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The Group Appointment Trend Gains Traction: How Dietetics Fits into a New Model of Health Care Delivery

      The traditional, one-on-one health care encounter has long produced a few concerns for patients. For example, thanks to the increasing use of electronic information storage and social media, patients are increasingly concerned about their privacy and who has access to their confidential information. In addition, out of embarrassment, shame, or fear of being judged, some patients lie to their practitioners about their lifestyle habits or compliance with recommendations or prescribed treatment (
      • Palmieri J.J.
      • Stern T.A.
      Lies in the doctor-patient relationship.
      ).
      But how would such concerns affect a nontraditional clinical encounter, where other patients and perhaps multiple practitioners are present? The concept of the group medical appointment—which is sometimes referred to as a group visit, shared medical visit or appointment, cluster visit, or chronic health care clinic—has been around since 1996, when Edward Noffsinger, PhD, of Kaiser of Northern California, introduced the drop-in group medical appointment model
      Although Noffsinger initially designed group appointments as a drop-in model, such medical visits are now usually scheduled (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ).
      low asteriskAlthough Noffsinger initially designed group appointments as a drop-in model, such medical visits are now usually scheduled (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ).
      (
      • Carlson B.
      Shared appointments improve efficacy in the clinic.
      ); however, a new iteration of this approach to care was identified in 2004 as an office redesign trend to watch by the American Academy of Family Physicians' (AAFPs') (
      American Academy of Family Physicians
      Group visits (shared medical appointments).
      ) Future of Family Medicine Project (
      • Martin J.C.
      • Avant R.F.
      • Bowman M.A.
      • Bucholtz J.R.
      • Dickinson J.R.
      • Evans K.L.
      • Green L.A.
      • Henley D.E.
      • Jones W.A.
      • Matheny S.C.
      • Nevin J.E.
      • Panther S.L.
      • Puffer J.C.
      • Roberts R.G.
      • Rodgers D.V.
      • Sherwood R.A.
      • Stange K.C.
      • Weber C.W.
      Future of Family Medicine Project Leadership Committee
      The future of family medicine: A collaborative project of the family medicine community.
      ). And sure enough, as more clinics and organizations look for ways to cut costs and maximize efficiency, many groups are adopting this model, and some major media outlets have taken notice (,
      • Mishori R.
      Group appointments give patients better access to physicians.
      ).
      Registered dietitians (RDs) too may want to take notice of this trend, as there are myriad ways in which dietetics services are beneficial to the group medical visit.

      Why Group Appointments?

      Group appointments function similar to the standard medical visit, but instead of a one-on-one exchange between clinician and patient, multiple patients, ranging from as few as five to as many as 20, with similar health care needs receive simultaneous care, sometimes from a multidisciplinary team. Also setting these visits apart is that educational, self-management, and skill-building components are combined with the clinical component in a visit that is much longer than a one-on-one visit (often between 90 minutes to 2 hours), allowing greater time to more thoroughly discuss a greater number of health concerns (
      • Rijswijk C.
      • Zantinge E.
      • Seesing F.
      • Raats I.
      • van Dulmen S.
      Shared and individual medical appointments for children and adolescents with type 1 diabetes: Differences in topics discussed?.
      ).
      Although there is an educational component, group medical appointments differ from classes or support groups because of the clinical encounter, which, depending on the nature of the condition or disease, may take place during patient check-in, during the group appointment itself, or with patients individually afterward (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ). If the encounter includes a full physical examination, these occur privately in one-on-one time between patient and clinician and are often scheduled to coincide with the group's meeting (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ).
      Because the group setting is not ideal for all personality or conditions/disease types, group medical appointments are intended as a voluntary alternative for patient care with the potential to augment the medical encounter for patients. The Figure details how the structure of the University of Virginia Health System Heart and Vascular Center (UVAHSHVC) aims to achieve this patient experience enhancement.
      Figure thumbnail gr1
      FigureHow one health clinic views shared medical appointments as a benefit to patients. Figure provided by Ann Rossi, DNP, RN, ACNP-BC, and reprinted with permission from the UVA Heart and Vascular Center. aSMA=shared medical appointment. bNP=nurse practitioner. cCVD=cardiovascular disease. dRN=registered nurse. eIT=information technology.
      Before choosing to offer appointments that follow the group model, however, worthwhile considerations for health care practitioners include the cost effectiveness of implementation, patient interest, and reimbursement (
      • Weinger K.
      Group medical appointments in diabetes care: Is there a future?.
      ).

      The Patients

      Patients who have chronic illness or need routine follow-up care are among the groups best suited for the group appointment setting (
      American Academy of Family Physicians
      Group visits (shared medical appointments).
      ,
      • Mishori R.
      Group appointments give patients better access to physicians.
      ,
      • Kirsh S.
      • Watts S.
      • Pascuzzi K.
      • O'Day M.E.
      • Davidson D.
      • Strauss G.
      • Kern E.O.
      • Aron D.C.
      Shared medical appointments based on the chronic care model: A quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk.
      ). It has been used in the following specific patient communities (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ):
      • cardiac risk factor follow-up;
      • hypertension;
      • diabetes;
      • weight loss and lifestyle management;
      • movement disorders;
      • asthma;
      • fibromyalgia/chronic pain management;
      • hematology, including leukemia, lymphoma, and chronic anemia;
      • women's health care; and
      • bariatric surgery.
      According to the AAFP, group visits, in general, are suitable for patients who frequently return for visits, who require more time with the clinician, who are anxious about their health, and who have wide-ranging emotional and psychosocial needs (
      American Academy of Family Physicians
      Group visits (shared medical appointments).
      ). However, April Ahrendt, RD, LN, MOVE! dietitian at the Sioux Falls, SD, Veterans Affairs Medical Center (VAMC), and other researchers (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ) believe that patients with moderate to severe cognitive impairment or active psychoses are not likely to benefit from this form of treatment for medical nutrition therapy. In the group appointments at UVAHSHVC, says Teller Stalfort, MPH, RD, dietitian with the Club Red Clinic, patients with active psychiatric diagnoses are not scheduled for group appointments unless their illness is very well-managed and they are deemed appropriate by staff; disruptiveness is the main concern with individuals from this patient population. She believes that patients with eating disorders would not function well in a group setting unless they were managed by highly skilled practitioners. Ahrendt also notes that patients who have experienced emotional trauma might not feel comfortable in this format and may prefer one-on-one appointments.
      Other patients for whom this setting may not be appropriate include patients who are scheduled for initial or one-time consults (
      American Academy of Family Physicians
      Group visits (shared medical appointments).
      ); patients with hearing impairments, who require an interpreter, or who are unable or refuse to honor the confidentiality of other patients (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ); or, adds Ahrendt, who have active substance abuse.
      Stalfort further notes that, from a time-management perspective, individuals with complex and complicated disease courses may not receive optimal care in this setting. There can be too much ground to cover, making it challenging to keep the other patients engaged in the discussion if they do not share similar diagnoses or concerns.
      Despite their best attempts to screen patients when setting group appointments at the UVAHSHVC in Charlottesville, VA, says Stalfort, “Sometimes you simply can't predict how patients will settle into the group atmosphere.” For this reason, patients are frequently reminded that traditional, individual appointments are always an option if they, or staff, determine that the group setting is not ideal for them.
      Although group appointments are not a suitable environment for all patients, a decisive majority of patients who have participated have found it to be an effective option. Among patients at the Cleveland Clinic who participated in group appointments, for example, 85% opted for reenlisting for a group appointment for their next medical visit and 79% described their visit as “excellent” (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ).

      Patient+Guest

      Some group appointments allow a family member or other support person to be present for the encounter (these individuals also must sign an informed consent waiver). Although this alteration to the typical structure does not necessarily lead to bad outcomes, it certainly does have the potential to change the dynamic.
      In a study of children and adolescents with type 1 diabetes (
      • Rijswijk C.
      • Zantinge E.
      • Seesing F.
      • Raats I.
      • van Dulmen S.
      Shared and individual medical appointments for children and adolescents with type 1 diabetes: Differences in topics discussed?.
      ), for example, patients participating in the group appointment format discussed a mean of 17.74 topics, compared with 12.43 topics in the one-on-one appointments. Whereas both appointment contexts included comparable discussion of topics such as well being, general development, insulin doses, and smoking and alcohol, problems such as intercurrent disease, hypoglycemia, hyperglycemia, self-control, insulin injection sites, insulin delivery method, and self-control were discussed in a substantially larger number of shared medical appointments than one-on-one visits. However, individual physical examination and blood pressure were discussed more often in individual appointments.
      Although a longer appointment is conducive to more topics being discussed, as the chief difference between this study's group and usual care patients was the required presence of parents/guardians—not all parents attended the one-on-one appointments—their attendance may have had an impact on the increase in topics discussed. In fact, in appointments where no parent was present, hyperglycemia, self-control, and insulin injection sites and dosage were discussed far less frequently (
      • Rijswijk C.
      • Zantinge E.
      • Seesing F.
      • Raats I.
      • van Dulmen S.
      Shared and individual medical appointments for children and adolescents with type 1 diabetes: Differences in topics discussed?.
      ). However, the presence of parents may inhibit children from disclosing all of their concerns (
      • Rijswijk C.
      • Zantinge E.
      • Seesing F.
      • Raats I.
      • van Dulmen S.
      Shared and individual medical appointments for children and adolescents with type 1 diabetes: Differences in topics discussed?.
      ).
      Because the patients are younger than 18 years old in the pediatric group appointments led by Sarah Koszyk, MA, RD, a medical nutrition therapist and sports nutritionist in private practice, parents are required to attend. It is especially important that parents be involved in the earlier appointments so they can hear the educational components regarding portion sizes and which foods to buy. Although the children seem to be more attentive to the group when their parents are present, Koszyk has also noticed that they occasionally become more open when the parents leave the room, as the children feel more comfortable discussing certain topics such as hiding food or unintentionally hurtful comments that a parent had said.
      At the bariatric surgery center where Nancee Vander Pluym, MS, RD, worked with postsurgical patients, group participants were allowed to bring a support person to the appointments. According to Vander Pluym, these additional persons did not necessarily affect the dynamic, because they were there mostly in a “quiet listening” capacity. There were some patients who did not want to speak and deferred instead to the spouse who did want to participate; however, when this occurred, other patients in the group themselves spoke up and urged the patients to know the details of their health and to become more active participants in their own care.

      What about Privacy?

      Patients who participate in group medical appointments are expected to give up some degree of privacy. For a group appointment for expectant mothers, for example, weights are taken and fetal heartbeats are monitored by a midwife in the room while health concerns are being discussed (
      • Mishori R.
      Group appointments give patients better access to physicians.
      ); in other contexts, however, such as at the VAMC MOVE! weight management program led by Ahrendt, weights are taken at the beginning of each appointment and laboratory data and psychosocial information are discussed as needed throughout treatment. Patient privacy and choice in treatment are supported by requiring veterans to fill out a group medical appointment consent for participation and release of information if they choose to participate in the group MOVE! appointments. Via this form, veterans are informed of right to privacy, that participation is voluntary and individual appointments are available, and requirements to participate with confidentiality agreement, and they are given space to write down any medical information they do not wish to discuss in the group setting to protect their privacy. As mentioned previously, patients who cannot or will not maintain confidentiality should not be recruited for group appointments.

      Is Reimbursement an Issue?

      Although group appointments are a relatively new concept, physicians who offer group appointments generally are reimbursed by insurance companies, billing in correspondence with the level of care received (rather than time spent) as if it were an individual appointment ().
      However, private practice dietitians who offer weight-management group appointments might not find this to be the case. Koszyk's experience has been that she needed to ensure a contract with the larger, national insurance companies to establish reimbursement for group appointments, whereas physician-owned insurance companies, also called “captive insurance programs,” which “help control the rising cost of insurance paid to third parties, provide added insurance protection by filling in the holes and exclusions of conventional policies, and provide coverage for either self-insured or non-insured risks more readily allow such contracts for billing” (
      Physician-owned insurance companies on the risee.
      ).
      The Centers for Medicare and Medicaid Services have not yet established official policies regarding reimbursement for group medical appointments. At one time, the code for “unlisted evaluation and management” (99499) was the recommended code for reporting group care, but because this approach gave the payor the power to determine the value of the service, additional codes, such as “medically necessary face-to-face E&M visit” (99213) are acceptable. The organization has indicated that: “There is no prohibition on group members observing while a physician provides a service to another beneficiary” ().
      It is good practice, however, for clinicians offering group appointments to consult with payors in advance of billing and coding submissions to identify or clarify their coding preferences for this type of health care encounter.

      The Effect of Group Appointments on Outcomes

      Patients in group appointment settings have proven to have successful outcomes—and comparisons frequently show better outcomes than patients in one-on-one medical visits. However, these results have been mixed.
      In a study of veterans with uncontrolled diabetes and hypertension receiving care via two VAMCs, for example, patients attending group medical appointments had better blood pressure measurements at 6 months and at 1 year and had fewer emergency department visits than patients receiving usual care; however, the researchers attributed this success to the substantial room for improvement in clinical outcomes of the attendees as well as the high attendance rate (
      • Edelman D.
      • Frederickson Z.K.
      • Melnyk S.D.
      • Coffman C.J.
      • Jeffreys A.S.
      • Datta S.
      • Jackson G.L.
      • Harris A.C.
      • Hamilton N.S.
      • Stewart H.
      • Stein J.
      • Weinberger M.
      Medical clinics versus usual care for patients with both diabetes and hypertension.
      ). Another study showed that group appointments for patients with type 2 diabetes not treated with insulin resulted in fewer visits to the emergency room, fewer disability days, and better overall health status (
      • Wagner E.H.
      • Grothaus L.C.
      • Sandhu N.
      • Galvin M.S.
      • McGregor M.
      • Artz K.
      • Coleman E.A.
      Chronic care clinics for diabetes in primary care: A system-wide randomized trial.
      ).
      Neither of those two studies observed improved hemoglobin A1c values in group appointment participants, but this outcome has been noted in other research. For example, a study by Trento and colleagues (
      • Trento M.
      • Passera P.
      • Bajardi M.
      • Tomalino M.
      • Grassi G.
      • Borgo E.
      • Donnola C.
      • Cavallo F.
      • Bondonio P.
      • Porta M.
      Lifestyle intervention by group care prevents deterioration of type II diabetes: A 4-year randomized controlled clinical trial.
      ) noted a statistically significant difference in mean hemoglobin A1c values (patients in the group appointments lowered their levels from 7.4% at baseline to 7%, compared with an increase to 8.6% in patients receiving usual care) and a higher average decrease in weight (2.6 kg among group appointment patients compared with 0.9 kg among usual care patients). A 1999 study by Sadur and colleagues (
      • Sadur C.N.
      • Moline N.
      • Costa N.
      • Michalik D.
      • Mendlowitz D.
      • Roller S.
      • Watson R.
      • Swain B.E.
      • Selby J.V.
      • Javorski W.C.
      Diabetes management in a health maintenance organization: Efficacy of care management using cluster visits.
      ) also showed a greater decrease in hemoglobin among health maintenance organization patients with baseline A1c greater than 8.5%, as well as lower hospital admission rates and more frequent blood glucose self-monitoring, when compared with usual care patients. Another study (
      • Kirsh S.
      • Watts S.
      • Pascuzzi K.
      • O'Day M.E.
      • Davidson D.
      • Strauss G.
      • Kern E.O.
      • Aron D.C.
      Shared medical appointments based on the chronic care model: A quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk.
      ) showed statistically significant improvements in A1c and systolic blood pressure (and statistically insignificant improvements in low-density lipoprotein cholesterol) among group appointment patients when compared with controls in a cardiovascular risk reduction program.
      Of note, however, is that researchers generally believe that the specific impetus for these improved outcomes is not readily identifiable (
      • Weinger K.
      Group medical appointments in diabetes care: Is there a future?.
      ).

      Obstacles to the Group Appointment Model

      Of course, like most models of care, there are challenges to effectively offering group appointments. For instance, some clinicians—eg, those with small private practices; with office hours at least half that of a traditional workweek; or with inadequate space, funding, or staff (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ,
      American Academy of Family Physicians
      Group visits (shared medical appointments).
      )—may have difficulty providing adequate resources or maintaining a large enough patient/client pool to make it work. In addition, it is important to remain mindful that these health care encounters are not meant to function as a health class but rather are individual patients in a group setting (
      • Bronson D.L.
      • Maxwell R.A.
      Shared medical appointments: Increasing patient access without increasing physician hours.
      ).
      Maintaining a group appointment program is challenging for some clinics and individual clinicians particularly if the group setup is to meet frequently. Furthermore, implementing a program of this nature may require additional training and a care team consistency that may be difficult to sustain over time (
      • Sikon A.
      • Bronson D.L.
      Shared medical appointments: Challenges and opportunities.
      ). For example, after group appointments were offered for more than 2 years at a bariatric surgery center, says former employee Vander Pluym, the administration ultimately determined that the bariatric center did not align with the long-term, corporate objectives.

      Starting a Group Appointment Program

      The basic steps to prepare and then implement group appointments at an organization or office include the following (
      American Academy of Family Physicians
      Group visits (shared medical appointments).
      ,
      • Kirsh S.
      • Watts S.
      • Pascuzzi K.
      • O'Day M.E.
      • Davidson D.
      • Strauss G.
      • Kern E.O.
      • Aron D.C.
      Shared medical appointments based on the chronic care model: A quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk.
      ,
      • Kirsh S.R.
      • Lawrence R.H.
      • Aron D.C.
      Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes.
      ):
      • establish the group's focus (disease specific or nonspecific);
      • get administrative support;
      • establish the multidisciplinary team (if applicable/necessary) that will administer group appointments;
      • determine the minimum and maximum number of participants that will be most conducive for patients and practitioners alike;
      • establish procedures
        • time and frequency of appointments
        • techniques and processes;
      • identify a comfortable meeting space
        • arrangement and size of room
        • if one-on-one time with a physician will be part of the protocol, an examination room should be in close proximity to the meeting space;
      • create forms
        • general information
        • patient specific;
      • address any internal organizational issues (including billing) before beginning;
      • recruit patients;
      • determine protocol for documentation; and
      • identify review processes for outcome measures, policies/procedures, and patient satisfaction data.
      It is difficult to sustain a group appointment model without administrative support or buy-in from practitioners with the power to refer patients. Because the MOVE! program (which includes this model of care as part of its structure) was developed and initiated at a national level, there was no resistance with regard to the group appointments; however, there were initial challenges with implementing this new form of treatment. “Referrals are important, as is communicating to interdisciplinary team staff how to refer for this type of appointment, who is a good candidate for this form of treatment, and how to introduce this information to patients,” notes Ahrendt. “That's why it's so important to put in front time when there's something new. To get buy-in, you have to write out and show [all stakeholders] what they will get from a program.”
      The means for recruiting patients will vary based on type of venue of the group appointment. For example, VA or bariatric surgery patients will be referred by physicians employed in the system. However, for RDs in private practice, from a marketing standpoint, says Koszyk, describing the benefits of the program and developing a good, professional rapport with three to five office managers at various physician offices will likely receive a windfall of referrals.
      Mary Lou Perry, MS, RD, CDE, a clinical nutrition specialist at the UVA Heart and Vascular Center (Morrison's) who works with Stalfort, advises anyone who is considering launch of a group medical appointment program to debrief with staff after each appointment and to be adaptable to changes in flow and process. “Having the flexibility of being able to morph our program into something that was meeting our needs was much more appealing than working with a program that wasn't meeting the needs of our stakeholders,” Perry adds.

      RDs in the Group Setting

      Nutrition assessment, monitoring, diagnosis, intervention, and education frequently factor into treatment of the conditions and diseases identified previously as ideal for the group appointment; thus, RDs in clinical settings may be invited to manage or participate otherwise in the clinical team delivering medical care in group appointments. However, RDs in private practice may also find the group medical appointment to be an effective way to serve the community seeking weight management care.
      Following are multiple contexts in which RDs have participated in group appointments.

      MOVE! Weight Management Program for Veterans

      MOVE! is a national weight management program of the Veterans Health Administration and is intended “to help veterans lose weight, keep it off and improve their health” (
      US Department of Veterans Affairs
      MOVE! Weight Management Program.
      ). Ahrendt meets once a week for 12 weeks with veterans enrolled in the MOVE! program at the Sioux Falls VAMC, where group appointments have been offered since 2007
      Although a national program, MOVE! has local variations across the VAMC system. The program described in this article applies specifically to the Sioux Falls MOVE!
      (MOVE! group care has been offered at some facilities since 2003 and the Veterans Health Administration has been doing group weight management care since the 1980s). After these 3 months, patients may enroll in a monthly support group; however, many opt to—and are allowed to—continue with the group appointment program.
      The physician who performs bariatric surgeries does not participate in the group appointments. Along with Ahrendt, the MOVE! team includes a psychologist, prevention nurse, physical therapist, dietitian MOVE! coordinator, and a mental health practitioner (who facilitates guided imagery for relaxation). In these appointments, the RD is present to facilitate the discussion, counseling, and education. Included among Ahrendt's duties are to write the curriculum, implement changes based on feedback or other issues that present, create the interdisciplinary schedule, teach the educational modules of some classes, and schedule the guest speakers who teach the others.
      Participants are referred to the MOVE! program by physician offices if their body mass index is greater than 25 and they meet other specific criteria, such as age younger than 70 years. A nurse performs the screening tool for enrollment and patients receive a pamphlet with information about weight loss. It is then the patient's decision if he or she wants to obtain a consult, enroll, or pass.
      According to Ahrendt, most referred patients do enroll in the MOVE! class. She estimates that 80% of these individuals are not ready to make a lifestyle change but rather are in the precontemplation or contemplation stages of readiness for change, and the program moves them into a state of readiness and action.
      Patients are given a printout of their most recent laboratory results during one appointment with the prevention nurse. The individual results are not necessarily discussed while the appointment is taking place. Weights are taken at each appointment. Vitals and individual appointments with the MOVE! physician champion are completed monthly for patients on weight loss medications.
      The first appointment is an orientation, where patients find out what to expect, receive standardized handouts in a folder, and sign informed consent forms. In a typical subsequent appointment, weight measurements are taken and documented, food records maintained by each patient during the previous week are collected, handouts are distributed (each week has a homework assignment), the educational component is discussed, and each patient sets one diet goal and one physical activity goal to work on until the next appointment.
      The program's success is monitored by satisfaction surveys completed by participants at the end of each session. Adjustments are made based on this feedback. For example, because many MOVE! participants are prediabetic or have type 2 diabetes, each 12-week session includes a lesson plan regarding carbohydrate counting and the steps to improve laboratory values. However, participant feedback indicated that many believed more time was needed for carbohydrate counting, so a follow-up session was added to the curriculum. In addition, the current length of the program was the result of feedback; originally set as a 6-week program, the program was extended to 12 weeks after many veterans indicated wanting more group appointments.
      And it's with good reason that they wanted to continue: According to Ahrendt, the participants who continued with the program after 12 weeks kept off the lost weight, whereas individuals who did not participate in follow-up treatment at the end of the initial 12 weeks were more likely to struggle with weight regain and often would call back to re-enroll. (Although a 1-year commitment is recommended, it is not a requirement.)
      Ahrendt believes that the camaraderie built among patients and rapport established with the care team is what keeps patients interested in participating. “It makes people feel more relaxed because they are interacting with others who have the same experience,” she says. “They feel less judged than they might in a one-on-one setting. . . .It is hard to do this alone. The patients aren't expected to say their weights out loud in the meetings, but they usually tell each other anyway.”
      The added support from other patients who also have long been struggling is the factor most favored by these patients. They appreciate that even though other participants are not experts, they might have helpful tips borne out of experience. Ahrendt notes, however, that she is quick to address any incorrect advice that is given. She employs motivational interviewing techniques, an approach that works best in this type of setting and via specific types of expression and wording counteracts the interaction between practitioner and patient that occasionally leads to individuals feeling judged.
      Any clinician who participates in group appointments needs training in group facilitation,” says Ahrendt, who notes that when she first started teaching, she didn't realize right away that a patient giving incorrect advice actually translated to a teaching opportunity for her: “For example, if a participant says something that is not a realistic solution, such as that if you can't stop overeating, you should wire your jaw shut,” Ahrendt offers. “Rather than dismiss the idea, use this as a teaching opportunity by reframing the discussion to be about coping with frustration and introduce problem solving other solutions that may help with this challenge.”
      In addition to group facilitation training and obtaining buy-in from stakeholders, Ahrendt advises anyone with an interest in implementing group appointments to create a strong curriculum. “If the program is not solid,” she says, “people will drop out.”
      Ahrendt believes that clinician benefits of group appointments include the cost and time effectiveness (“It's much more time efficient to meet with 14 people at one time than one-on-one 14 times,” she says) and that she gets to see improved outcomes that often exceed patient outcomes for usual care appointments. Among the group appointment patients, she says, “We are seeing decreases in weight, blood sugar, A1c, cholesterol, triglycerides, and blood pressure. My best days are the ones where a patient comes in and announces to the group that he is being taken off insulin.”

      Bariatric Surgery Center

      During the nearly 2 years that Banner Good Samaritan Bariatric Center in Phoenix, AZ, offered shared medical appointments, Vander Pluym was employed as the center's bariatric nutrition specialist. The idea to offer group appointments was put forth by one of the center's physicians—a younger surgeon experienced in the group appointment setting from his time at the Cleveland Clinic (which first implemented this care model in 2002) ()—in response to the emerging issue of having sufficient time to address the needs of all patients who, in addition to their regular appointments, were frequently calling or dropping in. However, some surgeons with more traditional ideals were resistant to the novelty and ultimately the program did not expand nor continue.
      Postsurgery patients were recruited for group appointments by the center's surgeons and staff—surgeons presented the option as a learning opportunity for patients during an informal seminar and staff discussed it with patients during clinical interaction. At each mention of group appointments, however, it was made very clear that it was an option, not a requirement, and any patient uncomfortable with the group setting could opt for one-on-one follow-up.
      Among the documents provided to patients before starting the group appointment was a letter for their primary care physician that outlined recommendations for medical follow-up such as diabetes, cardiac, hypertension management, and dual-energy x-ray absorptiometry screening. It also addressed avoidance of nonsteroidal anti-inflammatory drugs and tobacco use and instructions for emergency departments to contact the surgeon before proceeding with diagnostic tests. Having this letter presented during the group appointment provided optimal time management and did not derail the planned curriculum.
      These group follow-up appointments were offered weekly but patients enrolled in them at intervals of 3, 6, 12, 18, and 24 months, corresponding to the same follow-up schedule that an individual postsurgical patient would adhere to. Patients participating in group appointments were anywhere on the spectrum of postoperative care, which Vander Pluym says presented an excellent opportunity for patients to learn about the issues confronted by patients further down the postsurgical timeline and to see them physically—and the majority of patients appreciated this.
      The multidisciplinary team managing these appointments consisted of the RD, a psychologist, exercise physiologist, nurse, and the surgeon. Vander Pluym's role was to manage the list of patients due for the shared medical appointment, confirm their planned attendance, schedule postoperative classes and follow-up shared appointments, and monitor their preoperative and postoperative laboratory results (and communicate with patients between appointments if adjustments were needed). In addition, if any patient was a no-show, staff would contact that person and encourage him or her to join another group or make an appointment to see the surgeon individually.
      During sign-in at the shared medical appointments, patients would have their weight and blood pressure recorded and sign a release, while patients in the early stages (3 to 6 months postsurgery) discussed healing and medical concerns with the nurse to be discussed when the surgeon was present. Participants also received packets of information from the program's education manual that corresponded to their nutrition-related postoperative stage along with a packet from the exercise physiologist and their laboratory results (or, if the patient didn't show up for those tests, he or she received a new laboratory requisition). During this time, Vander Pluym also organized information to present to the surgeon during the appointment that was compiled from patient-completed questionnaires addressing gastrointestinal signs and symptoms; dietary issues; vitamin/mineral supplements; use of protein supplements; change in prescription medications; current exercise; follow-up with primary care physician, cardiologist, or endocrinologist; and if they had a specific concern/question to present to the surgeon during the appointment.
      At every meeting, when the surgeon arrived, after the group appointment had begun, the psychologist would reiterate the expectations of privacy and confidentiality and that participants could opt out and switch to individual appointments at any time if preferred. Then, as the surgeon would discuss issues with patients, including nausea, vomiting, and protein drinks, Vander Pluym would hand him the information she had organized and as he paused to scan the information, she would discuss how to address gastrointestinal concerns.
      During these 90-minute appointments, patients were encouraged to share what they had learned and to give each other suggestions on how to deal with certain postsurgical concerns (such as calcium and protein drinks that they individually found tolerable, with approval from the RD); if any one patient began to dominate the conversation with personal issues, however, Vander Pluym or the surgeon would steer the conversation to be inclusive of the group.
      After each shared medical appointment, Vander Pluym documented date and type of surgery (lap band, gastric sleeve, or Roux-en-Y), starting weight, percentage of excess body weight lost, and any gastrointestinal issues, changes in medication (from primary care), and other intermittent problems that were determined during the appointment. Patients completed a brief survey and would answer questions such as the following:
      • Did you find this helpful?
      • Would you recommend this to others?
      • What would you change about the appointment?
      • Were your needs addressed?
      • Do you have other comments?
      Vander Pluym notes that the vast majority of patient feedback regarding group appointments was very positive, with estimates that 85% to 95% were very or highly pleased with their experience. If any individual wrote feedback that was of concern to the clinicians, a team member would follow up privately with that patient to determine the root of the problem and whether it needed to be addressed by the team psychologist or another team member. She relates her experience with one particular patient who in the first year was standoffish and didn't participate much in the group. However, over time, she became more positive and frequently spoke of how much she appreciated the support of the center and the other team members.
      Adjustments to the program based on feedback included offering weekly appointments to keep the number of patients in each group to a smaller number—at first, the patient groups were far too large to facilitate effective care for each participant.
      Because not all patients attended a complementary support group, these appointments benefited patients by providing education and camaraderie to help each through the process. Patients were instructed by the surgeon to attend education classes scheduled at 3, 6, 12, 18, and 24 months.
      The shared appointments created some extra demands on time before and after the meetings; the half-hour before the appointment began was very busy, Vander Pluym notes, and documenting each patient's visit into electronic medical records afterward was required. Yet, despite this extra work, Vander Pluym believes the group appointments were a more productive use of time. “We had more time for follow-up and more patient contact than might have otherwise been possible. And we avoided having to repeat the same information over and over again to each individual patient.”
      Because of the increased interaction with patients, Vander Pluym and her colleagues noted better outcomes in patients participating in group appointments in terms of percentage of lost excess body weight, compliance with nutrition parameters of postsurgical care, and decrease in emergency room visits.
      Group appointments are worth all the time and effort that go into them,” Vander Pluym says. “Most people think of RDs as people who take things away, so it was reinforcing to hear of the positive changes and share the tears in these group appointments. These patients show that RDs really can make a difference with nutritional status and quality of life.”

      Private Practice Weight-Management Group

      The RDs at MV Nutrition in San Francisco, CA, have been offering group medical appointments since April 2009. The reason to begin offering appointments in this structure was twofold: the changing economy convinced associates to offer lower-cost options for clients, and a new office space offered the proper venue for facilitating such appointments. MV associate Koszyk leads weight-management group appointments for pediatric and adult cardiovascular and diabetes patients. (MV Nutrition offers similar appointments in Spanish and Chinese.)
      Koszyk offers both private group appointments—where patients, primarily adults, are recruited via company newsletter, referral, or word of mouth—and insurance-reimbursed appointments, mostly composed of pediatric patients referred by physician offices. The adult groups participate in eight 1-hour meetings over 3 months, assembling once each week during the first month then every 2 weeks thereafter; the pediatric groups meet once every 2 weeks for a total of six 1-hour appointments.
      The educational component of these meetings focuses on implementing lifestyle change and behavior modification rather than imposing diets. The emphasis is on enjoying what one eats in moderation and in appropriate portion sizes and the deliverables are presented as simplified, scientific, evidence-based medical nutrition therapy (for example, the effect of breakfast consumption on metabolism).
      In the first group appointment, anthropometric measurements including height, weight, body fat, and hip and waist circumference are taken. (Clients are requested to bring laboratory results for thyroid, cholesterol, and glucose to this meeting.) In addition to this general assessment at the first appointment, the following core principles are discussed:
      • eating breakfast within an hour of waking;
      • eating every 3 to 4 hours;
      • combining carbohydrate and protein foods so that snacks include at least two food groups and meals include at least three food groups;
      • eating 30% of the day's energy intake at dinner; and
      • exercise.
      In all subsequent meetings, height and weight of pediatric patients and only weight of adult patients are measured; at the last meeting, all original measurements are taken again.
      The second group appointment focuses on meal planning and portion sizes customized for each individual. For adults, these meal plans are based on metabolism, tested in the office, and basal energy expenditure. For children, meal plans are based on age.
      Subsequent educational components address dining out, traveling, setting an action plan, modifying behavior, and dealing with setbacks.
      Between meetings, adults must maintain an electronic food record (to which Koszyk has access) that includes recognition of feelings (such as feelings of stress, tiredness, boredom, and so on) and hunger cues (such as not hungry, ready to eat, to extremely hungry) in order to assist with behavior modification.
      Group appointment participants complete an outcomes evaluation at the end of each group appointment. Pediatric patients write down three things they learned during the appointment and identify one action-oriented, measurable goal they set for themselves. Similarly, adults create action plans with goals (“needs” rather than “wants”), which reframes a plan into actions they need to address and, in turn, helps encourage compliance.
      A final evaluation is completed by both adult and pediatric patients at the last appointment. The RDs at MV Nutrition meet often to review patient feedback and adjust the programs accordingly.
      Like Ahrendt, Koszyk notes the importance of motivational interviewing in the group appointment setting. “Because it is harder to focus on individuals in group appointments, practitioners need strong training in group counseling skills,” she says. “Group dynamics are challenging for some people, and the group leader has to make it interactive. A simple question like ‘What is your favorite fruit?’ can help to engage pediatric patients who are uncomfortable. It is important that they are comfortable, as it encourages continued attendance.”
      Furthermore, she adds, “You want to make sure the patients are getting the most information out of the meeting. Yes, it's an investment of time and money to properly prepare. Ultimately, it all works for the benefit of the patients.”
      In addition to the lowered costs, Koszyk believes that the patients receive a major benefit from the diversity of opinions and experiences that come up during the group discussions. In an adult group appointment, for example, when one patient was having a difficult time determining an afternoon snack that would address her hunger, another participant mentioned that she had had success with Greek yogurt. “Knowing that other people have similar challenges and they are not alone is a big benefit,” says Koszyk. “Mutual support helps them to avoid traps or barriers.”
      From a practitioner standpoint, Koszyk identifies benefits such as decreased costs; increased time management, since the program curriculum is set and she doesn't have to continuously develop it; and increased productivity, as the gathering of a group decreases the detrimental effects of patient no-shows.
      Koszyk believes that group appointments can be appropriate for many different pediatric and adult groups, as long as they are focused on the treatment of one disease or condition and, in the case of pediatric appointments, that they are culturally and age appropriate and address any issues related to language barriers. Although groups should not be divided by sex, her experience has shown that if there is only one person of a given sex among the patients in a group appointment, that person may not feel entirely at ease and might seek out another group or switch to private consultation.
      Koszyk has not detected any noticeable differences in outcomes of group patients compared with individual care patients; rather, she says, success varies based on individual needs. “If a client has a desire to change, that person will work hard to make changes whether in a group or in individual appointments. The people who don't succeed are the ones who may not be ready for it.”

      Diabetes and Endocrinology Center

      The staff at the Rutland Regional Diabetes & Endocrinology Center in Rutland, VT—where Lynn Grieger, RD, CDE, is a diabetes nutrition educator and certified personal trainer—began offering group appointments in July 2010 when it became apparent that there was a backlog of more than 2 weeks for patients in need of diabetes nutrition education. Because the program is so new, program adjustments identified in patient feedback have not yet been required and outcomes measurements are not readily apparent. However, this program has addressed the immediate need of shortening the wait time to see the RD, and, Grieger notes, the groups so far have had positive discussions that have enhanced their learning.
      In the Rutland system, newly referred patients first visit with the diabetes nurse educator, who decides which patients are best suited for a group appointment. Most of the patients who have been given the option to sign up for the group appointment agree to do so.
      Unlike other clinics' group appointment systems, the group appointment at Rutland is a one-time medical visit, not an ongoing, standing appointment. After patients check in—these groups so far generally have comprised two to three individuals with one family member often accompanying each—they convene in a classroom that affords more space. From there, notes Grieger, “The 90-minute appointment proceeds much like I handle a one-on-one setting: We introduce ourselves, talk about why they're here and what they hope to learn from the day's appointment, and answer any questions they have left over from their visit with the nurse. I explain the role of carbohydrates in diabetes management and we talk about the various foods that contain carbohydrate.”
      Once a patient volunteers to describe his or her typical breakfast, that sketch is used for illustration of portion sizes, carbohydrate content, and, typically, reading food labels. At the end of the session, participants are encouraged to discuss a specific goal for moving forward, and they are informed of the next step, which is attending a 5-week diabetes education class, and are given the option for one-on-one follow-up. Although group follow-up is not offered at this time, it hasn't necessarily been ruled out.

      University Cardiovascular Clinic

      Stalfort and Perry participate in shared medical appointments along with a team of cardiologists, endocrinologists, nurse practitioners, exercise physiologists, and pharmacists at the Club Red Clinic at the UVAHSHVC. This group began offering shared medical appointments in December 2008 with an interest in offering more comprehensive care and improved patient access to clinicians while simultaneously improving productivity—the group appointment model was attractive particularly because it allowed streamlined care in a supportive group dynamic.
      According to Perry, as the practitioners at Club Red Clinic began seeking out alternative modes for delivery of care that are cost effective and professionally satisfying, they were inspired by Noffsinger's story and passion and invited him for a consultation visit to help them envision this practice redesign.
      Although the program was initially designed for female cardiovascular patients only—primarily, notes Stalfort, because cardiovascular disease is an “underdiagnosed, undertreated and clinically unique” condition in women—the clinic now also offers cardiovascular and diabetes group appointments that include women and men.
      Physicians and nurse practitioners were the initial source of referrals for patients to these group appointments. The physicians hold clinically focused group appointments while the nurse practitioners hone in on lifestyle management of cardiovascular disease, diabetes, and obesity/overweight. Although several physicians wrote personal invitations to patients, serving as powerful motivators, Perry notes that the staff “still found ourselves ‘selling’ the idea to patients. It wasn't that they were against the idea; rather, they just had to wrap their head around what a visit like this would look like. We did find that spending the initial time up front, answering questions and addressing concerns, was well worth the effort.” For many, it was understanding that one-on-one time with the physician was still an option—and that toggling between group and one-on-one appointments was acceptable—that made the difference in whether they were interested.
      Stalfort adds that over time, additional patients have joined the program via self-referral or referral from specialists and primary care physicians. Follow-up appointments are set according to the individual's symptoms, diagnoses, and risk factor profile. Although individuals are able to come to group appointments as often as they wish, specific recommendations are made to patients with active cardiac symptoms and more complex diagnoses. In addition, it is suggested that patients with an interest in making lifestyle changes for cardiovascular risk reduction or weight management attend group appointments once a month for at least 6 months “to achieve lasting and sustainable change.”
      Club Red group appointments are managed by a program coordinator and led by a provider (physician or nurse practitioner) and a facilitator, with multidisciplinary staff in attendance to check in patients, take vital measurements, and offer counseling. As an RD, Stalfort is “involved in all facets of the clinic appointment, from providing nutrition counseling and education during the appointment to recruiting patients, preparing the clinic, facilitating the group, and documenting the encounter.” She notes that this is a unique opportunity for an RD to be deeply involved in so many aspects of the patient care experience.
      Perry agrees, adding that “The various roles needed in a shared medical appointment (facilitator, provider, documenter, and coordinator) create a rich and varied work experience for the RD. It is exciting to participate in this model.”
      Patients ultimately become accustomed to the rhythm of the appointment, says Perry. Upon arrival, staff members escort patients to the group room where they sign confidentiality forms, complete a brief systems review, and have their vitals taken and medications reviewed. As patients subsequently join the group, the facilitator ensures that all feel comfortable and safe and, once everyone is present (usually six to 10 patients are present in each appointment, but it has the capacity for up to 12), the medical appointment begins.
      The clinic staff records patient satisfaction data after each appointment; these data—along with vitals, body mass index, blood pressure, lipid level, and A1c measurements—are used as the primary indicators of success. Regular team meetings are used to evaluate the processes and patient feedback with the program coordinator. Potential adjustments are discussed and, if necessary, subsequently implemented.
      Stalfort believes that the timely access to clinicians and follow-up are a major benefit to patients; in fact, whereas the wait time for a one-on-one appointment may be up to 15 days, shared medical appointment wait times are only 3 days. Furthermore, spending 90 minutes with an extensive multidisciplinary care team enhances psychosocial support and educational opportunities. “Patients are exposed to information and questions they may never have thought to ask or did not know were related to disease risk and/or management,” Stalfort adds. Other systems improvements include the elimination of dead time in the waiting room, as appointments always start and end on time, and the more relaxed pace and atmosphere of the group context.
      But the experience of sharing medical time with other patients has also proven beneficial to patients enrolled in the UVAHSHVC group appointments. “Hearing information patient-to-patient rather than provider-to-patient can speak very powerfully and personally to patients,” says Perry. “Having the information or challenging question come from a peer can be received in such a way that creates a culture an openness of trust and community. We often have seen patients have an ‘a-ha!' moment when discussing something with another patient, despite that similar conversations have taken place between the patient and provider. It is a wonderful thing to witness.”
      Clinicians benefit from this program because all documentation is imported into the electronic medical record while the appointment is taking place; thus, all notes are complete and dictation needs and transcription costs are eliminated. Provider efficiency is also improved, as so many aspects of the visit—communication with the referring physician; referral for labwork and other procedures; schedules for follow-up appointments; and delivery of education regarding lifestyle, diabetes, medication, and so on—are all addressed within that 90-minute timeframe.
      Furthermore, the improved efficiency has an impact on delivery of care. Perry relates that one of the clinic's physicians “felt that he was often ‘playing the same tape’ every time he met with patients and discussed their diabetes plan.” Now that he only communicates this information once to the group, the information is delivered and received in a much different way.
      One change that will soon be implemented in the nurse practitioner-led group appointments will be a 6-month curriculum focusing primarily on lifestyle management for cardiovascular disease. Patients will be enrolled in waves, with 50% of their copay to be reimbursed by their employers if they complete the 6-month curriculum. Participation is voluntary and Stalfort believes that having a curriculum will help patients to focus on goal setting and small, steady changes that will accumulate over time. “Patients will have homework to complete between sessions and will be given the tools to carry what they have learned forward beyond the curriculum,” says Stalfort. “They will be able to continue in follow-up after the 6 months but likely without the reimbursement incentive.”
      The facilitator's management of the group is critical, Stalfort says, “to make sure that all patients have their needs addressed and no one leaves feeling shortchanged in their care. There will always be individuals who like to talk and those who prefer to observe, so knowing how to keep everyone involved but not dominant—and, if necessary, tabling complex, complicated problems to be discussed individually with the patient after the group appointment has ended—are critical to this appointment style.” However, she adds, “When you compare the 90 minutes spent with the provider [in group appointments] to the typical 15 minutes in a traditional one-to-one visit, this is still an improvement for both patient and provider.”
      Stalfort notes that a comparison study of Club Red Clinic group appointment patients and one-to-one general cardiology patients, performed at the end of the first year that group appointments were offered, yielded no clinically significant change data (laboratory values and vitals) between the two groups. “However,” she adds, “we have not yet tallied data for year 2, and one might speculate, as we have honed our skills in offering these types of appointments, that we might see different outcomes data as time goes on.”
      Nevertheless, the staff has seen consistently higher patient satisfaction scores among group patients than in usual care cardiology patients in each quarter. Furthermore, says Stalfort, “Write-in comments suggested that patients did indeed better understand their disease process, risk strata, and goals for lipids and hemoglobin A1c, as well as influence of lifestyle on these aforementioned components.”

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