-Life Practice Transformation is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.