Group appointments are a feasible way to deliver care to chronically ill, low-income women, a UCSF study has found. In this pilot study, a family physician and family nurse practitioner team guided six 90-minute appointments for patient groups as large as 15.
Appointments included a 15-minute check-in during which women received feedback on health goals they had set during their first session, a teaching period with time for patient questions, and a brief one-on-one encounter with a health provider. During teaching periods providers discussed a variety of topics including, nutrition and exercise, menopause, cancer screenings and general self care. Optional private exams were offered in the 30 minutes following each session.
"In modern-day ambulatory care settings, clinicians often feel caught between the frenzy of running from room to room to address a myriad of patient concerns and the task of repeating the same health information many times," said Daphne Miller, MD, former fellow in the UCSF department of family and community medicine and the lead author of the study. "Patients, on the other hand, express concern that rushed clinic visits leave them little opportunity to build a quality relationship with their provider, voice their needs or receive health education. The limitations of the one-on-one clinical encounter are most obvious when providing care to patients with chronic health problems. For those patients, this model allows a more efficient delivery of health education and preventive health services," she said.
Concerns about breaches in privacy or loss of personal attention were mentioned by relatively few participants, and participants reported that they developed more of a partnership with their provider and benefited from social exchanges with other patients, said co-researcher Pilar Bernal de Pheils, RN, FNP, UCSF associate professor in the department of family and community medicine. Bernal de Pheils, who presented the study on October 11th at the VII Pan American Nursing Research Colloquium in Bogotá, Colombia, added that chart reviews indicated a decrease in urgent care visits during the nine months of the pilot study, compared to the previous nine months.
Study participants included Latina (20), African American (4), Filipina (2), and white (2) women age 40-64 who had at least one chronic disease including, but not limited to, cardiovascular disease, diabetes and osteoarthritis, researchers explained.
"In general these patients require a range of health care services, which are often difficult to provide within a standard clinic encounter," said Miller. "Group appointments give physicians the opportunity to offer evidence-based treatments and preventive services, self management education, and ongoing psychosocial counseling."
In telephone interviews following the group appointments, 77 percent of the participants felt they had received personalized attention, even in the group format, said Bernal de Pheils. "This may be because we spent nearly two hours with patients, while more traditional clinic visits last on average 15 minutes," she said.
Nearly 70 percent of the patients cited the benefit of self-care education and convenient access to medication and refills and exams. More than 60 percent reported a benefit from peer advice. Only four percent of participants reported a loss of confidentiality.
Group appointments were offered at the Mission Neighborhood Health Center and San Francisco General Hospital Medical Center (SFGHMC) Family Health Center. Women with ongoing drug or alcohol dependence or severe medical or mental illness, which would prevent attendance and/or participation in the groups, were not contacted for the study.
Researchers emphasize that outcomes of this small study may not apply to midlife women in other inner-city settings, and that, without a control group, it is impossible to assess provider productivity or conclude whether the decrease in emergency room use during the study was due to the group appointments. The investigators also underscored the importance of informing prospective patients about group appointments before they are selected to be sure they can tolerate a group setting.
Additional researchers on the study include Kevin Grumbach, MD, UCSF associate professor in the department of family and community medicine; Hali Hammer, MD, UCSF assistant professor in the department of family and community medicine; Shotsy Faust, RN, MS, FNP, UCSF associate professor of family health care nursing; Colleen Foy Sterling, MD, director of the women's clinic at the Mission Neighborhood Health Center; and Veronika Zantop, MD, a family practice resident at the University of Washington. The research was funded by The UCSF Center for Collaboration in Primary Care.