Making Group Visits Work in Your Practice

In a “group visit” (or shared medical appointment), multiple patients meet together as a group facilitated by a team of clinicians. The group usually meets for around two hours at periodic intervals with an interdisciplinary approach. Each group session includes: medical management by a licensed practitioner, patient education, and coaching and counseling through a facilitated discussion.

During their presentation, titled “The Power of Groups: Making Group Visits Work in Your Practice,” at the 2013 Pri-Med East Conference and Exhibition, Stephanie Eisenstat, MD, and Kathleen Ulman, PhD, both of Massachusetts General Hospital, Harvard Medical School, outlined the history of group visits in the medical setting, reviewed the evidence supporting their effectiveness, discussed several different types of/approaches to successful group visits, and briefly talked about billing and other issues with reimbursement.

In 1907, internist Joseph H. Pratt, MD, created the first group meeting for tuberculosis patients at Massachusetts General Hospital. Since then, group visits have been used effectively and there is good evidence that groups can create behavioral change and improve outcomes. Groups work because participants in the groups are more suggestible, and the contagion and intensification from the group helps them change their behavior. Additionally, the group setting provides a healing community and decrease isolation.

The evidence supports the observation that group visits improve outcomes. Studies have shown that group visits can lead to:

• Increased compliance and adaptation to illness (Clancy 2007; Ulman 1993)
• Decrease in symptoms (Sadur 1999; Trento 2001, 2002, 2004)
• Decrease in office visits, ER visits, and inpatient admissions (Sadur 1999; Coleman 2001; Beck 1997)
• Improved blood pressure and blood glucose levels (Edelman 2012; Burke 2011; Jaber 2006; Trento 2001, 2002, 2004; Wolf 2004)
• Improved access to care (Thompson 2000; Bronson 2004; Gutman 2004; Bowers 2009)

Groups provide additional face-to-face time with the clinician leader or facilitator, who can then give more focused medical care and provide more efficient patient education. The group provides support for behavioral change and helps identify any psychosocial stressors, giving patients confidence and hope that they can effectively manage their condition, and helping them cope with feelings of shame and isolation.

Groups vary in their makeup and procedures. They may have an active clinician leader or merely a facilitator who encourages group members to take a more active role in driving the conversation. Educational material can be didactic or behavioral techniques may be taught. Groups may meet at fixed dates and times, or be more open-ended. Membership in the group may be fixed or patients may be encouraged to just “drop in.” Group members may be drawn from one practice, or multiple practices and clinics. Patients’ family members may be welcome to observe and/or participate, or not.

Groups are generally modeled on the Noffsinger Model (developed by psychologist Edward Noffsinger, PhD, who is considered “the father of billable group medical visits”) or the Scott Model (developed by John Scott, MD), but many groups are a hybrid of the two. They tend to follow the Noffsinger Model for access and same-day needs, and follow the Scott model when especially interested in behavioral change. Both types of groups provide patient education.

The Noffsinger Model brings together 16-20 patients for 90 minutes or more. The facilitator (typically an RN or LPN) coordinates the group for the physician while an administrative assistant takes notes. The physician addresses each patient (and uses the feedback to start the group discussion), examines each patient (in the room), posts all recent labs publicly, and gives a short educational presentation.

In the Scott Model, 6-10 patients meet for two hours or more. An interdisciplinary team coordinates the group together (often with no documenter present), while a behaviorist facilitates the interactive group discussion, focusing it on behavior change. Labs, medications, and exams are done individually during the session, but not shared. This approach also often features an educational presentation by an RN, a NP, or other invited speaker.

Group visits have been successfully used for patients with a wide range of chronic conditions and diseases, including diabetes, hypertension, cardiac disease, asthma, arthritis, chronic pain, menopause, sleep disorders, stress, chronic headaches, Parkinson’s Disease, and obstetric issues.

When it comes to billing, there is no nationally accepted standard for medical group visits. Some insurers have policies for reimbursement of group visits. Medicare has general policy statements in support of reimbursement of group visits, but there is regional variation.