IMPROVING PATIENT ACCESS TO CAREOpen Access

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

Yogi Berra

“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

Open Access

Why should you care?

Is Baldwin Family Health Care Ready for Open Access

Scheduling?

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.

Access Models

1) Traditional

2) First Generation Open Access Carve Out

3) Second Generation Open Access

Advanced Access

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 month’s work today.”

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 today’s work today.”

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 today’s work today.”

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

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

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.

Transition

How to get from “here” to “there”…

Principles1) 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).

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 today’s visit

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.

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

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

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.

Phone Scripts• Receptionist: “Which provider do you see?”

• Patient: “I have seen Dr. Doe but it doesn’t 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: “That’s fine, you can see one of the other providers today and next time we will try and get you in with Dr. Doe.”

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 3:00 today or she will be back on Thrusday and I could schedule you then.”

• (Patient gets to choose)

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.)

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.

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

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