Shared medical appointments

1. Introduction

Version followed: Edward Noffsinger's Drop-In Group Medical Appointment (DIGMA) and Physicals Shared Medical Appointment, as run at Cleveland Clinic (Bronson & Maxwell 2004) and described in Cynkar 2007. Also the Cooperative Health Care Clinic (CHCC), as set out in the Group Health Cooperative Group Visit Starter Kit (2001) and Houck, Kilo & Scott's "Group Visits 101". Two named variants are covered where they differ: Integrative Medical Group Visits (IMGV; Gardiner et al. 2017) and CenteringPregnancy (Centering Healthcare Institute).

Shared medical appointments (SMAs), also called group medical visits, are not a psychotherapy. They are a way of delivering medical care. A group of patients, often with the same condition, has its medical visits together in one extended session, usually about 90 minutes. Each patient still gets individual medical attention: assessment, prescribing, referrals and documentation. The rest of the group listens and joins in. [source: Bronson & Maxwell 2004; Cynkar 2007] A psychotherapist's usual role is the behaviorist (also called facilitator or co-leader). The behaviorist opens the session, protects confidentiality, manages time and group dynamics, runs the group while the physician examines or documents, and brings out psychosocial issues the physician may miss. [source: Cynkar 2007; Bronson & Maxwell 2004] This guide is written for that role and for clinicians who set up an SMA programme.

How change is said to happen. The sources describe four mechanisms:

• Patients learn from hearing other patients' problems being managed.
• Peers reassure each other and persuade one another to follow treatment, for example a patient afraid of insulin or of a test.
• The physician deals with a shared concern once, in depth, rather than repeating it in many short visits.
• Patients get faster access and more time with their own doctor.

[source: Relias Media, "Bringing patients together"; Bronson & Maxwell 2004] CHCC adds self-management education and community-building with an ongoing cohort. [source: GHC Starter Kit 2001] Centering describes three components: patients taking part in their own health assessment, one-to-one time with the provider inside the group, and community-building. [source: Centering Healthcare Institute, "What we do"]

Origins (verified, with conflicts).

• DIGMA. Developed by clinical psychologist Edward B. Noffsinger, PhD. It was introduced in 1996 at Kaiser Permanente San Jose (ACP; Relias). One trade article places it at the Palo Alto Medical Foundation, where Noffsinger later worked [uncertain: the most likely reading is that it began at Kaiser San Jose and Noffsinger later took it to PAMF]. "Group Visits 101" calls him "John Noffsinger". That is an error in that source.
• Physicals SMA. Also Noffsinger's, introduced in 2001. [source: Cynkar 2007]
• CHCC. Developed by John Scott, MD, at Kaiser Permanente Colorado (Denver) in the early 1990s. One source gives 1991, at Hidden Lake. It was first used with frail elderly patients who were high users of primary care. [source: Houck, Kilo & Scott; Managed Care 2005; GHC Starter Kit]

2. Framework

The sources do not describe treatment phases. SMAs are structured at two levels: programme set-up and the session agenda. Which model you use determines both.

Model choice

[source: Bronson & Maxwell 2004; Cynkar 2007; GHC Starter Kit 2001; Managed Care 2005; Gardiner et al. 2017; Klima 2009]

The disease-specific CHCC variant (1995) took up to 30 patients with a physician, a health educator and a medical assistant. [source: Managed Care 2005]

Programme set-up phases (GHC kit; Centering implementation plan)

1. Planning (at least 2 months before launch; Centering allows 2–3 months).
   • Get leadership support and agree outcome measures: satisfaction, clinical standards, utilisation.
   • Choose the population. Only 30–50% of invited patients take part, so you need at least about 50 eligible patients.
   • Book the room and staff.
   • Criterion to move on: a named population, booked staff and a booked room.
2. Recruitment (about 1 month before).
   • Send the invitation letter, then make follow-up and reminder calls.
   • Criterion to move on: enough RSVPs to fill the census.
3. Training. Centering requires every group leader to attend its Basic Facilitation Workshop 1–2 months before groups start.
4. Launch and early sessions. Debrief after the first session, then hold a team meeting each month.
5. Maintenance and fidelity.
   • Keep the census full and the schedule fixed.
   • Centering offers Site Approval once the first group has completed all its sessions and new groups are starting regularly. It also recommends an Advanced Facilitation Workshop after the first series.

[source: GHC Starter Kit; Centering Implementation Plan]

DIGMA and the Physicals SMA have no formal certification in the sources. Bronson & Maxwell stress following the model closely. [uncertain: whether Noffsinger's organisation offers certification was not found] CenteringPregnancy is a licensed model: you need the Centering trainings, and Site Approval confirms fidelity. [source: Centering Implementation Plan]

Staffing

• Physician (or other prescriber). Delivers and documents care. Must be present for the whole session where E/M billing is used (US). [source: Houck, Kilo & Scott; GHC kit]
• Behaviorist. A psychologist, social worker, nurse practitioner, nurse or health educator. Present for the whole session. [source: Bronson & Maxwell; Relias]
• Nurse or medical assistant. Takes vitals, prepares charts, gives immunisations.
• Documenter (optional). Writes the notes in real time.
• Scheduler or support staff. Handles invitations, reminder calls and name tags.
• Guest specialists. For example a pharmacist, dietitian or physiotherapist. Brief them to keep their contribution interactive.

[source: GHC kit; Bronson & Maxwell]

3. Guiding principles

• It is a medical visit, not a class or a support group. Every patient's individual medical needs are dealt with and documented at a level that supports billing. If you slip into lecturing, you lose the model. [source: Bronson & Maxwell; GHC kit]
• Participation is voluntary, and individual care stays available. Offer the group as a choice at every booking. Patients who decline keep their usual care. [source: Bronson & Maxwell; GHC kit]
• Present it as more care, not less. Talk about longer time with the doctor, faster access and peer support. Never present it as a cost-saving substitute. [source: Bronson & Maxwell]
• Confidentiality is a written precondition. Patients and staff sign the waiver before the group begins. The behaviorist reinforces it at every session. [source: Bronson & Maxwell; Relias]
• Facilitate; don't lecture. Turn questions back to the group ("has anyone experienced this?"). If a staff member talks about themselves for more than about a minute, they should stop. [source: GHC kit; Houck, Kilo & Scott]
• Use the group to manage each individual. After one patient's issue, ask who else shares it, so that one patient's care becomes everyone's learning. [source: Bronson & Maxwell]
• Hold the clock. All patients are seen and all notes are finished inside the 90 minutes. Extra charting time destroys the efficiency. [source: Bronson & Maxwell]
• Balance airtime. No single patient dominates. Move extended problems to a private appointment. [source: Bronson & Maxwell; Relias]
• Watch the psychosocial layer. The behaviorist looks for emotional and psychosocial issues behind medical complaints. Noffsinger estimates that 40–60% of medical visits are driven by these issues. [source: Cynkar 2007; Relias]
• Choose patients and conditions that fit. Stable chronic conditions and repeat follow-ups suit the format. Initial evaluations, procedures and acute or fast-changing illness do not. [source: Relias; Bronson & Maxwell]
• Keep a fixed, predictable schedule and a full census. Use the same day, time and room each week. A low census makes the model uneconomic. [source: Bronson & Maxwell]
• Stay faithful to the tested format. If you change it, you may not get the results the model produced. Debrief, then adjust carefully. [source: GHC kit; Bronson & Maxwell]

4. Intervention inventory

The items below are the procedures the sources describe. Part A covers programme set-up and Part B covers each step of a session. Part C covers the procedures specific to the variants. All example language is illustrative unless it is quoted.

Part A: Programme set-up

A1. Choosing the population, the model and the physician

• Purpose: match the format to patients and clinicians who will benefit from it.
• Steps:
  1. Pick physicians with long backlogs (patients waiting weeks or longer) or who repeat the same advice many times a day. [source: Bronson & Maxwell]
  2. Pick conditions that are stable and need repeated follow-up. Examples from the sources: hypertension, diabetes, asthma, chronic pain, bariatric follow-up, neurology, oncology support, depression medication review. [source: Bronson & Maxwell; Relias; Cynkar]
  3. Find candidates through registries, diagnosis codes, prescription data or frequent-visit reports. One example of a high user is 6 or more visits a year. [source: Houck, Kilo & Scott; GHC kit]
  4. Choose the model.
     • DIGMA: drop-in follow-ups.
     • Physicals SMA: annual physicals.
     • CHCC: an ongoing cohort.
     • Fixed series: a curriculum.
  5. Check that the eligible pool is large enough, about 50 or more for a CHCC. [source: GHC kit]
  6. A DIGMA can rotate conditions across the month. One example: cardiopulmonary in week 1, weight and diabetes in week 2, chronic pain in week 3. [source: Relias, "Inner workings"]
• Example language (to a physician, illustrative): "Which three things do you find yourself explaining ten times a week? Those patients are your first group."
• Watch for: a pool that is too small, or a physician who isn't committed. Both lead to a low census (see section 5).

A2. Screening for fit (inclusion and exclusion)

• Purpose: keep out patients who can't take part safely or usefully.
• Steps:
  1. Include established patients who choose the group.
  2. Exclude, or offer individual care to, these patients:
     • those who can't or won't keep confidentiality;
     • those with significant hearing impairment or cognitive impairment;
     • those who need an interpreter (unless you run a same-language group);
     • those with terminal illness or memory problems (CHCC);
     • those away from the area for long periods (CHCC). [source: Bronson & Maxwell; GHC kit; Cynkar]
  3. Exclude initial evaluations, one-time consults, most procedures, and acute or fast-changing illness. [source: Relias]
  4. For curriculum groups that target mood, IMGV also screened out psychosis or mania, active suicidality and alcohol dependence. The physician met each participant before session 1 as a second safety screen. [source: Gardiner et al. 2017]
  5. Centering groups can be built around language or age, for example Spanish-speaking or adolescent groups. [source: Klima 2009]
• Example language (to a patient who is a poor fit, illustrative): "Because we'll need to go through your new symptoms in detail, a one-to-one appointment is the right place this time."
• Watch for: patients who are excluded by default but would cope well with an accommodation, such as an amplifier or a same-language group. [synthesis]

A3. Recruitment and invitation

• Purpose: fill the census. The sources treat this as the main thing that decides whether an SMA survives.
• Steps:
  1. Send a letter signed by the physician, describing the visit and asking for an RSVP. The CHCC kit mails 40–50 patients about 1 month ahead. [source: GHC kit]
  2. A nurse phones 1–2 weeks after the mailing, then makes a reminder call about 1 week before the session. The reminder makes clear that this is a medical appointment, not a class. [source: GHC kit]
  3. Callers say the physician asked them to invite the patient, and a letter follows up. [source: Houck, Kilo & Scott]
  4. The physician invites patients face to face in ordinary visits. Schedulers use a script and offer every patient the choice of a group or an individual slot for their next appointment. DIGMA schedulers also call patients on the physician's waiting list. [source: Bronson & Maxwell; Relias, "Inner workings"]
  5. The invitation and the scheduler script should mention confidentiality. [source: Bronson & Maxwell]
  6. Let patients bring family members or caregivers. They attended about half of CHCC visits. [source: Houck, Kilo & Scott]
  7. DIGMA drop-ins are welcome, but ask patients to call a day ahead so their records can be pulled. [source: Relias, "Inner workings"]
• Example language (scheduler, illustrative): "Dr. Lee asked me to offer you a place in her group appointment next Tuesday. It's a full medical visit with her and runs 90 minutes. You can bring your partner, and everything you hear there stays confidential. Or I can book you a regular appointment. Which would you prefer?"
• Watch for: uptake below one-third. One-third to one-half of invited patients is typical. If uptake is lower, check the invitation script and whether the physician is personally endorsing the group. [source: Houck, Kilo & Scott]

A4. Pre-visit chart preparation

• Purpose: make the efficiency possible.
• Steps:
  1. A medical assistant or nurse pulls the charts 3–5 days ahead (CHCC kit). CHCC nursing staff spend about 2 hours on this. [source: GHC kit; Houck, Kilo & Scott]
  2. Identify the preventive services and tests each patient is due.
  3. Prepare the referral and lab forms in advance.
  4. Print labels and registry reports. [source: Relias, "Inner workings"; GHC kit]
• Example language: not applicable.
• Watch for: the physician doing chart work during the session. That means preparation was incomplete.

A5. Confidentiality waiver and group norms

• Purpose: this is the legal and ethical basis of the format.
• Steps:
  1. Every patient, and every support person or staff member present, signs a shared-visit confidentiality waiver before the group starts. It covers two agreements: the patient consents to their own information being discussed in front of others, and agrees not to disclose anyone else's. [source: Bronson & Maxwell; Cynkar; Relias]
  2. Agree group norms. In the CHCC kit these are: everyone participates, people treat each other with respect, confidences are respected, people come on time, attend every session and call if they can't come. [source: GHC kit]
  3. IMGV reviewed confidentiality and ground rules in session 1 and had participants sign a HIPAA confidentiality agreement. [source: Gardiner et al. 2017]
• Example language (illustrative): "Before we start, everyone signs this agreement. It says two things: you're happy for your own health to be discussed here, and what you hear about others stays in this room. If there's anything you want to keep private today, tell me and the doctor will see you separately."
• Watch for: hesitation when signing. Offer a private visit instead. Noffsinger reported no confidentiality problems in over 8,000 DIGMA visits, but this is a self-report. [source: Relias]

A6. Room and materials

• Purpose: set up a space that encourages interaction.
• Steps:
  1. Use a dedicated room for at least 15 people, close to an exam room. [source: Bronson & Maxwell]
  2. Seat people in a circle, semicircle or horseshoe, with the open end facing the speaker. [source: GHC kit; Houck, Kilo & Scott]
  3. Provide first-name tags (first names encouraged but not required), refreshments and a flip chart. Write on the flip chart in large letters, bullets and alternating colours. Keep prepared handouts to a minimum. [source: GHC kit; Houck, Kilo & Scott]
  4. Keep the same room, day and time every week. [source: Bronson & Maxwell]
  5. If there is no suitable room, improvise. One Denver clinic opened a conference room onto the lunch room with a folding door. [source: Houck, Kilo & Scott]
• Example language: not applicable.
• Watch for: rows of seats facing a lectern. That layout invites lecturing.

Part B: Session procedures

B1. Arrival, vitals and the written concern list

• Purpose: get each patient's individual agenda before the group starts, so that time can be managed.
• Steps:
  1. Patients check in and go straight to the group room. [source: Bronson & Maxwell]
  2. The nurse takes vitals in a nearby exam room. This can carry on after the discussion begins. [source: Bronson & Maxwell]
  3. Patients sign the waiver and write down their concerns for the behaviorist. [source: Bronson & Maxwell]
  4. The behaviorist reads the concern lists and decides the running order. Patients with complex or time-sensitive issues go earlier, and anything that is clearly a private matter is flagged for private time. [synthesis]
• Example language (illustrative): "Please jot down the two or three things you most want the doctor to help with today. I'll make sure each of you gets to them."
• Watch for: blank concern sheets. They can mean the patient is anxious about the group or holding concerns back for private time (see B5 and section 5). [synthesis]

B2. Opening and orientation (behaviorist)

• Purpose: explain how the session works, set expectations, make confidentiality explicit and lower anxiety.
• Steps:
  1. Start on time. [source: GHC kit]
  2. Welcome everyone and introduce the team.
  3. Explain how the session will run and its benefits: patients are seen by their own doctor, get more time and learn from each other. [source: Relias, "Inner workings"; Cynkar]
  4. Restate the confidentiality agreement and explain how to ask for private time. [source: Bronson & Maxwell]
  5. In a CHCC, the physician opens the session and models a short introduction (name plus a brief personal story). Each patient then does the same, and staff interrupt gently if stories run long. The first CHCC session spends about 30 minutes on an overview of group visits, group norms and the patient notebook. [source: GHC kit]
• Example language (illustrative, DIGMA): "Welcome. Dr. Patel will see each of you in turn, just as in her office, and she'll do any private examination next door. While she's with one person, the rest of us can learn from it. Many people find someone else asks the question they didn't think to ask. I'm here to keep us on time and make sure everyone gets heard."
• Watch for: an opening that goes on too long and eats into individual time. Aim for a few minutes. [synthesis: no fixed duration was found for DIGMA openings]

B3. Sequential individual encounters in the group (DIGMA core)

• Purpose: deliver each patient's medical visit while turning it into learning for the group.
• Steps:
  1. The physician takes patient 1 and goes through their concerns, results and plan in the group room, within the limits of comfort and privacy. [source: Bronson & Maxwell]
  2. The behaviorist bridges to the group. They ask whether others share the issue and draw out what helped them. Bronson & Maxwell's example: after one patient raised sleep problems, the group discussed caffeine and exercise. [source: Bronson & Maxwell]
  3. The physician documents (or the documenter records), writes the referrals and prescriptions, then moves to the next patient. [source: Bronson & Maxwell]
  4. Repeat until everyone has been seen. Each patient gets about 7–8 minutes of individual physician time. [source: Bronson & Maxwell]
  5. Use peers deliberately. Examples from the sources: patients who have had a test describe it, and peers reassure someone who is afraid of insulin or dialysis. [source: Relias]
• Example language (behaviorist bridging, illustrative): "Thank you, Maria. Who else here has had trouble sleeping since starting treatment? … What made a difference for you?"
• Watch for: bridging that takes over the physician's time. Keep each bridge short and come back to the medical sequence. It is working when patients spontaneously start answering each other's questions. [synthesis]

B4. Holding the group while the physician documents or steps out

• Purpose: keep the session going and use the gaps for psychosocial work.
• Steps:
  1. When the physician writes notes, or leaves for a brief private exam or conversation, the behaviorist leads the group. [source: Cynkar; Relias, "Inner workings"]
  2. Take up the psychosocial themes patients have raised: stress, emotional reactions to illness, life changes. [source: Managed Care 2005; Relias]
  3. In the Cleveland Clinic model, the behaviorist also reviews lab results and handles refills, within their scope, while the physician is busy. [source: Bronson & Maxwell]
• Example language (illustrative): "While Dr. Patel finishes with Joe, I noticed several of you mentioned feeling worn down by the illness itself. What does that look like day to day?"
• Watch for: the psychosocial discussion turning into group therapy, with deep processing that can't be finished before the physician returns. Contain it, and offer referral or a behavioral-health follow-up. [synthesis]

B5. Private exams and private time

• Purpose: protect modesty and privacy without breaking up the group.
• Steps:
  1. DIGMA. Brief private exams or private conversations happen at the end of the meeting, or when the physician steps out. Anything that needs a more extensive exam goes to a separate individual appointment. [source: Relias, "Inner workings"]
  2. Physicals SMA.
     • Half the group goes to exam rooms while the other half stays in the group room.
     • The physician examines each patient privately, without detailed discussion.
     • Meanwhile, the behaviorist collects concerns, reviews labs and handles refills.
     • Patients rotate between the rooms.
     • After about 45 minutes everyone reconvenes, and the physician manages each patient in turn in front of the group.
     • The behaviorist does not run a general discussion between patients in this phase. [source: Bronson & Maxwell]
  3. Sequence rule. Do the private exams before the group discussion. Cleveland Clinic found that when the group discussion came first, patients saved up their real concerns for private time. [source: Bronson & Maxwell]
• Example language (illustrative): "If something feels too personal for the group, write 'private' on your sheet. You'll see Dr. Kim alone before we finish."
• Watch for: a long queue for private time at the end. That suggests the group feels unsafe or the population is wrong. [synthesis]

B6. CHCC session agenda (cooperative model)

• Purpose: combine education, peer support and medical care in an ongoing cohort.
• Steps (GHC kit template; timings in minutes):
  1. Introductions and welcome (15).
  2. Topic of the day (30). The topic is chosen by the group the previous month.
  3. Break (15). The physician and nurse start at opposite ends of the horseshoe. They take blood pressures, address concerns, do refills and flag who needs a one-to-one visit.
  4. Questions and answers (15). Start with a prompt such as recent health news, and pass questions to the nurse where that fits.
  5. Planning and closing (15). The group picks next month's topic, ideas go on the flip chart, and the next date is announced.
  6. One-to-one visits (30), at about 10-minute intervals.
  7. Provider discretionary time (30).
  • "Group Visits 101" gives a slightly different split: a 30–40 minute break and 30–45 minutes of one-to-ones. [source: GHC kit; Houck, Kilo & Scott]
• Topic selection: choose from instructions you repeat often, the problem list, or patients' answers to the question of their biggest difficulty living with the illness. [source: Houck, Kilo & Scott]
• Example language (opening the Q&A, illustrative): "Has anyone seen anything in the news this month about blood pressure that they'd like to ask about?"
• Watch for: guest specialists lecturing. Brief them beforehand to keep it interactive. [source: GHC kit]

B7. Redirecting questions to the group (anti-lecture technique)

• Purpose: build patients' confidence and self-management, and stop clinicians lecturing.
• Steps:
  1. When a patient asks a clinical question, first ask the group: "Has anyone experienced this?" or "What worked for you?" [source: GHC kit]
  2. Acknowledge what patients contribute from their own experience. [source: Houck, Kilo & Scott]
  3. The clinician then adds or corrects briefly.
  4. Apply the roughly one-minute rule to any staff member talking about themselves. [source: GHC kit]
• Example language (illustrative): "Good question. Before Dr. Ruiz answers, has anyone here dealt with swollen ankles on this medicine?"
• Watch for: peers giving medically wrong advice. The clinician corrects it gently and immediately (see section 5). It is working when the clinician is talking less than the patients. [synthesis]

B8. Timekeeping and airtime management

• Purpose: make sure everyone is seen inside the 90 minutes.
• Steps:
  1. The behaviorist keeps time throughout. [source: Bronson & Maxwell; Cynkar]
  2. Gently quiet patients who talk too much. [source: Cynkar]
  3. Stop any one patient from dominating. [source: Bronson & Maxwell]
  4. Move extensive issues to a private appointment. [source: Relias, "Inner workings"]
  5. Keep a visible running order of who has been seen and who is still waiting, and tell the physician when the time per patient is running over. [synthesis]
• Example language (illustrative): "Bill, that's important and I want to do it justice. Let's book you time with the doctor this week, so that we can make sure Ana and Tom are seen today."
• Watch for: the session overrunning by more than a few minutes, week after week. That signals a staffing or census mismatch (see section 5).

B9. Referral and prescription follow-through; real-time documentation

• Purpose: make sure every patient leaves with their care completed, and keep the session efficient.
• Steps:
  1. Fill in referral forms during the session, with emphasis on follow-through. [source: Relias, "Inner workings"]
  2. The behaviorist checks that each patient's referrals, prescriptions and follow-ups have been arranged. [source: Bronson & Maxwell]
  3. Documentation:
     • A documenter records the findings, including what the physician says aloud during exams.
     • As groups mature, the behaviorist often takes over the documentation.
     • Templates speed things up. One DIGMA used a progress note that was mostly preprinted check-off items.
     • SOAP format is suggested. [source: Bronson & Maxwell; Relias, "Inner workings"; GHC kit; Houck, Kilo & Scott]
  4. Finish all documentation within the session. [source: Bronson & Maxwell]
  5. Billing (US) has no SMA-specific code. Each patient is billed as an individual E/M visit, supported by the documented care, and group time is not billed. The CHCC sources cite 99212 as the most common code. The behaviorist's time is not billed under the physician's code. Psychologists have been paid by salary or through the programme's overall cost. Billing rules vary by payer and region, so check them locally. [source: Bronson & Maxwell; GHC kit; Houck, Kilo & Scott; Cynkar; ACP] [uncertain: current US coding rules were not checked]
• Example language (illustrative): "Before you leave, Sandra, let's confirm your physio referral is in, and that you know your prescription is at the pharmacy."
• Watch for: the physician charting for an hour after the session, which makes the model inefficient. Add documentation support. [source: Bronson & Maxwell]

B10. Closing

• Purpose: consolidate learning and keep patients coming back.
• Steps:
  1. Give a clear summary. [source: GHC kit]
  2. Preview the next session and give its date. [source: GHC kit]
  3. In a CHCC, the group chooses the next topic. [source: GHC kit]
  4. In curriculum groups, end with goal check-out. The Alberta workbook sample ends sessions with a short goal-setting check-out, and IMGV session 9 has a closing ceremony with certificates. [source: Alberta workbook; Gardiner et al. 2017]
• Example language (illustrative): "Today we covered sleep, foot checks and two medication changes. Next month is the 12th, and you've picked stress and blood sugar as the topic. Please call if you can't make it."
• Watch for: patients leaving without knowing the next date. Confirm it.

B11. Team debrief and monthly planning

• Purpose: improve the sessions and catch any safety follow-ups.
• Steps:
  1. Debrief after the first session (what went well, what didn't), then review each month. [source: GHC kit]
  2. Hold a monthly team meeting to review the requested topics and plan the next session. [source: GHC kit]
  3. After each session, the nurse phones patients who need follow-up. [source: GHC kit]
  4. The behaviorist reports any psychosocial concerns to the physician and arranges behavioral-health follow-up. [synthesis]
• Example language (team, illustrative): "Who did we flag today who needs a call this week?"
• Watch for: the debrief being dropped once the group has "bedded in". [synthesis]

B12. Evaluation

• Purpose: show the programme's value and protect fidelity.
• Steps:
  1. Track outcomes agreed with leadership: patient and provider satisfaction, clinical standards (for example blood pressure or HbA1c targets set by the team), utilisation, census and access (backlog). [source: GHC kit; Bronson & Maxwell]
  2. Use pre- and post-assessments in curriculum groups. [source: Alberta workbook]
  3. Use a fidelity checklist at each session, as IMGV did. [source: Gardiner et al. 2017]
• Example language: not applicable.
• Watch for: measuring only satisfaction. Include a census or access measure. [synthesis]

Part C: Variant-specific procedures

C1. Integrative Medical Group Visit (IMGV) session sequence

• Purpose: combine medical group care with mindfulness and integrative self-care, for chronic pain with depressive symptoms in low-income, diverse primary care populations.
• Team: a prescribing clinician trained in integrative medicine, a co-facilitator trained in MBSR or yoga, and a group coordinator. [source: Gardiner et al. 2017]
• Steps (each session, per the protocol):
  1. Patients record their own weight, blood pressure and pulse under supervision.
  2. Patients complete an intake form covering pain, use of care since last time, home practice, smoking, medication changes and questions.
  3. A mindfulness centering exercise (awareness of breath).
  4. Group check-in.
  5. Review of home practice.
  6. Clinician-led discussion of chronic disease and pain management.
  7. The curriculum topic.
  8. An experiential activity, such as self-massage, acupressure, chair yoga, a body scan or loving-kindness meditation.
  9. Individual clinician time during and after the group, for refills, referrals, labs and primary care.
  10. A healthy meal, with informal time with the facilitators. [source: Gardiner et al. 2017]
• Curriculum (9 weeks plus 1 maintenance session).
  • Weeks 1–3: orientation, confidentiality and vitals tutorial; stress and the body; sleep and gratitude.
  • Weeks 4–6: healthy eating and pleasant events; the chronic pain cycle and non-drug options; inflammation.
  • Weeks 7–9: difficult communication and coping with depression; mindful eating; SMART goals.
  • Week 9 also covers a wellness review, resources and closing.
  • Session 10, 12 weeks later: new goals and a review of practices.
  • The protocol asks for about 20 minutes of home practice a day.
  • The mindfulness content is adapted from MBSR for literacy level and background. [source: Gardiner et al. 2017]
• Fidelity: facilitators had 3 days of initial training plus 3 one-day trainings, were observed and mentored, and had monthly calls. Safety protocols covered suicidal ideation and intimate partner violence. [source: Gardiner et al. 2017]
• Example language (centering, illustrative): "Let's take two minutes to arrive. Feel your feet on the floor, and just notice your breath coming and going."
• Watch for: patients for whom body-focused practices bring up trauma. Offer eyes-open options and the choice to opt out. [synthesis] Psychotherapists should only lead MBSR-derived content if they are trained in it. [synthesis]

C2. CenteringPregnancy: self-assessment and facilitative leadership

• Purpose: prenatal care delivered in a group, with the patient actively taking part.
• Steps:
  1. Form a group of 8–10 women at similar gestational ages after the first obstetric exam (usually 12–16 weeks).
  2. Run 10 sessions of 2 hours: every 4 weeks until 28 weeks, then every 2 weeks.
  3. Women take their own blood pressure and weight and work out their gestational age with a gestation wheel.
  4. Each woman has one-to-one time with the provider during the session. [source: Centering, "What we do"]
  5. Discussion is led by a facilitative leader and prompted by self-assessment sheets on topics such as nutrition, contraception, labour, birth and parenting.
  6. Provide snacks, and encourage women to swap contact details for peer support. [source: Klima 2009; Centering Healthcare Institute]
• Requirements: this is a proprietary curriculum. Every group leader must attend the Basic Facilitation Workshop. Site Approval assesses fidelity, and an Advanced Facilitation Workshop is recommended. The Essential Elements are taught in training but are not listed in the sources. [source: Centering Implementation Plan] [uncertain: the full list of Essential Elements]
• Example language (facilitator, illustrative): "Looking at your sheets, a lot of you circled sleep. Who wants to start us off?"
• Watch for: facilitators drifting back into didactic teaching. That is what the Advanced Facilitation Workshop is meant to address. [source: Centering Implementation Plan; inference]

C3. Psychiatric or medication-review drop-in groups

• Purpose: apply the DIGMA format to psychiatric medication follow-up.
• Source detail: at Cleveland Clinic, psychiatrist Lillian Gonsalves ran a weekly drop-in group of about 12 women with depression for nearly four years, mainly for prescription changes. [source: Cynkar 2007] One trade source explicitly excludes group psychiatry, behavioral medicine and support groups from its definition of an SMA. [source: Managed Care 2005] Procedures specific to psychiatric SMAs were not found. [uncertain]
• Steps (adapted from B1–B10) [synthesis]:
  1. Run brief standardised mood and side-effect check-ins on paper before the group, using whatever licensed measures your service already uses.
  2. The prescriber reviews each patient in turn. The behaviorist bridges to shared coping themes.
  3. Any patient who discloses suicidality or a crisis is seen privately the same day (see section 5).
• Example language (illustrative): "Several of you have mentioned the first weeks on a new medicine being the hardest. What helped you get through them?"
• Watch for: the group becoming a substitute for psychotherapy. Keep it a medication visit and refer for therapy. [synthesis]

C4. Virtual SMAs [synthesis]

• Purpose: deliver SMAs by video.
• Steps [synthesis]:
  1. Use a secure, organisation-approved platform.
  2. Get confidentiality agreements and virtual-care consent before the first session. The Alberta workbook notes that consent for email and virtual communication should be prepared. [source: Alberta workbook]
  3. Ask each participant to join from a private space and confirm who else is in the room.
  4. Agree that nobody records the session.
  5. Have a co-host handle technical problems and private breakout rooms for one-to-one time.
  6. Collect home vitals readings before the session.
• Example language (illustrative): "Before we start, please check nobody else can hear you, and let me know if you need a private room for part of today."
• Watch for: a family member listening in off camera; patients joining while driving or at work.

5. Handling problems

Problems marked [source] come from the sources. Responses marked [synthesis] are my own guidance. The GHC kit's appendix names several difficult participant types: too talkative, silent, "yes, but", argumentative, angry, know-it-all, chatterbox and superior observer. Its specific suggestions for each were not visible in the version opened, so the responses to those types below are synthesis. [uncertain]

Programme and team problems

• Low census. [source: Bronson & Maxwell; GHC kit; Houck, Kilo & Scott] A low census makes the model cost more than routine care.
  • Have the physician invite patients personally and give schedulers a script that offers the group at every booking.
  • Make reminder calls and invite family members.
  • Present the group as enhanced care.
  • Make sure the eligible pool is 50 or more.
  • [synthesis] Set a minimum census (for example 6–8 for a DIGMA). Below that, run individual visits that day rather than a thin group, and review recruitment that week.
• Physician lecturing; the session turning into a class. [source: Bronson & Maxwell; GHC kit; Houck, Kilo & Scott]
  • Pass questions back to the group.
  • Keep each encounter a real individual medical visit.
  • Apply the one-minute rule.
  • [synthesis] Agree a private signal in advance, for example the behaviorist saying "let's hear from the group on that".
• Overruns and documentation backlog. [source: Bronson & Maxwell] These come from too little support. Add a documenter, prepare charts beforehand and use templates.
• Losing staff. [source: Relias] One DIGMA was put on hold when staffing changed, and patients missed it. [synthesis] Train a back-up behaviorist and nurse, and avoid groups that depend on one person.
• Physician reluctance. [source: Managed Care 2005] Noffsinger argues the busiest physicians gain the most. One physician found he could talk to patients just as he did in the exam room. [synthesis] Let the reluctant physician observe a running DIGMA before starting one.
• Behaviorist access and payment. [source: Cynkar] Psychologists have had trouble getting access to physicians and can't bill the physician's E/M codes. One solution has been to build behaviorist fees into the programme's overall cost.
• Changing the format. [source: GHC kit] Changes may not reproduce the tested results. Debrief, and change one thing at a time.

Patient and group problems

• Privacy anxiety or reluctance to sign the waiver. [source: Bronson & Maxwell] Offer an individual visit. In physicals groups, do the private exams first. [synthesis] Tell patients they can share as little as they like, and that private time is always available.
• Concerns saved up for private time. [source: Bronson & Maxwell] Hold the private exams before the group discussion.
• A confidentiality breach (a participant repeats something outside the group). [synthesis]
  • Speak to the person privately and restate the agreement they signed.
  • Tell the affected patient and offer them individual care.
  • Follow your organisation's privacy-incident procedure.
  • Remind the whole group of the rule without naming anyone.
• Dominating or over-talkative patient. [source: Cynkar; Bronson & Maxwell] The behaviorist quiets them gently and keeps airtime balanced. [synthesis] Acknowledge what they've said, summarise it in one line and turn to someone else by name. If it keeps happening, speak to them privately at the break and offer an individual slot.
• Silent patient. [synthesis] Don't force them to speak. Make sure the physician still covers their written concerns, and ask a low-stakes question ("anything to add from your experience?").
• "Yes, but" or argumentative patient. [synthesis] Reflect the difficulty they're describing, stop offering solutions and ask the group for a range of experiences rather than advice. Take any medical disagreement up with the physician privately.
• Know-it-all, or a peer giving wrong advice. [synthesis] Thank them for contributing, and have the physician correct the content plainly without shaming. For example: "That works for some people. With your kidney function, Joe, it wouldn't be safe."
• Angry patient. [synthesis] Acknowledge the anger and name what lies behind it (waiting times, illness, losses). Offer private time. If it turns into personal attacks, see "abusive behaviour" below.
• Abusive behaviour. [source: GHC kit] Remind the group that it exists for mutual support, and set a rule against personal attacks. If the behaviour continues, ask the person to leave.
• Crying participant. [source: GHC kit] Offer tissues, say that it's okay and check in privately at the break or afterwards.
• Disclosure of suicidal thoughts. [source: GHC kit] Speak to the person privately, have a professional assess the risk and involve behavioural health services.
  • [synthesis] As the behaviorist, take the patient out of the group yourself while a colleague holds it.
  • Do a standard structured risk assessment and safety plan, including lethal-means counselling (safe storage or removal).
  • Arrange same-day follow-up and document it.
  • Back in the group, acknowledge briefly that someone needed support, without giving details.
  • IMGV had written protocols for suicidal ideation. [source: Gardiner et al. 2017]
• Patient in crisis or highly needy. [source: GHC kit] Limit how much session time they take, talk with them during the break and refer to social work or behavioural health.
• Disclosure of intimate partner violence. [source: Gardiner et al. 2017] IMGV had a written IPV protocol. [synthesis] Respond privately, never in the group. Assess safety and follow local reporting duties. Be aware that a partner may be attending as a "support person".
• Acute or fast-changing illness turning up at a DIGMA. [source: Relias] Move the patient to an individual or urgent visit.
• Hearing impairment, interpreter needs, cognitive impairment. [source: Bronson & Maxwell; GHC kit] These are usually exclusions. [synthesis] Consider same-language groups (as Centering does) or assistive listening devices rather than blanket exclusion.
• Non-attendance in cohort groups. [source: GHC kit] Set the norms: attend every session, be on time, call to cancel. Make reminder calls. A CHCC may add new members as the cohort shrinks. [synthesis] Phone anyone who misses two sessions running, to find out why.
• Home-practice non-adherence (IMGV-type groups). [synthesis] Review home practice without judgement at every session (part of the IMGV structure). Shrink the task to something the patient can actually do, and use peers' examples.
• Trauma reactions to body-focused or mindfulness practices. [synthesis] Offer choice, eyes-open options and grounding. Debrief privately.
• Rupture between the physician and the behaviorist (role confusion, contradicting each other in front of patients). [synthesis] Agree roles and signals before each session. Never correct each other in front of the group. Sort out differences in the debrief.
• The behaviorist drifting into group psychotherapy. [synthesis] Remember that the session's contract is medical care. Contain emotional material and offer a separate behavioural-health referral.

Sources

Sources:

• Bronson DL, Maxwell RA (2004). Shared medical appointments: increasing patient access without increasing physician hours. Cleveland Clinic Journal of Medicine 71(5):369
• Group Health Cooperative (2001). Group Visit Starter Kit (CHCC model; content from J. Scott, K. Lorig, C. Hawes), hosted by UMass Chan
• Houck S, Kilo C, Scott J. Group Visits 101 (from What Works; edited version in Family Practice Management, May 2003)
• Cynkar A (2007). Group doctoring. Monitor on Psychology 38(8)
• Relias Media: The inner workings of a DIGMA
• Relias Media: Bringing patients together can help them and you
• Managed Care (2005): Shared appointments
• American College of Physicians: Group Medical Visits (DIGMA and CHCC resources page; manuals restricted to members, not drawn on)
• Gardiner P et al. (2017). Design of the integrative medical group visits RCT. Contemporary Clinical Trials 54:25–35
• Klima C (2009). Group prenatal care: understanding the CenteringPregnancy approach. Contemporary OB/GYN
• Centering Healthcare Institute: Centering Implementation Plan
• Centering Healthcare Institute: What we do
• Alberta Medical Association: Workbook to implement group medical visits

Further reading (not drawn on) [uncertain]:

• Noffsinger EB (2009). Running Group Visits in Your Practice. New York: Springer.
• Noffsinger EB, ACP: DIGMA Orientation Manual (members only).

Further reading (not drawn on): the Health Quality Ontario group medical appointments manual. The link redirected to a 404 page.