EnhancingAccess to Care:Load Balancing
F E B R U A R Y 2 0 1 3
A collaboration with:
CPUP 3701 General Medicine
CCA, Penn Medicine at Rittenhouse
Scheduling Center
Contact Center
Joel Blanco
Ivy Robinson
Keena Woodall
Monique Leblanc
Mark Lari
Scott Schlegel
Brenda Martinez
Tiffany Smith
Rashawn Riddick
Derrick Fant.
enhancing access to care
background:What was the initial intent of the big idea?Use web scheduling to make it easier for new patients to gain access to Penn primary care doctors.
Why was it important?Fast access to a PCP is critical to the health of our patients and community. Delays also lead to cancellations, no shows, and the loss of patients to other health systems.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––Several of the “Your Big Idea” tournament winners.
enhancing access to care
7.8%
20,368Appointments
Scheduled
10.0%
18.7%
29.5%
12,623Appointments
Scheduled
1,6001,269
3,826
3,732
38%
No Shows Cancellations
Increase in Cancellations and No-Shows for appointments scheduled after 31days
Percentages of No-Shows and Cancellations to Total Appointments
0 - 31 Days
31 - 60 Days
7.8%
20,368Appointments
Scheduled
10.0%
18.7%
29.5%
12,623Appointments
Scheduled
1,6001,269
3,826
3,732
38%
0 - 31 Days
31 - 60 Days
Appointments Scheduled within0 - 31 days vs 31 - 60 days
7.8% 10.0%18.7%
29.5%
0
5000
10000
15000
20000
25000
food came up cold and some food missing
food bad, no taste
Hospital food is bland. They often get left out and turn cold because the doctor comes in the second the food arrives. I feel hesitant asking the nurse to keep getting me hot tea.
Very bad food. Better quality food and more appatizers. I don; get the food i want when they always run out.
didnít like the dietary
a couple times he asked for water and it was late.
food could be better
food terrible, same dish two times in a row
Food needs to be improved taste
The nutrition was appaling. Lost 20 percent of body fat. Too too carbohydrate intensive. Need more protein and fat. Serving processed sugar to people who are sick and losing weight is ridiculous. Had to bring food from home. Too much juice. The soup is bad. I can tolerate oatmeal and some soups. Going home on a full liquid diet. Can tolerate cottage cheese but the hospital doesn't have that. Greek yogurt suggested by nutritionist but the hospital doesn't serve that. With an ostomy the food goes right through you and you need more protein/fat. Much better nutrition. Perhaps during times of nausea a little more attentive care/focused/proactive care could have been better. Somebody with more understanding about how the gas pain and nausea goes would have been helpful.
Food was terrible.
Breakfast was late one morning
Problem with the meals. Three di�erent instructions on food. She didntt know what she was supposed to do.
food could be more desirable, didnít come hot
food sucked, problem with ostomy bag
oes not like the jello
Everything is great except food. Dont taste right.
food is not as good as lankenau
food is not good
never got a menu for food
Food was good
On the positive, the nutrtrionist has been very attentive getting me what food I need.
Care, cleanliness and food were all good.
even the food was not too bad.
Kitchen man went out of his way to bring me something
food is good
+ SERVICE:
Kitchen man went out of his way to bring me something
On the positive, the nutrtrionist has been very attentive getting me what food I need.
- SERVICE:
never got a menu for food
a couple times he asked for water and it was late.
I feel hesitant asking the nurse to keep getting me hot tea.
Very bad food. Better quality food and more appatizers. I don; get the food i want when they always run out.
food terrible, same dish two times in a row
Breakfast was late one morning
Problem with the meals. Three di�erent instructions on food. She didntt know what she was supposed to do.
+ QUALITY:
- QUALITY:
food bad, no taste
never got a menu for food
a couple times he asked for water and it was late.
I feel hesitant asking the nurse to keep getting me hot tea.
Very bad food. Better quality food and more appatizers. I don; get the food i want when they always run out.
Hospital food is bland. They often get left out and turn cold because the doctor comes in the second the food arrives. I feel hesitant asking the nurse to keep getting me hot tea.
food came up cold and some food missing
food could be more desirable, didnít come hot
food sucked, problem with ostomy bag
Changes in Appointments Due to Lag Time
Penn Scheduler / Improving New Patient Access | 11.26.12
13%
Affects of Appointment Lagtime
enhancing access to care
Misc
Hard freezeInsurance issues
No slots / not accepting NPV
Patient is sick, wants appt. asap
Patient wants to be seen sooner Conflicts with patients schedule
Patient wants specific physician
Reasons for Non Accommodated NPV | Internal Med Sample July - Oct 2012
Penn Scheduler / Improving New Patient Access | 11.26.12
22.0%
38.0%
22.0%
16.0%
06.0%
06.0%
04.0%
04.0%
04.0%
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––Internal Medicine Sample July - Oct 2012
Reasons for New Patient PCP Non-Accomodation
enhancing access to care
process:Gaining Insight
The Center for Innovation was brought into the project to help drive its execution, and we worked with two design students from The University of the Arts Masters of Industrial Design program to gain insight into the underlying PCP access issues.
Defining the problem
Web scheduling was proposed as an initial solution; however, it did not address the underlying issues related to internal scheduling access.
The primary care scheduling process requires most new patients to call 800-789-Penn and then get re-directed to separate call centers that do not communicate or share schedules.
Appointment access varies across the Health System: fewer than 50% of patients are able to schedule appointments with a physician at the Department of General Internal Medicine within 4 weeks of calling. For Rittenhouse, the percentage is 76%.
These findings point to some form of load balancing as a potential way to alleviate some of the problem.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––Center for Innovation team members and two design students conducted
contextual research including: engaging with scheduling and contact center staff; documenting workflow processes; patient reaction and experience
mapping; secret shopper scheduling to better understand the needs and experience of patients and staff.
enhancing access to care
New Patient Scheduling Journey
Patient selects UPHS as their choice for care and identifies
phone number(Based on Insurance,
Referred, Reputation, etc.) Patient Calls
800-789-PENN“Contact Center”
Patient selects appropriate
automated option to schedule
appointment
Patient selects appropriate automated
option to schedule appointment
Patient describes their need for appointment
and provides demographics
Patient describes their need for appointment and
provides demographics
Patient is notified of available appointments
and makes decision
Based on patient criteria, preferred location, insurance
requirements, etc the Rep connects them the
appropriate practice.
Patient waits for Rep to answer
Patient waits for Access Rep to answer
Patient calls practice specific
number
Patient speaks with Access Rep
If needs are urgent the patient Access Rep
connects the patient with Practice Nurse/PSR
PATIENT TOUCHPOINTS
Patient Journey | New Patient Scheduling to Penn PCP
INTERNAL PROCESSES
AppointmentScheduled
Patient Discovers Need
For care
Scheduling Appointment
Pre-authorizations and Records are Confirmed
Patient receivesconfirmation/reminder call7 days prior to appointment
Waiting for Appointment
Patient confirms appointment
Contact Center Rep. asks several questions to enter
patient into the system (Name, DOB, Insurance
type, Address, etc.)
If the practice utilizes the external call center the Access Rep is notified of
patient type
If the practice utilizes an internal call center the
Rep connects them directly to the practice
Access Rep enters the patient into the system (EPIC) and identifies available appointments at the
practice(s) in their que
Patient confirms appointment
Patient makes arrangements for
Transportation,Time off, etc.
Patient receivesconfirmation/reminder call3 days prior to appointment
Patient is sentInformation in mail
(Depends on Practice)
Patient Appointment
enhancing access to care
New Patient Narrative
Patient selects UPHS as their choice for care and identifies
phone number(Based on Insurance,
Referred, Reputation, etc.) Patient Calls
800-789-PENN“Contact Center”
Patient selects appropriate
automated option to schedule
appointment
Patient selects appropriate automated
option to schedule appointment
Patient describes their need for appointment
and provides demographics
Patient describes their need for appointment and
provides demographics
Patient is notified of available appointments
and makes decision
Based on patient criteria, preferred location, insurance
requirements, etc the Rep connects them the
appropriate practice.
Patient waits for Rep to answer
Patient waits for Access Rep to answerpractice specific
number
Patient speaks with Access Rep
If needs are urgent thepatient Access Rep
connects the patient withPractice Nurse/PSR
PATIENT TOUCHPOINTS
Patient Journey | New Patient Scheduling to Penn PCP
INTERNAL PROCESSES Patient Narrative
AppointmentScheduled
Patient Discovers Need
For care
Scheduling Appointment
Pre-authorizations and Records are Confirmed
Patient receivesconfirmation/reminder call7 days prior to appointment
Waiting for Appointment
Patient confirms appointment
Contact Center Rep. asks several questions to enter
patient into the system (Name, DOB, Insurance
type, Address, etc.)
If the practice utilizes theexternal call center theAccess Rep is notified of
patient type
If the practice utilizes an internal call center the
Rep connects them directly to the practice
Access Rep enters the patient into the system (EPIC) and identifies available appointments at the
practice(s) in their que
Patient confirms appointment
Patient makesarrangements for
Transportation,Time off, etc.
Patient receivesconfirmation/reminder call3 days prior to appointment
Patient is sentInformation in mail
(Depends on Practice)
Patient Appointment
I Waited for about 5 minutes listening to advertisements that
had nothing to do with me
Patient selects UPHSas their choice fo
e and ident
Patient waits for Repto answer
sed on patient criteriaerred location, insuranuirements, etc the R
onnects them theopriate prac
Patient waits for Access Rep to answe
Patient is notified ofvailable appointmenand makes decision
I am new to Philly and when I got sick I wanted to �nd a PCP. A friend said I should
try Penn. I searched Penn medicine and found a website with a phone number, I
called the �rst one I could �nd, I wanted to get in as soon as possible
The woman explained that there were several options I could choose from and provided examples based on my location, When I made my selection she then explained that if I cannot get an appointment soon enough there I can call back and try another practice that may be able to get me in sooner. I asked if there was any way she could tell me now which practice might get me in the fastest, and she said she could not access that information, but then recommended a di�erent location based on her general knowledge and connected me with that practice.
After selecting the appropriate automated option I was on hold for about ten minutes.
After explaining all of my information, the person on the phone told me that she would not be able to get me in that, a Wednesday, day but an appointment was available that following Monday, which I was satis�ed with and so took the appointment. They told me what information to bring with me and to come a 1/2 hour early to �ll out some paperwork, I appreciated the heads up...
enhancing access to care
Load Balancing Areas of Opportunity
Patient selects UPHS as their choice for care and identifies
phone number(Based on Insurance,
Referred, Reputation, etc.) Patient Calls
800-789-PENN“Contact Center”
Patient selects appropriate
automated option to schedule
appointment
Patient selects appropriate automated
option to schedule appointment
Patient describes their need for appointment
and provides demographics
Patient describes their need for appointment and
provides demographics
Patient is notified of available appointments
and makes decision
Based on patient criteria, preferred location, insurance
requirements, etc the Rep connects them the
appropriate practice.
Patient waits for Rep to answer
Patient waits for Access Rep to answer
Patient calls practice specific
number
Patient speaks with Access Rep
If needs are urgent the patient Access Rep
connects the patient with Practice Nurse/PSR
PATIENT TOUCHPOINTS
Patient Journey | New Patient Scheduling to Penn PCP
INTERNAL PROCESSES Load Balancing Areas of Opportunity
AppointmentScheduled
Patient Discovers Need
For care
Scheduling Appointment
Pre-authorizations and Records are Confirmed
Patient receivesconfirmation/reminder call7 days prior to appointment
Waiting for Appointment
Patient confirms appointment
Contact Center Rep. asks several questions to enter
patient into the system (Name, DOB, Insurance
type, Address, etc.)
If the practice utilizes the external call center the Access Rep is notified of
patient type
If the practice utilizes an internal call center the
Rep connects them directly to the practice
Access Rep enters the patient into the system (EPIC) and identifies available appointments at the
practice(s) in their que
Patient confirms appointment
Patient makes arrangements for
Transportation,Time off, etc.
Patient receivesconfirmation/reminder call3 days prior to appointment
Patient is sentInformation in mail
(Depends on Practice)
Patient Appointment
tBased on patient criteria,
preferred location, insurance requirements, etc the Rep
connects them the appropriate practice.
Waiting for Appointment
If needs are urgent thepatient Access Rep
connects the patient withPractice Nurse/PSR
Here Reps will sometimes notify the patient that if the practice they are connected to cannot accommodate them in a reasonable time they should call back and try another practice. How could we build on this by providing these reps with the knowledge to direct the patient to the practice that best accommodatea their needs.
While we don’t have any direct insight to this process, there would surely be a bene�t in provid-ing the necessary information / tools for these practices to accommodate these patients through load balancing, particularly because these are typically the most urgent cases
Another opportunity may be to utilize a waiting list type approach, as we have discussed in the past, which could be
shared and managed across practices.
Access Rep enters the patient intothe system (EPIC) and identifiesavailable appointments at the
practice(s) in their que
This is the area I believe we have been looking at for the load balancing approach, which
there would be an obvious bene�t in providing access to scheduling across practices.
enhancing access to care
Measures used to define success
New patients should receive appointments within 1 week for urgent issues and 3 weeks for non-urgent issues.
Explore solutions
Load balancing, through shared scheduling among primary care services, was our main area of focus as it would meet the needs of a large population.
We explored other solutions to better understand and meet the needs of other more specific populations, namely our own employee population and those patients already receiving Penn specialty care.
Rapidly validate
Practice managers and call center supervisors gave nineteen call center representatives the ability to schedule appointments at both CPUP practices and Rittenhouse CCA starting on December 28, 2012. This load balancing effort was aimed at redirecting new patients from the overcapacity CPUP practices to the under utilized CCA clinic.
Load Balancing | Shared Scheduling
Insights: While some practices are not able to accommodate new patients visits within what thepatient considers a reasonable timeframe, other practices are in need of new patientsand can accommodate them quickly.
Prototype:
By opening access to scheduling between practices in high demand of new patientsand practices with little capacity, we can increase new patient access and reduce lagtime to new patient appointments.
The scheduler notifies the patient that the next available appointment at 3701 is more than 3 weeks away but she can check another practice to see what they have available.
A Patient calls 3701 to make a new patient PCP appointment. They are sick and would like to be seen right away.
Let me see what I can do for you.
I am sick and would like to be seen ASAP.
3701
The scheduler tells the patient that they can be seen at the Rittenhouse practice in 2 days. The patient gladly accepts and the scheduler makes the appointment.
Rittenhouse
Specialty Access | Allowing specialty patients quick access to a PCP
Specialty Physician recognizes need for patient to see a Primary Care Physician and makes a notation in the chart
During checkout the PSR sees the note regarding scheduling a Primary Care Physician and references the flier for an expedited number
The PSR calls the number for the patient and schedules a Primary Care Physician using specially reserved spaces
Need a Primary Care Physician?
Call800-555-5555
Have you gotten your flu shot? Your
PCP can take care of that for you.
I see you need to schedule an
appointment to visit your PCP.
PriorityAccess
Schedule with a primary care physician
Now I know where to schedule!
UPHS Access | Giving employees direct access to a primary care physician
How can I see a primary care
physician?
Schedule an appointment with a primary care physician
PriorityAccess
Need a primary care physician?
Call: 1-877-354-4999
Insights: Employees do not have priority access to schedule an appointment with a doctor.
Prototype: Develop a dedicated phone number that is shared on the UPHSintranet for employees to use to schedule an appointment.
A link is located on the intranet homepage that is devoted to helping employees schedule an appointments for a primary care physician.
An employee logs onto the intranet to find out how to schedule an appointment with a primary care physician.
Once the employee clicks on the link, theya re taken to a web page that has a phone line devoted to scheduling employees.
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––We developed simple scenarios that illustrated concepts. These scenarios were
used to engage different stakeholders and understand their point of view on how potential solutions might work.
enhancing access to care
Current State Shared Scheduling
Load Balancing:
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––This visual represents the current state and purposed future state with share scheduling.
In the current state a patient is directed to a specific PCP based primarily on location. If they are dissatisfied with the time to appointment they are may be directed or transferred to another practice or the patient goes somewhere out side of Penn Medicine. This gap is
bridged with shared scheduling.
DGIM
Short Lag TimeLong Lag Time
800-789-PENN
Rittenhouse DGIM
Short Lag TimeLong Lag Time
800-789-PENN
Rittenhouse
enhancing access to care
What were the initial results and what did they reveal?
Load balancing has redirected 147 new patient appointments from CPUP to Rittenhouse CCA between December 28, 2012 and February 28, 2013, resulting in a reduction in lag time for patients from as much as 3+ months to several days. Approximately 80% of patients have shown up for their appointments. These positive results indicate that new patients appreciate and utilize options that reduce the time they have to wait for their first appointment. In addition, Rittenhouse CCA was eager to get new patients.
What are the next steps?
Our recommendations are to build upon the load balancing experiment with additional experiments in the following areas:
Test an intervention at the contact center that expands upon the triage that currently is used. Instead of directing new patients based on their zip code, consider triaging patients based on other important physician characteristics such as time to next available appointment.
Work with the call center to test the expansion of load balancing to other CCA clinics throughout the Philadelphia metropolitan area.
147 appointmentsscheduled ––80% show rate
RESULTS
