Group Visits for Diabetes and Other Chronic Diseases
By Edward Shahady, MD
Group visits are an innovative way to help patients with chronic disease better control their disease. Diabetes is the poster child for chronic disease because it is the most common chronic disease and excellent evidence indicates that improved management reduces the physical, fiscal and psychological burden of the disease.
What group visits are not
Group visits are not a substitution for diabetes educators. Diabetes educators play a major role in educating patients and empowering them to better care for themselves. Diabetes classes can be very effective for some patients. But these educators are usually located at diabetes centers, the offices of endocrinologists and hospitals. Because they typically take place in the office of the patient's personal physician, group visits are an excellent complement to teaching by diabetes educators. Some patients will require both and some will prefer one or the other. Any and all strategies are needed in order to reach as many patients as possible.
In the past, diabetes education has been based on providing information though lectures. "Knowledge changes behavior" has been the belief of most medical education. If only that were true. Unfortunately, knowledge alone does not provide the needed fuel to change behavior. Patients' experiences with their own diabetes mold their behavior. These experiences are based on the emotion and feelings that accompany diabetes.
Group visits are very definitely not lectures. Rather, these visits create an environment where patients feel safe asking questions and expressing their concerns about their diabetes. Being able to express feelings in a supportive setting is therapeutic. It is care in the truest sense of the word.
And because they take place as part of the patient's continuous care in their personal physician's office, group visits have the advantage of being conducted by a clinician and nurse/MA team that already have an established a relationship with the patient. Once the practice team learns the skills of facilitating group visits — their prior trusting relationship makes it easier to conduct group visits.
Learning to let patients lead
Diabetes knowledge is conveyed and patients learn, but not in the traditional way. Each group visit may have a focus like diet or exercise but instead of starting with the usual lecture the visit starts with asking the patients for their questions and concerns about the topic.
This interactive method of teaching is new to many and different teachers implement it differently. The key is to remember that knowledge alone does not change behavior. Group facilitators can learn a lot about the effectiveness of their session by asking patients what was most helpful to them, and what has helped them improve their self-care. They will usually find that the knowledge that was shared after a patient’s specific question or comment is what is most remembered.
Group visits are win-win-win — for patients, providers and practices
Group medical visits have been identified in the Future of Family Medicine's new model of as one of ten features that have a direct impact on practices and patients. They are especially valuable for conditions that require substantial personal motivation to initiate and sustain life-style changes.
Group medical visits can also strategically increase patient knowledge of disease and increase patient self-efficacy, or the confidence needed to make the changes to improve health. Self-efficacy, coaching and group support is especially helpful with those struggling to make life style changes, adhere to complex medication requirements and follow other instructions.
Studies of group visits have reported improved clinical outcomes, increased patient satisfaction, increased ability to address psychosocial issues, increased independence and functional abilities, and decreased medical costs1.
The group medical visit approach can also improve access issues, efficiency, improve financial outcomes for practices, and decrease medical costs2. AAFP has recognized the potential of group medical visits and has set the goal of every family physician conducting at least one group medical visit per month by the year 2010. Group medical visits are a part of the Future of Family Medicine's recommended "basket of services" provided by family physicians.
What are your practice's barriers to providing this innovative and efficacious care to your patients?
Although evidence supports providing group medical visits in primary care, many providers hesitate to initiate programs due to lack of confidence and skills in facilitating the group process. Group facilitation issues are always key areas of questioning and concern with health care providers about group medical visits.
1. Beck et al., 1997; E. Noffsinger et al., 1995; Scott, Gade, McKenzie, & Venohr, 1998
2. Johnson & Rutherford, 2002; E. Noffsinger, 1999; Scott et al., 1998)
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