BOSTON — Struggling to help your diabetic patients stay in control?
The answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.
During a traditional one-on-one office visit, physicians generally assess the patient and give out instructions. But diabetes is a self-management disease that requires patients to change their behavior, something that isn't likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.
The evidence is in the U.S. statistics on diabetes: Less than half of diabetic patients achieve recommended hemoglobin A1c goals, and about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.
Dr. Shahady and his colleagues at the foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.
Under the model, visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2½ hours.
During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with hemoglobin A1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.
The nurse also fields questions. Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. The sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.
During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.
Each visit has a set topic, and patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” Dr. Shahady said. This interaction is much more effective than getting suggestions from the physician, he added.
If a patient gets emotional, ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.
Groups should be kept to about 10 patients. Most of the members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they can offer advice to other group members.
If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.
Dr. Shahady has developed an 18-page manual with instructions on how to set up group visits for diabetes, including sample documents. The manual is available online at http://www.fafp.org/PDF_Diabetes/P2%20Group%20visit%20focus%20on%20diabetes.pdf