IMPROVING PATIENT ACCESS TO CARE

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IMPROVING PATIENT ACCESS TO CARE

• Open Access

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If we keep doing what we are doing, we will keep
getting what we got

• Yogi Berra

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Every system is perfectly designed to get the
results it gets

• Paul B. Batalden MD
• Co-founder Institute for Health care Improvement
• Founding Director Center for Healthcare
  Improvement and Leadership The Dartmouth
  Institute

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Open Access

• Why should you care?

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Is Baldwin Family Health Care Ready for Open
Access Scheduling?
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Reasons for Change

• Increased patient satisfaction
• Increased provider and staff satisfaction
• Improved continuity of care.
• Reduced rate of no shows
• Reduced demand for after hours care and use of
  urgent care (reduced costs)
• Reduced visits per patient
• When patients can see their own provider,
  demand drops by 5
• Reduction in telephone time for Triage staff as
  less time is needed when patients are scheduled
  to be seen today.
• Nearly eliminates need for patient reminder
  calls.

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Access Models

• 1) Traditional
• 2) First Generation Open Access
• Carve Out
• 3) Second Generation Open Access
  Advanced Access

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Traditional Scheduling

• Reservoir is full with routine visits at the
  beginning of each day
• Urgent cases are accommodated by double booking,
  overtime or running behind.
• Most Common System in offices
• Average waiting time for medical appointment in
  the US is 3 weeks.
• Accommodates demand with a restrictive and
  complex categorization system
• New vs. Established Pt.
• 10, 15, or 30 minute appointment
• Wellness vs. acute problem
• Per Murray and Tantau Do last months work
  today.

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Carve Out / 1st Gen. Open Access

• System utilized by BFHC / GLFC
• Hold a quantity of urgent care appointments for
  same day scheduling.
• Quantity is based on predicted demand
• Accommodates for some (much) of the urgent need.
• Increases complexity of scheduling
• Designating Urgent Care or Same Day provider
  decreases continuity of care.
• Drives dates for scheduled / routine appointments
  further into the future.
• Staff may be forced to steal from spots held
  for same day visits in order to get in patients
  who need to be seen.
• Per Murray and Tantau Do some of todays work
  today.

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Open Access

• Removes all distinction between urgent and
  routine visits.
• Patients are placed on the schedule as they call
  for appointments.
• Need More Here
• Per Murray and Tantau Do todays work today.

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Panel Size

• About 2,500 patients
• 0.7 to 0.8 percent of a providers patients will
  call for an appointment each day.
• Share data on BFHC panel sizes

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Causes for Failure

• Not assigning Primary Care Providers
• Continue to run under Carve Out system
  believing it is open access.
• Routinely running overtime for visits and
  overbooking providers
• Not maintaining continuity of care.
• Diverting care to urgent care or same day clinic

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Standard Pattern of Demand

• Increases very quickly in morning
• Flattens at about 10 AM
• Drops over lunch
• Drops more from 2pm til end of day
• Demand for appointments after 4PM is about 4 of
  volume.
• Late night demand often created when provider
  cannot fit patients into day appointments and
  only open time is evenings.

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Transition

• How to get from here to there

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Principles

• 1) Understand, measure and achieve a balance
  between supply and demand
• 2) Recalibrate the system (or reduce the
  backlog)
• 3) Reduce the number of queues by reducing the
  variety of appointment types or lengths (queuing
  theory)
• 4) Create contingency plans for times of
  heightened demand or lessened capacity
• 5) Influence the demand (e.g., by matching
  patients with their own physicians, making the
  most of current visits and rethinking
  return-visit intervals)
• 6) Manage the constraints or bottlenecks (e.g.,
  remove from the physicians any work that can be
  done by someone else).

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Open Access Tips

• Offer all patients an appointment on the day they
  call regardless of the reason for the visit.
• If they do not want to be seen the day of the
  call, schedule an appointment of their choosing.
  Do not have them call back on the day they want
  to be seen.
• Allow providers to pre-schedule patients when
  clinically necessary (good backlog). Normally 20
  to 30 patients per 1000.
• All appointments will be on standard length of
  time.
• Reduce types of appointments (the fewer, the
  better)
• Appointment length should match provider practice
  style.
• Panel size must be manageable
• Protect provider schedules from colleague
  overflow
• Develop plan for extreme demand or provider
  absence
• Reduce demand for unnecessary visits.
• Reduce future demand by maximizing todays visit

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High Demand Times

• Double book with patients PCP
• After several double bookings, offer an
  appointment with a different provider
• Agree to stay late
• Offer appointment with designated same day
  provider and advise patient that there will be a
  wait.

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How to Reduce Backlog

• Reduce Workload
• Increase intervals for return appointments
• Utilize alternatives to face to face office
  visits
• Phone calls
• E-mail
• Group Visits
• Maximize activities at each visit
• Transfer duties to support staff to allow
  provider to see more patients in same amount of
  time
• Reduce provider interruptions
• Support staff (RN?) manage sub-populations

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How to Reduce Backlog

• Increase Availability
• Add Appointments
• Use Administrative Time
• Defer Time Off
• Match Capacity to Demand
• Modify schedules to have more providers working
  when demand is the highest

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Key Points

• Reinforce the relationship between the patient
  and their PCP. This needs to be a key priority.
• Ensure accuracy of records as to who the patient
  identifies as the PCP
• Start every appointment on time.
• Agree what on time means.
• Make sure systems are in place to allow provider
  to see patient at the time scheduled.

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Phone Scripts

• Receptionist Which provider do you see?
• Patient I have seen Dr. Doe but it doesnt
  really matter.
• Receptionist It is really better for you to
  see the same one as frequently as possible so
  that they get to know you better and can take
  better care of you. Dr. Doe is not in today, but
  I can schedule you tomorrow with her when she
  returns.
• Patient I would rather come in today.
• Receptionist Thats fine, you can see one of
  the other providers today and next time we will
  try and get you in with Dr. Doe.

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Phone Scripts

• Patient I would like to make an appointment
  with Dr. Doe.
• Receptionist When would you like to come it?
• Patient Tomorrow sometime
• Receptionist Dr. Doe is not in tomorrow. She
  could see you today at 300 today or she will be
  back on Thrusday and I could schedule you then.
• (Patient gets to choose)

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Phone Scripts

• Patient I would like to make an appointment
  for next month with Dr. Doe for my physical
• Receptionist We really try not to schedule out
  so far, since plans change and it can be hard to
  keep an appointments that is scheduled so far in
  advance. Would you kike to come in sooner, or
  would you like to call back within a few days of
  when you would like to be seen? We will have
  appointments available then
• (If patient is insistent and the schedule is
  open, go ahead and schedule, but make a not for
  someone to confirm appointment the day before.)

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Phone Contacts

• It is the patients choice, accommodate them
  whenever possible.
• Always confirm PCP and schedule with that
  provider whenever possible.
• If a patient wants a future appointment, do not
  ask them to call back on the day they want to be
  seen, this just increases phone traffic.
• Try not to schedule out any further than 2 weeks
  since the no show rate rises dramatically after
  that time.
• When pre-scheduling appointments, guide patients
  toward known low demand days or times.
• When scheduling for another day, try to encourage
  the early morning appointments.

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Measures

• Percent of Same Day Work
• No Show Rate
• Patient Satisfaction
• Panel Size

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Next Steps

• Provider Buy In
• Key Staff Buy In
• The people who do the work need to transform the
  work
• Site Specific Plan and milestones
• Staff Education and Training
• Patient Education