KEY ACTIVITY #19:
Provide Group Visits for Chronic Care Management
This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; pre-visit planning and care gap reduction; behavioral health integration.
Overview
Group visits involve a healthcare team facilitating an interactive process of care delivery. A group visit allows patients to learn from each other while being supported and empowered with information and encouraged to make informed healthcare decisions by the care team.
A group visit requires coordination and advanced planning. It typically involves a group of eight to 15 patients, all of whom share a common condition. Patients are able to express a primary question or issue they hope to get addressed during their visit. The lead clinician will often provide general coaching and answer questions. Once a clinician has completed their initial portion of the visit, another care team member can take over the group visit, providing engagement, education and counseling. For example:
- A pharmacist might go over common medications and challenges patients face with their medications.
- A nutritionist can speak to dietary counseling and meal preparation for a healthy lifestyle.
- A behaviorist might address mindfulness practices.
While the general education time is underway, a clinician can see each patient individually and address specific questions or issues. While a face-to-face interaction with a medical clinician is necessary to bill for a group visit, in practice, different team members – such as a behaviorist, pharmacist or nurse – can and do take responsibility for developing and facilitating the group visit.
In a 90-minute visit, a clinician can see every patient individually while the patients benefit from the multidisciplinary care visit and peer learning and support. This visit model is more productive (even with no-shows) and frees up many individual slots for higher-intensity visits of other patients, thus improving access for the broader panel of patients.
Group visits are a powerful model to foster peer support and shared learning to help build patient self-efficacy. Peer support encourages patients and provides the opportunity to share lessons learned from life experience.
Group visits can be inclusive and offered to all patients. They break down social barriers that contribute to health inequities. Group visits also can result in new social bonds that result in strategies to address social needs (such as transportation issues through ride sharing). They help empower those who have not been able to develop the health literacy or self-activation skills necessary to be confident in managing their chronic condition.
Action steps and roles
1. Determine your group visit condition.
Suggested team member(s) responsible: clinical leadership.
Determine which condition you want to be the focus of your group visit. It is best to have group visits involving people with similar conditions who can share their own experiences and best practices in how they are adapting to their chronic condition.
2. Plan for group visits.
Suggested team member(s) responsible: LVN or MA.
Plan your group visit with a timed agenda outlining what will happen during the group visit (e.g., the educational component, nutrition counseling, when the clinician will see patients individually, any testing required during the visit, etc.). The Serve the People Community Health Center created a toolkit that provides guidance for planning and resourcing diabetes group medical visits, as well as flowsheets with roles and responsibilities outlined.
Pull charts three to five days before the group visit. As agreed upon by the team, perform chart review to identify specific patient needs to be accommodated and to identify gaps in care. Confirm whether you will have extended members of the care team participate, and recruit and prepare them for their roles (e.g., pharmacist, nutritionist, social worker, etc.). Staff should also prepare materials required for the visit (i.e., labels, education materials, etc.)
Remind the primary care clinician about the upcoming group visit. Ensure the room housing the group visit is ready and set up with all materials needed for the group visits. Community Medical Centers developed handouts for their group medical visits that address A1c, blood pressure, healthy eating and goal setting.
3. Determine how to bill for group visits.
Suggested team member(s) responsible: administration and billing staff.
Complete billing information as needed. Group visits should be billed as individual encounters as long as patients are seen one-on-one by the billing clinician during that visit. The level of complexity of the visit should include all services provided in this interdisciplinary shared medical appointment.
Billing is a common challenge for group visits. Keep in mind that during a group visit, the clinician sees every patient hands-on; therefore, this should be documented as a medical office visit and should follow traditional documentation for an individual visit. It is important to note that the physician's contact with the patient is longer than most routine office visits.
Since many other activities are happening during the group visit, you can add the appropriate modifiers to enable you to code at the correct level of intensity. For UDS purposes, the visit can be counted as an individual encounter as long as it meets the traditional criteria (each patient is seen one-on-one and the clinician is using individual clinical decision-making). See the UDS countable visits guide for more information.
4. Recruit patients for your pilot.
Suggested team member(s) responsible: clinicians and care team members.
Identify candidates and register them for a group visit after determining their level of interest. They should be identified based upon set criteria (i.e., current treatment adherence, care gap needs, treatment complexity, etc.).
5. Plan the visit with a clear understanding of the roles.
Suggested team member(s) responsible: Nursing Staff/Medical Providers
Circulate in the room during break, performing vital signs and identifying patients who need individual attention.
Provide a brief educational module and lead a discussion. An example would be for the physician/advanced practice professional to provide a five-minute brief education on what diabetes is and why complications arise. This might include visuals to help patients process the information. This would be followed up with a question-and-answer period where all patients benefit from questions from others.
During break, review individual needs and make one-on-one individual appointments for after the visit.
6. Evaluate and scale group visits.
Suggested team member(s) responsible: care team members.
A natural progression of group visits is to start with a single condition (such as diabetes) and an early adopter champion and then progressively scale your group visit model across your organization to be available for all eligible patients with that condition. Starting with a smaller group allows for challenges to be worked out before a larger rollout. This is not an insignificant challenge for health centers as it requires constant refreshing of the curriculum and updating information based on the latest evidence base.
A future activity is to expand your group visit model to other conditions, using what you have learned from your early pilots and scaling.
An advanced model for group visits incorporates your patients into the design and execution of the group visits. An example might be to include a patient with expertise in exercise and wellness as a future speaker for a module in a group visit.
Examples
In this quick video from a Canadian practice holding group visits for maternal health, the patients are empowered to do their own vitals. In this approach, an alternative clinician conducts the educational modules.
This alternative workflow from the University of Virginia focuses on women with cardiovascular disease.
The Group Visits Improve Diabetes Self-Management case study describes the implementation of diabetic group visits and the lessons learned at the East Valley Community Health Center.
Implementation tips
- Understand that group visits are not for every patient, condition or clinician. Like all new innovations, there will always be a small cohort that does not favor the group visit, and that is their prerogative. Some patients will not like group visits. Some clinicians are not suited for group visits. However, for certain populations, this visit model is highly effective.
- At the beginning of a group visit, remind participants of ground rules on confidentiality and respect.
- Encourage patient engagement during the group visit. Patients often comment that the peer support and what they learned from others were as valuable as the interaction with the care team.
- Inventory your staff to see if you have team members who have skills outside of work that can be leveraged for your group visits (e.g., personal trainers, yoga instructors, etc.).
- Consider teaching patients to do their own vital signs at the beginning of the group visits, thus positioning them to continue to do so at home and to take advantage of evolving remote monitoring technologies.
- Consider practical learning opportunities for patients, such as going to a grocery store to learn about reading nutrition labels and effective shopping techniques.
- Fully leverage your care team so that all documentation is completed by the end of the visit; this would relieve all from the burden of having to do documentation later.
- Consider using alternative staff (e.g., volunteers, AmeriCorps) to staff visits.
Evidence base for this activity
- Beck A., Scott J., Williams P. Robertson B., Jackson D., Gade G., Cowan P. A randomized trial of group outpatient visits for chronically ill elderly HMO members: The cooperative healthcare clinic. Journal of the American Geriatric Society 1997: 45;543-549.
- Masley S., Solokoff J., Hawes C. Planning for group visits with high-risk patients. Family Practice Management 2000; 7:33-38.
- McKenzie M., Scott J. “Cooperative healthcare clinics deliver primary care in a group setting.” Guide to Managed Care Strategies, Burns J & Northrup LM, Eds. New York: Faulkner and Gray, 1998.Noffsinger EB, Scott JC. Understanding today’s group visit models. Group Practice Journal 2000:48(2):46-8, 50, 52-4, 56-8.
- Sadur CN, Moline N., Costa M., Michalik D., Mendlowitz D., Roller S., Watson R., Swain B.E., Selby J.V., Javorski W.C. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999 Dec; 22(12):2011-7.
- Scott J., Robertson B. Kaiser Colorado’s cooperative healthcare clinic: A group approach to patient care. Managed Care Quarterly 1996:4(3);41-45.
- Scott J.C., Gade G., McKenzie M., Venohr I. Cooperative healthcare clinics: A group approach to individual care. Geriatrics 1998:53(5);68-81.
- Terry K. Should doctors see patients in group sessions? Medical Economics January 13, 1997;74-95.
- Thompson E. The power of group visits. Modern Healthcare June 5, 2000.
- Beck A., Scott J., Williams P. Robertson B., Jackson D., Gade G., Cowan P. A randomized trial of group outpatient visits for chronically ill elderly HMO members: The cooperative healthcare clinic. Journal of the American Geriatric Society 1997: 45;543-549.