Lifestyle Medicine Shared Medical Appointments

Abstract

Chronic diseases pose many challenges to health care providers and the health care system from a human capital, logistic, and financial perspective. To overcome these challenges, efficient and effective health care delivery models that address multiple chronic conditions need to be leveraged. Shared medical appointments are one potential solution to address these issues. This article offers a brief history of group visits and shared medical appointments and reviews the available data regarding their outcomes. It describes the benefits of using lifestyle medicine as the primary therapeutic modality within a shared medical appointment to treat, reverse, and prevent chronic disease. Key considerations and action steps for the implementation of lifestyle medicine shared medical appointments (LMSMAs) are outlined and the potential delivery of these services via telehealth is explored.

To achieve optimal health, patients require a team-based approach, sufficient time with providers, and education.”

The burden of chronic disease poses many challenges for health care providers, health systems, the economy, workplaces, and the public. Health care providers and systems regularly treat individuals who suffer from 1 or more chronic conditions. According to the Centers for Disease Control and Prevention, currently 6 in 10 Americans have at least 1 chronic disease and 4 in 10 have 2 or more. ¹

The preponderance of patients afflicted by chronic disease relative to the number of health care providers creates challenges for delivering care. Some evidence suggests that one-on-one interactions may be less effective clinically and financially. ² The time and resources required to deliver comprehensive care to each chronic disease patient requires a model focused on the efficient use of time and collaboration among professionals from different medical specialties. To achieve optimal health, patients require a team-based approach, sufficient time with providers, and education about how they can take control of their own health outcomes. Shared medical appointments (SMAs) address these issues and have been shown to be effective in the treatment of chronic diseases. ³

A SMA occurs when multiple patients are seen in a group setting for the management or treatment of a shared medical condition. Group visits provide an interactive, secure environment in which patients have access not only to a provider but also to an entire health care team devoted to helping them achieve optimal well-being. ⁴

Team-based health care delivered in a group setting, such as a SMA, is associated with improved patient clinical outcomes, increased patient satisfaction and trust, increased self-efficacy, improved resource and time efficiency, increased revenue, as well as less stress and greater satisfaction for the health care provider. ⁵

Treating chronic disease using the current model of health care has resulted largely in the management of illness rather than the restoration of health. Unlike traditional care management approaches, lifestyle medicine (LM) addresses the root cause of chronic disease using one or more of the following interventions: a predominantly whole food plant-based diet, regular physical activity, stress management techniques, strong social connections, risky substance limitation or elimination, and improved sleep. Research has demonstrated that LM approaches are effective for the treatment, reversal, and prevention of several chronic diseases including type 2 diabetes,^6,7 cardiovascular disease,^8-10 cancer, ¹¹ and obesity. ¹²

Delivering LM in group settings has been shown to be financially viable and effective in addressing chronic disease.^13-15 The term lifestyle-based group visits has been previously used to describe this model. ¹⁶ To emphasize lifestyle being used as medicine, increase awareness of LM as a medical specialty, and to highlight the shared experience of participants, the authors propose that this type of visit be referred to as a Lifestyle Medicine Shared Medical Appointment (LMSMA).

The authors of this article believe that LMSMAs are a model of health care that can address the challenges posed by chronic disease by (a) treating the root cause of chronic disease, (b) employing an efficient and effective multidisciplinary team–based approach, and (c) increasing patient self-efficacy for behavior change in a group setting. This approach is also amenable to being delivered via telehealth, offering safe, affordable, and convenient access to patients everywhere.

History of SMAs

Medical group visits or SMAs first appeared in the literature in the 1970s. They were conducted in large health care organizations such as the Cleveland Clinic and Kaiser Permanente and were originally a model for well-child visits. ¹⁷

The Cooperative Health Care Clinic (CHCC) and the Drop-in Group Medical Appointment (DIGMA) became 2 major types of group visit models. The CHCC focused on high-risk patients of all ages with similar chronic conditions. The DIGMA focused on a physician’s entire patient panel. ¹⁸ By the early 1990s, group medical visits were leveraged to assist general medicine patients in the care of their chronic illnesses. ¹⁹

Despite their early creation and positive outcomes, SMAs have been relatively slow to be fully embraced by health care providers and health care systems. It is unclear why adoption has been limited, particularly since organizations such as the American Academy of Family Physicians (AAFP) have stated that group visits are “a proven, effective method for enhancing a patient’s self-care of chronic conditions, increasing patient satisfaction, and improving outcomes.” ⁴

Benefits of LMSMAs for the individual

For individual patients, LMSMAs are an excellent way to form a supportive community focused on the treatment, reversal, and prevention of chronic lifestyle behavior-related health problems.

Published benefits of a SMA include:

• More time available for patients with the provider

• Patients share self-management tips and tricks

• Improved access to care

• Nonpharmacologic treatment

• Improved quality of care

• Decreased emergency room visits ¹⁴

Perhaps the largest benefit to SMAs is their documented ability to improve patient self-management of their chronic disease. Two reviews found that the SMA model improved older individuals’ involvement in their primary health care, and that group visits based on empowerment, participation, and adult learning had proven benefits in enhancing self-management and improving clinical outcomes in individuals with diabetes. They also showed improved blood pressure, weight management, and hyperlipidemia. ¹⁴

Advantages for the Physician and Other Care Team Members

A 2019 report found that increasing time demands over the past several decades have led to physicians spending less time with each patient in order to maintain a similar level of productivity. The average primary care visit typically lasts between 17 and 24 minutes. ²⁰ However, the amount of time required to manage chronic diseases using current guidelines is estimated to be much higher than that. ²¹ Because the LMSMA is typically one extended visit with multiple patients, it can offer increased resource efficiency, decreased risk of physician burnout, and increased revenue. ⁴

From a patient education perspective, rather than having to repeatedly explain chronic disease concepts to individual patients, providers can deliver it once for all the group’s patients to hear. Group visits have the added luxury of allowing patients to teach one another self-care and disease management tips and tricks. This social connection helps create an additional support network for patients to begin and sustain behavior change.

LMSMA Structure and Logistics

The health care team for a LMSMA typically consists of 2 to 4 health professionals. The session is generally led by a physician, physician assistant (PA), or an advanced practice registered nurse (APRN). A second facilitator, typically another ancillary staff member, is needed to help when the provider is examining patients individually. A nurse can gather biometric data and draw labs. Last, an administrator or coordinator helps arrange the session, take notes, check patients in, and set up future visits. Ancillary team members such as behavioral therapists, dietitians, health coaches, medical residents, medical assistants, nurses, pharmacists, physical therapists, researchers, social workers, and students can also be utilized. ¹⁷

SMAs are usually conducted over a 2-hour period. ²² It is important to note that each SMA requires private time for each patient with the provider. During this time, the patient will have the opportunity to discuss issues they may not feel comfortable discussing in the group format. It also gives the provider time to: do a focused physical examination; review previous test results, biometrics, goals and progress; prescribe medication; and order future lab work and other tests.

Although a SMA can be performed with any number of patients, it is recommended to have at least 10 to 12 participants for efficiency, patient participation, ¹⁹ and to ensure financial viability.

The SMA is typically held in a room large enough to be comfortable for the anticipated number of patients. When identifying where to conduct the LMSMA, the Health Insurance Portability and Accountability Act (HIPAA) standards require that a space have an associated National Provider Identifier (NPI) number. An NPI number is only granted to a physical location that has the provider or practice name affixed to the outside of the building. A provider cannot currently bill Medicare for any patient encounters taking place at a location without their NPI number. ²³ Although the COVID-19 (coronavirus disease 2019) public health emergency temporarily waived this rule for providers rendering telehealth services to Medicare patients, there is no clarity regarding long-term waivers at this time.

Patient participation in SMAs largely hinges on a good marketing strategy. Channels to market SMAs might include traditional print materials, newspaper ads, as well as social media, email, and television and radio ads. Although not studied, the use of a screening process to determine if patients are appropriate candidates based on their medical conditions, needs, and stage of change may help minimize no-shows, improve clinical outcomes, and increase revenue for the clinic. Established patients needing more time, support, and education for their chronic conditions are good candidates. Being very clear in marketing messages about what patients can expect out of a group visit can help ensure success and ease any concerns.

Data Collection for LMSMAs

The main goal of health care should be to improve the lives of the population served. Having measurable outcomes to demonstrate improvement is essential for future success. Relevant data to collect and report include:

• Clinical outcomes

• Financial data

• Patient satisfaction

• Physician and team satisfaction

• Office efficiency

• Health care utilization

An example of SMA finances can be seen in Figure 1.

Figure 1.

Real-World Example of Financial Success.

Documenting the SMA Visit

SMAs should be documented in each participating patient’s medical record. Each patient in the SMA is an individual and the medical record should reflect the individualized care provided. Some details of a SMA are consistent across all participants in the group visit and may be added to a template, but the emphasis must be on specifying what the physician and health care team did for each individual patient. Figure 2 provides a sample of SMA documentation.

Figure 2.

Lifestyle Medicine Shared Medical Appointment (LMSMA) Patient Medical Record Example.

Coding and Billing for LMSMAs

A review of the literature regarding SMA billing revealed that the most common billing method for SMAs was using standard individual Evaluation and Management (E&M) codes. Billing Current Procedural Terminology (CPT) codes 99212-99214 was the most popular method. ¹⁷ The code selected should be based on the individual visit complexity. While Medicare has not issued payment codes for SMAs, its response to billing queries was “a physician could furnish a medically necessary face-to-face E&M visit that is observed by other patients.” ¹⁷ The AAFP states that physicians who provide and document group appointments should code for the services provided using applicable, existing E&M codes found in the CPT guidelines. They also state that “third party payers should cover and pay for submitted E/M services for shared medical appointments.” ⁴

To maximize payment for services delivered during LMSMAs, behaviorists such as dietitians, nurses, diabetes educators, and psychologists can bill under their own NPI number using codes such as group Medical Nutrition Therapy (97804), Intensive Behavioral Therapy for Obesity (G0447), Behavioral Therapy for Cardiovascular Disease (G0446), Health and Behavior Assessment and Intervention (96164), or Diabetes Self-Management Training (G0109). Working with a billing and coding expert can optimize reimbursement and, ultimately, financial viability of a practice. ¹⁶

Delivering LMSMAs in a Virtual World

The COVID-19 pandemic led to an expedited utilization and acceptance of telehealth encounters. While virtual SMAs alter the typical in-person group dynamics, there are positive aspects of virtual appointments. Virtual SMAs require minimal physical space and create an opportunity for greater scheduling flexibility. They eliminate travel time, making it convenient for individuals to get to their appointments. Virtual SMAs offer new opportunities for nutrition education and culinary skill teaching, as well as involvement of other family members by taking place in a patient’s home.

Routine care for physical or mental chronic diseases, feasible through virtual SMAs, may help prevent future clinical events that require hospitalization. ²⁴ Leveraging virtual SMAs has the potential to enhance provider capacity and improve clinical outcomes, while mitigating virus transmission risks and protecting patient privacy.

Conclusion

Both the SMA method of delivering health care and the application of LM are well suited for the treatment, reversal, and prevention of chronic diseases. LMSMAs have the potential to dramatically reduce the burden of chronic disease by improving access to care, reducing cost to patients and hospitals, and improving clinical outcomes. Further data regarding ideal structure, design, and reimbursement will enable further expansion of LMSMAs. While more research is needed to evaluate the efficacy of offering SMAs remotely, they could play a major role in chronic disease care.