This article appears in the May 2012 issue of HealthLeaders magazine.
Picture this: In a conference room at a major healthcare institution's family health center, 10 patients sit in comfortable chairs waiting to discuss their asthma. After a few minutes, a facilitator enters—at some institutions, it's a social worker or a nurse; here it's a psychologist.
What questions do you have for the doctor? she asks. What concerns? Do you need medication refills? What are your goals for today? As each person speaks, the facilitator scribbles notes on a whiteboard, readying the group for the physician to arrive.
Once the doctor is in the room, the visit speeds up. She conducts an individual follow-up visit for every patient, ending with a care plan and next steps, leaving time for questions. An hour-and-a-half and a slew of queries later, the appointment ends. "Each person has the same visit that they would normally, but nine other patients are watching," says Marianne Sumego, MD, a staff physician at Cleveland Clinic's Willoughby Hills Family Health Center. "Can't you imagine the strength, if you're just sitting there listening?"
Sumego experiences a similar scene with every shared medical appointment she conducts, something she's done regularly for the past decade. "I start with patient A and go through her asthma. I fully complete patient A's visit and we develop a plan, then I go onto patient B. Patient B tells me about his asthma and we do a follow-up," she says. "Then we go to patient C, who may have asthma symptoms. We talk about her asthma, what she's currently doing, what she needs."
This model, around since the mid-1990s, is now getting more attention. In a shared medical appointment, eight to 10 patients with a common denominator—a chronic condition such as diabetes, or elderly adults in need of a road map to aging well—see the doctor together for a long visit, often 90 minutes. Joining the session in some cases are a nurse, a behaviorist, and a documenter, each working to help the appointment run smoothly.
For visits that require a physical exam, each patient sees the physician in private room while the facilitator leads the group. With exams complete, the group reconvenes for a physician-led discussion. Through this approach, not only do patients interact more with the doctor, but they also learn from each other in an open, safe setting. Even though the physician sees more patients, he or she doesn't feel rushed due to the extended length of the visit.
"Working harder and doing more isn't the best answer," Sumego says. With shared medical appointments, "we're utilizing a concept that is basically more effective; it leverages resources, and we're offering it to our patients so that they have a high-quality visit." The key to making this work requires selecting the right high-impact specialty, working with a physician leader and team passionate about that specialty, and designing the group visit with both its physician and patient population in mind.
Group appointments take root
Back in 1988, Edward B. Noffsinger, PhD, received the scary diagnosis of pulmonary hypertension, "potentially lethal cardiopulmonary condition" as he describes it. For the two-and-a-half decades prior, he'd been director of oncology counseling and chronic illness services at Kaiser Permanente, so he knew how this country's healthcare delivery system worked. Yet as a patient, he was underwhelmed by his treatment. "I had the best doctors really anyone could hope to have, but I found that medical care as it was being delivered just wasn't satisfactory," he says. "It was very frustrating for the patient, for the doctor, the waits were very long to get in, the visits too rushed. The poor doctors, they looked worse than you felt."
Noffsinger, author of Running Group Visits in Your Practice, decided that if he got better (which he did), he'd help others in his shoes. He came up with three wishes he'd had when receiving care: better access to his physician in a relaxed environment with other patients who could empathize (so he would not have to burden family and friends). What evolved were shared medical appointments. "The story is actually quite compelling," says Zeev Neuwirth, MD, formerly of the multi-specialty group Harvard Vanguard Medical Associates, where he led shared medical appointments for three years. He is currently chief medical officer and senior vice president of the physician services group at Carolinas HealthCare System, based in Charlotte, NC, an integrated delivery network composed of 33 hospitals and 650 healthcare locations. "This approach was actually created by a patient for patients. That's really critical to understand."
For Neuwirth, it represented a model that treated each patient as an individual, not as a disease or a problem. "Here's a way that we could actually create better-quality care and what I felt would be more respectful and dignified care," he says, "and actually do it in a way that's cost-effective."
He saw such great potential in shared medical appointments that he partnered with Noffsinger to implement them at Harvard Vanguard in specialties as varied as neurology and dermatology, pediatrics and pain management. Today, 10 practices within Harvard Vanguard offer 26 shared medical appointments.
Though Noffsinger says he hasn't yet seen a specialty for which the group-visit approach doesn't work, Neuwirth is slightly more prudent: "In my experience, and again, I have much less experience than Noffsinger, I've observed that they work better in certain situations than others," he says. "For chronic conditions like diabetes, rheumatologic conditions, as well as pediatrics, geriatrics, and obstetrics, they work exceptionally well."
Peter Cheng, MD, AGSF, a geriatrician with Sutter Health's Palo Alto (Calif.) Medical Foundation, has recently started what his team calls the successful aging shared medical appointment. It allows patients 65 and older to focus on "mind, body, and soul" aspects of aging—or put more bluntly, it allows doctors to check the dementia, fall, and depression risk of these patients.
"Geriatricians have always looked for new ways of taking care of older people," Cheng says. "We've always wanted to find ways of creating something that would be of value to the healthcare system, to primary care partners, and also to patients and their families. The way we designed this, we wanted to focus on screening for three high-impact diagnoses in this very high-growth patient segment." The nearly one-year-old program grew from a desire to provide great care for these specialized patients and to use the physician's time effectively. Cheng says it's the time of week he most enjoys.
Forming a community of care
Among the benefits of the shared medical appointment model is unprecedented access to the doctor. According to the Centers for Disease Control and Prevention, patients spent less than 20 minutes, on average, with their physician during an office visit in 2005 (the most recent data available). Here, they're in the same room for more than four times that. And though they're not the doctor's focus the whole 90 minutes, they still soak up what's being said and learn from questions they may not have thought to ask.
"The patients enjoy the visit; they like focusing on the disease," Sumego says. "Patients themselves end up being good role models, and that positively reinforces what they're doing to manage the disease."
They also lose the sense of isolation that can come from being a patient. This is particularly true for those with chronic conditions, Neuwirth says.
"The group visit is a compassionate, patient-centered approach to delivering care," he stresses. "Think about it. If you have six or eight or 10 other patients in the room, you've now got a community of care. You've got a whole bunch of ears and hearts listening to you."
That community of care is why physicians enjoy shared medical appointments, too. They can get off the stream-of-patients treadmill. They don't have to feel like a broken record, repeating the same information 10 times. And rather than writing up a visit note for each person, they simply review one completed by someone trained in doing this. "The physicians who do it love it. Many of them will tell you it's the best part of the week," he says. "The clinician is now supported by a team. So you can spend time talking to patients, thinking with patients, advising patients." Sumego brings it back to why many physicians went into this line of work: to spend time getting to know patients and, in turn, providing high-level care.
Measuring success
Starting a group medical appointment isn't without its challenges, however. Cheng remembers the growing pains well. "You're like the new kid on the block and you're going against the establishment," he says. Sure, this model has gained momentum, yet it's still counter to the notion of one-on-one appointments, and it's certainly not for everyone, patients and physicians alike.
Use data to show that the model works, Cheng suggests. His participants fill out a 13-question survey about topics like how in control of their health they feel. They do it three times: before they start, four weeks in, and three months later. "We wanted to measure the effect of this program on the patient. That's where it all starts," he says. "We're measuring patient activation."
Because the Palo Alto program is so new, Cheng has only anecdotal evidence—friendships formed, active listening during sessions—that it's working. Yet, backed by support from his organization, he has the green light to pursue additional patients.
When Neuwirth was at Harvard Vanguard, they used a Press Ganey survey to determine patient satisfaction. The results surprised even him.
"Patient satisfaction in the group visit was as good as the satisfaction in the individual visit." In some areas, such as how well patients felt their physician knew them, the group visits actually scored higher. Sumego recommends a combination of hard data and observation to measure a program's success. She also suggests varying metrics by topic—for example, emergency-room use for asthmatics or HgA1c levels for diabetics. "You're customizing shared medical appointments around the disease that you're managing, and every disease has a different quality metric," she says.
For institutions embarking on shared medical appointments, these physicians offer three pieces of advice: pick high-impact goals that doctors at the institutions are passionate about, establish the right team, and plan ahead. "Don't rush off half-cocked without getting all your ducks lined up. You need administrative support. You need a well-designed group program. You need the right team and the right facilities," says Noffsinger. "Design it correctly and you will really enjoy your experience. If you try to shortcut the process..." he pauses. "You'll get frustrated and you'll make the inaccurate conclusion that group visits won't work for you when, in fact, they will, if done properly."
Michele Wilson Berger is a contributing writer for HealthLeaders Media.
This article appears in the May 2012 issue of HealthLeaders magazine.
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