PCHC Experience With Advanced Access

SchedulingElaine Hardman, MBA, Chief Operations Officer

Jackie Fantes, MD, Associate Medical DirectorThe Providence Community Health Centers

Providence, Rhode IslandAugust 16, 2013

Health Choice Network Quality Institute

To reduce scheduling barriers for under-served patients for improved access to care

High no-show rate (40%)◦ Tried multiple ways to reduce

Reduced provider productivity/idle staff resulting in inefficiencies

The work of tracking down patients that no-showed Patients did not get care if they did not show up Eliminate the perception of “too much” demand Improve provider and staff satisfaction The organization was ready to commit

Why PCHC Implemented Advanced Access Scheduling

Do today’s work today Access is a key determinant for consumers

choosing a health care provider (something all of us CHCs will need to consider with ACA)

6 high level changes◦ Match demand and supply daily◦ Reduce backlog◦ Simplify appointment types and times (apply queuing

theory)◦ Create contingency plans◦ Reduce demand for unnecessary visits◦ Optimize the care team (no easy task!)

Principles of Advanced Access

Provider and staff resistance Implementation takes up to 3-6 months due

to fluctuations in demand Tracking demand – initially and constantly Finding hidden capacity Longer staff hours to reduce backlog All staff need to work at their highest level Disparity between efficient and non-efficient

providers

Challenges to overcome

Pre-work Baseline Data Establish a Call Center Educate Patients Work Down the Backlog Reduce the Demand Revise Schedule Templates Staff Cross-training Establish Safety Net

Steps to Implementation

Identify a team Training staff on Advanced Access concepts Establish timeline

◦ Generally 3 months out Baseline Data:

◦ No show rate at each site◦ No show rate for each department◦ Panel size by Provider◦ 3rd next visit for each Provider◦ Patient Satisfaction Surveys◦ Measure demand

Measure demand vs. capacity for each day of the week for each provider

Steps of Implementation – Pre-Work

Worksheet for appointments Sample of appointment capacity vs.

demand◦ Pediatrics, Internal Med, OB/GYN

Sample of no-show rate Need to tracking phone calls Worksheet for tracking unmet demand

Steps of Implementation – Baseline Data

Phones open 1 hour before start of appointments

Phones routed to central area of clinic where triage RN would also assist

Measure call volume by each hour of each day◦ Sample Queue

Steps of Implementation –Establish a Call Center

For each patient that arrived for their appointment, we provided them with a instruction sheet on advanced access◦ Open Access is coming◦ Call us the day you need appointment◦ Call center opens at ….

Steps of Implementation –Educate Patients

Approximately 3 months Providers agreed to work extra hours to see

today’s demand Guidelines on booking out into the future

◦ Transportation issues◦ Special interpreter needed◦ Patient insisted◦ Brittle patients that we needed to track more closely

or at risk to fall out of the system At end of visit patients were given provider’s

card with his/her schedule and the date when they should call for next visit

Steps of Implementation –Work Down the Backlog

Increase visit intervals Have providers see their own patients

◦ Improved efficiency to see own PCP Give as much phone advice as possible for

the short period of time when many appointments already pre-booked

Max-packing visits

Steps of Implementation –Reduce the Demand

Simplify appointment types◦ 4 visit types

Pre-book Long (30 minute appointments) Pre-book Short (15 minute appointments) Open Long (30 minute appointments) Open Short (15 minute appointments)

Schedules 30% pre-book and 70% Open◦ Pre-Intergy open appointments could be set as

unavailable until the day of the appointment but Intergy will not allow this feature

Steps of Implementation –Revise Schedule Templates

Developed the roll of the Health Center Assistant◦ Allowed more flexibility to assigning staff from call

center to clinic support◦ Allowed flexibility with vacations and variability in

volume

Steps to Implementation –Staff Cross training

Example of Hot List (get new one) Scripts and Tips for Making Appointments Recall and Reminder Policy

◦ Had difficulty re-establishing in electronic environment

◦ Copy of our recall and reminder policy for everyone

Steps of Implementation –Establish Safety Net Plan

THE PROVIDENCE COMMUNITY HEALTH CENTERS, INC. NURSE TRIAGE LIST

FRONT DESK MUST DIRECT THE FOLLOWING CALLS TO THE NURSE

VERY IMPORTANT! ● Any sick patient that wants to be seen today for sick visit and can’t be

accommodated must be transferred to Nurse. ● If the patient’s complaint sounds unusual to you or you are not

comfortable with it or if the patient/parent thinks the patient is too sick to wait, transfer the call to a nurse and wait for someone to answer.

● Be sure to get the patients name, DOB and phone number.

ALL PATIENTS: PREGNANT WITH: Trouble Breathing/Asthma Trauma to abdomen Accidents Accident/fall Bleeding from a wound Abdominal pain/contractions Question of a broken bone Baby has less or no movement Fell and hit head Headache/dizziness Burn Think water broke Allergic reaction Vaginal bleeding/large fluid loss Chest pain/Severe upper back pain Vomiting Confusion Difficulty speaking/swallowing CHILDREN: Fever greater than 102 Blue/grey color of lips or nails Left arm or jaw pain Heart beating fast/skipping beat Loss of consciousness/fainting Rash Severe headache Limp Severe Abdominal Pain Stomach pain/Back/kidney/pain when

urinating boy or girl Seizure Vomiting projectile/bile/blood/diarrhea Stiff Neck Wheezing/breathing problem/cough Suicidal thoughts Headache/stiff neck Weakness of an extremity Overdue for or needs Immunization POISONING: SICK INFANT: (less than 3 months) Call Poison Control All sick infants under 1 month old

@ 1-800-222-1222 Irritable/won’t stop crying Not eating as usual/decreased urine Overly sleepy/too quiet Rectal temp>100or AXtemp>99

Vomiting/diarrhea

Fast Breathing

Need to manage the impulse for providers to pre-book (providers that do not pre-book many patients tend to see the patients of providers that pre-book a lot – need to have clear guidelines for the call center)

Develop a good recall and reminder system especially for chronic care and well child care

Manage panel sizes Need to have a good system for tracking chronic care

and well child care◦ Amalga can help, but no pediatric view yet◦ Need to track immunization

CLEAR can help◦ Audit cancellations

If patients < 18 months of age cancel their appointment then it needs to be rescheduled, not asked to call back another day

Lessons learned

Demand management for sudden or prolonged provider absence or big projects like implementation of the EHR or seasonal fluctuations in demand (for example, H1N1)

Managing unmet demand Maxpacking is a great idea but the provider “spirit”

cannot handle 18-20 maxpacks daily which can be difficult in a CHC setting

Need to have a very robust call center Manage quick saturation of appointments

◦ All sick visits do need to be handled today (HC vs. Express)◦ Well visits should be put on unmet demand list

Need a detailed training for new providers

Lessons learned (cont.)

Strategies for Managing Patient Demand During EMR Go-Live Draft 12/05/2011 Assumptions Go-live period will be 8 weeks in duration (eg, February 6 – March 30 for initial sites) Provider schedules will be reduced by as much as 50% during initial few weeks with gradual increase so as to

arrive at 100% at the end of eight weeks Similar demand reduction strategies will be needed during pre-Go-Live training weeks

Demand Reduction Increase Capacity IMED PCHC/Site: Defer new patients for two

months Go-Live period (except those assigned by NHPRI/UHC). Keep waitlist for those requesting appts and contact post-Go-Live.

PCHC/Site: limit prebooks during initial month

Providers: extend follow-up intervals & use recall

Providers: reduce # of referrals/work-up patients longer at site so RNs more available to assist with history/initial record set-up (this will increase capacity of support staff to help enter date/history)

Site: Add hours/sessions for existing providers

PEDI PCHC/Site: No PEs for children over 5 years of age during initial month of Go-Live

PCHC/Site: limit prebooks during initial month

Providers: develop guidance for call center/RNs in order to triage/give advice for issues provider visit may not be necessary (eg, develop “cold list” of issues, like vomit once, etc where further phone assessment & advice would be appropriate)

PCHC/Site: Defer new patients for two month Go-Live period (except those assigned by NHPRI/UHC). Keep waitlist for those requesting appts and contact post-Go-Live.

PCHC/Site: consider weekend/evening make-up session for PEs (all Pediatrics or by site)

PCHC: Increase Express capacity (add provider hours) to meet demand for sick care

OB/Gyn PCHC/Site: No annuals for initial month of Go-live (if calling for annual, ask if pt having a problem instead)

PCHC/Site: limit prebooks during initial month

PCHC/Site: Defer new patients for GYN for at least initial month of Go-Live period. Keep waitlist for those requesting appts and contact post-Go-Live.

PCHC/Site: Continue to accept new patients for Family Planning, pregnancy tests, OB care throughout Go-Live

PCHC/Site: r educe Colpo to 2x per month (and free additional session for OB/Gyn)

PCHC/Site: add hours/sessions for existing providers (by site or as a dept, eg, annuals on Saturday)

All Sites: Actively record unmet demand via waitlist in Intergy. Review daily. Reinforce use with call center & front desk staff.

Admin: In Dec/Jan, clearly explain to providers how productivity bonus will be affected/calculated during Go-Live time period.

No-show rate has dropped – was 40%◦ Pediatrics < 10%◦ Adult Med 10-12%◦ OB/GYN 14-16% (OB greater than GYN)◦ Pre-books tend to no show greater than open

appointments Improved access for patients Improved productivity Improved revenue

Benefits of Advanced Access for PCHC

Once the providers better understand the recall and reminder system, their resistance decreases

PCPs get to see their patients when the patient needs them and especially for acute needs which in a traditionally packed schedule acute patients often get sent to urgent care or ED and the provider is left doing a full day of chronic or preventive care

Benefits of Advanced Access for PCHC

Elaine Hardman◦ elaineh@providencechc.org◦ Office: 401-444-0400 Ext 3112◦ Cell: 401-226-3957

Jackie Fantes◦ jfantes@providencechc.org◦ Office: 401-444-0400 Ext 3374◦ Cell: 401-864-1951

Contact us with questions