On March 18, Devin Sawyer, M.D., director of the residency program at Providence St. Peter Family Medicine in Olympia, Wash., sat down with two of his patients -- sisters in their 40s he's been seeing for years -- to help them accept that they have diabetes and create action plans to help them control the disease. The group grew a bit larger, he said, after they decided to call in a third sister, as well, to help her get her diabetes in check. (Sawyer is the physician for the entire family of six Samoan sisters.)
Devin Sawyer, M.D., treats three diabetic sisters during a group visit at Providence St. Peter Family Medicine Residency Program: (from left) Camille Maae, Madlyn Mapu and Christine Mapu.
"I finally convinced them that they might be able to help each other," Sawyer told AAFP News. "We spent about an hour and 20 minutes with all three in the same room, basically doing what I would have done normally with one after the other. We spent a lot of time talking about lifestyle changes, behavior changes and self-management, and by the end of it, they were making bets with each other on who was going to do better."
This experience, pretty commonplace in Sawyer's office, is what he calls a "mini-group visit."
Sawyer was a panelist at the Health is Primary(www.healthisprimary.org) city tour kickoff in Seattle on March 19, where he discussed his successes using group visits to treat patients. Health is Primary is a multiyear communications campaign of Family Medicine for America's Health, a partnership of eight family medicine organizations, including the AAFP.
Success of Mini-group Visits
Sawyer has been practicing at Providence St. Peter Family Medicine for 18 years and has been running the residency program for the past five years. He still sees patients, but because he spends 70 percent of his time running the program and training residents, his panel has diminished from about 600 to 280.
- Devin Sawyer, M.D., director of the residency program at Providence St. Peter Family Medicine in Olympia, Wash., has had great success using what he calls "mini-group visits" to treat patients.
- Sawyer said the mini-groups work best when the same three patients meet for the group visits every three or four months.
- The two biggest barriers to regularly using these mini-group visits to see similar patients, said Sawyer, are "productivity widgets" and the payment system.
According to Sawyer, whenever he sees a diabetic patient who is trying to learn how to manage the condition, he can't help but think that patient could benefit from meeting others with the same diagnosis.
"So when I am seeing my patients, I am always thinking what other patients would benefit from meeting each other," Sawyer said. "Then I put them together in groups of three, and over time, I try to convince them to try something a little different. Rather than coming in and seeing me for 15 minutes, they can come in and share their time with other people who they don't know and help each other."
Sawyer said he has tried various iterations of group visits, from two people to as many as 25, but three seems to be the magic number.
"Arranging three people to see the same doc on the same morning or afternoon just requires lining up their appointments and having them come in for the same hour," he said. "I also encourage family members to come if they are living with a spouse, mother, son or daughter, because these conversations are about living."
A designated medical assistant (MA) does all of the prep work for the mini-group visits, including calling the patients a week or two ahead of time to schedule lab work and get their shots and referrals taken care of. Then when patients come in for the one-hour visit, Sawyer has all the data he needs. The ideal setup is for the same MA to attend the group visit and transcribe what takes place, he said. Sawyer uses a whiteboard to display all of the patients' data including their glycated hemoglobin, low-density lipoprotein and blood pressure levels; their weight; and the list of medications they're currently taking.
"Then my focus is on those three patients and not a computer," Sawyer said. "We navigate through a conversation of what it's like to live with diabetes. I integrate the medical piece toward the middle of the visit, then give the patients suggestions on what they can do to try to create action plans out of that interaction -- medication, referrals, lifestyle changes, exercise and stress management."
Devin Sawyer, M.D., has seen great success using "mini-group visits" to treat diabetic patients at his family medicine residency.
These group visits do not replace the patients' regular office visits, and patients are still seen periodically between mini-group visits. "The visits essentially augment the patients' other visits and I try to connect them all," Sawyer said. "If a patient is making an action plan at a mini-group visit and I see them back two months later for an infected toe, I will ask about the action plan."
He also said the mini-groups work best when the same three patients meet for the group visits every three or four months. "They hold each other accountable, check in with each other, and I've had patients exchange phone numbers and call each other between appointments," Sawyer said. "That is really when it works wonderfully."
Sawyer has also found success using group visits for other patients, including those who are trying to quit smoking and pregnant teenagers. In the latter group, members meet from early in their pregnancy until they deliver their babies.
Launched in 1994, the teen pregnancy group meets every other Thursday afternoon from 2:15 to 5 p.m. Eight to 10 pregnant teen patients are invited to the group meetings, which use a classroom format designed to educate them about being pregnant. Topics covered include what's happening to their bodies, nutritional needs, delivery, postpartum expectations and being a new parent.
The teens rotate through five rooms during each group visit to meet with integrated care team members: a social worker, the group's designated MA, a nutritionist, two third-year residents who are learning how to do group visits and Sawyer.
"These eight to 10 pregnant teens get to know each other through the course of their pregnancy," he said. "In a regular clinic, you would usually see these patients once a month until you got to the last trimester. The classroom format is more dynamic and conversational than a regular 15-minute office visit. We teach the residents how to run these classes and integrate games, competitions and different teaching approaches that can best reach 15-year-old teens."
Sawyer said group visits don't have to occur solely in the office, either; he's done them as home visits, too.
"We had a really great (group) home visit a couple years ago where my medical assistant and I had two grandparents -- both diabetic -- their daughter, who had just had a baby, and two other teenage kids who needed their shots," he said. "So in their kitchen over the course of two and a half hours, we did two diabetic visits, two teenage well-child checks, a postpartum depression check and a 2-month-old well-child check, giving the baby its first set of shots."
A week before the home visit, the MA had the two diabetic patients come in to get their labs done so they could discuss the results during the upcoming visit. Having the results in hand allowed the medical team to bring with them a prescription for the diabetic man and to convince him to take it -- a first for this patient, who previously had denied having the disease.
Learning About and Overcoming Barriers to Group Approach
During their three years in the Providence St. Peter Family Medicine Residency Program, 21 residents, working with 20 practicing faculty members, see the bulk of the 7,000 to 8,000 patients who visit the clinic.
Thomas Tavai poses with an action plan to control his diabetes that Devin Sawyer, M.D., wrote for him on exam-table paper.
The residents Sawyer oversees now are taught how to perform mini-group visits as part of the curriculum. Once a month, two residents are assigned to a diabetes mini-group and medical staff members help them get three of their patients scheduled for the visit at the same time.
"It is a different skill set for facilitating a group visit versus a one-on-one visit," Sawyer said.
According to Sawyer, the two biggest barriers to regularly using these mini-group visits to see similar patients are "productivity widgets" and the payment system.
Regarding productivity, he pointed again to the need to break each primary care practice day into 15-minute segments -- regardless of what the patients actually need that particular day -- to maintain the financial stability of the practice.
"You see your four patients an hour and you do that until 5 o'clock, try to get your notes done, come back the next day and try to do it again," Sawyer said.
Arguably, the payment picture is even worse, he said, because trying to do group visits with no related codes or with codes that reimburse poorly or aren't reimbursed at all by half of the insurance carriers means losing money and creating financial stress for the clinic.
Sawyer said one reason he's chosen to continue concentrating on mini-group visits is because even though it takes more time to do one such visit than the three independent visits he would otherwise have conducted, he still bills the same. "On paper, it doesn't look any different for my work overview," he said.
Why the Groups Work
Sawyer recommends using a group approach to patient care because, he said, "it fits so much better to where the patient is at."
"Part of the frustration of primary care is the concept of noncompliant patients," he said. "And really, it's our own fault. We have plugged patients into these 15-minute time slots, tell them what to do and then wonder why they didn't do it. Instead, we need to use motivational techniques to get them engaged and ready to participate."
Sawyer said this is most easily accomplished when a physician has an hour with several patients who have shared experiences and are at different places in their disease. This helps them self-manage, engage and even re-engage, when necessary. And it helps them connect better with the medical team, particularly the MAs.
Sawyer said he now participates in two to seven group visits a month, including a couple during which he teaches residents how to conduct them, and sets of three of his own patients in mini-groups every three or four months.
"If I was in private practice doing my own thing, I'd be doing (group visits) every day, without a doubt," he said. "My highlight of the day today will still be those three sisters, by far."