Virtual Group Visits: Hope for Improving Chronic Disease Management in Primary Care During and After the COVID-19 Pandemic

Introduction

One of the greatest frustrations for primary care physicians is quickly progressing through a busy clinic schedule and spending only 15 minutes with a patient who clearly needs more time, attention, and care. Ms. B was one of those patients. She was an independent, elderly African American woman who lived with many of the chronic conditions that disproportionately impact patients with low socioeconomic status, including obesity, diabetes, hypertension, and coronary artery disease. Ms. B was socially isolated, spending most of her day alone at home watching TV to distract her from the stressors of life. Over the years, she had been compliant with her medications, even as they were adjusted up and down, but she struggled to make meaningful changes in her diet and physical activity level between her clinic visits every 6 or 12 months. In 2020, after she expressed frustration with the rising number of medications in her pill box, she agreed to log in to her primary care practice’s online (i.e. virtual) group visit program focused on healthy lifestyle changes.

Virtual Group Visits (VGVs)

Virtual group visits (VGVs) are a promising new model of care delivery for improving chronic disease management in primary care. ^1,2 Although VGVs are nascent in development, in-person group visits, also called Shared Medical Appointments (SMAs), have become increasingly popular over the past 2 decades. ³ Group visits are run by health care providers and include multiple patients who are seen at the same time in the same place. In contrast to the typical 15-minute primary care visit, group visits generally last 60-120 minutes and thus allow for ample time dedicated to education and peer support in addition to individual care. There is evidence that group visits focused on patient education and lifestyle change improve outcomes for some of the most burdensome and expensive chronic diseases, including hypertension ⁴ and diabetes. ⁵ Importantly, group visits can be billed to insurance, usually as low-level complexity medical visits. Despite early successes of SMAs, however, group visits have been limited in uptake in most health care systems. This is likely due to multiple factors, including a lack of evidence for cost-effectiveness and generalizability to different settings and populations; difficulty implementing programs in busy practices; and regulatory challenges involving consent, confidentiality, and billing. ³

CORE Health: A Primary Care Model for VGV Integration

The COVID-19 pandemic has forced rapid innovations in ambulatory care delivery. This includes group visit programs that previously relied on in-clinic appointments. ⁶ As a result, VGV programs have emerged as a viable alternative care delivery model for safely and effectively managing chronic diseases via telemedicine. One such example is the Massachusetts General Hospital (MGH) Center for Organized Research and Education for Health (CORE Health), which was established in 2012 to provide group visits at the MGH Revere Healthcare Center to patients such as Ms. B. Before the COVID-19 pandemic, CORE Health patients came into the clinic for SMAs focused on healthy lifestyle changes to improve chronic conditions such as obesity, hypertension, diabetes, and psychological stress. These in-person group visits were suspended from March to May 2020 due to the pandemic, but in June 2020, all programming was transitioned to a video platform to allow patients to continue to access and benefit from the group visits while the clinic was effectively shut down for non-essential patient care. Within weeks, the workflow shifted to accommodate virtual waiting rooms and group conversations over video. Patients are now able to sign up for and attend these groups from their own homes, mitigating pre-COVID-19 logistical challenges, such as lack of transportation or time, as well as reducing COVID-19-related barriers, such as infection risk. Beginning in April 2020, patients are able to stay motivated between VGVs by communicating with a health and wellness coach (HWC) by telephone or video. Patients have also been able to participate in free virtual exercise classes, beginning in September 2020, that help them stay physically active and engaged in the programming.

Although the health center clinicians and staff were initially concerned about how patients would respond to the quick transition to VGVs, many, including the patient Ms. B, embraced the change. CORE Health VGV volume has continued to increase after switching to VGVs following the start of the pandemic, and HWC volume has been steady in the virtual setting (Figure 1). In the most recent quarter, there were 68 patients who participated in at least one VGV, 46 patients engaging with the HWC, and 16 patients participating in virtual exercise classes. The VGV volume increase likely reflects enhanced patient engagement as a result of initiating HWC visits just after the COVID-19 pandemic began as well as improved patient outreach efforts by the CORE Health team. Patient feedback demonstrates support for the virtual group visits, with similarly positive reviews relative to feedback from in-clinic groups (Figure 2). Moreover, several patients are enthusiastically active in all 3 offerings, including Ms. B. The experience in CORE Health suggests that VGVs can be established in health systems that have accelerated the use of telemedicine in primary care as a result of the COVID-19 pandemic.

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Figure 1.

CORE Health Patient Volume. Quarterly totals represent the number of patient encounters for virtual group visits (VGV), with the health and wellness coach (HWC), and for exercise classes (Exercise). CORE Health group visits in clinic were paused in March 2020 and restarted as VGVs in June 2020, HWC visits began in April 2020, and virtual exercise classes began in September 2020.

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Figure 2.

CORE Health Patient Feedback. Patients completed feedback forms after CORE Health visits in clinic and after virtual groups. Means were calculated for Likert scales responses for each question (1 = strongly disagree; 5 = strongly agree).

Next Steps to Establish VGVs as Standard of Care

Beyond the success of the CORE Health program, there are gaps that need to be addressed before VGVs can become a standard in primary care. Most importantly, although preliminary studies have suggested improved chronic disease outcomes, more evidence is needed to demonstrate the effectiveness of VGVs for improving health. A pilot study of VGVs delivered by the Honolulu Veteran Affairs Medical Center to 31 patients in Guam with poorly controlled diabetes demonstrated improved A1C control, ⁷ and a retrospective study of 22 patients at Cleveland Clinic showed weight loss in an obesity-focused VGV program. ⁸ Research to determine the impact of VGVs on vulnerable populations should be prioritized. Patients from these populations, which include patients with limited English proficiency, elderly patients, and patients with low health literacy, potentially stand to benefit the most from this innovation given disproportionately high rates of lifestyle-dependent chronic diseases and barriers to care. ⁹

Another gap is the need for establishing VGV best practices that will enable efficient and effective scaling of VGVs in primary care. Rapid implementation with research and quality improvement evaluation will help to identify ideal opportunities for incorporating VGVs into care delivery. For example, practices might develop and test curricula for multi-session series that focus on patient education and remote patient monitoring to improve specific chronic disease (e.g. diabetes or hypertension) management. Alternatively, some patients might benefit most from “drop in” VGVs highlighting self-management techniques for stress and anxiety reduction or sleeping difficulties. It will also be important to identify optimal ways to incorporate all members of the healthcare team to engage patients and keep them motivated to maintain lifestyle changes, including nurses, HWCs, and community health workers.

Finally, it will be important to create sustainable financial models of VGV care delivery for health systems and primary care practices. In a strictly fee-for-service environment, VGVs can produce a net-positive impact on revenue due to the ability to see multiple patients at once. Moreover, with the global transition to risk-based contracts, VGVs will likely become increasingly attractive to payors and providers if research demonstrates improvements in chronic disease prevention and care. Additionally, research examining cost effectiveness will help identify beneficial programs that utilize VGVs to increase the value of care.

VGV Challenges

Multiple challenges will require close attention as VGVs are studied and implemented in the years to come. Primarily, limited technology access and low health literacy could hamper VGV participation by patients from vulnerable populations and thus contribute to widening health inequities. Therefore, the adoption of VGVs must be part of broader health system strategies that facilitate equitable use of technology for all patients. In the future, VGVs could help reduce some of the important drivers of such disparities, including transportation barriers, time constraints, competing priorities during individual visits, and health concerns associated with in-person visits (e.g. COVID-19 or influenza exposure). Another potential challenge of VGVs is that the benefits of in-person group visits might be hard to replicate in virtual settings, due in part to less perceived patient accountability. To mitigate this risk, additional modifications, such as smaller group sizes, shorter group visit time slots, and remote patient monitoring of blood pressure or blood glucose, could be integrated. Ultimately, when COVID-19 risk is acceptably low, offering in-person group visits alongside VGVs, and developing workflows to optimize the pairing of patients with the setting that works best for individual health needs, will likely be the best strategy.

Conclusions

During the first months of her group visit journey, Ms. B regularly participated in multi-session VGV series on obesity and hypertension in CORE Health. She had regular check-ins with the HWC and started exercising daily at home, eating more fruits and vegetables, and connecting with friends and family for positive social support. She lost weight, lowered her blood pressure, and stopped using a cane for balance. VGV-based programming enhanced her access to primary care services during the COVID-19 pandemic and has provided her with the tools and support necessary to make sustainable healthy lifestyle changes.

VGVs offer a unique opportunity to prevent and improve lifestyle-dependent chronic diseases that require more than just infrequent medication modifications at primary care visits. Widespread adoption of VGVs and other virtual services, such as HWC visits and exercise classes, could supplement traditional primary care delivery to help patients improve lifestyle factors that are difficult to adequately address during a 15-minute clinic visit. Utilization of VGVs in primary care could be particularly impactful amidst the transition to virtual care during and after the COVID-19 pandemic. With additional research and focus on implementation, VGVs have the potential to become a powerful asset in the telemedicine-based primary care of the future.