Group Primary Care Visits Improve Outcomes for Patients With Chronic Conditions
Group Primary Care Visits Improve Outcomes for Patients With Chronic Conditions
Hill Physicians Medical Group, an independent practice association in Northern California, offers 60- to 90-minute group appointments for patients with chronic conditions such as diabetes, hypertension, and chronic obstructive pulmonary disease, as well as menopause, prenatal care, and precolonoscopy. These group appointments can enhance physician productivity, as they allow physicians to provide followup care and counseling to a greater number of patients (up to 15 patients are seen in an hour during the group visit, compared with 4 patients who can be seen each hour via regular appointments). A study conducted by the independent practice association found that diabetes patients receiving group care had better outcomes than those receiving usual care, including being more likely to meet goals related to blood glucose, blood pressure, and low-density lipoprotein cholesterol levels. Anecdotal reports also suggest that the program has resulted in high levels of patient and physician satisfaction and fewer outpatient and emergency department visits and hospitalizations.
San Ramon, CA
Date First Implemented
Timely access to office-based medical care is a persistent problem, causing long waits for appointments and excessive emergency department (ED) use. As a result, physicians face continued pressure to increase their productivity, especially as they are called on to provide care to growing numbers of patients with chronic illnesses. One innovative alternative to one-on-one office visits is a group visit, in which a physician simultaneously provides followup care and counseling to 10 to 15 patients with the same chronic illness.
- The growing access problem: Numerous studies have illustrated delays in receiving care.1 For example, a 2001 Kaiser Family Foundation survey of insured adults younger than 65 years of age found that 22 percent had difficulty gaining timely access to a clinician when health problems arose.2 A 2001 survey found that almost 30 percent of women in fair or poor health reported a delay in or a failure to receive care due to their inability to obtain a timely physician appointment.3 Furthermore, patients' inability to schedule a primary care appointment promptly accounts for a significant portion of the 40 percent of ED visits that are for nonurgent conditions.4 Access to timely care is becoming a bigger problem; for example, a study found that 33 percent of people reported an inability to obtain a timely appointment in 2001, up from 23 percent in 1997.5
- Inefficient use of clinician time: Physicians who treat numerous patients with the same chronic disease or condition [e.g., diabetes, chronic obstructive pulmonary disease (COPD)] often spend a lot of time providing the same information and educational advice in separate one-on-one visits. This inefficient use of physicians' time can have a significant negative financial impact on the practicw6 and has negative implications for access (e.g., the ability to get timely appointments) for the entire patient population.7
- Group visits as an alternative: Group visits allow the physician to maximize productivity and efficiency by bringing together like patients for routine testing, counseling, and other services. Evaluations of group visits in other settings show that patients like them and that they lead to enhanced physician productivity (with increases of as much as 30 percent) and shorter waiting times for appointments (with wait times being reduced by approximately two-thirds).8
Description of the Innovative Activity
More than 50 of Hill Physician Medical Group's primary care physicians (PCPs) and a few of the independent practice association's specialists offer group visits as an alternative to one-on-one followup visits to patients with certain conditions. Key elements of the visits are described below:
- Chronic conditions included in group visits: Physicians may offer group visits for patients with any of a variety of chronic conditions, including diabetes, hypertension, postmyocardial infarction, asthma, and COPD. Some physicians also offer group visits to patients who are about to undergo a colonoscopy and to elderly patients with a variety of conditions who are high utilizers of health care services. Patients with any of these conditions are provided with the option of participating in group visits, but they are free to stick with traditional one-on-one visits if they prefer.
- Soliciting participation: Physicians post a generic flyer in the examination rooms to solicit patient interest. More effectively, physicians may suggest group visit participation to appropriate patients during one-on-one visits. Interested patients simply schedule their followup appointment with the group instead of with the physician alone. Patients may join or drop out of group sessions at any time.
- Scheduling logistics: Group appointments are slotted into the physician's schedule well in advance. Each physician-led group visit can hold up to 15 patients and lasts 60 to 90 minutes. By contrast, the typical one-on-one visit lasts for approximately 15 minutes.
- Elements of a group visit: Patients are provided the same care in a group visit as they would receive in a one-on-one appointment, including the clinical components of care.
- Group discussion: The session begins with patients being asked to share any issues or concerns they may have; other group members often contribute to the discussion by offering strategies and advice from their own experiences. Physicians can invite guest speakers, including specialists, to address a particular topic at the PCP office, rather than sending the patients one-on-one to the specialist office. For example, a podiatrist can do foot examinations and discuss foot care with diabetics. This expands the physician's knowledge and allows the specialist to consider offering his/her own group appointments.
- Clinical component: Each patient receives any necessary clinical services, including weigh-ins, blood pressure readings, prescriptions, and discussion of laboratory test results. The physician frequently enlists a medical assistant or nurse to assist with the clinical services, which can be done in the group, in a separate area while the patient excuses her/himself from the group, or a few minutes before or after the actual group. Individual's clinical measures are shared and discussed during the session (with the patients agreement and reminders for the group members to retain confidentiality). The physician charts each patient's condition and progress as would be done for a one-on-one visit. Patients who require a physical examination can be seen individually before or after the group session.
- Development of an action plan: An action plan is developed in collaboration with each patient at each group session. These plans help the patient to set specific goals that can help them to better manage their condition; for example, a patient with dietary issues might agree to maintain a food diary until the next group session. Questions that help the physician and patient to develop the action plan include the following:
- What action are you (the patient) willing to take?
- How often are you going to do it?
- When are you going to do it?
- What challenges might prevent you from meeting your goal?
- What idea(s) do you (or others) have to meet these challenges?
- Who will be your support person?
- How will you reward yourself?
- On a scale of 1 to 10, how confident are you that you can complete this goal?
- Teleclasses: Some physicians—typically specialists—offer telephone-based group visits. These “teleclasses” are offered for conditions where there is a great need for information exchange but relatively little need for face-to-face contact. For example, gastroenterologists offer teleclasses on irritable bowel syndrome, hepatitis C, and gastroesophageal reflux disease.
- Reimbursement: Hill Physicians Medical Group reimburses physicians for group visits at the same rate they would for one-on-one visits. Patient copayments for the group visit are also the same as they would be for an individual visit. Physicians holding teleclasses, however, are paid a flat fee to facilitate the telephone visits, not according to a per-patient visit rate. Visiting specialists are paid an honorarium or an office visit fee depending on the type of visit they are providing (educational vs. clinical.)
Context of the Innovation
Hill Physicians Medical Group is an independent practice association with more than 3,000 independent physicians practicing in approximately 900 locations across northern California; physicians may exclusively treat Hill patients or may be affiliated with other medical groups as well. The association is reimbursed by health plans on a capitated basis (i.e., a flat rate per member per month) but pays its physicians according to a fee-for-service schedule. Hill's leadership developed the group visit program as part of an effort to better align the organization's vision of quality improvement with factors of importance to practicing physicians. Hill's leaders were attracted to the idea of group visits because of their potential to increase clinical outcomes (a potential that was based on evidence from social learning theory), access to care, patient flow, and patient volume.
The group visits have led to improved clinical outcomes for diabetes patients, along with anecdotal reports of high levels of patient and physician satisfaction and fewer outpatient and ED visits and hospitalizations. Group appointments can generate more office visits than one-to-one appointments; however, the independent practice association believes the clinical improvements attained prevent more expensive care down the line. The added satisfaction attained by those attending group increases the likelihood the patient will still be with the independent practice association when these gains are generated.
- Better outcomes for diabetes patients: Given that diabetes care lends itself to the combination of clinical treatment, education, and support, Hill Physicians Medical Group studied the outcomes of diabetes patients who participated in group visits. The analysis indicated that patients who participated in group meetings had higher levels of improvement than did patients who received only one-on-one care:
- More likely to achieve goals: Overall, 88 percent of patients who attended at least two group sessions lowered their blood glucose (hemoglobin A1c) levels, while 66 percent reduced their blood pressure. Before attending group appointments, 27 percent of patients had achieved their hemoglobin A1c goal ( & lt;7), compared with 50 percent who were at goal after attending two or more group sessions. Before group participation, 44 percent of patients had met their diastolic blood pressure goal ( & le;80 mm Hg), compared with 75 percent who had achieved the goal after attending two or more group sessions. Comparable figures for achieving cholesterol goals (low-density lipoprotein & lt;100) show 27 percent of patients being at goal before participation, compared with 44 percent being at goal after attending two or more sessions.
- Comprehensive testing for microalbumin: All patients who attended two or more groups had a microalbumin test result in their chart; all patients testing positive were placed on an angiotensin-converting enzyme inhibitor.
- Weight loss: Overall, 64 percent of patients attending group visits lost weight (with an average loss of 14 pounds, ranging from 5 to 56 pounds), while 36 percent reported a minor weight gain (with an average gain of 5.6 pounds, ranging from 3 to 8 pounds).
- Anecdotal reports of reduced downstream utilization: Anecdotal data suggest that patients attending group visits have fewer ED and hospital visits, fewer requests for urgent appointments, and higher satisfaction with the physician.
- Anecdotal reports of enhanced physician and patient satisfaction: Anecdotal reports suggest that group appointments have enhanced physician satisfaction by allowing more time for patient education, ensuring that visits are less boring and repetitious, enabling group support to reinforce the physician's message, promoting greater alignment of care with evidence-based guidelines, providing a more efficient way to provide care, and improving access to care. Anecdotal reports also suggest that the program has increased patient satisfaction, quality of life, and confidence in the ability to live with chronic health problems.
Planning and Development Process
Key steps in the planning and development process include the following:
- Development of curricula: Hill's director of integrated health developed group visit curricula and associated materials for women's health issues, annual physicals, and diabetes care. After being briefed on the curricula, physician leaders in various Hill practices expressed their opinion that group visits for diabetes care held the most promise.
- Piloting of group visits for diabetes: The director of integrated health selected eight practices (including some practices of the physician leaders who were initially consulted) to pilot the diabetes group visits.
- Withdrawal of set curriculum: The pilot sites found that use of a set curriculum required physicians to function primarily as teachers, rather than clinicians. This finding led Hill Physicians to change the program to emphasize the provision of clinical care but in a group setting; any patient education required is provided at the physician's discretion, without a set curriculum.
- Setting a billing code and reimbursement level: Hill Physicians Medical Group decided to reimburse group visits as physician-led group appointment; by using a separate code for group visits, Hill physicians could easily track participation and outcomes.
- Obtaining physician buy-in: Physician buy-in was obtained informally, via a combination of physician champions, sharing of the experiences of early adopters, and general relationship-building between the director of integrated health and physicians. As part of physician education about group visits, the director created a 20-minute video to be shown at quarterly PCP panel meetings; the video, which was discussed as part of a continuing medical education class on group appointments, depicts an actual group appointment with voice-overs highlighting the benefits and mechanics of group visits.
Resources Used and Skills Needed
- Staffing: The program requires no additional staff. The director of integrated health at Hill spent time developing and implementing the group visit program.
- Costs: The group visit program entails no significant additional costs, and, as noted, saves physician time. However, patients can attend group appointments every month, which increases outpatient utilization for many patients. Since the association pays primary care doctors fee for service rather than capitation, this increases costs. However, clinical outcomes improve and should reduce more expensive utilization downstream.
Tools and Resources
The measures used by Hill Physicians Medical Group to assess their group visit program were the measures used by the California Office of the Patient Advocate for the California Health Plan Health Maintenance Organization (HMO) Pay for Performance report card (see http://reportcard.opa.ca.gov/rc/hmorating.aspx). These measures are closely aligned with National Committee for Quality Assurance's HEDIS ® (Healthcare Effectiveness Data and Information Set) measures.
Getting Started with This Innovation
- Check health plan reimbursement rules: Paying physicians at the same rate for group and individual appointments is possible in a capitated system that offers payment on a per-member, per-month basis regardless of how the dollars are spent. However, health plans that cover medical services directly may offer limited per-patient reimbursement for group visits. (California HMOs use the delegated model; after the medical group is capitated by the health plans, the group has control over how its spends these funds as long as the mandated services are provided.)
- Schedule early and account for no-shows: Schedule ongoing appointments well in advance to “routinize” group participation. Assume a 25 percent no-show rate when booking appointments; however, be prepared for all participants to show.
- Target potential participants: Use registries; electronic medical records (EMRs); and pharmacy, laboratory, and claims data to identify lists of potential participants. Include “model” patients along with “problem” patients, so that best practices in self-care can be shared, and patients can be motivated by success stories.
- Employ multiple strategies to ensure high participation: Encourage all physicians in the practice to recruit potential participants during one-on-one visits and have group appointment slots programmed into the appointment system on an ongoing basis. If necessary, issue written invitations approximately 4 to 6 weeks before the group meeting. Promote visits with posters and/or flyers. Make reminder calls to attendees a few days before the appointment.
- Ensure that the lead physician is prepared for the appointment: Identify and collect needed materials (e.g., name tags, laboratory slips, prescription pad, educational materials) before appointments so that the physician has all needed supplies readily available. Pull participant charts or run EMR reports and review them before the group appointment.
Sustaining This Innovation
- Allow customization: Meetings can be tailored to the physician's personal style and comfort level.
- Respect patient confidentiality: Remind patients to respect each other's confidentiality, use first names only, and ask permission to share clinical information.
- Ease participants into the session: Explain the meeting agenda to patients before beginning the formal session. Begin the visit with an “icebreaker” question (e.g., “What bothers you most about your diabetes?” or “What is one thing you would like to accomplish today?”)
- Encourage the physician to act as a facilitator: Physicians should listen to patients rather than lecturing them. Let participants suggest solutions to each other whenever possible. Identify and publicly acknowledge patient successes.
- Include action plans: Each session should close with an action plan to promote improvements in clinical outcomes and health status.
- Add group appointments to the regular physicians schedule: This allows patients to make group appointments as their next visit and avoids the need to send separate invitations as the group appointment approaches.
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