Case Study: Group Visits Improve Diabetes Self-Management

East Valley Community Health Center, located in Pomona, Calif., has five clinics and approximately 22 providers. It serves the San Gabriel and Pomona Valleys in the Greater Los Angeles Area, where the majority of residents are Hispanic. In preparation for payment reform, they are implementing multiple strategies to improve the quality and efficiency of health care delivery, such as Patient Centered Medical Home principles and Lean Six Sigma. Adopting group visits is one of the important methods to engage patients  in their own health care and improve access.

East Valley’s target population for the diabetes group visits was patients with uncontrolled diabetes, which means their blood glucose (sugar) levels are above recommended target ranges. A hemoglobin A1c (HgA1c) test measures the average blood glucose level and East Valley enrolled more 700 of their 4,000 diabetic patients with HgA1c>9, which is above the recommended level for controlled diabetes. When left untreated, uncontrolled diabetes can lead to major complications such as heart attack, stroke, eye disease, kidney disease, nerve disease and infection.

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Designing the Pilot

East Valley had previously implemented group visits in a limited capacity at one location. Its initial results were promising, but patient engagement was increased only minimally. The team endeavored to implement a larger study of group visits with a more comprehensive design, which is why they piloted multiple cohorts:

• Cohort No.1 included English speaking females.
• Cohort No. 2 included English speaking males.
• Cohorts No. 3 included Spanish speaking females.
• Cohort No. 4 included Spanish speaking males.
• Cohort No. 5 was reserved for no shows.
• Cohort No. 6 included Spanish speaking females.

The team’s initial assumption was that they would need to separate out language and gender to fully test the solution. In addition, a provider was completing her dissertation on group visits at the time and had been working with separate male and female groups.

The team schedule three group visits for each cohort.

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Milestones During Implementation

Start-up and planning

• East Valley identified key roles for the pilot including:
  • A project lead to coordinate the timeline, group visit schedule, and other team members.
  • A provider who co-led the group visits and provided face-to-face medical consultations with patients.
  • A behavioral specialist to address mental health issues such as depression and individual therapy as needed.
  • Staff to assist the provider, take vitals, perform HgA1c tests, and collect data.
• In addition to measuring blood pressure, HgA1c, and patients’ ability to make a plan to manage their diabetes, East Valley also tracked anxiety levels by asking, “How often in the last week have you felt overwhelmed by living with diabetes?” This metric was an important indicator of patients’ likelihood or ability to self-manage their diabetes in the face of emotional and stressful triggers, such as a challenging new medical task like insulin management.

Testing

• There were many no-shows to the first group visit, but reminder phone calls helped improve attendance in subsequent group visits. In the end, approximately 50 percent of patients attended all three visits, an expected outcome, as recruitment is so challenging.
• East Valley served healthy food at the second group visit, which stimulated a good discussion about healthy nutrition.
• East Valley discovered that larger groups were hard to facilitate. For instance, a group with seven participants got very loud and it was a difficult to hear from all attendees during the two-hour appointment.
• The project lead — a registered dietician, provider, and behavioral specialist — co-facilitated the group visits with a RN when addressing insulin and foot checks.
• When patients couldn’t read or write, the behavioral specialist served as a translator and read questions aloud.
• It was a struggle to coordinate and implement six different cohorts of patients. The initial rationale for separating men and women was to ensure all were comfortable discussing sensitive health issues. But the team later found little benefit in splitting them up.
• The patients were happy to have access to multiple providers and staff. The multidisciplinary approach made them feel well taken care of and having special treatment — like “VIP service.” Some of the patients called to find out when it was happening again and asked the staff to not forget to call them for the follow-up visit, demonstrating eagerness to be a part of the group visits.

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Benefits of Diabetes Group Visits Pave the Way for Spread

Group visits can enhance access, efficiency, patient-engagement, and clinical outcomes. They create social cohesion among the group and improve provider and staff satisfaction.

The East Valley diabetes group visits had 100 percent of patients saying yes to the question “Do you feel you can make a plan with goals that will help control your diabetes?”

In December, all of the pilot patients had controlled blood pressure and blood glucose, as well as low anxiety. Both HgA1c and anxiety levels ultimately improved compared to the baseline.

The fluctuation in data may be partially explained by the inconsistent attendance of each of the six cohorts to the three group visits. Also, there was a dip after the December holidays, which can be a time when self-management routines are disrupted and anxiety increases.

East Valley group visits were successful in garnering high patient and provider satisfaction. All of the patients rated overall satisfaction of group visit with top two scores in seven out of eight months. Measuring the top two scores is also known as top box scoring, a common method for reporting and analyzing scale questions. There was month when 92 percent of patients rated the group visits with the top two scores, instead of 100 percent. In that case there was one patient who was unable to read or write, which may have pulled the scores a bit lower, according to the project lead. Another reason for the lower satisfaction score may be related to the team learning that some patients still preferred the privacy of individual face-to-face visits.

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Success Factors

• East Valley’s Chief Operating Officer was supportive of the pilot. She fought to continue to spread group visits in other clinics, despite only approximately 20 percent of patients improving their HgA1c levels at the time of the decision.
• The patient feedback was a strong motivator for staff, as they were very grateful for the group visits. Patient commented, “When is this going on again?” and “I want to tell my friends.”
• Clinica Family Health was extremely helpful. The training prepared the team well with practical and operational guidance to become group visit facilitators. Clinica provided a flash drive with a lot of helpful information and handouts on topics such as foot checks and icebreaker ideas.  A compilation of materials and resources can be found here and here.
• Creating a plan for implementation is an important way to structure the work and keep momentum going. For instance, set up clear goals about how many group visits and with which providers and clinics. Design measures and a data collection plan, especially for patient feedback. Establish team meetings to hold each other accountable for results and timelines. Provide peer-to-peer coaching.

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Challenges and Strategies

• Lack of dedicated time: For much of the grant period the project lead had only up to two hours per month dedicated to work on implementing group visits. It helped to engage other staff at the site to help with tasks such as making copies.
• Turnover: The team experienced turnover when the first provider champion, RN, and various MAs left East Valley. Fortunately the project lead was a consistent presence who coordinated plans moving forward and oriented new team members to the work.

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Key Advice to Organizations Considering Implementing Group Visits

• Plan a communication strategy with your team. This can entail regular team meetings, updates to larger staff meetings, and regular status updates with senior leadership.
• Allot sufficient time for team members to implement the program. For example, ensure that the project lead has enough hours approved to fully plan, schedule group visits, conduct team meetings, and train and orient team members to the roles.
• Be very organized with a calendar of all due dates and milestones. For instance, call patients with a reminder two weeks ahead of time.
• Ensure there is project leadership at multiple levels. This includes a project lead aligning staff members to the plan, while a provider champion paves the way for spread amongst other providers throughout the organization.
• Provide adequate reporting to senior leadership, in addition to the executive sponsor, so that you have an array of leaders to help with barriers like staffing.
• Since scheduling group visits and coordinating their set up can take up a lot of time, ensure the cohorts you develop are not overly complex. East Valley, for instance, learned that you may not need six separate groups divided by gender and language.
• Make sure to collect patient feedback, as positive comments can provide motivation for staff during implementation and rationale for sustaining the program.

 

As with many other clinics, Olive View found there was limited awareness of advance care planning amongst care teams and patients. Additionally, it was a difficult and sensitive topic that many providers found challenging to discuss with patients, especially if there were medical comorbidities that competed for the providers’ attention and time during the primary care visit.

Since Olive View had successfully implemented group visits for chronic conditions and age cohorts in the past, it decided to pilot group visits for advance care planning.

Group visits were an enticing care model because of enhanced access, efficiency, patient-engagement, and clinical outcomes. Olive View knew that group visits create social cohesion among patients and improve provider and staff satisfaction. Moreover, group visits would provide focused, patient-centered care to vulnerable populations.

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Designing the Pilot

Olive View launched the advance care planning group visit model in their Los Angeles County Department of Health Services primary care clinic. Nine providers participated in the pilot.

Providers identified appropriate patients, then their medical assistants contacted patients to tell them about the session and invite them bring a guest, like a caregiver or family member.

These one-hour group visits were embedded in a regular clinic session and were led by physicians, along with a social work staff person. (Other kinds of group visits, like diabetes for example, are led by nurse practitioners and have had challenges recruiting both team members and patients.)

During group visits, patients were assisted in completing an advance directive, which includes a living will and durable power of attorney for health care. Living wills describe a person’s desires regarding their medical treatment (wanted or not), while and the durable power of attorney for health care designates an individual to make decisions on behalf of the incapacitated patient.

Group visits focused on adults older than 65 years old, “geriatric” patients, but could also include younger adults with frailty and complex comorbidity. At least three patients and their family members/caregivers were recruited for each group visit.

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Milestones During Implementation

Start-up and planning

• Olive View identified key roles for the pilot including two physician co-leads, who served as leaders for the clinic and for this project. Other roles included a nurse manager and the nine providers, their MAs, and a palliative care social worker.
• From the beginning, it was made clear that providers would be leading group visits, testing them, and then rolling them out the wider organization. This is a departure from other group visits, which are led by nurse practitioners.
• Previously, there was a disconnect between the clinic and the social work department, resulting in gaps in services. The pilot was a great opportunity to improve that relationship. This interdisciplinary approach to advance care planning is important because patients may be suffering not just from physical problems, but also problems associated with psychological, social, spiritual, and financial concerns. They can also provide grief counseling for pre-bereaved or bereaved family members.
• The team engaged the social worker early on. She become a key part of the planning process, especially in developing the toolkit and facilitation slides.

Testing

• The team conducted two large all-clinic trainings, where they introduced a group visit toolkit and strategies for recruiting patients. The toolkit includes:
  • A provider group visit facilitation guide, plus an accompanying slide presentation
  • Medical assistant group visit invitation script
  • Group visit agendas
  • Pre- and post-visit surveys for patients and guests
  • Group visit confidentiality consent
  • Provider documentation and billing guide
  • Tracking for patient and guest demographics, patients contacted, patients booked, show rate, and advance health care directive completion
• Patient participation varied depending on a providers’ recruitment strategy and time invested. Some providers would talk with the patient during a regular visit. Others had the MA call patients on a list and say that their provider would like them to come back for a group visit on advance care planning, which didn’t work as well. The percent of patients who booked group visits ranged from 20 percent to 90 percent.
• The first cohort of four providers demonstrated successes in recruitment and conducting the group visits. They debriefed the results of the group visits in at a large staff meeting, which gave the pilot momentum. Learning from this feedback, the next cohort of two providers implemented group visits three months later. And the final three providers implemented their pilot one to two months later.
• Patients often had many health needs that required specific one-on-one primary care provider discussion during the traditional visit. This which made it challenging for the provider to find the time to provide education, counseling, and guidance on advance care planning and completion of the advanced health care directive.

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Benefits of Advance Care Planning Group Visits Pave the Way for Spread

Despite advance care planning being a challenging topic to address and targeting a patient population with typically higher no-show rates, Olive View achieved productivity levels similar to usual care (average of 2.7 patients/hour). After five months, 26 percent of patients completed an advance directive.

No shows varied across the different group visits.

 

Olive View measured the ratio of cost/effort effectiveness, which was calculated as the number of group visit slots booked divided by the number of usual care slots. The results of greater than 1 suggest that group visits have higher cost/effort effectiveness than usual care.

 

Patient and provider/staff satisfaction was high:

• 100 percent of patients and guests strongly agreed that they would recommend the group visit to other patients.
• 94 percent of care team members strongly agreed that the group visits are a means to provide higher quality care and improve relationships with patients.

Knowledge increase as measured by the question “Do you know what an advance care plan/directive is?” varied by group visit over time and averaged 63 percent overall, with 90 percent amongst Spanish-speaking patients and 47 percent amongst English-speaking patients.

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Success Factors

• • Clinica Family Health was invaluable. Its materials were well-curated and generously shared. Clinica Family Health was also very responsive, supportive, and helpful to the team if there were any questions they had throughout the program. A compilation of materials and resources can be found here and here.
  • Assessing patient and provider satisfaction helped the team see the true value of group visits.
  • Creating a plan for implementation is an important way to structure the work and keep momentum going. For instance, set up clear goals about how many group visits and with which providers and clinics. Design measures and a data collection plan, especially for patient feedback. Establish team meetings to hold each other accountable for results and timelines. Provide peer-to-peer coaching.

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Key Advice to Organizations Considering Implementing Group Visits

• • Invest in laying a foundation. While creating a toolkit and attending the training at Clinica Family Health was time consuming, it was vital to a successful launch.
  • Give primary care providers hands-on training for conducting group visits. The ideal scenario would be for providers to shadow a group visit with your target population. You can also enlist an experienced facilitator provide on-the-ground training at your clinic.
  • Complex topics, such as advance care planning where patients face end of life decisions, necessitate an interdisciplinary approach. Engaging a social worker in facilitating group visits ensures that you’re focusing on the psychological, spiritual, social, and financial aspects.
  • When going on a “site visit,” where you learn from an exemplar organization, be sure attendees bring back pictures, videos, and stories to inspire other staff and providers.