May 2003 Table of Contents

IMPROVING PATIENT CARE

Group Visits 101



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Group visits can improve patient care and relieve you from the treadmill of office practice. Here’s how to get started.

Fam Pract Manag. 2003 May;10(5):66-68.

Physicians have many reasons to feel frustrated with medical practice today. They face ongoing pressures to increase productivity and see more patients per hour. They face the demands of caring for increasing numbers of patients with chronic diseases. And they face growing financial strains. To counter these problems, many physicians are considering innovative alternatives to traditional one-on-one visits. Group visits are one such alternative.

The two most common types of group visits are cooperative health care clinics (CHCCs) and drop-in group medical appointments (DIGMAs). DIGMAs, first initiated by Edward Noffsinger, PhD, are generally 90-minute appointments coled by a physician and behavioral health professional. They are held at a designated time every week and are open to patients with any condition who simply “drop in” for the visits if they have need.

CHCCs, initiated by John Scott, MD, are perhaps the more common group visit model and the primary focus of this article. CHCCs are generally two-hour appointments led by a physician with nursing support. The visits are devoted to a specific disease or health topic, and patients struggling with it are invited to attend. In our experience, between one-third and one-half of all invited patients usually participate. Practices can also invite family members or caregivers, who will attend about half of the time.

The value in group visits is that they relieve physicians from the treadmill of office practice. By allowing physicians to see groups of patients at one time, they help increase physician productivity and decrease the practice’s cost per visit. They provide a break from traditional office visits, where physicians often find themselves repeating the same advice. They reduce backlogs in schedules that are clogged with low-acuity, recheck appointments. They also help improve care for patients, particularly those with chronic diseases, and can increase patient compliance and satisfaction.

A two-year randomized clinical trial of 321 chronically ill older patients enrolled in Kaiser Permanente in Colorado found that, compared to controls, group-visit patients had fewer emergency room visits, fewer visits to subspecialists, fewer repeat hospital admissions, fewer phone calls to physicians (although more phone calls to nurses) and greater overall satisfaction with care.1

In another study, a clinic found a 32-percent reduction in total cholesterol/HDL ratios, a 30-percent drop in HbA1c levels and a 7-percent reduction in health care expenses among patients attending group visits for poorly controlled type-2 diabetes.2

Preparing for a group visit

Initial preparation to launch group visits can be significant and involves the following steps:

1. Decide on an appropriate group of patients. Group visits are most effective with high-volume, costly patients, such as those with hypertension or obesity, older patients with numerous comorbidities or patients with six or more visits in the last year. Select a group that is particularly problematic, costly or otherwise notable for your practice.

2. Determine group visit frequency. Group visits can be ongoing, perhaps meeting monthly, or can meet for a limited period. The frequency will depend on the needs of the group of patients you select.

3. Enlist support. You will need strong nursing and administrative staff support during the visits. For a group of 15 to 20 patients, you generally will need one administrative person available at the outset of the visit and one or two nurses or medical assistants present to take vital signs and assist with discussions.

4. Identify potential patients. You can identify patients suitable for group visits based on ICD-9 codes, disease registries or available prescription data.

5. Develop a message to enlist patients. Physicians can deliver the invitation personally to patients during regular office visits, or practices can invite patients by phone or by mail. (See the sample invitation.) Be sure to let patients know that their physician has selected them to receive the invitation and communicate the benefits of attending, such as peer support, education, improved self-care and the potential for improved clinical outcomes.

GROUP VISIT INVITATION

Download in Microsoft Word format

You are invited to join your doctor and other patients in our practice for a “group visit.” It’s an idea that other doctors around the country have found helps them care for their patients in ways that cannot be accomplished during the usual 15- to 20-minute office visit.

Here’s how it works: Your doctor and one of our nurses will visit with you and approximately 15 to 20 other patients for about an hour and a half in a conference room here at our office. During the visit, there will be time for talking with other patients as well as education about specific health problems. Then, your doctor will spend time talking with each patient individually about health problems and concerns. If you have additional health concerns that need to be addressed, there will also be time to meet alone with your doctor after the group visit. Of course, the visits are completely voluntary.

The group visit program was set up to provide an additional opportunity for patients to meet with their doctor on a regular basis and to learn how to deal with common health problems. Group visits also give patients the opportunity to learn from other patients who are dealing with similar health problems and to get their health needs met and their questions answered. From time to time other health professionals, such as pharmacists or health educators, may join your doctor and nurse at the visits.

The date and time of the next group visit is listed at the bottom of this letter. If you are interested in attending, please let your physician or nurse know. You are welcome to bring a family member or friend with you.

When you come in for the group visit, simply check in as usual with the front desk and pay your usual co-pay. The receptionist will direct you to our meeting place.

We welcome your possible interest in this new opportunity for you to participate with your physician in your health care. Of course, if you decide not to participate, your doctor will continue to see you at the office as in the past.

Sincerely,

Your Doctor’s Office

Next group visit date and time: __________________________

Our phone number: ______________________________

Copyright © 2003 Suzanne Houck. Published with permission. Physicians may photocopy or adapt for use in their practices. All other rights reserved. Houck S, Kilo C, Scott JC. Group visits 101. Fam Pract Manage. May 2003:66–8; www.aafp.org/fpm/20030500/66grou.html.

Group-visit format

Group visits generally begin with a brief check-in and greeting period. During this time, the administrative staff registers patients, collects co-payments, etc. This is followed by a general discussion of the targeted disease or health topic, focusing on common problems among attendees (approximately 30 minutes). Patients are seated in a circle or semicircle to promote interaction and are encouraged but not required to share their personal information and experiences.

Following the discussion, the group takes a break, often with refreshments, while a nurse or medical assistant completes vital signs and the physician confers with each patient individually – yet still in the group setting – about specific health problems. (This could take 30 to 40 minutes for a group of 15 to 20.) This is followed by a question-and-answer period (approximately 15 minutes). Finally, if needed, physicians conduct private one-on-one visits, usually with just two to three patients (30 to 45 minutes).

Prior to the group visit, nursing staff typically spend about two hours of preparation time, reviewing and documenting medical records as well as completing forms for diagnostic tests and lab work. Physicians may spend about an hour after the group visit to document findings.

HOW TO CODE GROUP VISITS

Group visits have been the subject of ongoing discussions by the CPT Editorial Panel. Until a specific CPT code is developed for group visits, if ever, the panel has recommended that physicians use E/M code 99499, “Unlisted evaluation and management service.” However, physicians who conduct group visits say they successfully bill for them using E/M office-visit codes (e.g., 99212 or 99213) according to the level of care that is provided and documented for each patient. Physicians should check with their individual payers to confirm that the codes they submit for these services are reimbursable under the circumstances.

A common pitfall of group visits is the tendency for physicians to assume a didactic role when clinical questions arise. In more successful groups, physicians will refer clinical questions back to the group for discussion and feedback. This builds self-care confidence and helps patients shift from a passive role to a more active role in their own care.

Although pressures to “do more with less” will certainly continue into the foreseeable future, group visits offer a way to “work smarter, not harder” while satisfying patients and physicians alike.

Sue Houck, CEO of Houck & Associates in Boulder, Colo., has assisted physician groups and hospitals nationwide in achieving sustainable improvement in clinical operations. She also has experience as a manager and clinician in ambulatory care and is a frequent speaker and author on key trends in health care.

Dr. Kilo practices with GreenField Health System in Portland, Ore.

Dr. Scott is an assistant professor of medicine in the Division of Geriatrics, University of Colorado Health Sciences Center in Denver.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

1. Beck A, Scott J, William P, et al. Randomized trial of group outpatient visits for chronically ill older HMO members: the cooperative health care clinic. J Am Geri Soc. 1997;45:543–549.

2. Masley S, Sokoloff J, Hawes C. Planning group visits for high-risk patients. Fam Pract Manage. June2000:33–37.

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