Group Visits: Treadmill Medicine or Meaningful Encounter?
Posted Dec 02 2008 2:50am
I have been encouraging physicians to explore group visits for a while. Group visits are especially suited for stable patients with chronic disease–think hypertension, diabetes, COPD. Patients with chronic diseases make up the majority of the primary care office visits, especially for internists. Group visits can increase patient and physician satisfaction, and encourage healthier patients and lifestyles.
Following is a short primer on what must go into a group visit:
Privacy issues must be addressed. The patient must sign a confidentiality form, allowing their case do be discussed in a group, and also agreeing NOT to discuss other patients’ medical issues outside of the group appointment.
The chronic disease addressed must NOT require the patient to disrobe. (Duh.)
A physical exam must be done. In order to bill appropriately, a nurse should document vital signs for each patient, and the physician should document an appropriate exam for the problem.
Patients should be encouraged to have questions formulated for the physician ahead of time. These questions may be posted on white board and reviewed through out the meeting.
Physicians should be prepared to answer questions as they examine each patient. This is where the efficiency exists–many of the patients will have the same questions, and will be relieved that they are not the only one with questions/problems.
Time should be available after the group appointment for individual questions ON THAT SPECIFIC DISEASE PROCESS.
Schedule enough time and enough patients. Eight or nine patients in one hour is a good number. You may need to have the initial group visits be 2 hours and discuss how the group visit will run. Realize that Seniors tend to have more flexibility as to scheduling an hour long visit, while working folks may require early morning, lunchtime or late afternoon appointments.
Have enough support staff to take vital signs, sign privacy statements and get patients situated.
Be prepared for emergencies–if Mr. Pickwick shows up for the group visit with a pulse ox of 70%, be prepared for how you will handle the emergency AND the group meeting.
As to billing issues: each patient is billed as if seen individually, hence the emphasis above on vital signs, appropriate physical exam, lab tests, level of decision making etc. Utilize E/M codes 99212-99215 as appropriate. Documentation is key here. Consider a check list form, or a template for your EMR, that patients fill in regarding symptoms and questions, and then a check off form for the physical examination.
So what do patients think of group visits? About 75% of patients that have participated would do so again, and 5% would not.
I personally have done group visits with diabetics, and enjoyed it tremendously. We served lunch at the first meeting, and had a nutritionist and pharmacist there as well. The patients enjoyed it, and learned a lot. I think group visits will go a long way towards easing the treadmill approach we employ in primary care medicine, and encourage physicians to try it. Some practices delegate this to the “mid-level” providers, but I think patients get more out of the group visit when it is physician run. I also believe that most physicians enjoy the interaction and ‘teaching moments.’
Let me know if you do this, and what works or doesn’t work.