Ever waited an hour for a 15-minute check-up? If so, dropping by for an uninterrupted hour-and-a-half of physician consultation, prescription-filling and behavioral-health consultation might sound too good to be true. But that's exactly how some patients see their doctors these days, and the benefits to patients and physicians-prompt access to care, more provider time, increased productivity and support from other patients integrated into the health-care experience-are catching on, says health psychologist Edward B. Noffsinger, PhD, who developed two popular shared medical appointment models-"Drop-in Group Medical Appointments" and "Physicals Shared Medical Appointments." These physician-led sessions include supporting roles for psychologists, nurses, a shared medical appointment scheduler and a documentation specialist, who helps the doctor complete charts and fill prescriptions, all working together, he says.
But despite the growing appeal of group medical appointments, especially among large and mid-size medical systems, psychologists have been slow to enlist, says Noffsinger, former director of clinical access improvement at the Palo Alto Medical Foundation.
"By having a trained psychologist in the room, patients receive better care because physicians can do a much better job in diagnosing and treating depression, anxiety, substance abuse and other conditions that are notoriously underdiagnosed and undertreated in the primary-care setting," Noffsinger says. "But psychologists have been among the last to step forward to occupy the behaviorist role."
The reason for this, some psychologists say, may not be for lack of interest, but lack of access to physicians. Without the support of a large integrated behavioral health department, most medical centers may run into structural and payment issues in setting up psychologists' participation in shared medical appointments, says clinical psychologist Paul Schoenfeld, PhD, director of behavioral health at The Everett Clinic, a medical group system in the state of Washington.
"I just don't know that psychologists have found a great way to get these set up with doctors," he says.
However, change may be in the air, Schoenfeld adds.
One-stop health care
Attendees of a traditional drop-in medical appointment, which were introduced in 1996, generally have a 90-minute time in which 10 to 16 patients see their own physician. Although they are occasionally used for new patient intakes, these appointments are best designed for follow-up visits, says Noffsinger, and doctors ensure confidentiality by asking patients to sign releases that bar them from sharing other patients' medical information.
In 2001, the introduction of Physicals Shared Medical Appointments, often segregated by sex and age, allowed physicians to complete private exams on about eight patients before the group comes together to discuss symptoms, address health concerns and discuss treatment options.
"The intent is to max-pack visits to provide patients with as much medical care as we can fit into a single visit, and make it a one-stop health-care shopping experience," he notes.
Surveys from Cleveland Clinic, a multi-specialty group medical practice in Cleveland that began running shared medical appointments in 2002, confirm the model's success, says Richard A. Maxwell, MD, director of the clinic's shared medical appointments project. According to a 2005 patient visit satisfaction survey, 85 percent of patients seen in group medical appointments opted for another shared visit, and almost 75 percent marked "excellent" for overall visit satisfaction. However, shared appointments aren't for everyone, including those who can't maintain confidentiality, the hearing impaired, and patients who require an interpreter, says Maxwell.
Cleveland Clinic uses shared appointments with patients across a range of medical specialties, including diabetes, bariatric surgery-even chronic headaches. In addition, one of the clinic's psychiatrists takes advantage of the drop-in model for medication management. Lillian Gonsalves, MD, meets weekly with approximately 12 female clients diagnosed with depression to discuss their medications' effectiveness and side effects, as well as new research trends related to the disorder. She's been running shared appointments for nearly four years and uses the setting mainly to refill or change client prescriptions, she says.
"My clients love having the opportunity to exchange information with other patients and learn about new coping methods and new medications," she says.
Psychologists, with their advanced training in managing group dynamics and identifying and addressing psychosocial disorders, bring skills to a shared medical appointment that many physicians lack, says Noffsinger. Typical roles include explaining how a shared appointment works, keeping the session running smoothly and on time, quieting overly talkative participants and temporarily taking over the group when the physician is documenting a chart note or steps out of the room for a private discussion or exam. Psychologists can also spot psychosocial and emotional issues-which often accompany chronic illness-that may not be noticed by a physician, says Noffsinger.
"The behaviorist fosters interaction between patients and gets them to help each other," he says. "It's a natural fit for psychologists."
So why hasn't this role caught on?
For one thing, in a shared medical appointment, psychologists cannot bill through traditional evaluation and management codes, says Maxwell. Therefore, a medical practice must arrange alternative payment for a psychologist-often in the form of a regular salary. Payment arrangements can also be made through the physician and medical group, but that's often time-consuming and paperwork-intensive, says Schoenfeld, who has run the Everett Clinic's shared medical program since 2004. To solve that problem, Schoenfeld's group works closely with the medical practice to run shared medical appointments, and the fees associated with the psychologists' time are rolled into the cost of running the program. But even large medical systems may have a tough time getting psychologists into a shared medical appointment program if the system does not have an integrated behavioral health department, he says.
"These groups are really a value-added service for our patients," Schoenfeld says. "But until we have a national health policy incorporating behavioral health into medical care, [bringing psychologists and physicians together] is a tough thing to make happen."
- Noffsinger, E. (in press). Running Group Visits in Your Practice. New York: Springer.
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