The idea of group visits is not new.  This model has been used successfully by psychologists and therapists for a variety of issues for group therapy and patient education. The first paper using the group model in pediatrics was published in 1977 by my mentor, Dr. Martin Stein, who used groups for mother-infant care. Another set of papers were published by Dr. Lucy Osborn in the 1980s examining its use for well child care and patient education.

In 2005, I was given the opportunity to see parenting groups in action. The group dynamic is powerful. I was able to watch skilled facilitators work with a group of parents who were strangers at first but became a support system to each other over time. Those bonds usually lasted beyond the groups. I was also able to see the methods used to engage participants so they felt the group a safe place for idea exchange, a place to come and learn from each other and even role play parenting techniques. I quickly became a believer. However, its use in pediatrics has remained limited for several reasons. Outpatient primary care pediatrics is high volume and busy. Visits are brief.  Scheduling changes and space considerations and yes, at the end of the day, how would we get reimbursed for these visits?  These issues must be addressed as clinics consider implementing group visits.

One of the things we have learned about designing and implementing group visits for ADHD is that there are common logistical elements to think through before starting:

1. Identify a champion who can help create enthusiasm and buy-in from within the clinic. This is the essential step. While having a champion is important, it is how the champion can mobilize everyone in the clinic to work together. Even the champion  needs a team to support the efforts. This includes front and back office staff, the clinic manager, nurses and other providers.
2. Identify physical space for groups. In our group model we chose to run two groups at the same time–one for parents & a separate one for children. This allowed for appropriate knowledge and skills regarding ADHD chronic care for participants. We also wanted a space large enough to allow parents to invite another caregiver or partner, as well as the faciltator.
3. Determine the frequency of groups.  In our model we chose to offer a new session every 3 months so to coincide with the need for families to come back to the clinic for stimulant prescriptions.  However, we learned from parents that the motivation to come to the groups for the support was more important. Parents were willing to come back every month just for the group. Groups used for parenting support is usually offered weekly; whereas groups for well child visits are overlaid upon the periodicity schedule for health supervision.
4. Determine the ideal time for groups. In one clinic we offered these appointments consistently at 4:30-5:30pm so to not interfere with school. Another clinic offered it over the lunch hour. In the end, families appreciated the appointments after school for convenience.  It was not uncommon for families to get push back from schools for lunch time group visits since families ended up keeping their children out the entire school day.
5. Determine a tracking system for families who no-show. Sometimes families just cannot get to the clinic on the day and time the group visit appointments are. Make sure you think through how you will track families who no-show so you can make arrangements for them to follow up. Clinics with electronic medical records could flag group visit appointment days and used a particular group visit template for documentation.
6. Map out the workflow and assign roles. Consider walking through the process from the family perspective from check-in through check out. This is especially important if the groups are held in a separate space from the clinical exam rooms (for example, a separate conference room).  When will children’s vitals be taken? Take into account if families are being asked to move from one area of the clinic to another. If it makes sense for the medical assistant or nurse to bring scripts to the group after being printed or if you can keep patients in the group space for the duration of the group visit vs. moving families back into individual exam rooms once the group portion ends.
7. Reminder calls. In our clinics, these were done twice for each visit. In one clinic, one front desk person’s role was to call the day before and the day of; in another clinic, there were automated reminder calls but a few days before a “live” person called the families.
8. Consider scheduling group visits on a regular basis or at least 6 to 12 months in advance. Families appreciated knowing that the groups were always going to be offered once a month on the 3rd Wednesday of the month. This makes it easier for families and clinic staff. It also makes it easier for parents to plan in advance and take the time off of work or arrange for transportation.
9. Consider snacks. The children routinely mentioned the snacks were a perk! After school time can be challenging so we offered easy grab and go snacks like granola bars and pretzels.
10. Have a team huddle the day of a group visit to review expectations and go over logistics.  This is key if the group visits were only 1 or 2 days per month. It was a helpful reminder to all about the logistics of the group visits and allowed for team members to plan ahead.

This was our TOP 10 list of ‘nuts and bolts’ our teams found helpful before implementation of group visits on a system-level. The details will depend on each clinic’s workflow, personnel and populations served. Our curriculum and billing information will be shared in the coming posts.