Nurse-Led Group Visits for Chronic Disease Management in Primary Care Settings

Introduction

Primary care practices face escalating demand to deliver comprehensive chronic disease management within appointment structures that were largely designed around acute, single-problem visits. Patients with type 2 diabetes and hypertension, two of the most prevalent chronic conditions managed in primary care, typically require frequent monitoring, ongoing medication titration, and sustained behavioral education, needs that are difficult to fully address within the ten- to fifteen-minute individual appointment slots common to most primary care scheduling models (Bodenheimer et al., 2002). This mismatch between chronic disease management demands and traditional visit structure has contributed to growing interest in alternative care delivery models capable of extending clinical contact time without proportionally increasing clinician staffing burden.

Nurse-led group visits, sometimes termed shared medical appointments, represent one such model. In a typical group visit format, a cohort of patients sharing a common chronic condition attends a scheduled group session, usually lasting sixty to ninety minutes, during which a registered nurse or nurse practitioner conducts brief individual clinical assessment, often including vital signs and point-of-care laboratory review, within the group setting, followed by structured educational content and facilitated peer discussion (Jaber et al., 2006). This model is grounded in the premise that peer interaction and mutual accountability, layered onto clinical care delivered by a consistent nursing provider, can enhance self-management skill acquisition and motivation beyond what is typically achieved in individual visits, while simultaneously increasing the total clinical contact time available per patient relative to conventional scheduling.

Prior evaluations of group visit models, conducted predominantly in diabetes populations, have reported favorable effects on glycemic control, patient satisfaction, and selected utilization outcomes, though the evidence base has been constrained by considerable variability in group visit format, facilitator discipline, session frequency, and study design rigor (Edelman et al., 2010; Housden et al., 2013). Fewer studies have specifically evaluated group visits led primarily by nursing staff, as distinct from physician- or multidisciplinary-team-led formats, despite the nursing scope of practice aligning closely with the assessment, education, and care coordination functions central to the group visit model. Additionally, relatively few studies have examined group visits serving a mixed diabetes and hypertension population, despite the frequent co-occurrence of these conditions in primary care panels. The purpose of this study was to evaluate the effect of a nurse-led group visit program on clinical outcomes, healthcare utilization, and patient activation among adults with type 2 diabetes, hypertension, or both, managed in primary care, relative to a matched usual-care comparison group.

Methods

Design. This study used a quasi-experimental, nonrandomized pre-post design with a nonequivalent comparison group. Randomization was not feasible given that the group visit program was implemented as a clinic-level operational change at two of four participating primary care sites, while the remaining two sites continued to deliver usual individual care throughout the study period, serving as the comparison group.

Setting and participants. The study was conducted across four primary care clinics within a single health system between September 2023 and September 2024. Adults aged 18 years or older with a diagnosis of type 2 diabetes, essential hypertension, or both, and at least two primary care visits in the preceding twelve months, were eligible. Patients with end-stage renal disease requiring dialysis, active malignancy, or a life expectancy of less than twelve months were excluded. At the two intervention sites, eligible patients were offered enrollment in the nurse-led group visit program by their primary care provider; 214 of 301 approached patients (71.1%) enrolled. At the two comparison sites, a matched sample of 226 eligible patients receiving usual care was identified through electronic health record query and invited to participate in outcome data collection without receiving the group visit intervention.

Intervention. The nurse-led group visit program consisted of six monthly, ninety-minute sessions, each facilitated by a registered nurse trained in chronic disease self-management education and group facilitation, with physician or nurse practitioner availability for same-session medication adjustment as clinically indicated. Each session began with individual, semi-private review of vital signs, point-of-care hemoglobin A1c or home blood pressure log review, and brief individual check-in, followed by a structured group educational module addressing topics including medication management, dietary pattern modification, physical activity, and recognition of warning signs, and concluding with facilitated peer discussion and goal-setting. Session curriculum was standardized across both intervention sites using a shared facilitator guide to promote consistency.

Outcome measures. Clinical outcomes, including hemoglobin A1c among participants with diabetes and systolic blood pressure among all participants, were extracted from the electronic health record at baseline and six months. Healthcare utilization, including emergency department visits and hospitalizations in the six months preceding and following the intervention period, was similarly extracted from the electronic health record. Patient activation was assessed using the 13-item Patient Activation Measure, administered at baseline and six months in both groups.

Statistical analysis. Between-group differences in the change from baseline to six months were analyzed using difference-in-differences linear and logistic regression models, adjusted for baseline age, sex, number of chronic conditions, baseline clinical value, and clinic site. A secondary, per-protocol analysis examined the association between group visit attendance, dichotomized as four or more versus fewer than four of six sessions attended, and clinical outcomes among intervention participants. A two-sided p value of less than .05 was considered statistically significant.

Results

A total of 440 participants were included in the final analysis, 214 in the intervention group and 226 in the comparison group. As shown in Table 1, the two groups were broadly similar at baseline across demographic and clinical characteristics, supporting the appropriateness of the difference-in-differences approach for estimating intervention effect despite the nonrandomized design. Among intervention participants, mean attendance was 4.3 of 6 scheduled sessions, with 148 of 214 participants (69.2%) attending four or more sessions.

At six-month follow-up, the intervention group demonstrated significantly greater improvement across all primary clinical outcomes relative to the comparison group. Among participants with diabetes, mean hemoglobin A1c declined from 8.4% to 7.5% in the intervention group, compared with a decline from 8.3% to 8.0% in the comparison group, yielding an adjusted between-group difference of −0.62 percentage points (95% CI −0.84 to −0.40, p < .001). Mean systolic blood pressure declined from 142.1 to 132.6 mmHg in the intervention group, compared with a decline from 140.8 to 137.3 mmHg in the comparison group, yielding an adjusted between-group difference of −6.8 mmHg (95% CI −9.7 to −3.9, p < .001).

Healthcare utilization outcomes also favored the intervention group. Emergency department visits in the six months following the intervention period declined by 29.3% relative to the pre-intervention period among intervention participants, compared with a 4.7% decline among comparison participants (adjusted incidence rate ratio 0.76, 95% CI 0.62–0.93, p = .007). Hospitalization rates were low in both groups and did not differ significantly between arms, likely reflecting insufficient statistical power for this less frequent outcome within the study’s six-month follow-up window and sample size.

Patient activation increased substantially more in the intervention group than in the comparison group. Mean PAM score increased by 9.4 points among intervention participants, compared with 2.1 points among comparison participants, yielding an adjusted between-group difference of 7.1 points (95% CI 5.2–9.0, p < .001). This increase was sufficient to shift a meaningful proportion of intervention participants across activation level boundaries, with 61 of 214 intervention participants (28.5%) advancing to a higher PAM activation level by six months, compared with 19 of 226 comparison participants (8.4%).

The per-protocol analysis summarized in Table 2 demonstrated a clear dose-response relationship between group visit attendance and clinical benefit. Intervention participants attending four or more of six sessions achieved more than double the mean HbA1c reduction and more than double the mean PAM score increase observed among participants attending fewer than four sessions, with statistically significant differences observed across all four examined outcomes. This pattern suggests that sustained engagement with the group visit program, rather than mere enrollment or exposure to a single session, was necessary to achieve the largest clinical and behavioral benefits.

Discussion

This quasi-experimental study found that a nurse-led group visit program was associated with clinically meaningful improvements in glycemic control, blood pressure, emergency department utilization, and patient activation among adults with type 2 diabetes and hypertension in primary care, relative to a matched usual-care comparison group. The magnitude of the observed HbA1c reduction, an adjusted between-group difference of 0.62 percentage points, exceeds thresholds commonly considered clinically meaningful in diabetes management literature and is comparable to reductions achieved through the addition of a second oral antidiabetic agent, suggesting that the group visit model may offer benefit of a magnitude relevant to clinical decision-making rather than a purely statistical improvement (Edelman et al., 2010).

The observed reduction in emergency department utilization is consistent with the theoretical mechanism underlying the group visit model, in which increased clinical contact frequency, combined with enhanced self-management skill and confidence, is expected to facilitate earlier recognition and outpatient management of emerging problems that might otherwise progress to an acute care encounter. This finding also aligns with the broader chronic disease self-management literature, in which structured, sustained educational and coaching contact, delivered through varied formats including individual coaching and, as demonstrated here, group visits, has been consistently associated with reduced acute care utilization (Wagner et al., 2001).

The substantial increase in Patient Activation Measure score observed in the intervention group, more than four times the increase observed in the comparison group, offers a plausible explanatory mechanism for the clinical improvements observed. The peer-support and group-discussion components central to the group visit format may enhance self-efficacy and behavioral engagement through mechanisms, including vicarious learning and social modeling, that are less readily available within individual, dyadic clinical encounters (Bandura, 2004). The finding that nearly three in ten intervention participants advanced across a full PAM activation level within six months is notable, given that activation level is generally considered a comparatively stable, slow-changing patient characteristic, and suggests that a structured, sustained group intervention delivered by a consistent nursing facilitator may represent a genuinely effective activation-building strategy rather than a incidental byproduct of increased clinical contact alone.

The clear dose-response relationship observed between session attendance and clinical benefit has direct implications for program design and implementation. Rather than treating group visit enrollment as a binary exposure, health systems implementing similar programs should anticipate that sustained engagement across multiple sessions is likely necessary to realize the largest clinical benefit, and should consider incorporating attendance-support strategies, including flexible scheduling, transportation assistance, and proactive outreach to participants who miss sessions, to maximize the proportion of enrolled patients achieving the attendance threshold associated with the largest observed benefit in this study.

Several limitations should be considered when interpreting these findings. The nonrandomized, quasi-experimental design, necessitated by the clinic-level nature of the intervention implementation, leaves open the possibility of residual confounding by unmeasured differences between intervention and comparison clinics or by self-selection among patients who agreed to enroll in the group visit program versus those who did not. Although baseline characteristics were similar between groups, patients who opted into the group visit program may have differed from non-enrollees in unmeasured motivation or readiness for behavior change. The six-month follow-up period, while sufficient to detect meaningful clinical change, does not establish whether observed improvements are sustained over longer time horizons, and prior group visit literature has suggested that some benefits may attenuate without ongoing programmatic engagement (Housden et al., 2013). Finally, this study was conducted within a single health system, and the specific curriculum, facilitator training model, and session structure used may not generalize directly to programs implemented with different staffing models or patient populations.

Future research should include cluster-randomized trial designs where feasible to strengthen causal inference regarding the effect of nurse-led group visits, alongside extended follow-up periods to characterize the durability of clinical and behavioral gains beyond the initial six-month program period. Further investigation into the specific attendance threshold and session dosage required to achieve maximal clinical benefit, as well as the relative contribution of the individual clinical review and group educational components to overall program effect, would help refine implementation guidance for health systems considering this model. Economic evaluation comparing the staffing and facility costs associated with nurse-led group visit delivery against the observed reductions in acute care utilization would also strengthen the business case for program adoption. Taken together, the findings of this study support nurse-led group visits as a clinically effective, scalable model for chronic disease management within primary care, capable of extending nursing-delivered self-management support to a larger patient volume than individual visit models allow, while producing meaningful improvements in clinical outcomes, healthcare utilization, and patient activation.

References

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