Planning Group Visits for High-Risk Patients
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You'll not only have more satisfied patients and better compliance, but you'll also be compensated for your services.
Fam Pract Manag. 2000 Jun;7(6):33-36.
The changing health care environment has altered the relationship between many physicians and their patients. Physician productivity demands have resulted in larger panels, increased use of midlevel providers and other trends that threaten patient education and outcomes by limiting patients' access to their personal physicians.
Group visits offer a cost-effective solution. In contrast to the typical 15-minute office visit, a two-hour group visit with 20 patients permits ample time for education and discussion. The benefits are wide-ranging: reduced health care expenses, improved patient and provider satisfaction, higher immunization rates, fewer repeat hospital admissions and fewer visits to the emergency department and subspecialists.1 And group visits are billable services (see “Documenting and coding a sample group visit”).
With appropriate data and documentation, group visits are reimbursable services.
Group visits increase compliance, improve patient satisfaction and reduce health care expenses.
Allow about four hours to plan and conduct a group visit.
In our experience, group visits have enhanced patients' dietary compliance and improved intermediate markers for diabetes and coronary artery disease. We attribute these improved outcomes to patients having more time with their physicians and getting answers to questions they might otherwise never have asked, as well as our sense that they seem more empowered.
We started experimenting with group visits as part of a pilot study of group visits in the management of poorly controlled type 2 diabetes. After one year, we noted a 32 percent reduction in total cholesterol/HDL ratios, a 30 percent reduction in HbA1c levels and a 7 percent reduction in health care expenses. After this success, our clinic expanded group visits to patients with coronary disease, GERD (gastroesophageal reflux disease), hearing impairments and obesity. A subsequent randomized clinical trial in patients with known coronary disease showed improvements in dietary intake that were associated with reduced health care expenses. (S.M., unpublished data, 1998)
Documenting and coding a sample group visit
The patient: A 60-year-old female with type 2 diabetes and diabetes-related neuropathy who takes glyburide 10 mg daily.
Before the visit: The physician reviewed the progress note from the patient's first group visit six weeks ago. Her HbA1c level was 8.3, her foot exam revealed sensation loss, and she was referred for high-risk foot care instructions. She was also referred for eye screenings, and she received 45 minutes of education regarding diabetic targets, diet and exercise. A follow-up creatinine was 1.2. Fasting lipids were at target.
The physician noted the patient's “past medical history of neuropathy and history of MI two years ago” on the group-visit progress note form. He wrote a prescription for an additional diabetes medication and filled out a lab slip for a repeat HgbA1c test in three months. He noted his assessment — “type 2 diabetes, not at target, with complications” — and customized the plan.
At the visit: The nurse obtained subjective and some objective information, added it to the progress note and delivered the new diabetes medication prescription to the patient. The physician briefly mentioned the new medication to the patient and discussed its indications and side effects in detail with the group. The physician signed the note.
After the visit: This physician billed the patient's insurer for a 99214 established patient office visit under the diagnosis code 250.02. (Visits with patients with controlled diabetes who had the same evaluation and plan but no medication change were billed 99213 under the diagnosis code 250.00.)
Editor's note: Ensure that the level of service you bill corresponds to your documentation.
A guide to planning
Group visits can proceed relatively smoothly if you plan them carefully in advance. Each part of your planning process sets the stage for you to empower your patients to improve their compliance and clinical outcomes.
Focus. Not all patient problems are appropriate for group visits. Physical exams, acute care needs and topics involving sensitive personal issues should continue to be addressed on an individual basis, but many types of medical problems lend themselves to the group-visit format, particularly those that are common, costly and responsive to lifestyle changes. The following are just some of the conditions that can be effectively addressed in group visits:
CHF (congestive heart failure),
Coronary artery disease,
Irritable bowel syndrome,
Goals and curriculum. To empower your patients to take responsibility for their health, it's important to choose and share evidence-based screening and therapy targets with them. And think beyond what's covered in typical office visits and use a format that isn't lecture-based — one that will engage your group more. (See “Developing your curriculum.”)
Developing your curriculum
Here are some ideas to help you start planning the educational content of a group-visit program:
Create individualized flow sheets that list patients' current laboratory results and target values.
Request lecture materials from local chapters of the American Diabetes Association, American Heart Association, or your local hospital's dietitians, physical therapists or nurse educators. Obtain and hand out AAFP patient education materials, and review them with your patients.
Develop reading lists of books your patients can use to address lifestyle changes. Often, a book can guide future group visits and discussions.
Plan cooking demonstrations to emphasize healthy eating.
Plan a field trip to an area grocery store to teach food-label reading and shopping techniques.
Organize a potluck meal with recipes picked from health-oriented cookbooks.
Compile lists of healthy foods patients may add to their diets rather than a list of foods they should cut from their diets. (See “Dietary Therapy for Preventing and Treating Coronary Artery Disease,” American Family Physician, March 15, 1998, page 1299.)
Invite an outside speaker, such as a dietitian, to address the group. You should plan to remain present during the entire group visit to answer specific questions and provide follow-up assistance.
Scheduling. Group visits can be held annually or more frequently, depending on the need. For example, a group of patients with coronary artery disease might be seen annually to monitor evidence-based therapy targets, including lipid levels, medication use, emergency use of nitroglycerin, anticoagulation use, blood pressure levels and current diet and activities. In contrast, a cohort of patients with poorly controlled type 2 diabetes might be better served by being seen every six to eight weeks to address disease-specific therapy targets with emphasis on glycemic control, hypertension and lipid management, and foot and retinal exams. In our experience, two hours is the optimal length for most group visits.
Patient participation. Once you determine what the group will focus on and how often it will meet, you must identify which patients should be included. Here are two potential methods:
Review pharmacy prescription data (e.g., to identify all patients treated with diabetes medications).
Search billing data for disease-specific diagnosis codes (e.g., to identify patients with angina or coronary disease).
Your findings can be used to develop a diagnosis-specific patient registry, which can be updated as patients visit the office and request refills and at scheduled intervals. [See “Building a Patient Registry From the Ground Up,” FPM, November/December 1999.]
To permit adequate enrollment, you should issue written invitations at least six weeks before the first group visit. Our experience suggests that half to one-third of the patients you invite will agree to attend. For us, dropouts have not been common in group visits that are conducted annually, but we've had a 10 percent to 15 percent dropout rate for group visits that occur fairly frequently (e.g., every eight weeks). Explain in your invitation letter that the two-hour group visit requires payment of the usual office fee or co-pay. The letter should also encourage spouses or partners to attend the visit at no charge. (Anticipate that for every 20 patients, 10 significant others will join the group.) Your letter should also reassure patients who do not want to participate that you will continue to see them as you have in the past.
Accommodations. If your clinic does not have a room that will accommodate 30 people in classroom-style seating, contact your local hospital, community center, church, synagogue or school. They often allow outside organizations to use rooms in their facilities.
Staffing. Schedule two to three medical assistants or licensed practical nurses for the first 30 minutes of the group visit to collect data such as blood pressures and weights, conduct foot exams (for patients with diabetes), ask a few focused questions for progress note documentation and distribute laboratory slips and handouts. Make sure all staff involved modify their schedules so you can begin your group visit on time.
Chart review. A few days prior to the group visit, you or your nurse should review each patient's chart, document recent lab results and the dates when recommended screening tests were last completed and determine whether each patient in the group is at target. In our experience, this review enables us to complete the assessment and plan during the chart review and document them in the note prior to the group visit. We use a standardized progress note form to streamline the documentation process (see “A group-visit progress note form”). Of course modifications can be made based upon information obtained at the group visit. Often prescriptions and referrals can be written and lab slips can be completed during the chart review as well. For example, hypertension or lipid therapy can be initiated or adjusted. The benefits, risks, side effects and treatment options of different therapies typically can be reviewed with the whole group during the visit.
A group-visit progress note form
The progress note form was developed as part of a group-visit program for patients with type 2 diabetes. It is designed to enable physicians to complete much of their documentation prior to the group visit. It's always necessary to make additions and changes during the patient encounter, but preparing for group visits with a form like this one can help you to proceed more efficiently.
Anatomy of a group visit
Allow about two hours to plan and two hours to conduct a group visit with 20 patients.
Before the group visit: 60 minutes for preparing or obtaining discussion material and/or scheduling guest speakers; 60 minutes for chart review and documentation.
During the group visit: 30 minutes for collection of subjective and objective data, discussion of potential changes in therapy with patients, signing of chart notes and completion of billing slips; 15 minutes for group members to introduce themselves and for you to share your agenda and time schedule on a flip chart; 45 minutes for didactic information sharing; 15 minutes for questions and answers specific to your educational message and to plan the next group visit.
After the group visit: 15 minutes for one-on-one meetings with patients to discuss urgent or unrelated problems they may bring to your attention during the group session. In our experience, one or two patients, at most, have needed attention for minor complaints.
Pitfalls to avoid
A couple of obstacles, if not thought about ahead of time, can derail a group visit.
Interruptions. You obviously need to start a group visit on time; however, emergencies, admissions and newborn deliveries easily can thwart your best intentions. Make advance arrangements for hospital and clinic coverage.
Low attendance. No-shows can increase during group-visit sessions, particularly if patients think of these activities as a class rather than a visit. One day prior to the group visit, have someone from your office staff call the participants and say, “Your physician expects to see you at your appointment tomorrow,” which confirms an appointment they cannot skip. Group visits led by physicians usually have better enrollment and far fewer no-shows than group visits led by midlevel providers. When guest speakers are planned, advertise that information to your patients, and let them know that you will also attend. Special events such as cooking demonstrations also promote increased attendance.
If you focus on an appropriate condition and plan thoroughly, the group visit format offers you and your patients a win-win situation. [To learn how one practice in Olympia, Wash., put group visits to work, read “Making Good Time With Group Visits,” FPM, July/August 1997, page 70.]
For willing patients, group visits provide several advantages, including greater patient satisfaction, improved lipid and blood sugar levels, improved dietary intake, better immunization rates, lower urgent care and emergency room visits and reduced health care expenses. For physicians and other health care professionals, group visits are billable services that increase the time available for direct patient education.
Dr. Masley is assistant director of the Morton Plant Mease Family Practice Residency Program in Clearwater, Fla., and an assistant professor of family medicine at the University of South Florida College of Medicine in Tampa. Dr. Sokoloff is a family physician in private practice and a clinical instructor of family medicine at the University of Washington, Seattle. She also works with the Family Practice Residency Program at Providence St. Peter's Hospital in Olympia, Wash. Collene Hawes, RN, is director of care management at the Group Health Cooperative of Puget Sound in Olympia, Wash. The authors coordinated their initial group visit work with diabetic and cardiac trials with funding from the Group Health Cooperative of Puget Sound.
1. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: The cooperative health care clinic. J Am Geriatr Soc.1997;45:543–549.
Copyright © 2000 by the American Academy of Family Physicians.
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