Group Medical Visits
Don't go it alone—it may be better to share appointments
The American health care system is based on a simple model: the one-on-one medical visit. Some practices, though, are trying to move toward a more social approach to health. Group medical visits, also called shared medical appointments, allow people with the same chronic disease to come together and learn from one another.
Meet the Group
Doctors first dabbled with group visits about 25 years ago, according to Robert Burke, MS, RN, FNP-BC, DNP, a nurse practitioner at Pace University in New York. Since then, group visits have taken various forms, but the key ingredient—what separates them from a support group—is that they double as a doctor visit. "Diabetes self-management classes are a wonderful intervention, but [historically] these visits were separate from the primary-care visit," says Burke. "If [patients] needed medication changes, they needed to make a separate appointment." The group visits allow patients to have a session with peers, either before or after meeting privately with their doctor. The private sessions allow for specific medication adjustments and personal questions patients would prefer not to share with the group.
Another critical part of the group visit model is the idea that people learn best from someone facing similar challenges. "I don't have diabetes so I don't have that lived experience," says Eileen O'Grady, PhD, RN, NP, a wellness coach. "It's a community of like people, so you don't feel alone. You're getting motivated by people's journeys, struggles, and successes."
Beyond offering access to a health care provider and the experiences of peers, group visits can vary considerably. Groups may include anywhere from three to 30 participants, meet weekly, monthly, or quarterly, and include a wide range of group leaders, including peer leaders, doctors, nurses, or other specialists. Some groups get together for a fixed number of diabetes self-management training sessions, typically three or four, while others meet regularly and indefinitely. Some sessions meet on a drop-in basis.
Take a group that meets in the Bronx, N.Y. It includes about 10 people with type 2 diabetes, a nurse practitioner, a mental health therapist, a diabetes educator, and a nutritionist. Lucille Ferrara, EdD, MBA, RN, FNP-BC, an assistant professor at the Lienhard School of Nursing at Pace University, is the Bronx group's nurse practitioner. She stresses that "there is no leader of the meeting." Instead, she says, patients drive the agenda. The group meets three times, once every two weeks for two hours. Right after each session, Ferrara meets with patients individually to change prescriptions, do examinations, or run tests.
Research shows that group visits generally help people with diabetes get healthier. A recent analysis of 11 high-quality studies found that group visits improved A1C (average blood glucose over the previous two to three months) compared with standard care. Plus, the longer people took part in group visits, the better their health outcomes were. People with diabetes who attended group visits for three months dropped their A1Cs an average of 0.3 percentage points. At four to six months, A1Cs went down by 0.4 percentage points. In nine to 12 monthsthe decrease was 0.6 percentage points. Two years of group visits lowered A1Cs by 0.8 percentage points on average, and four years led to a whopping 1.5-percentage-point reduction. People with diabetes who participated in group visits lowered their blood pressure levels, too, but didn't improve cholesterol results, according to the analysis.
Some studies show that group visits boost participants' self-confidence and quality of life, says Burke. "You're creating an environment allowing everybody to share their personal life experiences and allowing others to respond to it," he says. "Validation can be therapeutic." The research also shows improvement in participants' knowledge of diabetes and their self-care, suggesting that groups provided first-rate diabetes education.
Group visits seem beneficial, but no one has yet done the tedious work of figuring out what kind of group visit is most effective. "There are no best practices," says O'Grady. "No one knows the best way to do it." What is the ideal group size? How frequently should people attend sessions, and how long should they last? Do members fare better when the group includes, say, a dietitian? No one knows the answers.
Insurance reimbursement for group visits is a source of frustration among providers. There is no "code" for a group visit. Codes tell insurers how a particular medical service is reimbursed. Practices use many different strategies to get paid for group work, says O'Grady, and it's unclear whether having a single code would help or harm practices that do such visits.
The lack of a code also poses challenges for patients. Because there's no code for group visits, no one knows how many doctors are using them in their practices. This makes group visits difficult for patients to find. Burke suggests asking if your doctor is aware of any local groups; if not, you can propose starting one.
Carlton Lauray, 51, lives in the Bronx, has type 2 diabetes, and is an enthusiastic participant in group medical visits at Montefiore Family Health Center. "Something like this should have happened many years ago," says Lauray. "This program is exactly what [people with diabetes] need."
Last October, Lauray's health care provider, nurse practitioner Lucille Ferrara, invited him to join a health center group for people with type 2. At first, Lauray thought the sessions seemed like some kind of 12-step program. "You hear people's stories, and you start hearing your story," says Lauray. "You have to choose a new way of life to beat the addiction of eating wrong."
For the most part, the various providers left the group to itself, only piping up to lead the group to the next topic of discussion. This freedom allowed the people in the group to grow closer, to be open, and to learn from one another, Lauray says. "Our group got real deep," he adds. "We all became friends."
The group spent one session on overeating, discussing foods and situations that trigger it. Some said the holidays were hard. Others shared a weakness for fast food. One woman had a particular passion for chocolate; Lauray joked to the group that the way she described chocolate had a Sex in the City ring to it. "That really broke the ice," he recalls. "We all laughed; that really got us all close. We all started pulling for each other."
At another session, the providers invited participants to rate the care they got at the clinic. One gripe Lauray aired was about what he calls "mass production" health care, where a patient sees a doctor for only a few minutes before being ushered out the door. Group visits slow down the assembly line, he says, giving people time to talk about their issues with providers in the room before meeting with a doctor one-on-one. "They teach us as providers," says nurse practitioner Ferrara, who values the give-and-take of the group visits. "We have time in this meeting to listen."
Lauray is doing what he can to apply the things he's learned to living well. "I can't eat the things I used to eat," he says. He works to fit physical activity into his daily life, such as hopping off the subway a stop early and power walking the rest of the way to work. "I have a 6-year-old son," he says. "I want to be here for him."