Can Group Power Mean Less Pain?

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1 We need your feedback on this article. To share your comments, see instructions at the end. Can Group Power Mean Less Pain? By Jackie F. Webb, R.N., M.S.N. & Kim Dupree Jones, Ph.D. Tired of hearing the same feedback from your health care provider during traditional one-on-one, patient-provider, medical office visits? Alternative health care delivery models such as group care can address many of the challenges encountered by patients and their health care providers when managing conditions such as fibromyalgia (FM). Traditional care is usually problem-focused and too often leaves very little time for the patient s psychosocial needs, patient education, and patient empowerment which are central to group care visits. The concept of group care is not new. Group models of care have been practiced in primary care settings since the 1980s when they were first introduced by health psychologist, Dr. Edward Noffsinger. 1,2 Group care is successfully being used in primary care settings to manage various chronic conditions such as diabetes, hypertension, asthma, obesity, and chronic pain. 3-7 Group care involves a series of patient encounters over time ranging from just two to four sessions to monthly meetings. These sessions take place in group settings involving four to ten patients at a time with one provider, a nurse, and sometimes other health professionals, such as pharmacists, psychologists and dieticians. 1,5,8 A group visit appointment can last from minutes which allows each patient much more time with the provider than the traditional one patient/one provider model. 1,2 Group care sessions are different from support groups or self-help groups. The focus of group care is to discuss health care issues related to the condition as well as to evaluate and educate. Patients will have various health care indexes evaluated such as their functional status, pain levels, blood pressure, pulse, and weight. Important health information such as laboratory results may be reviewed. Support groups do not have access to this type of information. Having a medical provider involved is central to group care visits. Shared learning is another feature of group care. Group members discuss their concerns, what works well for them, and ask questions. In essence, patients determine the focus topics that need to be discussed. Educational groups usually have a set of topics that are discussed by group leaders. These topics are usually not set by the patients but by the persons involved in the teaching. Chronic pain management is challenging, requiring providers to make appropriate assessment and diagnosis as well as active collaborative treatment plans, while keeping up to date with various policies and research involving pharmacological and non-pharmacological management strategies. Despite advances in various management modalities, people with FM are often dissatisfied with treatment processes and outcomes. 9 Various studies over the years have suggested that providers managing patients with chronic pain concerns should focus on patient-centered approaches. 9 A national survey found that primary care providers manage approximately 52% of chronic pain patients. The survey also found there are substantial variations and attitudes and best practice approaches to chronic pain. 10 The majority of patients with FM will receive care from a primary care provider. Group care has been successfully initiated in various primary care settings. Advantages To Group Care Group care can address many of the challenges encountered by health care providers when managing patients with chronic conditions. These challenges include access to timely appointments; the ability to manage the whole patient including the emotional, behavioral, psychological, and lifestyle factors; providing ongoing support and education; Copyright 2015, National Fibromyalgia Partnership, Inc. (NFP). 3

2 partnerships between the patient and the clinician; as well as satisfaction for the clinician and economic feasibility. 2,11 The Cleveland Clinic Foundation (CCF) has been incorporating the group care visit model in their health system since 2002 and has been evaluating its effect on patient outcomes and provider satisfaction. The CCF conducts group care for their patients experiencing diabetes, Parkinson s disease, gastric bypass, gender-specific annual physical examinations, depression, medical weight loss, asthma, gynecology, and women s health. 12 CCF providers published their findings after evaluating 855 group visits with over 6,295 patients and 26 physicians who are involved with group care. 12 Researchers found patients rated satisfaction with their physicians at 74.67% compared with traditional care physicians who were rated at 59.17% by their patients using the American Medical Group Association satisfaction survey. CCF researchers also found that across the various clinics involved with group visits physician productivity improved by as much as 20% per month and reduced patient appointment backlog. These results differ from systematic literature reviews that found most studies of group care did not significantly demonstrate cost savings due to few longterm studies, lack of procedural code for billing, and lack of clarity of what is best group care practice. 13 Once patients chose to be associated with group care at CCF clinics, they continued to want to associate with group care and had high rates of rescheduling of roughly 85%. Group care patients reported feeling more relaxed and were willing to share personal information because they were able to hear other patients share similar experiences and concerns. 12 This is consistent with a cross-sectional survey of 321 adults done to determine the proportion and characteristics of patients willing to attend group medical visits, which found 80% of respondents were willing to participate. 7 One of the many goals of group care is to promote patient activation which may influence adoption of self-management measures. Primary care providers often do not feel capable of supporting patient self-management and the delivery of problem-solving therapy or cognitive-behavioral therapies because of limited experience and available resources A randomized, controlled trial of 1,337 patients aged 19 to 69 years who self-reported at least one month s duration of pain at a level of three or more on a five-point scale, studied the effects of a telephone-based, nurse educator intervention that provided basic pain self-management skills and problem-solving therapy. 14 When compared to their control groups, researchers found patients in their intervention groups at their six-month assessment had improvement in the self-reported pain scores, had less decline in their Functional Interference Estimate scores, and fewer number of days in the hospital compared with patients receiving usual care. 14 The researchers of this study based their utilization data on self-reporting information which raises concerns of the studies validity and accuracy. However, even with these limitations, this study suggests patients with chronic pain respond to the opportunity to learn self-management skills and learn how to problem-solve therapy issues. What Skills Can Improve With Group Care? Providing self-management skills is a central tenet of group care. Wilkinson & Whitehead defined selfmanagement as the ability of the individual with the assistance of family, community, and healthcare professionals to manage the symptoms, treatments, lifestyle changes, and psychosocial, cultural, and even spiritual consequences of chronic diseases. 17 When addressing the complex needs of patients with chronic conditions such as chronic pain, it is important for providers to understand four concepts of self-management that provide clarity, direction and specificity when attempting to address the various goals associated with self-management skill building. 18 The four concepts of selfmanagement, developed by Richard and Shea, include: (1) self-care, (2) self-monitoring, (3) symptom management, and (4) self-efficacy. These can help providers coordinate better pain management for their patients. Understanding the concept of selfmanagement can allow providers to not only target specific interventions but also provide individualized care which ultimately can improve patient outcomes Copyright 2015, National Fibromyalgia Partnership, Inc. (NFP).

3 (1) Self-Care Can Improve. Self-care has been defined in the literature as activities in which individuals often are involved to achieve, maintain, or promote maximum health. 18,19 Richard and Shea define self-care as a broad concept referring to individual responsibilities for healthy life-style behaviors required for human development and functioning, as well as those activities required to manage acute and chronic health care conditions. 18 Group care provides the opportunity for individual members to discuss and share self-care activities that help them promote a better state of health. (2) Self-Monitoring Can Improve. Self-monitoring, another concept of self-management, involves the person s ability to recognize not only specific signs and symptoms of a chronic condition but also the ability to process and interpret measurements associated with his/her specific condition. For example, for a diabetic patient this would involve understanding symptoms that signal that blood glucose levels are either too low or too high. This includes not only recognizing the physiological symptoms but also using a glucose monitor which provides a specific number and then knowing what to do with this information. (3) Symptom Management Can Improve. The exchange of symptom-management strategies and health care resources are considered integral components of group care. A randomized, controlled trial of 187 participants was done to investigate a wellness intervention for women with chronic FM. 20 The intervention group received information and support to develop skills to engage in health promotion behaviors in the context of FM, including physical activity, nutrition, stress management, discussions of resources, and barriers to healthy behaviors. The control group received information about other health-related topics such as medications used to treat FMS, heart health, enhancing memory, and understanding health information. Both groups demonstrated significant improvement on measures of self-efficacy, health promoting behaviors, and quality of life. An important difference between traditional care and group care is the shared learning that is accomplished when group members discuss symptom management skills with each other. (4) Self-Efficacy Can Improve. Bandura defined self-efficacy as beliefs in one s capabilities to organize and execute the courses of action required to produce given attainments. 21 According to Richard and Shea, a key attribute of self-efficacy is in the individual s belief and confidence in his/her ability to perform self-care measures. 18 A person s self-efficacy judgments are not stagnant but dynamic and can be positively affected and changed with increased knowledge and experience. 18 Group care can foster self-efficacy. Group care members not only learn from each other, but they also receive support and encouragement. As pain research demonstrates that chronic pain is not only influenced by somatic pathology but by psychological and social factors as well, there have been wide attempts to develop multidisciplinary intervention approaches. 22 Most of these interventions are based on cognitive-behavioral approaches (CBT) aimed at modifying maladaptive behavior or operant-behavioral approaches (OBT) which support healthy behaviors and withdrawal of attention from pain behaviors. Many patients with chronic conditions including chronic pain experience uncertainty regarding their etiology and prognosis. Cognitive reassurance, another central tenet of group care, which includes providing explanations and education, was found to be beneficial to patients experiencing nonspecific low back pain, neck pain and irritable bowel syndrome pain. 23 Potential Problems In Group Care While providers are expert in making diagnoses and prescribing medications, they may have fewer skills in facilitating a group visit. Group care is not an educational session where patients listen to lectures by providers. Providers must recognize that the people in the group often have valuable information to share. Then, providers must create a safe environment where everyone who wants to share a skill has that opportunity. Providers must also redirect conversations that may be well-meaning, but Copyright 2015, National Fibromyalgia Partnership, Inc. (NFP). 5

4 not medically accurate. For example, a group member may state, I bought some pain medications from a late-night infomercial and feel so good that I now sell the product myself. Providers or clinic administrators will have to provide space for the visits. In some clinics, the only large space is the waiting room. It is not appropriate for group visits to occur in a public space where others are checking-in or out. Providers will also have to code and bill insurance differently than traditional one-on-one, patient-provider visits. Group visits are not appropriate for all concerns and will not replace all patient-provider visits. People with FM may express concerns about confidentiality and length of the visit, especially if child-care is needed or a ride is waiting. For both patients and their providers, group care for FM is new. However, we have the advantage of learning from group visits that are now successfully delivered in other diagnoses. If you have participated in group care for FM or any other diagnoses, we would like to hear your stories. If you haven t participated but have questions, ideas or concerns, we would like to hear those too. Maybe group care will be the next frontier for us all to explore. Please Share Your Comments & Ideas! There are two ways to send them. fmfrontiers@earthlink.net (your will be forwarded to the authors) Write: Attn: FM Group Care, c/o NFP, Inc., P.O. Box 2355, Centreville, VA (your mail will be forwarded to the authors) The above addresses are for article comments only. Do not include other NFP correspondence. About The Authors Jackie F. Webb, R.N., M.S.N., FNP-BC has been a Family Nurse Practitioner for over 25 years with a focus in chronic illness and self-care management. Her clinical background has focused on vulnerable populations such as adolescents, the uninsured, and patients who don t qualify for health insurance. Patient education remains the focus of her practice. She currently teaches at Linfield College School of Nursing in Portland, OR, and will be completing a doctoral in nursing practice in 2015 with a focus in innovative health care delivery models in primary care. Kim Dupree Jones, Ph.D., is an associate professor in the School of Nursing, having taught at Oregon Health & Science University in Portland since Her Ph.D. is in nursing with a focus on exercise physiology; she obtained her degree from Oregon Health & Science University. She also completed post-doctoral work in neuroendocrine physiology. Her area of research expertise is fibromyalgia. As an investigator, she has been funded by the National Institutes of Health, foundations, and industry. She has been an investigator or co-investigator on over 36 fibromyalgia studies including clinical trials on exercise and drug interventions to optimize physical function and symptom management. She is also President of the Fibromyalgia Information Foundation, a non-profit organization whose aim for the past three decades has been to disseminate scientifically sound fibromyalgia data ( References (1) Noffsinger, E.B. (1999). Increasing quality of care while reducing costs through drop-in-group medical appointments. Group Practice Journal, 48(12). (2) Noffsinger, E., & Scott, J.C. (2000). Understanding today s group visit models. Group Practice Journal, (2), (3) Angeles, R.N., Guenter, D., McCarthy, L., Bauer, M., Wolfson, M., Chacon, M., & Bullock, L. (2013). Group interprofessional chronic pain management in the primary care setting: A pilot study feasibility and effectiveness in a family health team in Ontario. Pain Research and Management, 18(5), Copyright 2015, National Fibromyalgia Partnership, Inc. (NFP).

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