Most medical care today is provided via the brief office visit - one person visits the doctor. Clearly appropriate in some circumstances, this one-to-one model often falls short of meeting patients' real needs - especially patients with multiple chronic illnesses.
Fifteen minutes is hardly enough time to uncover psychological and social factors that may be causing symptoms or be key to the solution. There's little time for learning about the disease and how to manage it, or for exploring how the disease may be affecting the patient's moods, emotions, and ability to function at home. Brief office visits certainly do not provide social support or the opportunity for patients to experience how others cope with day-to-day challenges. In fact, both patient and physician often emerge from traditional visits feeling time-pressured and shortchanged - a situation getting worse as pressures to reduce costs force doctors to serve more and more patients.
What if you could have a full two-hour visit with your physician every month? And what if during that visit you could learn not only from your doctor, but from other members of the health care team as well as from other patients with similar problems?
These were the questions that led John Scott, MD, and his colleagues at Kaiser Permanente Medical Care Program in Colorado to rethink the office visit and try a completely different model: the group visit. The pilot project for their "Cooperative Care Clinic" involved group meetings of 20 elderly patients with multiple chronic conditions, their personal physicians, and a nurse team. The patients met once a month for two and one-half hours and were encouraged to bring a spouse, other family member, or caregiver.
The group appointments allowed time for socializing, interactive educational sessions, extensive questions and answers, blood pressure checks, x-ray and lab test ordering, review of medications, and discussion of preventative medicine, nutrition and exercise, living wills and advance directives, stress and relaxation, coping with grief, loss, and chronic pain. Time was reserved (but not always needed!) for brief, one-to-one visits with the physician for physical exams and symptom evaluation.
The patients began to take over the group, setting the agendas for future meetings. If they were concerned about medications and drug interactions, a pharmacist was brought in. If they wanted to learn more about safe exercise, a physical therapist was scheduled for a future group appointment. The patients began to feel more confident, involved, and responsible for being informed, active partners in their own care.
As group trust developed, most members eventually felt comfortable discussing very personal matters, including sexuality, death, and disability. Physicians noted that the patients often raised concerns they hesitated to discuss in individual office visits. Group support blossomed. When one member was ill or hospitalized, others rushed to help. Patients learned as much from each other as they did from the professionals. Physicians and nurses got to know their patients and could share their own personal sides. As one care team member commented: "We taught them medicine and they taught us life."
The pilot results supported these observations. When compared to a similar group of patients who continued to receive traditional, one-to-one care, the Cooperative Health Care Clinic patients were more satisfied, reporting that their health care needs were better met and overall access to care was improved. Physicians, too, were more satisfied, noting that they felt they had more time to deal with the patients and that patients were more informed, helping the physicians to better diagnose and treat their conditions.
Medical costs and utilization decreased; group patients made fewer individual doctor visits, visits to the emergency room, and spent fewer days in the hospital and skilled nursing facilities. Preventative care also improved. More group patients received influenza and pneumonia immunizations. And more group patients had completed a living will or durable power of attorney to designate someone to make decisions on their behalf if they were too ill to do so.
Most patients could not conceive of going back to the old way of care. The pilot has been extended into a larger, three-year evaluation and the model is being tried for patients with diabetes, hypertension, and routine well-baby visits.
The Cooperative Health Care Clinic appears to be a win-win solution. With careful structuring and evaluation, this group model offered better-quality care - care that is more satisfying for patients and physicians - while significantly lowering costs.
For More Information
Scott, John C. and Robertson, Barbara J.: Kaiser Colorado's Cooperative Health Care Clinic: A Group Approach to Patient Care. Managed Care Quarterly 1996;4(3):41-45.
Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.