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Back: Group Visits for Diabetes

Dr. Shahady

 Edward Shahady, MD
 Medical Director
 Diabetes Master Clinician Program
 Florida Academy of Family Physicians Foundation
 President
 North Florida South Georgia Chapter, American Diabetes Association
 Board Member
 Primary Care Metabolic Group


Life changes dramatically for a patient and their family once the diagnosis of diabetes is made. Nutritional food choices, increased physical activity, multiple medications, visits to a physician, and blood tests are no longer optional. They now have a means of changing the length and quality of life. The patient has to rapidly become knowledgeable about nutritional content of any food they eat, different ways to be active, blood sugar testing, medication doses and side effects, and new words or abbreviations like A1C, LDL, HDL and Triglycerides.

Multiple barriers exist for the patient trying to become knowledgeable about all of the above factors and include costs of medication, depression, transportation, and lack of confidence in their ability to control diabetes. With all of these barriers it is not very surprising that less than 50% of patients are able to achieve American Diabetes Association (ADA) goals for A1C, LDL and BP. These barriers for patients also create barriers for their health care providers and additional barriers are created by a health care system that is broken.

Traditional one to one office visits are not working for over 50% of diabetic patients. Additional strategies like group visits are needed to help overcome these barriers and help more people achieve goal. Multiple studies indicate that group visits increase goal achievement, patient, and provider satisfaction and create significant short term and long term cost savings. Group visits are reimbursed similar to an office visit and can be income positive. The following information and suggestions are about: planning and conducting group visits; patient and clinician views about group visits and lessons learned from my 10 year experience of conducting group visits.

What’s different about group visits?

Group visits are different from group education classes or support groups. They provide similar support for self-management skills but also provide medical evaluation, medication adjustment, care coordination, and preventive services. Education classes provide knowledge and information through lectures. Unfortunately knowledge alone does not provide the needed fuel to change behavior.  Patient’s experiences with their own diabetes mold their behavior. These experiences are based on culture, values, and the emotion and feelings that accompany diabetes.

Group visits provide a setting where patients feel safe asking questions and expressing their concerns about their diabetes. Being able to express feelings in a supportive environment is therapeutic. Group visits are more effective if they are conducted by a clinician and nurse/MA team that have an established a relationship with the patient. The prior trusting relationship with the office team they know makes it easier to express feelings, achieve goals, conduct more effective group visits, and achieve sustainable results. Diabetes knowledge is still conveyed but not in the traditional way.

Each group visit may have a focus like nutrition or exercise. But instead of starting with the usual lecture, the visit starts with asking the patients for their questions and concerns about the topic. Not all clinicians and nurses are comfortable with this method of teaching and implement it differently. The key is to remember that knowledge alone does not change behavior. Clinicians and office staff can learn a lot about the effectiveness of their session by asking patients what was most helpful about the session. The answers reveal what behaviors may change. In my experience, knowledge gained as a result of a patient’s questions or comments is what’s remembered and has a sustained impact on behavior.

Patients who are not reaching goal have been prescribed medication and advised about exercise and nutrition. The problem is they are not doing what is recommended. Clinicians think the patient is not listening and the patient thinks the physician is not listening. Group visits provide an opportunity for them to listen to each other. I have found that the majority of what I do in a group visit is listening to patient concerns, asking others if they have similar concerns, and how they have addressed the concerns. Although at times new prescriptions are written more often than not, my time is spent motivating patients to adhere to previous medication, exercise, and nutrition recommendations.  

Preparing for a group visit

Once you have decided to offer group visits, have a meeting with all your office staff and let them know why you are doing group visits and share your excitement about the potential. If you are enthusiastic, they will convey that excitement to your patients. If you are not, they will also convey any perceived concerns and doubts. Explain they are not support groups, there will be a charge like a regular visit, and the group visit will replace some of the routine diabetes visits. You still will do their yearly preventative visit and see them for urgent problems in the exam room one on one. Be sure your office staff understands what a group visit is. Patients rely on staff to answer lingering questions and obtain more information. A well informed enthusiastic staff is a key to successful recruiting.  The next issue is who to invite to the meeting. Patients who are not well controlled will benefit most from the group visits. Identify those whose A1C is > 8%, LDL >130 mg/dL and B/P >140/90 mm Hg. This group usually has multiple chronic problems and can be billed as a 99124, a moderate complexity visit with minimal physical exam (vital signs). Your first group visit may be a little anxiety-provoking so loading it with your favorite patients may give you more confidence.

After you start to feel more comfortable invite the more challenging patients. Some patients may not want to come to group visits and some patients who are not mentally stable should not be invited. An ideal number is 10 to 12 patients. Try also to involve a few patients who are well controlled at every visit so they can offer advice to the not well controlled patients. More than 12 individuals in a group session promote the chance of less interaction and the session becomes a lecture. Patients should feel free to bring family members. There is usually no problem with mixing patients of different race, culture, gender, and age. Teenagers do better in a group of their peers. Initial invitation is best done one on one by the clinician and/or the nurse/medical assistant.
 After the clinician and staff become comfortable with group visits, other strategies like letters, posters and phone calls can be utilized for invitations. Timing of the group visit can vary depending on availability of space, staff, and clinician schedules. Group visit frequency varies from one a month to one every 3 to 6 months. The sessions we conduct last about 2 hours.

The first portion of the meeting is conducted by the nurse or medical assistant. The initial 15 to 20 minutes is used for vital signs, updating records and completing questionnaires that are used to document history. The lead staff person meets with the clinician the day before the group visit to review the list of patients who have confirmed attendance. All needed scripts, lab tests and immunizations are listed by the staff person, and the clinician gives the OK to have all those functions performed before he/she enters the room for the second hour. The staff  person performs much of the needed documentation for the visit. The clinician reviews what the staff person has done, edits it and adds key information. We ask the same group to stay together for three group visits, 6 weeks apart.
 


The first visit focuses on signing all forms including a HIPPA agreement, an explanation of the group visit, a review of their recent lab data and adherence to other quality criteria like eye and foot exams, and immunizations. The second group visit focuses on physical activity and nutrition and the third visit on medications and complications. This is our preferred way to do group visits but it is not the only way. Some clinicians ask all their patients with diabetes to come to group visits for all their routine diabetes care and others use different strategies. Do the group visits your way and measure success by how many patients improve their A1C, LDL and BP.

Coding, charging and documenting

As previously suggested, group visits are for patients who are not well controlled and are not at goal. The following include helpful information for coding, charging and documenting:

  • The ICD 9 codes for the diagnosis should reflect the level of control and complications.
  • 250.00 is the code for type 2 diabetes well controlled with no complications and would not usually merit a 99214 E & M code.  
  • ICD 9 codes, like 250.62, indicates uncontrolled diabetes with complications.
  • The 5th digit indicates the level of control.
    • 0 is type 2 in control
    • 1 is type 1 in control
    • 2 is type 2 not controlled
    • 3 is type 1 not controlled.
  • The 4th digit is for complications. An example would be diabetic neuropathy (fourth digit of 6). A patient with type 2 not in control with renal disease would be an ICD 9 code of 250.62.  

Documentation is the key and most patients qualify for a 99214 if they are established patients, not in control and have at least 3 chronic problems. Controlled diabetics are usually 99213.  

99214 documentation

Most of your patients in a group visit are the most difficult to control and have A1C’s of  > 7% or LDL >100 mg/dL or Systolic BP greater than 140 mm Hg. All numbers should be documented. Other items that require documentation include a chief complaint, two review of systems questions review of and one question about either past medical history and/or social history. Be sure to document you are dealing with an uncontrolled diabetic patient not at target.

A moderate complexity visit that has three chronic problems does not require a physical exam other than vital signs. Medicare code requires a face to face visit not a one to one visit or visit in the exam room.

More information about charging and documenting for group visits can be found online at http://www.fafp.org/diabetes_mc.html#P. The first article listed is a review of group visits in diabetes and the second is the training manual the author uses to teach group visits. This document discusses coding and documentation in more depth.  

Conclusions

Diabetes is a challenging illness for both the clinician and the patient. Some patients are able to respond to the challenges, understand their diabetes, and respond well to one to one care provided by the routine office visit. But the routine office visit does not work for all patients. There are about 3000 waking hours during the year and at best, clinicians spend about 1.5 hours a year with the more difficult patients. Our role is clearly coaching, motivating and encouraging the patient. But our measurement of goal achievement indicates that the traditional office visit is not effective for many of our diabetic patients. We need additional strategies to help empower patients.  Group visits are a creative and innovative way for clinicians to manage diabetes, especially those patients who are difficult to control.