| ||More Care in Group Settings May be Key to Transformation of Medicine||
Summary: Kjersten Gmeiner, MD is a "group visit" leader with Group Health Cooperative. Gmeiner and a board member of the American Holistic Medicine Association. She believes that this "innovative practice model" - which is being implemented at systems like Cleveland Clinic and Kaiser Permanente - is a particularly good fit for holistic practitioners: "If you have an educational or patient empowerment focus, group visits are it." In this Integrator interview, Gmeiner describes her incorporation of group visits in her practice, touches on the national movement and speaks of the particular fit with whole person, integrative and holistic healthcare.
Kjersten Gmeiner, MD, is a board member for the American
Holistic Medical Association (AHMA). She and I met recently to discuss
AHMA business. But our conversation quickly turned to a shared passion. I
learned that Gmeiner's family medicine practice includes a practice innovation
that has been featured in multiple postings in the Integrator: group visits, or "shared
medical appointments." (See the Integrator report on treatment of Chrysler
employees, the exploration of the community room acupuncture model, and a call to a
dialogue on expanding the use of groups in integrative health care.)
Gmeiner's day job is in family practice with Seattle-based Group Health
Cooperative, where she is "group visit leader." She is part
of a system-wide effort to promote the use of these shared medical appointments inside this staff-model health
maintenance organization (HMO). She concurrently has a grant to study this
"innovative practice model" in other systems nationally.
Kjersten Gjmeiner, MD
Gmeiner believes that incorporating this approach is a "better fit for the
holistic community than for orthodox practitioners." Why? "If you
have an educational or patient empowerment focus, group visits are it."
The she adds with curiosity: "For all our talk about 'alternative
medicine' and the new paradigm of care we stand for, mostly we accept the
one-to-one model of delivery." This interview was constructed from the
notes of our exchange.
Integrator: So what do you see as the value in these
Gmeiner: Patients like them. Physicians like them - even
traditional specialists who you might not think would. We know from surveys
that satisfaction is higher with both patients and doctors. How many things that
we are doing in healthcare have both of those outcomes? There are studies with
some populations which have shown cost benefit through reduced ER visits and
reduced office visits. The quality data that has been collected shows at
least even quality, perhaps a bit better.
Integrator: That's bound to please the HMO.
and that's some of the motivation for why the use of group visits is expanding
in health systems around the country. Cleveland Clinic has
used 6,000 groups in their clinical care in the last 5 years. A hospital-physician
group in Kalamazoo (Michigan), Borgess-Promed is offering 16
group visits a month to their patients. But to me as a clinician, using
group visits is a practice innovation that is aligned with my beliefs about
what I should be doing as a doctor.
Integrator: How do your group visits work? For what types of patients?
Gmeiner: The kind of groups you run are really determined by
your patients' needs. They have been done somewhere for every
conceivable condition: from diabetes to hypertension to menopause to osteoporosis to
bariatric surgery to childhood asthma. Groups may have up to 12-15
patients. I have a large panel that is
mostly women, so there is an ongoing need for physicals. I do two shared
preventative groups every month, one for women age 50-64, and one for women age
65 and above. These are relatively small groups, just 5-6, because of the
comprehensive nature of the preventative exam. I schedule 90-120
minutes for the group visit. At the outset I take them each aside individually and do private
physical exams. This takes 30-45 minutes of the time. For the rest of the time we all meet
Staff model HMO promotes group visits
Integrator: What is the
group doing with the nurse while you do the short exams?
Gmeiner: She does
some basic education, and elicits the most important issues form each patient
and puts them on the board. When I am through with the individual visits, I
join the group and I address each woman's health concerns, but it often
turns into a full-group discussion. There is so
much overlap of experience that typically each person learns a lot and has a
lot to share on each topic, regardless who suggested the topic. That's part of
the genius of the group. That is when the magic happens, because
then they are all activated and involved in trying to find their own health
solutions. After one of my groups, for instance, two patients set up a date to be
"This is much more of a
natural fit in the holistic
community than the
orthodox community ...
are a teacher,
you know in a heart beat
that the group visit will
- Kjersten Gmeiner, MD
Integrator: How much are these used throughout Group Health?
Health has committed to a campaign to expand shared medical appointments
throughout the system. There are doctors doing physicals, diabetes groups,
senior groups (patients with high needs who benefit from monthly
contact). It's a culture change. Every single person in the system has to
be recruited into believing that a group visit might be useful. Every personal care
representative has to learn about them. We've had several trainings. We've had
doctors from throughout the system come watch established groups, and we have
day-long workshops to teach docs who are just starting out. Group Health
is one of a handful of national leaders. I am visiting other national
leaders as part of a grant to examine large-system integration of group visits.
Integrator: What the story with payment and
reimbursement - a big question for those practitioners whose services are
usually reimbursed by 3rd parties?
Gmeiner: Most people don't know you can code for it as
long as you do a personal interview, a personal exam, and make a personal
assessment and plan. You need an ICD 9, of course. With Medicare it is a little
uncertain. A decision written in 2001 or 2002 says you can't bill for
simultaneous services to multiple patients at they same time. But Cleveland
Clinic is among those which has a strategy which they've cleared with their
area Medicare representatives. And really, it is important to understand
that these are sequential individual medical appointments, just with others in
the room to learn by observation and discussion. They are not classes.
about among your colleagues in holistic medicine, what's going on there? What
response do you get?
Gmeiner: I've had tons of people say, "it's great, send me
stuff." But I haven't seen a lot of movement. Docs don't take their heads
out of the sand long enough to innovate. I feel that it is much more of a
natural fit in the holistic community than the orthodox community because the
holistic approach is far more focused on teaching and on the whole person. If you
are a teacher, you know in a heart beat that the group visit will be better.
Among the naitonal leaders
Integrator: The fit does seem to be broad, and a fit
for almost all holistic practitioners. Naturopathic doctors make much of the
principal of docere, and of their role as teachers and their focus on
lifestyle change. All of that fits this model. Even a practitioner with a
narrow practice like a chiropractor who mainly adjusts people or a massage
therapist might see value of having group visits with an educational bent. The community
room acupuncture visits are an interesting model that could be expanded to
include group visits for other parts of a traditional Chinese medicine
Gmeiner: We have to get information about this practice
innovation into our conferences and educational programs. I find it interesting
that for all the talk about alternative medicine and the new paradigm of care
we stand for, mostly we accept the one-to-one model of delivery, one patient,
one doctor, one room, as the way to do medicine.
Integrator: I started getting interested in the model
when I realized that three of the more powerful early bodies of research in
alternative and mind-body medicine from the early 1980s -- Ornish's work,
Herbert Benson's group at Mind Body Medical Institute and Jon-Kabat Zinn's mind
body stress reduction programs - all have group visits at their heart. Then
addiction acupuncture pioneer Michael Smith, MD just shook me by the shoulders
with a statement about group: "If you want to empower people, put more patients
than providers in the room."
Gmeiner: Dean Ornish has said he thinks the support of the
group was the most powerful influence on the success of his interventions. His research analysis shows that the most powerful predictor of a good patient
outcome was the quality of their support group ... It's so good to be talking with someone who
knows about this.
"There hasn't been a
major innovation in clinical
delivery in a long time.
I think this is it."
Integrator: I totally agree with your view about
the alignment with holistic and whole person care. This is one of those places
where I feel that the integrative medicine and natural healthcare educators and
disciplines could truly provide leadership in healthcare transformation.
Gmeiner: There hasn't been a major innovation in clinical
delivery in a long time. I think this is it.
Additional Internet Resources on Group Visits
The Internet Journal of Family Practice
Family Practice Management
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