Healthcare Systems Improvement Analysis and Recommendations Report

Alexandra Giselle De la Rosa Berro

HSO Type: Primary Care Clinic

Issue: Management of chronic conditions

Situation

Chronic illnesses are defined as diseases that last a year or more and require ongoing
medical attention. Conditions such as diabetes, hypertension, cholesterol disorders, heart disease,
asthma, or arthritis are among the most common in the United States (CDC, 2009). The advances
in technology of the last few decades that have increased longevity and disease detection, this
along with an aging baby boomer population, and an increase in behavioral risk factors have left
chronic conditions to be the central health need for the American public (IOM, 2001).
Today, 145 million people in the US have at least one chronic condition (Anderson,
2010). This number continues to grow at exceedingly rapid rate and by 2030 it is expected to
surpass 170 million people (Anderson, 2010). Chronic diseases account for 70% of all deaths in
the U.S (CDC, 2009) and the leading cause of disability, bringing severe activity limitations to a
quarter of those who have them (Anderson, 2010). Not only is nearly half of total population
chronically ill, 1 in 4 have multiple chronic conditions. Among those 65 years and older, the
fastest growing sector of the US population, that number is 3 in 4 (Anderson, 2010). These
alarming numbers, not only magnify the need for suitable specific disease management, but the
critical component of coordination of care across different care settings and specialties.

Financially, chronic conditions are by far, the biggest burden of the health care system.
Currently 84% of all healthcare spending in the country is on chronic conditions, (Medical
Expenditure Panel Survey, 2008). This is even more of a drain on public funds as 99% of
Medicare and 80% of Medicaid spending is on chronically ill persons (Medicare Standard
Analytic File, 2007). The increased cost of multiple chronic conditions is exponential (Figure 1),
a single chronic condition nearly triples the amount of healthcare spending, and those that have
three conditions have more than seven times greater spending. (Medical Expenditure Panel
Survey, 2006). In fact, 95% on Medicare spending is for those with more than one chronic
condition, 79% on people those with five or more, although this last group is only 12% of all
Medicare beneficiaries (Medicare Standard Analytic File, 2007). All this comes to a total of more
than $2 trillion being spent every year for care of chronic conditions, but few positive health
outcomes to show for it.

Figure 1: Per capita healthcare spending by number of chronic conditions. Reprinted from
Chronic care: Making the case for ongoing care, by G. Anderson, 2010, Robert Wood
Johnson Foundation.

Background
Despite these technology and costs of the American healthcare system, its current state is
nowhere near being able to successfully manage chronic conditions. The healthcare system has
developed over the last century to primarily to treat acute/episodic illnesses and accidents. This
translates to a set-up of short visits and financial compensation maximized by individual
diagnosis and treatment procedures (Wielawski, 2006). However, a completely different
approach is necessary to prevent the onset and complication of chronic conditions.
Chronic care requires a collaborative, multidisciplinary and longitudinal process.
Conditions rely on both medical and self-management (eg: home blood glucose/blood pressure
measurement, insulin dosing changes according to meals, peak flow meters for asthmatics), and
thus, clinical problems and plans must be defined and understood equally by patient and their
providers (IOM, 2001). Because of the high numbers of multiple conditions and degrees of
severity, 81% of chronically ill patients receive care from more than one doctor, usually a series
of specialists, as well as a primary care provider (Anderson, 2010). If their conditions are
unstable, they may also require advanced nursing care and/or hospitalizations, making
communication and coordination between all these agents even more crucial (IOM, 2001).
Yet, the latest surveys find that an average length of an outpatient clinic appointment is
13 to 16 minutes (Medscape, 2011), and 3 in 4 adults report not having enough time with their
doctor during appointments (Davis et al, 2006). Not surprisingly, only 36% of physicians are
satisfied with the care they provide chronically ill patients, and 46% of the chronically ill report

having unmet needs in their care (Anderson, 2010). Even though substantial evidence exists that
system level shifts away from the acute model towards these aims will lower the disability and
financial burden of chronic conditions in society; the system, for the most part, remains
unchanged (Wielawski, 2006). Using the Institute of Medicine (IOM)s six aims for health care
system improvement (2001), the current mis-management of chronic conditions can be
analyzed by gaps in every single one of these aspects:
Safety
IOM defines safety as avoiding injuries to the patients from the care that is intended to
help them (2001). The precarious hurried manner in which chronic care is given in America
leaves a lot of possibility for errors that leave patients at risk for harm. In an international survey
of sicker adults, 15% of American respondents believed that there had been an error in their
medical care in the last two years, this was the highest percentage among the six industrialized
countries surveyed (Davis et al, 2006). Being prescribed the wrong medication or dose, receiving
incorrect or delayed abnormal lab results, or contradicting diagnosis by different providers,
among others, are all commonly reported errors by the chronically ill in the U.S (Davis et al,
2006; Anderson, 2010).
Effectiveness
Effectiveness or evidence-based care, refers to providing care that is backed by scientific
knowledge to ensure interventions (e.g: preventive screening, diagnostic test, treatment) are
given to the appropriate people and are not under or over utilized (IOM, 2001). In the fee-perservice structure of the American system, it is not uncommon that overutilization of interventions
is the norm for a lot of health service organizations as revenue relies upon it. Yet, underutilization

of services is also an issue when hurried providers do not have the opportunity to do a thorough
assessment of needs. For example, the American Heart Association, the American College of
Cardiology and the American Medical Association (2011), all recommend yearly cholesterol
screening for all people with hypertension, yet 15% of patients report not having this requisite
met (Davis et al, 2006). Similarly, the American Diabetes Association (2014) recommends
annual cholesterol, foot and eye exams and bi-annual hemoglobin A1C measurements for all
diabetes, yet this requirement was only met by 56% of American diabetic respondents in the
Davis et al international survey (2006).
Patient-Centeredness
The aim of patient-centeredness, is a focus on meeting the individual patients needs and
respecting their values and expressed preferences. It encompasses qualities of compassion,
empathy at this time when technology has given to patients being more informed than ever on
their healthcare (IOM, 2001). It is not surprising that this satisfaction is lacking from patients
with chronic conditions in the current expensive system of hastened encounters. Among
American respondents to the Davis et al survey (2006), half report being offered options and
asked for their opinion in their treatment, 15% feel their doctor doesnt always listen to their
concerns, and 1 in 4 have left an appointment without getting an important question answered in
the past 2 years (Davis et al, 2006). This humanistic aspect is an often forgotten one in discussing
quality at a systems level, but IOM ranks it as important as all others. Ultimately, healthy people
are satisfied people, and not simply ones that meet statistical goals of clinical health outcomes.
Timeliness

Long waits for short encounters is the norm for patients in the current system. More
worrisome, is harmful delays in getting timely appointments of laboratory results. Delays in
receiving lab results is reported by about a quarter of people (Davis et al, 2006). Various surveys
have found between a quarter and a third of people reporting difficulty gaining timely access to a
health provider when problems occurred (Davis et al, 2006; Murray & Berwick, 2003; Kaiser
Family Foundation 2001; 2002). More worrisome is that the number of people reporting these
delays has been and continues increasing (Agency for Healthcare Research and Quality, 2008).
The multiple providers most chronically ill people are being followed with only compounds this
waiting time patients deal with just to keep up with their care.
Efficiency
An efficient system is a cost-effective one, one where resources are used to get the best
value for the money spent (IOM, 2001). Given all the aforementioned it goes without saying
that the current system could not be further away from efficient on a national level. The weight
placed on both individuals and the system is very extensive for such little value. 26% of patients
report visiting the emergency room for an issue that could have been addressed in an outpatient
basis, that is more than any other country in the Davis et al study (2006), and 22% report
receiving duplicate tests or procedures (Anderson, 2010), also a measure ranked highest in the
international survey. On an individual level, chronically ill patients carry a significant financial
burden for their subpar healthcare, with an average out of pocket cost of $1,057 per year, 4x that
of people without a chronic condition (Medical Expenditure Panel Survey, 2006). This burden is
enough for 65% of chronically ill patients to have to take from retirement or education savings,

27% borrow funds from family/friend, or 8% even declare bankruptcy just to finance their
healthcare costs (Anderson, 2010).

Equitable
IOM defines an integral purpose of the health system that it function for all people. They
define equity as critical both in an individual level with equal treatment and respect, and at the
population level to reduce health disparities and ensure universal access to services (2001). The
United States has by far, some of the worst health disparities in the industrialized world (Davis et
al, 2006). There is substantial differences between races in just about very chronic condition, for
example African Americans have 15% higher rates of diabetes, 4.5 times more visits to the ER
for asthma emergencies, and double the risk of stroke than Whites (Wilding, 2013). Among
Hispanics there is nearly double the rates of diabetes (Wilding, 2013). At an individual level,
both these groups report not receiving needed treatments for their chronic conditions at higher
rate than Whites, 16% more African Americans, 28% more Hispanics (Anderson, 2010). The
health disparities between socioeconomic classes are equally daunting with a 26% difference
between below and above average incomes reporting not visiting their doctor or getting
recommended treatment due to cost (Davis et al, 2006). The diversity of the American
population brings a lot of difficulty in the area of equitability, but its a fundamental tenant of a
healthcare system, and it is a moral duty to continually strive to achieve.
Opportunity for Improvement

The gaps and troubles of current chronic care management are extensive and complex,
transformations are necessary from the highest levels in our systems to address many issues.
Primary care clinics are the trenches of chronic care management, trapped within a faulty
system having to deliver low-quality care to an overwhelming number of patients with
increasingly complex needs. Concurrent with the rates of diagnosis, almost half of visits to
primary clinics are by those with chronic conditions, and that number has been snowballing for
years (Hing & Udding, 2010). However, despite the system-level gaps, there are potential
adjustments at the clinic-level that could address many of the difficulties facing chronic care.
Safety, as always, should be a number one priority of any healthcare system. Yet, the
uncoordinated nature of care between primary and specialist providers in clinics, home care, and
possible inpatient care, leaves dangerous holes for medical errors. Primary care clinics are the
medical home for patients with chronic conditions navigating the system, thus, they hold the
highest promise for addressing the issue frontline by improving coordination efforts.
Nevertheless, the rushed arrangement of outpatient clinics leave little time for this to be done
effectively and only further increases possible errors. Primary care clinics must prioritize
reducing risk of error with efforts in collaboration and time structures.
The fragmented and hurried nature of outpatient chronic management also contributes to
distancing the most important part of the care puzzle, the patients. Patients overwhelmingly
report their dissatisfaction, and providers agree in their shortcomings to provide adequate care
and meet all of patients needs (Anderson, 2010). The current hasten structure considerably limits
the time to spend on disease management, yet chronically ill patients tend to have multiple
comorbidities and complex needs for their condition(s). The IOM warned against care designed

around specific conditions to avoid defining patients by a single condition or disease (2001). It is
not unreasonable to describe the current acute-based system as one focused on single conditions.
The limited time spent with patients simply does not allow for the comprehensiveness necessary
for the growing multifaceted nature of chronic care.
Lastly, the matter of cost is a tremendous and disastrous factor for care of the chronically
ill. Cost is an issue at every level, from system-wide spending, to the costs of physicians for
organizations to treat so many, and the personal ongoing financial burden for patients. This factor
can be easily shrugged by clinics as one to be addressed by larger political bodies, yet, lowering
costs of chronic disease management at the clinic-level is possible with suitable changes and
primary investment for long-term savings. While it is impossible to address every issue of
chronic care at the organizational level, improvements in these key factors is achievable. There
exists optimal arrangements that better address the needs of patient, providers, and organizations,
if clinics are willing to remove themselves from traditional models.
Improvement Proposal
Root Cause Analysis
Factors of low-quality chronic care which can be addressed at the organization-level can
be grouped into four categories. (1) Uncoordinated care, which affects nearly every aspect of
quality, weakening measures of safety, efficiency, timeliness and effectiveness. (2) Low patient
satisfaction and engagement, essentially the absent patient-centeredness of acute-based care. (3)
High costs, the culprit of the systems lack of efficiency and arguably, equitability. Lastly, (4)
haste, which like fragmentation of care, affects almost every aspect of quality, including safety,
efficiency, effectiveness and patient-centeredness.

Policies
Cumbersome record
relase protocols
even oral
communcation
between providers
Insurance limits
where and which
providers to be seen
for which services
Procedures
Scheduling appts
independently for
each
service/provider/clini
c
Limited coordiation
between inpatient
and follow-up
outpatient care.
People
Multiple care
providers and
support staff that
look at disease
through different
and possibly
contradicting angles
Family and/or home
nurse also part of
Plant/technology
care
provision
No EHR or
incompatible EHRs
between providers
No features in EHR
for inter- provider
communication
EHR lack of errorcheck for duplicate
orders

Uncoordinate
d

Policies
Low provider
education fon
management of
multiple chronic
conditions
Insurance limitations
and costs for
treatments
Procedures
Limited time spent
with provider for
patients to have
questions and
concerns answered
No designated part
of chart for patient
preferences
People
Patients unaware of
how to be more
active in their care>
Lack of health
education
Provider burn-out
and lack of empathy/
communication skills
Plant/technology
Bleak clinic
atmosphere
Hassle of different
locations for
different services
Patients have limited
access to self-care
resources

Low patient
engagement
and
satisfaction

Policies
Billing per service,
per visit
Insurance/
organization
limitation on what
can be done and
billed by who results
in need for multiple
providers
Procedures
Physician care time
that could be
provided by other
less costly providers
No urgent
scheduling option for
outpatient visits>
unecessary ER use
People
Complex physical,
social and emotional
needs of chronic
condition(s) require
lots of services for
proper management
Provider specialize in
only one aspect of
chronic care
Plant/technology
Recurrent labs/
procedures for
different providers>
possible duplication
Costly at-home
equipment options
offered or prescribed
unecessarily

Costly

Policies
Organizational goals
of productivity that
maximize number of
pts to be seen
Multiple care
guidelines for
multiple conditions
required to be
followed
Procedures
Appts scheduled in
day hours- when
many pts have other
responsibilities
Redundant aspects
of administrative
intake and charting
required at every
visit
People
Pressured providers
and support staff to
see patients quickly
Patients with
multiple conditions
and complex needs
to be met in short
visits
Plant/technology
Clinic spaces not
designed to
minimize travel time
for support staff &
providers
Lack of EHR charting
features like short
hand or autopopulation of notes
from labs & previous
visits

Hurried

Problem Statements
1. The current system of management for chronic condition involves many agents, resulting
in uncoordinated, sometimes duplicated care for patients and an increased risk for
medical errors. In the next year, the clinic will be aim to decrease fragmentation and
reduce duplication with specialist provider(s), reducing the number of medical errors over
the next five years.
2. Chronically ill patients individual needs and preferences are not being met by the current
system, leading to low levels of satisfaction and engagement in their care. In the next
year, clinic-level efforts will be made to increase patient satisfaction at every
appointment.
3. The current demands of chronic condition management is costly for the patient, clinic and
system. Over the next year, clinic-level changes will be made to use resources more
efficiently and lower costs for the clinic over the next five years.
4. Current demands of the system have shortened provider care time to a few minutes per
visit, requiring a hasty approach to care that lowers satisfaction for both patient and
provider ,and increases the risk for medical errors. Over the next six months, clinic
changes will allow for services to have less a hurried method that will increase patient
and provider satisfaction, and reduce the number of medical errors over the next five
years.
Improvement Plan:
One of the most effective tools that addresses all four of the identified gaps in chronic
care in the outpatient setting is the use of group visits (GV). GVs, also known as shared medical
appointments are clinic visits that include group education and interaction, along with the
critical elements of an individual patient visit (AAFP, 2014). They combine the element of peer

support and individual appointment standards like history taking, physical exam, and treatment
management. While these visits take place instead of individual appointments, the latter are still
necessary in the clinic structure for patients not eligible or willing to participate in GVs or for or
more intense individual management of those that do. In this model, the healthcare team (not just
the main provider) interacts with the patients in the periodic program of group visits, replacing
the minimum recommended number of visits, but not excluding patients from additional
individual appointments if necessary.
While GVs can be used for management of single diseases, the reality of chronic care in
America is multiple comorbidities. Particularly, the most common, costly, and deathly ones:
diabetes, hypertension and heart conditions including coronary artery disease and congestive
heart failure and strokes (Van Dusen, 2008). The GV model proposed will better address the
uncoordinated and costly nature identified in the current system by focusing on those individuals
affected by multiple chronic illnesses.
Planning for GVs
It is recommended that planning for GVs start no less than two months prior to the first
visit (Group Health Cooperative, 2001). Important tasks during this phase include (Houck et al,
2003; Group Health Cooperative, 2001):

Establish GV team, training of all clinic staff and willing providers in group visits
Ordering or preparing patient educational materials or facilitator guides
Determine whether snacks will be provided for GVs at all or for select visits
Scheduling of space, and if needed, appropriate adaptations or renovations
Deciding which clinical, satisfaction and feedback measurement standards to utilize

for program assessment

Identifying number of eligible patients (Table 1)

For a sustainable GV structure, at least 30% of eligible patients should enroll in the group
visit program (Group Health Cooperative, 2001). To best tackle the aforementioned problems,
selected patients must be those with an increased burden on themselves and on the system. The
following eligibility criteria be used:

Group Visit Program Eligibility

Diagnosis of at least three of the following conditions:
- Type 2 diabetes
- Hypertension
- Congestive heart failure
- Coronary artery disease
- Cerebrovascular disease
- History of cardio or cerebrovascular events (heart attack or stroke).
High-risk/uncontrolled status of at least one condition
Currently being seen at least every three months with good show-up rates to
appointments
Desire or need for health education (i.e.: problems with adherence to treatments or selfmanagement goals)
Table 1: Criteria for invitation to participate in group visit program.

Implementing GVs
Eligible patients of the facilitating providers should be invited and encouraged to attend
the GV program (Appendix 1), and be familiar with the group visit norms (Appendix 2),
particularly on the notion of confidentiality and attendance. GVs will be scheduled every three
months as established by the standard guidelines for hypertension, heart disease and diabetes
care set by the American Heart Association, the American College of Cardiology, the American
Medical Association (2011) and the American Diabetes Association (2014). To minimize the
hurried pace of the clinic and make attendance feasible for participants, GVs will be scheduled at

an evening or weekend time. Visits last between 1.5 to 2 hours and consist of about 10-20
patients.
The GV-format makes use of the entire healthcare team (Table 2). A GV generally starts
with a brief check-in and greeting period where registration, vitals and initial nurse assessments
are done, as well as some individual conferences by the provider, within or outside group setting,
as preferred by patient. This is followed by a general discussion facilitated by the provider
(Houck et al, 2003). The discussion topic could be on the targeted diseases, related health issues,
stress/social issues, nutrition, lifestyle interventions, or other patient-suggested concerns. The
topic(s) of the visit could be determined either by a set curriculum team is trained in, or prepares
in visit planning meetings. Each discussion portion of the GV should include ample time for
patient concerns and suggestions.
Following the discussion, the group takes a break, which can include a clinic or patientprovided snack, or no snack at all. During this break, vitals or individual conferences with
providers are conducted if they were not in the beginning. The group returns from break for a
general question and answer session with the provider and goodbyes. For patients that require
more thorough or private assessment, practitioners could provide one-on-one visits after the
group session or schedule the patient for another time before the next GV.
In order for GVs to run smoothly, there is time spent outside of the GV to ensure
preparation and success. The nurse conducts chart reviews for patients before each GV,
highlighting any key areas, and completing forms for diagnostic test or lab work before reporting
results to the provider. Likewise, a provider may spend additional time after GVs to ensure
proper documentation for each patient. This outside GV time is critical for ensuring coordination

of the patients care, its during these chart reviews that providers communicate with fellow
providers, make referrals and double check for errors without the hurried pressure of daily clinic.

Team Roles Group Visit Program

Team Member
Nurse or
medical
assistant

Prior to GV
- Remind provider of upcoming GVs
- Perform chart review, give results to
provider

Patient care
representative
and/or health
educator

- Schedule date and time for visit and

coordinate with provider
- Make reminder phone calls for
scheduled patients
- Ensure room reservation and materials
are prepared

- Participate in planning for visit with

suggestions from patients and team
Provider (MD, - Review charts, identify individual
OD, APN, PA)
problems
- Prepare needed referral and treatment
paperwork

Day of GV
- Take charts and supplies to room
- Perform intake, vitals & immunizations
- Charting or data entry, if appropriate
-

Check-in/register patients, print labels

Help set-up and support other team
members during visit
Identify patients that need individual
attention and ensure its given
Discharge patients and schedule for
next GV or individual appt, as
determined by provider
Facilitate discussion in group visit
Conduct 1:1 assessment and
management during or after GV
Document visit

Table 2: Healthcare team roles in GVs, adapted from Group visit starter kit, by Group
Health Collaborative, 2001

Long-term goals of GV program

The Plan-Do-Study-Act of the GV program is seen in Figure 2. A full initial course of the
GV program is one year in length (four visits), afterwards the provider can continue the GVs
with the same group and/or start a new group. After year participation, patients are also free to
return to individual visits if they choose. After the initial pilot year, feedback from the team and
patients will be used to adopt and adapt features of the program. A second provider and/or a

second group for the same provider will then be started for another year cycle. By the start of the
second year 30% of eligible patients of the participating provider should be enrolled in the GV
program to ensure sustainability. Outcomes for the program will be evaluated at the end of each
year cycle, with a through clinic-wide assessment after five years.

Identify patients that meet GV criteria (Table 1)

Figure 2: PDSA for group visit implementation in clinic. Adapted from "Plan-Do-Study-Act (PDSA) Examples http://www.imp

Value of Investment Analysis

The American Academy of Family Physicians concludes that the research on GVs shows
them as a win-win for physicians and their patients (2014). In fact, the analyses of costs of GV
in primary care found that it decreased the annual cost per patient by around $150 (Scott &
Robertson, 1996; Reid et al, 2010), and has been estimated to generate an additional $15,411 per
physician per year (Spann, 2004). Moreover, the gains in health outcomes and satisfaction for
both patient and providers is extensive.
A 2006 review (Jaber et al) of all 33 group-visit research articles published between 1974
through 2004 consisting of more than 5,000 participating patients, found across the board gains
in factors including reduction in obesity, blood pressure, glucose/A1C and cholesterol levels,
improved quality of life and health behaviors, increased patient satisfaction and doctor-patient
relationship, decreased usage of emergency services and need for specialist referrals, and
improved patient adherence to treatment. These findings have been confirmed with recent studies
specifically focused on multi-disease cardiovascular risk (Kirsh, et al, 2007) and by the Agency
for Healthcare Research and Quality (2008) and the Kaiser Permanente network (Reid et al,
2010). Furthermore these newer studies have found, a decrease in calls to physicians with an
increase in calls to nurses, patients making more visits to primary care, and increased satisfaction
and lower burnout rates for physicians. Additional qualitative analysis of participants in the
Kaiser Permanente study found common themes in what patient value from their GV experience,
such as, the trusting relationship, hands-on care, and time they get to spend with their provider;
the opportunity to learn new information, ask questions; and get to know and enjoy company
with peers with similar issues, helping them feel less alone (Reid et al, 2010).

Reduced cost per

patient
Improved patient
satisfaction and
compliance
Improved clinical
outcomes

Value

Reduced provider
burnout and
disatisfaction
Increased
revenue
Inceased
productivity:
more pts per hr,
less calls to
physicans
More visits

Value of
Investment

Training costs

Investment

Setting
adaptation or
renovation
Possible overtime
pay for
evenings/wkends
Materials: snacks,
facilitation guides
or patient ed

Figure 2: Value of investment analysis of group visits. Adapted from Control and resources
management-human resources and fiscal management [PowerPoint slides], by N. Wehbi, 2014.

Recommendations
Within the next three months,
o Propose GV program idea to clinic staff and receive feedback/interest
o Form GV committee to determine budget and administrative logistics
o Identify willing providers and form GV healthcare team
Within next six months,
o Conduct preliminary survey of patient interest
o Determine which and complete GV training for providers and staff
o Develop unique or adapt training curriculum to patient population
Within nine months,
o Establish system for identifying eligible patients
o Develop format for GV data collection and/or extraction from EHR
Within a year, begin GVs

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Appendix 1: Invitation to Group Visit Program

Reprinted from Group visits 101, by S. Houck, C. Kilo & J.C Scott, 2003, Family Practice
Management.

An Invitation From Your Doctor

You are invited to join your doctor and other patients in our practice for a group visit. Its an
idea that other doctors around the country have found helps them care for their patients in ways
that cannot be accomplished during the usual 15- to 20-minute office visit.
Heres how it works: Your doctor and one of our nurses will visit with you and approximately 15
to 20 other patients for about an hour and a half in a conference room here at our office. During
the visit, there will be time for talking with other patients as well as education about specific
health problems. Then, your doctor will spend time talking with each patient individually about
health problems and concerns. If you have additional health concerns that need to be addressed,
there will also be time to meet alone with your doctor after the group visit. Of course, the visits
are completely voluntary.
The group visit program was set up to provide an additional opportunity for patients to meet with
their doctor on a regular basis and to learn how to deal with common health problems. Group
visits also give patients the opportunity to learn from other patients who are dealing with similar
health problems and to get their health needs met and their questions answered. From time to
time other health professionals, such as pharmacists or health educators, may join your doctor
and nurse at the visits.
The date and time of the next group visit is listed at the bottom of this letter. If you are interested
in attending, please let your physician or nurse know. You are welcome to bring a family member
or friend with you.
When you come in for the group visit, simply check in as usual with the front desk and pay your
usual co-pay. The receptionist will direct you to our meeting place.
We welcome your possible interest in this new opportunity for you to participate with your
physician in your health care. Of course, if you decide not to participate, your doctor will
continue to see you at the office as in the past.
Sincerely,
Your Doctors Office
Next group visit date and time: __________________________
Our phone number: ______________________________

Appendix 2: Group Visit Norms

Reprinted from Group visit starter kit, by Group Health Collaborative, 2001

Group Visit Norms

We will
Encourage everyone to participate.
State our opinions openly and honestly.
Ask questions if we dont understand.
Treat one another with respect and kindness.
Listen carefully to others.
Respect information shared in confidence.
Try to attend every meeting.
Be prompt, so meetings can start and end on time.