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Overview
Medical group visits or shared medical appointments are an approach to chronic care management. They have been viewed as an adjuvant to the chronic care model as it has the potential to address multiple aspects of patient care in a personalized and tailored way. This method allows for providing medical care in combination with education while maintaining productivity and revenue. While group education and interaction led by a care provider is one of the elements of the group visit, aspects of the individual patient visit such as collection of vital signs, history taking and physical exam are incorporated. They emphasize patient self-management and address topics such as medical and pharmaceutical management, nutrition, exercise, and psychosocial contributors to health and illness. Group visits typically follow three basic formats: Drop-in group medical appointments (DIGMAs), physical shared medical appointments (PSMAs) and cooperative health care clinics (CHCCs).

History
Group visits were originally developed in 1974 for well-child care as a means to dedicate time to social, psychological and emotional health. The hope was to increase patient-provider contact while increasing patient participation helping to establish better rapport, education, and improved outcomes.

With further research, the application of the group visit thought to be applicable to the adult population. The three formats of the group visits of DIGMA, PSMA, and CHCC were initiated and publicized by Edward Noffsinger, PhD and John Scott, MD respectfully.

In 1991, Scott who is an internist and geriatrician at Kaiser Permanente Clinic in Hidden Lake, Colorado, originated the CHCC for his geriatric patients. As the director of clinical access improvement at Palo Alto Medical foundations Noffsinger introduced the DIGMA model in 1996 and the PSMA model in 1999 as a means to address problems of access for physical exams in the private sector, armed services, and in the VA system.

Drop-in Group Medical Appointment
Drop-in group medical appointments (DIGMAs) consist of patients who “drop in” when they have a particular medical need. These are generally 90-minute appointments held at a designated time every week and led by a physician and behavioral health professional. They are open for patients with any medical condition and involve 10 to 15 patients at a time. DIGMAs can focus on a specific medical condition or include all chronically ill patients in a particular practice. Typically, a behaviorist facilitates the group and addresses psychosocial concerns. A physician meets with patients individually in the group context and invites the group to provide solutions to problems, thereby providing education rather than a lecture. Following the educational sessions, patients may meet with the physician privately if desired.

Physical Shared Medical Appointment
Physical shared medical appointments (PSMA) are physical exam visits conducted rapidly but thoroughly by a physician in which talking is minimized and discussion is deferred to a subsequent interactive group session resembling a smaller DIGMA. PSMAs are used in primary care and many medical subspecialties for new patient intake as well as in chronic disease management. In primary care, group size ranges from six to nine patients and in the medical and surgical subspecialties, group size ranges from 10 to 13 patients. Typically, PSMAs utilize a small group room and four exam rooms and involve a multidisciplinary team of a physician, two nurses or medical assistants, a behaviorist, a documenter and a scheduler. While the physician is performing physical exams, the behaviorist is in the group room with the remaining patients documenting their medical concerns. In the group session, patients learn from one another and physicians discuss health concerns with numerous patients at the same time.

Cooperative Health Care Clinics
Cooperative health care clinics (CHCCs) are generally two-hour appointments led by a physician and nursing support. This type of group session involves up to 20 patients and is typically used to provide care to elderly patients with chronic conditions or who frequently utilize medical resources. One variation is the high-risk cohort model, which is used to provide care to patients of all ages with similar chronic illnesses. Another variation is the chronic care clinic, which focuses on interactive discussions regarding patient-self management. In all these models, a physician conducts individual medical sessions in a separate room near the group meeting place, for up to five minutes. A nurse takes vital signs and other measurements. Collecting patient data and individual physician-patient meetings take about 30 minutes and the rest of the time is dedicated to addressing group concerns, providing educational material and answering participants’ questions. CHCCs include at least one physician, but may involve a variety of other practitioners such as dietitians or pharmacists. Either the group facilitator or patients may suggest topics and in programs focusing on self-management, physicians and patients create behavior-change action plans. Family members are also invited to attend group meetings.

Benefits
Beneficial aspects of group visits include self-management education, the support gained from a group setting, minimizing barriers to language and literacy issues, and access to already limited health care resources. Group visits attempt to address the already limited access to health care resources faced by many patients. Group visits give patients the opportunity of having increased face-to-face time with physicians while also allowing access to other health care providers. Patients utilize other resources during group visits such as interpreters, language sensitive educational materials, and self-management skills. Research studies have demonstrated that patients who utilize group visits have overall decreased emergency room visits and hospitalizations. Most importantly group visits are well suited to address the needs of patients with chronic illnesses.

Self-Management Education
Patients living with chronic illnesses need the tools and resources necessary to adequately manage their disease in the long run. Group medical visits are a good resource for patients to gain more knowledge regarding their chronic illnesses. The self-management education made available during group visits not only provide patients with the necessary tools to better manage their disease but also reinforces any information that was given during the individual medical visit. Self-management training also has the capability to improve patient self-efficacy, which is associated with successful management of chronic disease. There is also a sense of empowerment in group settings; the social support and collaboration that occurs with group problem solving may reduce the perceived barriers a patient has towards behavior change.

Support System
Studies have demonstrated that support groups tend to improve patient satisfaction and psychosocial outcomes for patients with chronic disorders. Group settings allow patients to engage in conversation and gain the perspective of others living with similar disorders or life conditions. In group settings, patients are given the avenue to discuss various aspects of their disease including psychosocial factors that a physician might not necessarily have the time to address during the individual medical visit. There is also a sense of responsibility and accountability on a participant’s part toward other group members, which may result in positive behavior changes, and practices that improve the overall health status of the patient.

Improved Health Literacy
Group medical visits have the potential to greatly reduce barriers to language and health literacy. Patients with chronic illnesses who face language barriers and/or have low functional health literacy have difficulty navigating the health care system and directly participating in their health care. Language and health literacy barriers may result in poor quality of care, decreased patient satisfaction, decreased knowledge about disease process, decreased medication adherence due to a lack of understanding regarding medication regimen and overall a worse health status. Group visits are generally effective in addressing those pitfalls. Trained interpreters can aid in facilitating group sessions, which in turn can be cost effective and efficient for the medical center as one interpreter is used for multiple patients. Educational efforts and materials used during group visits can also be better tailored to the literacy needs and language of the patients. Patients are more likely to engage in their health needs if there is a better understanding about their illness and the steps required to improve their disease state.

Challenges
The medical group visit is quickly receiving recognition by hospitals, physicians, medical groups, and insurers, yet it is still at its infancy that faces multiple challenges to meet improvements. There is immediate challenge of cost in monetary and human resource terms, as well as designating a place for the group visits. Other challenges are maintaining continuous flow of patients and physicians, while sustaining credibility from both patients and physicians, and managing the group size and time duration of the session as the enrolled attendees increase.

Cost
Whether it is monetary, infrastructure, or workforce the initiation cost usually sits on the top of the priority list. Once implemented, the Future of Family Medicine Project estimated that the medical group visit will save $15,411 per physician per year. However, in order to implement any changes there are initial costs incurring from building or remodeling a room, setting up appropriate instruments and environment for the attendees, and advertisement-marketing to increase awareness of the program. In order to meet these costs, the savings of the program providers need to be invested for the program initiation, which may be burdensome to hospitals and/or other providers running on tight budget.

Moreover, another concern is reimbursement for the physicians. Albeit medical group visit’s proposed goals of increasing health care quality while reducing cost and other additional benefits are in accordance with the implementation of the Patient Protection and Affordable Care Act, the group visits have not yet received recognition in order to be reimbursed by Medicare or private health insurance plans. There is no specific billing code established for the medical group visits. However, there are billing codes, 99411 and 99412, for group setting that the group visit may or may not meet depending on the model. The reimbursement for these billing codes are lower compared to the individual billing code 99213. The reimbursement difference may discourage physicians to continue to provide for medical visits, especially the physicians in the capitated system whereas, the physicians in fee-for-service practice may produce long-term net benefit. Therefore, without the designated billing code for the medical visits, it would be challenge to keep physicians for long-term.

Management
Medical group visit is rapidly emerging in the mainstream medical care. As it is gaining recognition from the patients as well as the providers, there is a challenge of managing the group size and the time limit for each session. Referred in the model section, the group size and the time limit vary depending on the model. For example, for DIGMA it is preferable to involve 10 to 15 patients per session; whereas, it is preferable to have 10 to 13 patients and 20 patients for PSMA and CHCC respectively. Though similar, each model provides different types of services and has different types of patients. Nevertheless, as the group visits gain popularity, the group size may exceed its preferred size limit. There are risks in excessive group size for both patients and physicians. First, the individual patient-physician meetings, during sessions, decrease because the physicians need to see more patients with limited time. Patients may feel rushed and personal care diminished, which defeats the purpose of the group visit. Next, the increased group size leads to excessive workload for the physicians, which lead to rapid burnout. It is a challenge to achieve satisfaction level for both patients and physicians while maintaining the goals of the medical group visit model such as giving increased face-to-face time with physicians.

Confidentiality
Patient confidentiality is another challenge presented by the medical group visits because the patients who attend the sessions discuss about their conditions to some degree. In order to protect patients’ sensitive information, the providers may have the patients sign a consent form or full disclosure document describing the limits of the confidentiality. Nevertheless, the challenge still remains to protect the patient-physician confidentiality.