Goals are key to successful group appointments
Have a clear concept of what to achieve
The first step to setting up a group appointment is to have a clear idea of what is to be accomplished. "We have found that if you do not have clear goals about what you want to accomplish by a group visit, it will not work," says Andrew Bertagnolli, PhD, project manager for group appoints at Regional Health Education for Northern California in Oakland.
Have clear goals about who you are targeting, why you are targeting them, what you hope to accomplish by targeting them, and what needs you think are contributing to the reason you want to target them, advises Bertagnolli.
For example, the target population may be asthma patients, but for the group appointments to be successful it is wise to select a subset of this patient group. This may be nonadherent patients, those who are newly diagnosed, or patients with significant psychological and psychosocial issues that impede their ability to self manage.
"If you just say I want to do a group for asthma patients, you will get all kinds of different patients with asthma with all kinds of different needs and you won’t be able to respond to that," says Bertag-nolli. Selecting subsets is a way to make the group more homogeneous.
Once clear goals are set, it will be easier to determine how long the group appointment should last, how frequently the group should meet, and who should lead the group visit. For example, if the group appointment will target asthma patients who frequently use the emergency department, then someone who can adjust medications should lead the group. Also, because asthmatics who use the emergency department generally have problems with anxiety, someone with mental health experience would work well, says Bertagnolli.
The frequency of the group visits should be based upon a patient’s need for rapid accessibility to medical care. "We found with asthma and heart failure, having a weekly drop in group was helpful. We were able to catch people before they got to such a state they went to the emergency department," said Bertagnolli.
On the other hand, diabetic patients usually don’t get distressed when their blood sugars are high, so this patient group may be scheduled according to the usual standard of care. For example, if physicians see patients with diabetes every three months, then group visits should be scheduled accordingly.
At Kaiser Permanente, there are two types of group appointments, the drop-in group and closed-format. In the closed format, a group of patients stay together as one group. Diabetes groups usually are organized in the closed format.
The drop-in group is referral-based, and a few new patients are generally introduced on a weekly basis. Return patients can drop in on the group when they choose to do so. It’s important not to add more than three or four new referrals to the group each week so that the providers who lead the group will have time to address the problems and issues of the established drop-in group members, says Bertagnolli.
To get referrals, group leaders at Kaiser do presentations at various medical team meetings. Closed groups usually target a particular physician panel. Patients for these groups usually are pinpointed by going through the computer database and selecting those that fit the criteria. A letter of invitation is sent to patients or their physician suggests that they participate in the group appointment when they are seen at an office visit.
Groups should be no larger than 12-15 patients so that the health care provider leading the group has time to check in with each patient. At Kaiser, all group appoints must have a clinical intervention, which is discipline-specific based on the purpose of the group.
The size of the group should be based on the types of health problems patients have, what needs to be done during the 1½- to two-hour sessions, and the size of the room, says Bertagnolli. If the group leader is a physical therapist and patients will be exercising, there should be enough space for everyone to exercise. However, there must be enough patients scheduled to make the group cost-effective, he adds.
The group appointment works well for several different types of patient populations. At Kaiser facilities throughout Northern California, there are group appointments for newly diagnosed patients with diabetes, patients with diabetes that are transitioning to insulin, patients with diabetes and co-occurring psychosocial issues, anxious asthma patients who are frequent users of the emergency department, hypertension, irritable bowel syndrome, back problems, knee problems, headaches, and chronic pain.
"Having patients with a common diagnosis participate in group appointments works best. Less learning takes place when you address different kinds of health conditions in one group," says Bertagnolli.
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