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 More Care in Group Settings May be Key to Transformation of Medicine 
The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series
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.)

holistic medicine leader, group visits, shared medical appointments, innovative practice models
Kjersten Gjmeiner, MD
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.

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 group visits?

: 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.

: That's bound to please the HMO.

: Yes, 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.

: How do your group visits work? For what types of patients?

shared medical appointments
Staff model HMO promotes group visits
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 together.

: What is the group doing with the nurse while you do the short exams?

"This is much more of a
natural fit in the holistic
community than the
orthodox community ...

"If you are a teacher,
you know in a heart beat
that the group visit will
be better."

- Kjersten Gmeiner, MD

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 walking partners.

: How much are these used throughout Group Health?

: Group 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.

: What the story with payment and reimbursement - a big question for those practitioners whose services are usually reimbursed by 3rd parties?

: 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.

: How about among your colleagues in holistic medicine, what's going on there? What response do you get?

group visits, sharerd medical appointments, holistic medicine
Among the naitonal leaders
: 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.

: 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 practice.

: 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.

: 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."

"There hasn't been a
major innovation in clinical
delivery in a long time.
I think this is it."

- Gmeiner

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.

: 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.

: 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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 About The Author
Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......moreJohn Weeks
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