Group appointments create opportunities for education
Interaction reinforces educational message
In today’s health care setting, providers often have trouble finding the time to educate patients during an office visit. Yet when several patients are seen at one appointment in a group setting, the education component is no longer overlooked because groups are allotted more time and there are more opportunities for education.
"You are educating at a much slower pace, and it is easier to get the education piece done," says Andrew Bertagnolli, PhD, project manager for group appointments at Regional Health Education, Kaiser Permanente Northern California in Oakland. Also, when a practitioner discusses one patient’s problem, everyone present benefits from the information shared.
Another educational benefit of group appointments is that patients are able to interact with one another, says Linda Macdonald, MD, a staff physician at New Mexico Veterans Affairs Health Care System in Albuquerque and assistant professor of medicine at the University of New Mexico.
Macdonald decided to start a group clinic for patients with diabetes when she had a patient come to her with a problem of high blood sugar while exercising and couldn’t figure out why. The very next patient revealed that he had figured out how to solve the same problem. "I thought that if these two guys had been in the room at the same time, they could have shared with each other," she says.
When she started the diabetes management group and the intensive insulin therapy group, patients were told that the group clinics were being introduced because there were two types of experts. There are experts who know a lot about an ailment because they have studied it and others because they lived with it. "We told patients that our purpose is to bring those two groups together," says Macdonald.
During a weekly drop-in group visit for anxious patients with asthma at a Northern California Kaiser Permanente facility, participants would discuss ways to help one another get their asthma in control, says Bertagnolli. For example, if someone in the group had more trouble with asthma in the fall, they would discuss triggers and medication adjustments before the physician provided input on the solution to the problem.
One of the goals of this group clinic was to teach patients how to take their peak flow, look for trends, and adjust their inhaled steroids based on the peak flow meter reading. The goal was met, because the group appointment was two hours — providing more time for teaching — they met more frequently than patients who made individual appointments, and meeting weekly provided an opportunity to reinforce the education and behavioral changes, says Bertagnolli.
Patients said that they liked this drop-in group appointment format for several reasons:
- They had weekly access to medical care.
- They could learn from other patients as well as physicians.
- Other patients ask questions they usually don’t think to ask.
- They learned how to adjust medication and keep their asthma in control.
- They learned how stress and worry contributed to their asthma attacks and frequent visits to the emergency department.
Not a class
Although education is a prominent piece of group appointments, they are not to be confused with a class, says Macdonald. "There is no set agenda; so when the patients come in, they set the agenda. They say, This is my problem today,’ just like they would at an individual clinic visit," she says.
For example, the patient may come to an individual appointment complaining of high blood sugar at bedtime, and Macdonald will try to figure out why the patient is having this problem. During a group appointment, it is the other patients who try to resolve the problem.
Macdonald does teach a diabetes education class, and although it is interactive, she is the teacher. During the group clinic, she is a facilitator and the patients are the teachers, she explains.
"There are educational components to the group appointments, but even if you have a very interactive class, there is no individualizing as there is at group appointments," says Bertagnolli.
At Kaiser Permanente clinics in Northern Cali-fornia, group visits are conducted by a licensed health care professional. The goal of the group appointment is to replace the individual office visit. There also is a clinical intervention, which is discipline-specific. For example, a physical therapist conducting a group visit might help patients modify an exercise according to each patient’s condition, which is a clinical intervention, says Bertagnolli.
Group visits shouldn’t have a formal curriculum, but provide education as needed. "My phrase is education PRN," says Bertagnolli. The education is individualized as each patient checks in reporting how they put into practice what they learned at their last visit and any new problems they are experiencing. Patients support one another during the individualized part and offer information if they have something to contribute.
"We recommend that practitioners incorporate education into the group visit. It is a big shift for a lot of health care providers that feel like you have to do an education dump on the patient," says Bertagnolli.
Macdonald has chosen to focus her groups on problem solving issues. With diabetes, people need to learn how to problem-solve, she says. In the group visits, she attempts to teach them to identify the problem first, then think of possible causes and ways to test for the cause, and finally to come up with possible solutions and ways to determine if the solutions work.
To do this, at the beginning of each group visit, Macdonald has participants tell about any problems they are having with their diabetes or questions they may have as she writes them on the board. If people do not state a question or issue, Macdonald pulls something from what they said. For example, if a patient says he or she worked hard at eating the right foods, Macdonald will write: "What are the right foods and how do you choose the right foods?"
People are discouraged from engaging in discussion of the problems until everyone has had a chance to speak and the issues have been grouped into topics. Once the process is completed the group determines which topics to focus on first.
Sometimes Macdonald will write down individual data if the person is willing to share the information and have the group analyze it to figure out how to solve a problem. For example, if a patient states that he or she has high blood sugar at bedtime, Macdonald would write on the board what was eaten, what activities the patient engaged in, and the medications that were taken.
"We focus on education problem solving using the premise that you need more than knowledge — you need to be able to use your knowledge. I think a lot of our patients with diabetes have the knowledge, but they don’t know how to apply it. What we are really working on is applying knowledge as well as gaining new knowledge," says Macdonald.
When setting up the group appointment, figure out what the key messages will be, advises Bertagnolli. For example, for the Kaiser asthma group, the educational goals were to address the impact of stress and worry on asthma, how to take medications appropriately, to learn which medications work best in which situations, and how to monitor asthma with a peak flow meter. It’s OK to have a short agenda for education as long as the information is delivered when patients are ready to hear it, says Bertagnolli.
Also, he advises that practitioners figure out what materials they will need and put them in a box marked as patient education materials. The educational materials would focus on the type of patients that would be included in the group visit.
As a result of the education that takes place during group appointments, visits to the emergency department are decreased in certain populations, reports Bertagnolli. Also, patients’ conditions seem to improve and their satisfaction increases.
"The patients in the intensive insulin therapy group have learned a lot about diabetes management, and they have also developed a camaraderie with the people in their group," says Macdonald. She used to see these patients individually every two or three months but now sees them on average once every six months because they come to group clinic once a month.
She sees patients from the diabetes management group in her office more frequently because they do not come to the monthly group appointments as regularly. Even so, there has been an impact. "They are more aware of problems with diabetes and are doing some problem solving. They are thinking about issues more and not relying on me as much," says Macdonald.
Sources
For more information about group appointments, contact:
- Andrew Bertagnolli, PhD, Project Manager for Group Appointments, Regional Health Education, Kaiser Permanente Northern California, 1950 Franklin, 13th Floor, Oakland, CA 94612. Telephone: (510) 987-1301. E-mail: [email protected].
- Linda Macdonald, MD, Staff Physician, New Mexico VA Health Care System, 1501 San Pedro Drive, S.E., 111GIM, Albuquerque, NM 87108. E-mail: Linda. [email protected].
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