Welcome to the Evolution of Medicine podcast! This week, we’re continuing our Group Visit Series with Donna Naumann, NP. She has been successfully running group visits in the St. Louis area for nearly three years, and has seen amazing moments of patient transformation that have convinced her of the power in community care. Her perspective adds so much to the group visit conversation because it is from the front lines of group visit implementation—she shares her experiences, plus practical tips on recruiting patients for group visits and running successful appointments that you can apply to your practice. No matter what topic you’re planning for your next group visit, or if you’re still on the fence about getting started with group visits, you will take away important, real-world information from this episode. Highlights include:

  • Her transition to group visits and the resources she used to make implementation a breeze
  • Examples of how the group dynamic motivates patients and builds connection in ways that one-on-one consultations cannot
  • How to successfully recruit patients for group visits and keep them engaged
  • How to structure group visits that are focused on stress and weight loss, two topics that many patients struggle with
  • And so much more!

Resources mentioned in this podcast:
lifestylematrix.com
lifestylematrix.com/gvthome

James Maskell: Hello and welcome to the podcast this week we continue our group visit series with Donna Naumann, a nurse practitioner from the St. Louis area, who’s been doing group visits for around three years. Super interesting. Just to go deep with a practitioner who’s been doing it and see how much we can learn. And there are some great tips in here for running a group. Challenges that come up running a group, recruiting people into a group, and just a ton of great information for someone who’s been out on the front lines. If you’re interested in weight loss, if you’re interested in stress, if you’re interested in getting people off medication, there’s a ton of great information here for you. Enjoy.

James Maskell: So a warm welcome to the podcast Donna Naumann. Welcome, Donna.

Donna Naumann: Hey, thank you for having me. I’m so excited to be here.

James Maskell: Well, we’re really excited to have you on this group visit series and over the last eight episodes we’ve spoken to all kinds of clinicians from across the spectrum. Running group visits, and having experience with doing them, and adapting them, and changing them, and building them. And so yeah, I’d love to just I guess start with a little bit about your story, how you got into functional medicine, and how you started doing your first group visit.

Donna Naumann: I got into functional medicine probably about seven years ago. I bought the practice from the family physician that I had been working with for 10 years and I just felt like we needed to start refreshing the practice and bringing in some new ways of taking care of patients. And I think after a while you realize everything that we’re doing as healthcare providers, we’re patching, we’re not fixing, we’re not getting into what is really causing disease and problems.

My passion has always really been about weight loss. I was doing weight loss probably the first time I walked into practice as a nurse practitioner. And it’s all about diet, and over, and over, and over, and over, and over there’s so many success stories with patients that changing what they do really does make them feel better.

James Maskell: Amazing. Yeah, I know that obviously functional medicine and weight loss can go super hand-in-hand. Now you’re running your practice, you’re seeing a lot of those kinds of patients. What’s the first inkling that you had that one-on-one care might need to evolve for this patient population?

Donna Naumann: Well, the more you dig into functional medicine and you realize it’s huge, anywhere from the toxins, the bacteria, the foods, the hormones, the stress, all of those things play a part into who we become as health of our body. Exercise included in that. And I found that my visits were getting longer and longer, and we can’t bill longer and longer. So I had to do something that made more sense to get the information to the patients that would provide them a resource to become healthy.

And I still do insurance-based medicine, and I use the functional model to help offset some of the other things in the practice. So using a group visit has been a huge thing because I can get a lot of information to a lot of patients in a very short time. And it’s all good stuff. People have never heard of so many of these things that are wrong with us.

James Maskell: Yeah, absolutely. So started sort of like you’re running out of time to do the education, you want a more efficient way to do it.

Donna Naumann: Yeah.

James Maskell: Yeah. Tell us about that transition, the first group, how you got there and how it went.

Donna Naumann: So the first time we used the Lifestyle Matrix information. And we bought one of the programs, brought it into the practice. We had somebody in St. Louis that was very familiar with how that process worked, and invited her to come, and help me do the first group visit. She kind of did the kickoff, we had a television, we did the whole video. I used the information that we got from the CDs from the Lifestyle Matrix and those were our handouts. I mean, it was all very laid out, very easy, easy to implement in the office.

James Maskell: And obviously helping you also thinking about how to bill it, how to organize it, how to like, I know that the soap notes and tracking what happens, all of that stuff becomes important too, right?

Donna Naumann: Yes, absolutely.

James Maskell: So yeah. So was that something in the first group that got you excited enough to want to continue doing this for the last, I guess what, three years you’ve been running these groups?

Donna Naumann: Yeah. Well, I’m a Toastmaster by nature and I’m not sure if you know what that is. It is a group of people that get together and do public speaking and practice public speaking. So I have always had a good passion about being in front of people and helping people. And I moved from using that Toastmaster and then bringing that into the group visits. And I think that was a huge, it was very helpful for me, learning how to connect with the people in the audience, learning how to bring them into the story that we’re trying to create change. And then implementing my own type of agenda for the meetings.

James Maskell: Yeah. So let’s talk specifically about weight loss and group visits. You know, now you mentioned there’s a lot of different reasons why people might not be able to lose weight. You mentioned some of those root causes that a functional medicine approach can help with. What did you find when you started putting people in a room together and what was the difference between sort of trying to do those consultations one-on-one versus the group dynamic?

Donna Naumann: It is interesting. You are taking the information and you’re bringing it into a group and the group has its own dynamics. They want more, they want them to start an email list. They want to know when you’re going to do it again and they start to connect. One of the patients in the group developed a walking program over at the college that’s across the street from where our office is. And she took everybody’s phone numbers and she was like, “Let’s go out to dinner and have our last big dinner together and then we’re going to get on this program.” And so everybody was so…everybody gets animated. That’s just part of the group process.

We do a Medicare wellness, so I have all the older adults come together and it’s amazing, they’re so lonely, bringing them into this group atmosphere. It’s so, so beautiful. They spend time together, we’d go over fall and risk reductions. We go over hearing issues and gait problems and we can bring all that into a group that otherwise you just couldn’t do that, and they have such similar stories. And it’s so interesting for them to put those similar stories together in a group setting.

James Maskell: Yeah. So I mean, how do you sort of coalesce the group at the beginning? What’s the feeling at the beginning and how do you create that convergence of desire and goals and meaning?

Donna Naumann: It’s so fun. At first you’re like, “Oh my gosh, what’s happening?” You walk in, the room is quiet. Everybody’s just sitting there in their little space and sometimes they’ll even sit way off to the side. So a lot of the times I first walk in, I’m already laughing because I know in about five minutes everybody’s going to be congeal and they’re going to be kind of animated and back into what we’re doing.

And it’s just walking into the room and being who you are, and being energetic about why they’re here and this is going to be an awesome experience for them. The big thing is making the connections to the patients so that they know that you’re really here for them, which is why would you do this if you weren’t, right? And so already just your presence and walking in the room changes the dynamics because that’s who they come here to see, right.

You’re the provider. I do eye contact. I try to eye contact with each and every one of the members. I know most of them by name so I can call on them. I’ll ask questions and allow them to answer. I am not there to answer all the questions. I’m there to facilitate and give them information and then allow them to participate. I also try, during the meeting I try to back step and ask questions about things we already covered to see if they’re getting the information and allow each person to have an opportunity at the end. Like what was your favorite part about today? What did you learn today? And it really transition, from the moment you walk in to the time you get done. When you get done, everybody is up in there talking…everybody’s communicating together. It is so wonderful to see such a great community coming out of group visits.

James Maskell: Yeah. You said you know all of them. What’s been your best practices for recruiting people into, to wanting to turn up for a group session as opposed to one-on-one?

Donna Naumann: Well, I’m glad you asked that, because I feel like that’s been kind of the struggle that I had at the beginning was getting patients into the group visits. Nobody’s ever heard of these, they don’t understand them. And why would they want to come to a group visit? It’s an hour long, but at the end of the day it is so amazing. And I think the biggest key is using the staff. At first I was trying to do it all on my own. So somebody would come in and let’s say we have a stress patient, we do a stress visit. And I tell them we’re going to put you in a stress visit. And the first thing is, “Well yeah, I don’t have time or I work that day.” Or some excuse why they’re not going to be able to make it.

And then I had to sit there and talk them into it. And I’m done talking everybody into these things. I’m now being very direct about what this looks like. We’re going to make you a follow up visit, it’s going to be a group visit and on that day we’re going to go over information to help you. And the girls will help you make an appointment on your way out. There’s no room for them to decline that. So when they get to the desk, the girls will put them in the group visit automatically.

It kind of started, in the beginning I didn’t have anybody helping me. So this has gotten better and better over time and the groups are getting bigger and bigger, which is amazing. I think we have 23 in our Medicare wellness this last time. Now we didn’t end up with all of those patients because a lot of times they do back out of the group visit, but we still had a good 10, 15 patients.

But it starts when they come in, the medical assistant leaves me a little note on the chart that says, “This would be a good weight loss, a good stress or they’re due for their Medicare wellness.” So I get already triggered before I walk into the room that the patient may be a group visit. And then she’s kind of brought it up, “Oh, we’re doing group visits for stress now. You’d be a great candidate for that.” So she gets some kind of the first touch. Then I get them and then the girls at the front desk get them. So it’s a process of everybody doing it together.

One of the things that we also did was you can look up your diagnosis codes so we can find the group of patients that are in that diagnosis code and we can target them. So we did a smoking one. I don’t do those once a month. I do those periodically. We pull all the smokers and then we call them all and say, “We want to put you in a group visit to help with smoking.” And then we get them kind of signed up that way. When they’re hearing it from the staff, “We’re going to put you…Donna is asking us to call you. She’s doing a group visit and she’s going to put you in that.” Then it makes the patient feel like they’re being asked personally to get into a group visit. And I think that helps, too. So then we have everybody in the whole program, everybody in the whole practice is geared to put in the visits and so that really helps too.

James Maskell: Yeah. So those codes, that seems like a great way to think through is that. How big is your patient population that you’re drawing from in the practice?

Donna Naumann: Well, I work full-time. I would say we probably have probably 4,000 active patients. So all of them are not coming in all the time. So the goal is to try to get these patients to come in for wellness instead of sickness, because most of the time they’re coming in for sickness and not for wellness.

So this is a completely different way of approaching patient care. And when you’re sitting across from them, it’s a perfect opportunity to be asking them or telling them and inviting them. I also invite back other members from prior groups, so one of the weight loss patients lost like 70 pounds. He’s been to two meetings and he presents his like what happened for him and how this worked and it’s amazing. People are so connected to him, the meeting…all the meetings always go over. You think it’s going to be an hour, but patients start really getting into it and then all of a sudden it’s an hour and 10, then it’s an hour and 15 minutes. So by the end everybody is so hungry for information that they’re not getting anywhere else, and so inviting other patients to come in has been a really good thing too.

James Maskell: Yeah, that sounds valuable. How do you integrate those kind of new patient stories into your groups for maximum impact?

Donna Naumann: Well, because I’m newly doing that, I don’t usually have any agenda for him. I basically, he’s already been to one of the group visits and he knows what we’re going to be talking about and then he’s telling his story. Mostly the agenda, what happens for him is people start asking him questions and then he does his part based on what the need of the other patients are.

James Maskell: Beautiful. Yeah, that’s great. I mean we certainly heard that from other people doing group visits that that patients who have been along the journey can be a lot more authoritative in these situations for the patients than any of the providers. Because they kind of feel like this person’s been in my shoes and this person has a lot to offer the conversations.

So you know, I know that…but you mentioned that the stress group is the one that you’ve been doing. What’s specific about stress that you feel is well dealt with in a group, and what have been the results of running the stress group as a part from their weight loss group?

Donna Naumann: Well, my funny story on that is one of the patients called to get a refill on Xanax. And the girls told her, “You’re going to have to come in and we’re going to put you in a group visit and learn some strategies to help with the stress.” And the patient just fricking flipped out. She was so angry about, “You can’t hold my drugs hostage,” is what she told the girls. And eventually she succumbed to the meeting. At the meeting she was in tears. She was crying because she had learned so much.

People don’t understand that stress, that between the ages of zero and 12 we are creating our ways of dealing with life. And some of the things that are causing us stress as we age are things that we learn, that behaviors that we learn. Outside of the other things, the hormones, the foods and all the other burdens on the body.

And anyway, so when we started getting into all that, she just at the end was grateful. She sent me a thank you card. She went to the window, she talked to all the girls, apologized for being rude to them on the phone, and was calling her sister to get her sister in the next group visit. So these things are powerful, you can never know where they’re going to go. They’re always beautiful and right target on.

I do Reiki, I do Pranic healing and I do a lot of spiritual work outside of what I do as a family nurse practitioner. And I try to incorporate a lot of that into the stress visit. The stress visit is about learning to calm yourself down. So all of the stress visit, the beginning, we start with the physiologies of what’s going on, the vagus nerve, the adrenal glands.

And then what we’ve learned, we’ve learned behaviors, and then we move into doing. And so that last part of the visit is always about doing. We’re doing breathing exercises, we’re doing a state, we’re doing state change where we try to go from the sad to the happy. We do power poses. We do running in place for a minute to get the heart rate up and then practice breathing to bring the heart rate back down to kind of simulate what the stress is really doing to the body.

And then at the end we’ll do a meditation and sometimes we do like a one minute meditation. People don’t realize long a minute really is. And we use the time to really implement some strategies for patients to get better. Because the medication is just a patch. It’s not making the pain go away.

James Maskell: Yeah, do you ever…can you recruit people or pull up people based on the medication that they’re taking?

Donna Naumann: No.

James Maskell: Okay. And so who have you found to be a good fit for the stress group visit? What kinds of conditions seem to do that? You said someone was taking Xanax. What is your experience with mental health?

Donna Naumann: I invite patients, anybody that is trying to get on any kind of medication for depression, I invite them to come to the visit. And I tell them like, “You have to do this work, you have to show up for yourself because the medication, yes, it’s going to make you feel better. But without it, those pains and problems are still there and you haven’t learned anything about how to cope with stress.” So anybody that’s going on medication, patients do FMLA because they’re so stressed out. You wouldn’t believe how many FMLA patients there are for stress and anxiety. And they all go into the stress visit because obviously they’re not coping with the stresses of regular life, and you cannot get better and cope with things if you don’t have any strategies. And most people don’t have any.

James Maskell: Yeah, absolutely. So I’d love to just get a little bit of your thoughts just on functional medicine on insurance, right. Ultimately we, evolution of medicine for a long time been helping doctors to move away from insurance with functional medicine, because you can really spend the time that you need and be in control.

But ultimately if we want functional medicine to grow, we need to find ways to bill it on insurance. And one of the emerging strategies that we’re seeing that’s working really well is doing it in groups, because of the efficiency there. What are your own thoughts, having run this practice. Obviously you’ve been involved for 10 years and more and then obviously you’ve been running it now yourself as a nurse practitioner. What is some of your thoughts on the best way to bring functional medicine concepts and functional medicine care to a wider audience than you’d probably find in the practice of someone just taking cash?

Donna Naumann: That is more challenging, because if you’re doing functional medicine and you are really doing it right, there is a time constraint in there. The way that I overcome some of that is I send a lot of forms home with patients to fill out and bring back. And then we go…so we make more step approaches to it. Obviously they’re going to be doing more visits because in the functional medicine world there is more things to be looking at and trying to figure out why are people sick.

People that are sick already and they’re coming in to just get medications for their diabetes or medications for their blood pressure, they’re not doing functional medicine. So those visits are very different, but when you’re looking to really help somebody, it’s a step approach and really there’s some beauty in that. Because you can still bill insurance as long as you’re doing a billable service.

If that patient has RA and you’re trying to help them get through RA, you can do a series of more visits, but they need to be billable obviously. And all providers know how to make a billable visit. You just have to meet the criteria. And so I just have them come in more frequently. Instead of having patients that are coming in every six months for their blood pressures, we’re having the functional medicine patients come in every couple of weeks based on what kind of labs we did, or what kind of vitamin implementation that we’ve had, or what kind of lifestyle changes that we had.

I do a lifestyle program for weight loss and I have them come in and they come in almost every week for four weeks. We bill it to the insurance. But again, we have to have a billable service. So it’s my job to make sure that when they come in, we’re also doing billable visits along with it. But that really grows your practice too. I mean, how would I be growing a practice? As a nurse practitioner there’s no physician and in St. Louis you have to have a physician collaborative. So building this practice using functional medicine has been a huge key and has been, it’s been awesome for me.

James Maskell: Yeah, absolutely. And you know, how do you…What are some of the tips that you have for other practitioners who maybe thinking about doing group visits, or have thought about it or maybe have tried it once or twice? I know that sometimes it can be really exciting at the beginning and then, what have you done to be able to keep longevity into your group visit program? Because I know you’ve been doing this for three years now and expanding it, right?

Donna Naumann: Yep. In the beginning we did group visits and then they would drop off, because we wouldn’t have any patients in it. And then a couple of months would go by and then I would try it again. And then we do that for a couple months and that would drop off. But then at some point I got very serious about it. And I came up with four different things that I really see a lot, and then we just stopped giving up on it. And when we stopped giving up on it and kept trying to work through the problems that we’re having, that’s where we became successful. I think in the beginning, patients don’t know what this is. You don’t really know what this is and you don’t know what the process is and how long, what are you going to talk about, what are you going to do and how does this all look?

And so coming up with, we do as a group that people in the office come together and I ask them, “How can we make this part of it better? What is your ideas about this?” And then that gets the staff on board as well. At first it was very challenging, because if you didn’t have any patients in the visit, you want to cancel them because you don’t want to stay an hour and take care of two patients and bill two patients. Because it’s not a money maker.

And so happened to redesign what it looks like over and over until you finally get to that sweet spot. Once you get to the sweet spot, it’s so easy to walk in and do your thing. You know this stuff, you’ve done this stuff. It’s what you do every day as a practitioner and you’re just doing it in an hour visit. I never get tired of it, because there’s people there, they’re communicating and they change the dynamic of the meeting, every time we have one it’s different.

And as a provider I’m getting, I’m seeing the light, I’m right in front of them, giving them information that they need and that’s so fulfilling. And I always say at the end of the visit, “Please take one thing that you learned today and give it to somebody else.” People have no idea what is going on with their health. People have no idea what is insulting their body.

And after we go through all the different things that can be insulting, people learn a lot. And the shock of what goes on in the food industry is just one example. And then they’re able to take those ideas and give them to somebody else. And the whole goal is let’s help the group help their group and help their group, so that it becomes a new way of health.

James Maskell: Yeah, absolutely. Well that’s really exciting actually. And that’s one thing that I haven’t heard from anyone else is really like how you seed the people in the group visit to go out and actually communicate. Because I know, even in regular patient care, one thing about functional medicine is that if you help one kid get well in a family, the family is really changing their behaviors. And when a family changes their health and other kids in the school and other parents notice. And I’ve seen a sort of a knock on effect of health creation. But it sounds like in this group you have the potential to use the structure and use what people are educating and helping people who are…the first-time learners become very quickly kind of teachers to everyone else. What have you learned in that process?

Donna Naumann: I learned how patients really lack a lot of information. We as providers, we learn all this stuff and I’ve been doing it 17 years, been a nurse since ’86, so all this stuff is so natural to me. Everything about it is pretty natural. And because of that long-term of being in the healthcare industry, I just assume people know these things. And it’s shocking how much they don’t know and how little they know about the body in general, physiologically and about all the chemicals and things that we’re putting on and in our body.

It surprises me, I didn’t realize people didn’t know. And when you start doing these groups, you realize people don’t know. Nobody’s teaching this stuff. So we as providers have to show up and start getting this information. Change is only going to happen when we’re able to touch more lives.

James Maskell: Beautiful. Yeah, I love that. Well look, thank you so much for sharing that. And I think that is such a key point. And I think yeah, in our own little functional medicine bubble, it’s very easy to just assume that everyone is aware of all of the same media sources and all of the same information that’s coming through.

But we really have a big road to climb. And ultimately, practitioners like yourself who put themselves in the sense of the community and really build community through these group visits are an incredible…have an incredible opportunity to be able to just create little pockets of health creation and spread the word. And if there’s enough practitioners doing that and enough groups being created, then ultimately we can find a way to get all of those people in the right place.

You know, one question I do have is just, I guess the…it’s just about the billing. What are your experiences of billing people’s insurance with high deductibles? And when people sort of get the bill that reflects the full amount that’s being billed to insurance? Have you had any issues with that or have you found ways around that?

Donna Naumann: I have not had any patients complain about getting a bill for services. I think we’re at a place now that people understand that part of their bill is going to be their responsibility. All of them pay their copay before we do the group visit and some of them have $25 copays and they still show up. I think it’s a matter of, “Are you going to show up and help yourself, or not?” Because that’s where all of this begins, is patients taking the responsibility of their own healthcare.

They don’t understand a lot of this. If you say things about gut health, they just look at you like a deer in headlights, and so sometimes throwing out some of that information during the visit kind of initiates what they don’t know and what they want to know. And so sometimes I try to use some of the acronyms that we use in functional medicine to really stimulate the patient to begin to think, “Huh, I wonder what that is?”

That curiosity increases their need to be in some of these group visits, because now they’re kind of curious about what exactly is she talking about? And I’ll send them home with homework to do too. I can’t go over the whole gut issue with you. Here’s a couple of good people to look up online and they’ll give the information that you need. And then that kind of starts the cycle to get them into the visit.

They pay their copay when they get there. As far as the billing part goes, I haven’t really had any issues. I mean, there’s a certain group of people probably that don’t pay their bill, but I don’t sit there and analyze all that. I mean, I’m doing this for helping people. Yes, I want to get paid and we do submit them as bills. And for the most part it’s been working out fine. I think it’s a very successful way to bill really.

James Maskell: Beautiful. Well, Donna, look, there’s so much to take out of that and I really appreciate you sharing all of that insight. And I’m sure if practitioners who are listening in to this, there’s a lot of wisdom that’s being shared. And I guess one of the things that I want to feed back as an entrepreneur myself is just getting in there, trying things and work it out.

You mentioned at the beginning the Group Visit Toolkit from the Lifestyle Matrix Resource Center is like a starting point to do the first couple. But ultimately it sounds like where you’ve landed is a little bit further away from that foundation. But that’s all about working out what is needed for your community and where they are, and what they’ve already learned and what they need to learn. And ultimately that just comes from doing it.

And so I definitely salute you in taking the steps that are necessary to work that out and having some tenacity to get to a point where this is a part of a flourishing functional medicine practice. So thank you for all your wisdom that you’ve shared here today. And we will put details in the show notes about where you can find out more about Donna’s practice. Excited to see the to see the nurse practitioners really taking some leadership role in the development and growth of functional medicine.

Donna Naumann: Thank you.

James Maskell: All right, so this has been the Evolution of Medicine podcast, has been our Group Visit Series. We’ve been talking with Donna Naumann, she’s a nurse practitioner in the St. Louis area, about her group visits. And to find out more, if this is the first episode you’ve heard, we have seven previous episodes and we have a whole season here on group visits. So thanks so much for tuning in. I’m your host James Maskell and we’ll see you next time.

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