A Better Way to Manage Chronic Diseases: In-Person and Virtual Group Visits

Healthy choices and behavior like better nutrition, exercise, stress management and good sleep help patients with chronic diseases feel and live better.

But busy physicians rarely have time to provide the information and help that most patients need to take better care of themselves. Shilpa P. Saxena, MD, IFMCP, found a solution to this problem: In-person group visits. “People loved the group visits. They received 90 minutes with me and learned so much more. I did four visits worth of care in one visit and was able to maintain my productivity,” says the founder and president of SaxMD.

A nationally recognized expert and educator on functional and integrative medicine, Dr. Saxena is a pioneer in lifestyle-based group visits. She works with her patients to identify the source of disease symptoms and develop a personalized care plan that addresses the underlying root causes of the disease. The plan includes all appropriate therapies—conventional, complementary and lifestyle—based on current evidence.

Group Visits Help Physicians, Practices and Patients

As Dr. Saxena’s practice grew, she and her physician’s assistant were seeing up to 50 patients each day. She needed to find a better way to provide care than the typical one-one-one visits.

In her search for a solution, Dr. Saxena read about group visits, which she defines as “an extended clinical encounter that allows physicians and their patients to exchange valuable information regarding optimal chronic disease management within a supportive group format.”[1] CMS, Medicare, and the American Academy of Family Physicians all promote group visits.[2] Leading medical institutions and payers, such as Harvard Vanguard, Kaiser Permanente, Cleveland Clinic, and Yale Health use group visits—some have been using them since the mid-1990s. 1,[3]

Dr. Saxena began offering one or two group visits each month in 2008. She focused most of the group visits on solutions, such as diet or stress management. “People share more when it’s about solutions,” she says. When there weren’t enough patients for solution-based group visits, Dr. Saxena did chronic disease-based group visits.

Efficient and Effective Patient Education and Support

Group visits are easy to implement and billable, Dr. Saxena says. In a typical 90-minute group visit, 10 to 16 patients receive lifestyle education about a topic or set of topics along with support for behavior modification from providers and their peers.1 The education occurs during the first 30 minutes of the visit, followed by discussion.

Group visits can be done in a conference room or, at the beginning or end of a clinic day, in the lobby. 1  Also, group visits can be done virtually.

Jeffrey Geller, MD, has been called the godfather of group visits. Dr. Geller created the largest group visit program in the U.S.  and has been running virtual group visits since the COVID-19 pandemic started. “We anticipate a future where only a small percentage of people will have a visit in person,” he says. Dr. Geller is director of Integrative Medicine and Group Programs at Kronos Health, president and creator of the non-profit organization Integrated Center for Group Medical Visits, and clinical professor at the University of Massachusetts Medical School and Tufts University School of Medicine.

Billing for In-Person and Virtual Group Visits

A billable provider and an educator run the groups visits together. During the educational part of the group visit, the provider does a brief targeted physical exam with each patient (five minutes or less), which validates the billing.3 The provider and the educator work together to engage patients in the discussion. 1

Policy changes in response to the pandemic allow virtual visits, including virtual group visits, to be billed like in-person visits. The Integrative Medical Group Visits website offers tips on documenting and billing virtual group visits. For example, the brief targeted physical exam with individual patients can be done virtually as long as the practice has a HIPPA-compliant telemedicine environment and a confidential virtual room.

New codes have been developed for virtual visits, which were typically not reimbursable before the pandemic. The billing document for a virtual group visit needs to state the technology and software vendor used and why the visit is being held virtually instead of in person. “To prevent the spread of COVID-19” is a valid reason for a virtual group visit.

Repeatable Group Visits on Many Topics

Each group visit focuses on a topic or set of topics related to managing chronic diseases. General topics, which can be customized to different patient populations, include:

  • Nutrition
  • Exercise
  • Weight management
  • Stress management
  • Sleep optimization1

Pain management is another good topic for group visits.[4]

Group visits can easily be repeated many times. For example, physicians can use ready-made videos or create their own videos instead of doing live teaching at each group visit.

“Do the first one and get over the fear. Once you do one, it’s not so bad,” says Dr. Saxena. Patients will be understanding as you learn how to deliver group visits if you’re humble. Let them know that they’re helping you better serve all your patients.

Dr. Saxena suggests inviting patients with chronic diseases to participate in group visits during a typical office visit, and providing a “prescription” for the group visit.  Physicians can also recruit patients through fliers, e-mails, and so forth. 1

Group Visits Work

Just two group visits a month benefits patients, physicians and primary care practices, says Dr. Saxena. 3  Group visits also contribute to integrative primary care, the coordinated delivery of evidence-based conventional medical care, complementary medicine and lifestyle medicine within a primary care practice.

Patients who participate in group visits have more knowledge and self-efficacy, better outcomes, and higher satisfaction. 1  “A patient may listen to another patient going through the same problem more so than a provider. Knowing that you’re not alone is part of the healing,” says Dr. Saxena. She also says that group visits can reduce symptoms and even reverse progression of chronic diseases without expensive medications, procedures, or technologies. 1

Operationally, group visits reduce appointment wait times, expand access to care, improve patient adherence, and lead to higher provider satisfaction. “Physicians get fulfillment from actually talking with their patients. Group visits reduce burnout,” says Dr. Saxena. Since group visits are reimbursed in the same way as individual appointments, physicians can boost their productivity by at least 200 percent.

One-on-One Care Combined with Group Visits

Most individual medical care is provided through individual medical appointments; however, group visits are an effective way to leverage the time that is necessary for optimal management of chronic diseases that involve common issues and patient education.

“When you leverage time by putting 16 people in a room for 90 minutes, you’re seeing 16 patients and giving them 90 minutes of education. Group visits allow you to do the volume, but still provide quality care and education,” says Dr. Saxena.

Best Practices in Integrative Primary Care

Chronic Disease Management with Group Visits is a case study on how to promote healthy behaviors among patients with chronic diseases. The case study shows how incorporating integrative medicine into mainstream primary care practices enables physicians and other health care providers to:

  • Deliver higher quality care
  • Improve patient outcomes and satisfaction
  • Lower costs
  • Reduce burnout.

Tips on getting started in groups visits are included here.

This case study is part of our series of Integrative Primary Care Case Studies. Each case study highlights a best practice in integrative primary care. The other case studies cover:

A Return to the Craft of Healing with Patient-Centered, Team-Based Care

Featured primary care provider:

William L. Miller, MD

  • Chair emeritus, Department of Family Medicine, Lehigh Valley Health Network
  • Professor of family medicine, University South Florida Morsani College of Medicine
  • Patient-centered, team-based care enables physicians to develop the relationships—with patients and with team members—that are essential to health and healing.

Helping Patients with Chronic Diseases and Conditions Heal with the HOPE Note

Featured primary care provider:

Wayne Jonas, MD

  • Practicing family physician
  • Executive Director, Samueli Integrative Health Programs
  • The HOPE (Healing Oriented Practices & Environments) Note is a simple tool for adding integrative health care to a routine office visit. This patient-guided process identifies the patient’s values and goals in life and for healing so the physician can assist the patient in meeting those goals with evidence and other support.

Empowering Patients With Chronic Diseases to Live Healthier Through Health Coaching

Featured primary care provider:

Thomas Bodenheimer, MD, MPH

  • Professor, Department of Family and Community Medicine
  • Founding director, Center for Excellence in Primary Care, University of California, San Francisco
  • Half of all adults in the United States have at least one chronic disease and 25 percent have two or more.
  • Health coaching helps these patients understand their chronic disease(s) and actively participate in their care. Coaches support patients in developing and following action plans for healthier behaviors. Health coaching has clinical and operational benefits and contributes to integrative primary care.

Helping Patients Manage Chronic Pain with Integrative Primary Care

Featured primary care provider:

Henri Roca, MD

  • Program director, Integrative Medicine Patient Care Team
  • Central Arkansas Veterans Administration Healthcare System
  • Integrative primary care enables providers to help patients treat and understand their pain and become actively engaged in making lifestyle, behavioral and self-care changes to manage their pain. This case study looks at a program providing non-pharmacologic chronic pain solutions for veterans.

Evidence-Informed Decisions that Help Patients Live Longer, Better or Both

Featured primary care provider:

Allen F. Shaughnessy, PharmD, MMedEd

  • Director, Master Teacher Fellowship
  • Professor and vice chair, Family Medicine for Research
  • Tufts University School of Medicine
  • Information mastery enables physicians to make decisions by combining useful information that matters to patients with clinical experience. Information mastery on integrative care adds value to the delivery of health care by decreasing over-diagnosis, over-treatment and low-quality care. It provides a focus on key underlying determinants of health in chronic disease. This lowers health care costs. This case study discusses how to use evidence in primary care especially when providing integrative care.

References

[1] Saxena SP. “Leveraging time with Lifestyle-Based Group Visits,” American Journal of Lifestyle Medicine, September, 2016. Abstract accessed 4/12/20.

[2]BILLING, CODING and HIPAA in the Group Visit Model,” webinar. Lifestyle Matrix Resource Center. Accessed 4/12/20.

[3] Saxena SP. “Group Visits: Leveraging Time for Clinical, Operational & Financial Success,” American College of Lifestyle Medicine, webinar 2/14/18.

[4] Dr. Wayne Jonas, 4/9/18.