Clustering appointments increases efficiency
Clustering appointments increases efficiency
Patients get more bang for the buck
Group appointments or group visits have become an effective method of delivering care at many institutions. Depending on the mix of providers, group appointments can combine educational, medical, psychological, and supportive care, says Andrew Bertagnolli, PhD, project manager for group appointments and chronic pain at regional health education, Kaiser Permanente Northern California in Oakland.
At Kaiser, group appointments have been used to meet the needs of chronic disease patients such as those with asthma, diabetes, congestive heart failure, or hypertension. "Kaiser has found them to be very helpful. They have worked when they are well thought-out, have clear goals, and staff have a clear vision of what their role is," says Bertagnolli. Group appointments have improved health care utilization, quality of life, and patient and provider satisfaction, he says.
Staff at the Diabetes Care Center at the Univer-sity of Washington Medical Center in Seattle finds group visits beneficial as well. They have initiated them when the teaching in one-on-one appointments is repetitive or patients have to wait months to obtain a personal appointment.
"We started doing group insulin pump appointments simply because we found that you repeat yourself over and over again, and people in a group situation can learn from each other. We also found that it was cost-effective and emotionally supportive," says Dori Khakpour, RD, CD, CDE, nutrition and education coordinator at the Diabetes Care Center.
The groups at each health care facility are designed to fit the needs of the institution. At Kaiser, all groups have a physician and a health educator or behavioral medicine specialist, such as a psychologist or social worker, as leaders. They co-lead either the structured group model or facilitated group model.
The structured group model has a planned curriculum and low physician involvement. Usually a health educator covers lots of educational material, and a physician pulls people from the group one by one during the teaching to do a private assessment.
In facilitated groups, there is a high degree of physician and patient interaction, and the assessment is a group process. For example, the physician may do diabetic foot exams. Although there is a key message, education is given as needed. "The facilitated group is more efficient because it doesn’t duplicate the one-on-one office visits. Also, in the facilitated group physicians can use each patient as a teaching point for the next," says Bertagnolli.
Clustering patients
There are also two formats for the groups at Kaiser. A drop-in group meets at a set time each week and patients come as needed. This type works well for diagnoses that cause distress when symptoms are not controlled such as asthma, heart disease, or irritable bowel syndrome, says Bertagnolli.
For example, people having problems with congestive heart failure symptoms would come to the group and a physician would provide a medical assessment and perhaps adjust their medication. A psychologist, meanwhile, would be on hand to assess depression and anxiety problems and treat them.
"One of the main strengths of the drop-in group is that if you offer it weekly, there is frequent access and for some medical conditions that saves going to the emergency department or urgent care," says Bertagnolli.
The closed group clusters patients who meet at a particular time and date and no new patients are added once the group has about 15 members. This type is good for people with chronic diseases who do not experience stressful symptoms, such as diabetes or hypertension. Group participants can all be from one provider or referred from throughout the medical center. (To learn how to determine what to consider when establishing group appointments, see article, right.)
The group visits at the Diabetes Care Center at the University of Washington Medical Center focus on education. In addition to appointments that start people on the insulin pump, group visits are initiated to teach carbohydrate counting and basic nutrition. "The group visits have worked very well in terms of being able to see people in a timely fashion. There is almost a two-month wait to see a nutritionist," says Khakpour.
Patient service representatives make the appointment for five to seven patients, giving them the choice of waiting for a one-on-one session or being seen in a group. To work with a group of people simultaneously, Khakpour has them fill out a form when they come to the 90-minute appointment. It contains such information as the type of diabetes they have, how long they have had it, what diabetes medications their physician subscribed, and their normal exercise routine.
The sessions are conducted in a room with a large table, so she places the forms in front of her, directly across from each patient in order to individualize her teaching. The first 45 minutes of the session is education, while the last half is interactive exercises to reinforce the teaching.
The only downside to the group visits is that it doubles the amount of time spent charting, says Khakpour. Usually she sees about six patients in one day, but with the group visits, the amount doubles.
Confidentiality can be an issue as well, says Bertagnolli. Tell the patients not to share anything in the group they don’t feel comfortable sharing and to let the group leaders know they need a private consultation at the end of the session if they have an issue they can’t share. "Generally, people don’t mind sharing if it is relevant to the reason they are there," he says. n
For more information about group appointments, contact:
• Andrew Bertagnolli, PhD, Project Manager for Group Appointments and Chronic Pain, Regional Health Education, Kaiser Permanente Northern California, 1950 Franklin St., 13th Floor, Oakland, CA 94612. Telephone: (510) 987-1301. E-mail: [email protected].
• Dori Khakpour, RD, CD, CDE, Nutrition & Education Coordinator, Diabetes Care Center, University of Washington Medical Center, Box 356176, 1959 Pacific St., Seattle, WA 98105. Telephone: (206) 598-4882. E-mail: [email protected].
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