Group visits are effective use of case managers’ time

Pilot for chronic pain patients was a success

When Ira Mandel, MD, MPH, was a physician in private practice, he found that group visits were an effective way to cover disease-management issues with his patients with diabetes. As executive medical director for Health Integrated, a Tampa, FL-based provider of care management services, he adapted the group visit concept for telephone-based case managers.

"The idea of marrying group visits with complex case management is interesting. Since most case management is not done on site, we explored ways to hold a group visit on a conference call," he says.

Mandel and three case managers who manage the care of complex patients conducted two pilot projects for patients with chronic pain. After the pilot project, the company has begun exploring ways to expand the group visits for its case managers and disease managers.

The nurses in medical case management brainstormed about the condition they felt would benefit most from a group visit and came up with chronic pain, says Robin Johnson, RN, case manager at Health Integrated and one of the participants in the two group sessions.

"I wanted to start with chronic pain because those patients have so many psychological issues and they encounter so many biased feelings about people who are on chronic pain medication. It’s an area where patients become hopeless, and we wanted to give them hope," she says.

The group got permission to involve patients from CoverColorado, a state-sponsored program for disabled people who are not eligible for Medicare or Medicaid and can’t get insurance through their work.

The case managers went through their caseloads and identified 15 patients with chronic pain who would be good candidates for a group visit and approached them about participating in the session.

Seven of the patients expressed a real interest in the experiment, Mandel reports.

The company sent participants an agenda that listed what would happen during the session, goals of the meeting, potential topics for discussion, and ground rules, along with information about chronic pain web sites, common problems, and opiates that might work when the physician has run out of options.

Ground rules included respect for each other’s time during the meeting, keeping what was discussed confidential, avoiding being judgmental of or preaching to other participants, and emphasizing that the sessions are not designed to take the place of medical treatment.

"For the first call, we felt we needed to introduce them to the process so they would know what to expect and use the time well," Mandel says.

Health Integrated set up a toll-free one-hour conference call for each of the two sessions, allowing patients who wanted to participate to dial in.

The sessions were held early in the day at a time when chronic pain patients are most refreshed and able to concentrate, Mandel says.

When patients dialed in, they were cautioned to give only their first names and, as an icebreaker, asked to tell about one of their hobbies.

Mandel led the session, encouraging participants to discuss common difficulties they encountered in seeking care and alternate approaches for overcoming the barriers.

After a while, the patients started interacting among themselves, offering tips and consolation, Johnson says.

"We just stepped out of the way and let them talk about what they wanted to," she says.

The patients like the fact that they were anonymous, Johnson says. "When they’re talking among themselves, and they know only the first names of the other participants, they tend to say more because they feel safe."

The patients exchanged techniques, such as meditation, that they had found useful in coping with the pain. "The response from the patients was very enthusiastic. We did two sessions as a pilot, and those patients have been calling their case managers and asking when we are going to have another session," Mandel says.

Patients who participated in the session told the case managers that they were relieved to know that they weren’t the only ones who were experiencing problems, Johnson says.

"Patients really love it. They’re eager for someone to listen to them and to get more information about coping with chronic pain. I see group visits as a tool that case managers could use to effectively deal with a lot of different problems," Mandel adds.

For instance, several of the patients discussed how they had encountered physicians and other providers who did not take them seriously or treated them like drug addicts.

"Managing the care of people with chronic pain is not so much about behavioral change, but it does involve a lot of emotional issues. There’s the stigma of taking narcotics and being regarded as drug addicts. These people feel that they are misunderstood. Because you can’t see pain, people don’t believe that they are really in pain," Mandel says.

The concept for group visits began in physician offices, he points out.

"There are a lot of similarities between patients with chronic diseases; and typically, 90% of what occurs during an office visit is talking and 10% is the exam," he says.

Mandel’s diabetes patients responded very positively to the group visits, bonding with each other and discussing topics they never would discuss one-on-one with a physician, he adds.

Case managers don’t have the opportunity to meet their clients face-to-face in most settings but, like physicians who deal with chronically ill patients, they often find themselves covering the same issues over and over with every client.

"The challenge case managers face is that many of the interventions they need to apply for their patients address behavioral changes. Patients who don’t understand their disease have problems with adherence, feel depressed, and believe that nobody else has the same disease," Mandel says.

A telephone group visit may not have the same impact as a face-to-face group visit, but it can work very well, particularly since patients don’t have to leave their home to participate and can remain anonymous, he adds.

"One of the reasons group visits are appealing to practitioners is that you can spend time with patients more efficiently. They allow case managers to do more than just hand holding," he says.

Case management group visits allow patients to interact with other people who have the same problems. They can talk about what they are doing to cope and share each other’s experiences, Mandel points out. "Group visits allow the most intensive level of care management for patients who need a lot of interventions and are not getting the care they need," he says.

One of the challenges the Health Integrated case managers faced was identifying enough patients with similar conditions who were willing to participate in a group visit.

Chronic pain was a leading candidate for the pilot project because it’s a very common condition that causes patients a lot of frustration, Mandel says. "There is strength in numbers. It’s the group talking, rather than just one patient, and often one person will ask questions about things the others were too bashful to bring up."