OBJECTIVES
Objectives
Define the group medical visit.
Review the most common group medical visit models.
Discuss the advantages of group medical visits, particularly for underserved populations.
Describe some of the obstacles to establishing group-based models of care in safety-net health settings, at the clinic, provider, and participant levels.
Liu Su Chen is a 72-year-old woman with type 2 diabetes, hypertension, and osteoarthritis. Mrs. Chen neither speaks nor reads English. Mrs. Chen’s diabetes is now poorly controlled. Consultations with a nutritionist and diabetes educator have had little effect on her glycemic control. She is now on maximum doses of oral diabetes medicines and medications for other chronic medical problems. When her doctor begins the discussion of adding insulin treatment, Mrs. Chen becomes visibly upset. “I only know one person who has taken insulin for her diabetes, and she died within a year of starting the shots!” she says. A colleague of Mrs. Chen’s physician recently began offering diabetes care to groups of 8 to 15 patients in Cantonese and English and she wonders if those visits might help her patient.
INTRODUCTION
Efforts to reform ambulatory care have focused on optimizing access to care while making efficient use of limited resources. This chapter describes the group medical visit (GMV), an approach that is gaining widespread acceptance and has been studied in diverse health-care settings and patient populations. Both the advantages and challenges of providing group-based care, particularly among underserved populations, are reviewed.
WHAT IS A GROUP MEDICAL VISIT?
Mrs. Chen’s doctor convinces her to attend one of the new group medical visits by pointing out that she may meet other people who are taking insulin, and that everything will be presented in her language.
Many different models of group-based care have been developed, each tailored to the specific population served. Most of the existing models of group-based care were developed in managed care or academic practice settings. The GMV has taken a variety of names, such as the “cluster visit,”1 “chronic care clinic,”2 “shared medical appointment/drop-in group medical appointments,”3 “cooperative health-care clinic,”4,5 and group prenatal and early parenting visits trademarked as “CenteringPregnancy®” and “CenteringParenting®.”6 All of these groups have been implemented as a means of improving the quality of care, the patient care experience, and access to care when compared with the traditional brief, one-on-one clinical encounter (see Box 16-1).
Box 16-1. Components of Group Medical Visit Models
Peer support and community building included in the clinical encounter.
Point-of-care collaboration by an interdisciplinary team.
Interactive group learning.
Focus on self-management and self-efficacy.
A GMV is a clinical encounter typically organized and run by a team that includes a provider (physician or advanced practice clinician) plus another member of the health-care team and is comanaged by the participating patients. Most GMVs target patients with a common health concern, such as concerns around aging, a particular chronic illness, pregnancy, or early parenting/well-child support. GMVs offer routine medical care, support, and learning. Some GMVs meet more frequently than usual individual visits (typically monthly to quarterly); most GMVs involve a stable membership of 8–25 patients, and last from 90 minutes to 3 hours. GMVs can be structured either to supplement or to replace individual patient visits (see Box 16-2).
Box 16-2. Elements of the Group Medical Visit
Must include a provider who can bill for services to ensure financial sustainability.
Most commonly, groups are co-led by a team of a provider and other health-care team member, such as an RN, a health educator, a nutritionist, a social worker, a medical assistant, or a community health worker.
Participating patients are often actively involved in management of the group.
May replace the one-on-one medical visit or be supplemental.
All GMV models include some element of facilitative leadership, to encourage peer-to-peer learning, participant engagement, and empowerment.
The medical provider component of the GMV can include limited physical examination and medication prescribing/adjusting.
Table 16-1 presents a rough outline of a GMV format. Most models include elements of group time—“check-ins,” goal setting, learning—as well as one-on-one time for each participant with the group’s medical provider to tend to medical aspects of care. GMV models with continuity of participants over a series of visits may have an intentional focus on community building, out of appreciation that social support can be an important determinant in health outcomes.7
| Time (min) | Activity | Content |
|---|---|---|
| 15–60 | Preparation prior to group session | Chart prep, planning the session content, setting up the space (chairs, food, music, materials) |
| 15–45 | Check-in |
|
| 30–75 | Group learning |
|
| 30 | One-on-one | Medical providers or a group facilitator meets briefly with each participant for a one-on-one assessment; components of this assessment can include:
|
| 5–30 | Closing group session |
|
| 15–60 | Wrap-up after session ends |
|
MODELS OF GROUP MEDICAL VISITS
The following are brief descriptions of different kinds of GMV models. In the descriptions, “provider” refers to the health-care provider who can bill for services (physician or advanced practice clinician).
Cooperative health-care clinics were developed by John Scott and colleagues at Colorado Kaiser Permanente Medical Group. The primary goal of this was to decrease unnecessary emergency department and urgent care use, initially among elderly patients.4,5,8 These monthly GMVs are cofacilitated by a provider and a nurse for a targeted group of 20–25 patients. Each cooperative health-care clinic includes group education, social time, one-on-one contact with the provider and/or nurse, and an opportunity for questions and answers. Cooperative health-care clinics also have been used in specialty settings with patients with diabetes or stroke. Typically, cooperative health-care clinics replace the individual encounter or decrease the frequency of one-on-one visits. One study demonstrated decreased outpatient and emergency utilization of care.9
Drop-in group medical appointments target all of the patients on a busy provider’s panel (i.e., a medically heterogeneous group of patients) rather than patients who share a common medical problem or characteristic (as in cooperative health-care clinic). Developed by Edward Noffsinger at the San Jose, California, medical offices Kaiser Permanente Northern California, drop-in group medical appointments increase patients’ access to their provider by opening up extended appointments that they can use as often as they choose.10 Usually co-led by a provider and a behavioral health professional (psychologist, social worker, health educator, or therapist), drop-in group medical appointments provide the opportunity for more holistic health care than is typically provided in an individual clinic visit. By seeing many patients simultaneously, drop-in group medical appointments have been successful in easing time constraints commonly imposed on both primary and specialty care practices. Drop-in group medical appointments usually use a nurse and a behavioral health clinician to maximize the impact of the visit for the patient.11
Chronic care clinics (CCCs) are periodic primary care sessions organized to meet the complex needs of patients with chronic conditions to improve outcomes. These have been used for patients with diabetes, congestive heart failure, and geriatric patients. They are planned clinical encounters for targeted patients with a specific medical condition in a primary care setting.2 Based on the “mini-clinic” developed in general practices in the United Kingdom, the CCC is a half-day–long session that includes a stable cohort of 8–12 participants. Sessions include brief one-on-one visits with a primary care provider and can include involvement of other clinic staff and providers (such as pharmacists). Each session also includes group education and discussion. These clinics focus on the need for active patient participation and support patients’ confidence and skills in managing their illness. CCCs typically occur three to four times per year and supplement the regular one-on-one visit.
Cluster visits are directed at patients with a particular chronic illness, most commonly diabetes.1,12 These are monthly GMVs of 10–18 patients for a finite period of time, usually 6 months. They are led by a specially trained nurse educator, and supported by physicians and other clinicians who are readily available for consultations. There are referrals to nutritionists, behavioralists, pharmacists, and social workers. Some cluster visits use a multidisciplinary team led by a nurse educator and include a dietitian, a pharmacist, and a behavioral therapist. The cluster visit model, which was developed at Kaiser Permanente, incorporates nurse care management, including frequent telephone follow-up between visits, coordination of needed ancillary services, and intensive medication management. In contrast to the models previously described, cluster visits replace usual primary and specialty care for the targeted chronic illness during the intervention period.
A GMV called CenteringPregnancy6,13 has emerged as the most promising model for group care during pregnancy, with strong evidence to support its efficacy and appeal to participants. In this model, a cohort of 8–12 pregnant women, whose babies are due in the same 1–3-month period, meets as a group beginning in the early second trimester and continuing through 40 weeks of pregnancy. Each session is co-led by a consistent team made up of an obstetric provider and another member of the perinatal services team. During each 2-hour group session, women (and sometimes support people) participate in self-care activities, group discussions on topics related to pregnancy, childbirth and parenting, community-building activities, and routine physical assessments by the obstetric provider. After initial entry into prenatal care, these group sessions replace one-on-one prenatal visits, with 10 group visits over the course of pregnancy. Multiple studies, including a randomized controlled trial, demonstrate improved health outcomes, knowledge among participants, and satisfaction with care when compared with one-on-one prenatal visits (see section “Improved Care Outcomes”).
Group well-child visits were one of the first models of GMVs in the United States.14,15 In most settings, the group well-child visit is a primary care visit in a group setting and replaces the usual periodic well-baby visits in the first year of life (newborn, 2, 4, 6, 9, and 12 months). With an emphasis on age-specific anticipatory guidance and group support for parents of infants of the same age, these visits minimize the repetition inherent in well-child care and also are an efficient way for providers to provide routine primary care. One study noted that participating mothers recognized several benefits of group well-child visits, including (1) support from other women, (2) opportunities to make developmental comparisons with other infants, (3) the chance to learn from other participants’ experiences, (4) enhanced parental involvement in the visit, and (5) more time with the provider.16
Another centering group care model is CenteringParenting, a mother (or other caregiver)/infant dyad model. Typically, there are six caregiver/infant dyads, or 12 patients, in each cohort. Groups meet beginning in the early neonatal/early postpartum period (around 2 weeks of the baby’s life), and continue through at least the first year of the baby’s life. As in CenteringPregnancy, these groups replace individual care visits, in this case both for the woman and for the infant. In some settings, groups transition seamlessly from CenteringPregnancy to CenteringParenting, thereby building on the relationships formed and group learning achieved during the prenatal period. Each group visit addresses the physical health of both mother and infant, as well as offers a setting where parents build on their collective knowledge about caring for their babies. Activities during the group visits are tailored to the specific needs of the dyads; for example, the Edinburgh Postpartum Depression Scale is employed in the early infancy period to facilitate discussion of stress, support, and self-care for mothers.
BENEFITS OF GROUP MEDICAL VISITS IN UNDERSERVED POPULATIONS
Mrs. Chen has few friends or family members who have diabetes, and no close acquaintances who use insulin injections. At the first group medical visit appointment, she is interested to hear another Cantonese-speaking woman talk about her experience of initiating insulin therapy, and how much better the woman had felt after she learned to give herself injections and her blood sugar levels improved.
Although many GMV models were developed in managed care settings, others have taken a firm hold in public health settings. For a summary of benefits of GMVs with underserved populations, see Box 16-3.
Box 16-3. Advantages of the Group Medical Visit Model for Socioeconomically Disadvantaged Patients
May alleviate access issues common in low-resource settings.
Designed to mitigate the challenges of language and literacy.
Potential to more effectively promote self-efficacy and positive behavior change.
Opportunity to develop community and gain social support from a peer group.
Support groups for patients with chronic illness have been studied in a number of different settings, and group support has been shown to improve patient satisfaction and psychosocial outcomes.17,18 Moreover, support groups are effective in diverse patient populations. Individuals with chronic illness express satisfaction and show improved self-management practices when they interact with others living with the same condition. Also, there is the opportunity to discuss psychosocial sequelae of their illness (sexual dysfunction, social isolation, disability, depression, changes in body image), which is less likely to occur in the brief individual visit with a health-care provider who has not experienced similar problems and who is not a peer. The simple process of identifying oneself with another individual in the group can have a powerful effect, especially when there is isolation or confusion. In addition, GMV participants have a sense of accountability to other members of the group or discover that sharing their personal experiences may be of help to others, either of which may promote positive behavior change and healthy practices. The social support aspect of group visits may reinforce a patient’s self-efficacy, leading to positive health behavior change.19 In pregnancy, positive social support and self-esteem may provide a sense of mastery and reduce feelings of helplessness.20
There is growing evidence that GMVs are associated with improved care outcomes. Research has shown that diabetes care in a group setting can result in greater reductions in A1C21
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