Group Visits Mix Learning With Laughter

Charm. Coax. Prod. Teach. And, says FP Scott Whiddon, M.D., give patients with diabetes “unconditional positive regard” in a group visit setting. Add patient-to-patient mentoring, mix in lots of laughter, then sit back and watch the magic.

Twice a month here, Whiddon gathers together some of his patients with diabetes for group visits. After a year of effort, he pronounces the concept a success.

“It’s the highlight of my week,” he says. “We have a good time.” And, adds Whiddon, group visits play an important part in providing quality care for patients with this chronic disease.

The Future of Family Medicine report encourages group visits. FP Report visited Whiddon and one of his partners to spotlight the visits in this fifth article in a series on the report’s recommendations. To read the FFM report, go to http://www.annfammed.org/cgi/content/full/2/suppl_1/s3.

The FPs’ practice, Tallahassee Memorial Family Medicine, Quincy, with three FPs and one pediatrician, serves a rural area northwest of Tallahassee. Whiddon alone has nearly 500 diabetic patients. Before he began group visits, Whiddon repeated the same medical information over and over again. “Why would I want to go through the same spiel eight times a day when I can do it once in a way that’s fun?” he asks.

Whiddon is participating in a group visit pilot project sponsored by the Florida AFP Foundation with funding from Pfizer Inc. and AstraZeneca (see Group visits get boost from Florida AFP Foundation pilot project). In the past year, he’s organized six groups of patients with diabetes, each group meeting once every three months. “It’s a little like an Alcoholics Anonymous group,” says Sandy Baker, E.M.T., who assists Whiddon. “By talking, patients teach one another.”

For each patient attending a group visit, the practice bills for a level four visit with CPT code 99214.

“We’ve not had any problem with reimbursement,” says office manager Quinton Nealy. Because the practice is designated as a rural health clinic, it receives a flat monthly fee from Medicare and Medicaid, he says. The practice’s two largest HMOs are capitated, resulting in capped checks each month. Nealy says he hasn’t seen much of a jump in revenue yet, but scheduling hassles have dwindled. “By getting a group of patients in at one time, we’re opening up slots during the day for other patients,” he says.

Whiddon measures success differently. “If I can do as well or a little better (financially), have this much fun, and make an impact on patients, how is that not successful?” he asks.

On the day of the FP Report visit, seven patients keep their group visit appointment with Whiddon. Each had received a written invitation two weeks earlier and a reminder call the day before the visit. Patients due for lab work had blood drawn ahead of time so their charts would be up-to-date.

Shortly after 2 p.m., patients filter into a meeting room set up with fresh fruit, bottled water and an array of brightly colored patient education materials. Whiddon has already spent one-on-one time with each patient, checking vital signs.

Patients greet one another like old friends. “How are you feeling?” “I hurt so bad I could hardly get out of bed.” “I gained nine pounds over the holiday!” “I cut back on my eating.” “I was walking a lot, but I got lazy.”

Eventually, Whiddon gains control of the hubbub and reminds the group why they are assembled. “You guys are pioneers in what will probably be a standard across the country in 10 years,” Whiddon says. “It’s up to you whether you continue to do group visits or schedule appointments the boring, old-fashioned way.”

Whiddon eases the discussion toward diabetes issues, going over the basic review of systems necessary every time he sees one of these patients. But the conversation is surprisingly fun. Imagine this: Four women and three men sit around a table with their physician, discussing how diabetes affects their bodies and doing so with frequent outbursts of laughter.

As Whiddon goes through his checklist, which includes topics such as pain assessment, compliance, diet and exercise, and various body parts, he keeps his audience engaged. The camaraderie and Whiddon’s unconditional positive regard for each individual in the group help draw these patients here every three months.

Group visits also provide an opportunity to include guest speakers (for diabetes, think podiatrist, ophthalmologist, nutritionist). Today, an exercise physiologist waits to take center stage (see Outside speaker spices up group session).

It’s 5 p.m., the patients have gone home, and Whiddon remains to answer a few last questions. “We’re the pioneers working out the bugs,” he says, acknowledging that group visits require some time-consuming preparation. “Right now, it’s front-end loaded. I spent an hour with charts this morning, and Sandy had about an hour of preparation as well,” he says. But with a computer database set up exclusively for his patients with diabetes and with constant improvement to software templates, Whiddon sees that prep time shrinking in the future.

He’d like to expand group visits to include other disease groups such as chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease. “Our whole model for chronic care management is wrong,” says Whiddon. “We’re set up for acute care.”

Whiddon’s dream in five years? “Every afternoon would be a group visit about some chronic disease,” he says.