Patients learn from each other about managing chronic disease
By JULIE MINDA
Under health care reform, providers must find ways to deliver care more efficiently without decreasing the quality. Increasing numbers of providers are doing this with group medical appointments, in which clinicians see several patients with the same condition together at one appointment.
According to a study by the American Academy of Family Physicians, 6 percent of family physicians provided some care through group appointments in 2005. Thirteen percent did so in 2010.
"We have found that our shared medical visits improve patient satisfaction, understanding and participation" in their treatment, said Dr. John Schafer, director of the Mercy MS Center at Mercy General Hospital in Sacramento, Calif. He has been offering his multiple sclerosis patients the option of participating in group visits for about five years.
"The sessions empower people to be more involved in addressing the problems" associated with their condition, Schafer said.
Jessica Hayes, second from the right, and Marie Simpson, at far right, answer questions from participants of a group medical visit at CHRISTUS St. Frances Cabrini in Alexandria, La. Hayes is a dietition and Simpson is a diabetes educator, both at CHRISTUS St. Frances Cabrini.
A mix of patients
Normally about a dozen patients — many of them with a caregiver — participate in Schafer's 90-minute appointments as a supplement to their routine one-on-one visits. The group appointments are for patients whose multiple sclerosis is stable
— not for those experiencing an acute episode.
A different mix of patients accepts the offer to the group visit each month — participants are of various ages, both male and female; they are at different places in their disease progression and severity.
All sign a confidentiality agreement and affirm they will not share what they hear in the visit outside of the group.
At each group visit, participants briefly explain their personal history with multiple sclerosis. Schafer speaks with each patient individually, but so that the entire group can hear. He asks each about symptoms, how treatments are going, what's causing concern. He also examines each patient in the group setting — including assessing eye movements, coordination and gait.
Throughout Schafer's interaction with each patient, others in the group can chime in with questions or comments.
The group visits are typically billable to a patient's insurer, provided the visit is voluntary, not the patient's first or only encounter with the practice, that topics specific to the patient's condition are covered and the visit is documented in the patient's medical record, according to information from the Mercy MS Center.
Open forum Terry Farmer, a 69-year-old retiree, has been Schafer's patient for a decade and has been attending the group visits regularly since Schafer began offering them. Farmer finds the discussions among patients invaluable. "With multiple sclerosis, they don't understand the causes and there are no known cures, and there are more questions than answers. You can't 'fix' multiple sclerosis with medications — you have to live with it — and so doctor appointments tend to be discussions. That lends itself to group visits. You can discuss with others what works and what doesn't."
He said he's learned from others during the group sessions how they deal successfully with symptoms, the side effects of various drugs, and how the disease manifests differently in individuals.
Schafer said participants speak candidly about private topics, including how multiple sclerosis impacts their sex lives and bladder function.
Farmer said discussing such topics within the group "is not awkward. I've gotten over that because I know" the value of shared information.
Patients can talk privately with Schafer at the end of the session if they wish.
Increased access CHRISTUS St. Frances Cabrini Hospital of Alexandria, La., offers a two-session group medical visit for diabetic patients. Each session lasts four hours and patients attend for two consecutive weeks. The hospital does not bill for the visits but may in the future.
The sessions are for patients who've been assessed and have a care plan in place. In a one-on-one visit prior to the group medical visit, St. Frances Cabrini's diabetes educator discusses the severity of the patient's condition, knowledge of the disease, diet and exercise habits and helps the patient develop a diabetes management plan.
The two-session group visit gives patients the opportunity to learn more about the ways diabetes impacts the body, how to manage medications, what to eat, the benefits of exercise, and how to manage complications associated with diabetes. St. Frances Cabrini patients talk with dieticians, personal trainers, physicians and others about their specific situations and develop goals and interventions particular to them — all within a group discussion format.
The hospital's diabetes educator Marie Simpson said, for diabetics, "it is crucial to learn to take care of yourself," and these visits allow that to happen in a setting where patients can compare notes on the practicalities of managing a chronic disease.
Stretching resources Good Samaritan Free Health Center in Cincinnati uses the group visit as a way to provide diabetes education to patients. About 20 patients participate each month, including a core group of regulars and others who attend according to their needs. At each group session, clinicians take patients' vital signs; a physician reviews the patients' charts with them; and the group talks about such subjects as diet, exercise and medication management. There are cooking demonstrations and field trips where patients get tips for buying healthy food on a budget.
"It's a way to care for more people when clinicians have a limited amount of time," said Linda Smith Berry, manager of the Good Samaritan Free Health Center, which relies on volunteer clinicians. She said under health reform, "there will be a huge influx of people (into the medical system), and we need a way to treat them all," and group visits are a way to extend clinical resources.
Cincinnati's Mercy Health Physicians began offering the option of shared medical visits to diabetic patients at two of its 80 practices in June. Nanette Bentley, Mercy Health spokesperson, said early feedback has been positive, and, if that continues, "We will expand the program to other practices and perhaps set up group medical appointments for patients with other illnesses."
Traditional appointments with physicians and nurse practitioners normally last about 15 minutes, but group visits last about 90 minutes.
Anita Mattingly, director of operations for Mercy Health Physicians, said the group visits improve care access in the community because when more patients are seen in groups, their slots open up on the schedule for other patients. This helps with the primary care physician shortage, she said.
Group cohesion Mattingly said patients value the convenience of talking to multiple experts in one visit. A clinician leads the group; a pharmacist, social worker and/or diabetic educator may participate.
"We have an evaluation tool, and all the results have been overwhelmingly positive. People enjoy the interaction," she said.
Mattingly said it's uncommon for one person to dominate all of the group's time; group dynamics mitigate the potential for such an imbalance. "There seems to be mutual respect in the group," Mattingly said.
In fact, she said, group members thrive on one another's encouragement. In one appointment, patients cheered a patient who had stopped smoking. Mattingly said group members swap cell phone numbers and email addresses. "They want to chat with each other."
Farmer said in the multiple sclerosis group medical appointments he and other patients draw upon each other for emotional support. "Especially for the newly diagnosed, the greatest benefit is to talk to others in the same boat. It's frightening to have something that can't be fixed. But we talk about our fears and concerns.
"Group appointments help you see that you can live with it and you can have a full life," Farmer said.