Improving Access

SHCPQI

Learning Session

September 2, 2009

Christine St. Andre

Objectives

Define 2 methods for improving patient access without adding provider staff

Describe the fundamentals of advanced access scheduling and how to get started

Describe elements of group visits—logistics and benefits

Why Access?

Waiting creates dissatisfaction and potential unwanted reduction in demand

Delays in getting appointments lead to no shows and non-revenue provider time

Inability to see one’s one provider compromises continuity errors, rework, risk management issues

Access and communication is one of the areas of focus for patient-centered medical home

What is Advanced Access ?

NO delays for an appointment. No delays during the appointment (cycle time) CONTINUITY for patients and physicians. Doing today’s work today.

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What is your current Access?

Who has tried to implement Access principles?

High Leverage Changes for Access Improvement

Balance demand and supply daily

Reduce backlog

Reduce demand for visits

Decrease appointment types

Develop contingency plans

Optimize the Care Team

Back–log reduction

No substitution for hard work, start work is also important

“Work Hard” Strategies Include . .

Develop a written plan and a date goal Add daily capacity

Working days off or parts of days offStarting clinic earlyWorking over part of lunchSaturday clinicEvening clinicUse of NP/PAs

“Work Smart” Strategies Include . .

Look ahead into schedule/ remove demand Extend visit interval Maximize visit efficiency-max pack Support the team with tools and system

improvements to allow them to be more effective and eliminate waste

Track and display metrics

Next Steps for Advanced Access . . .

Decrease appointment types• Times = types• Decrease variation

Increase flexibility

• Eliminate the need to sort and match• Eliminate “qualifying” criteria

• Makes scheduling easier

Project daily demand...

ExternalAppointment requests, calls regardless of

day appointed+ Walk-ins+ Other portals of entry+ Deflections

Internal+ Returns booked today

= Total Demand

Next Steps

Once you project demand...Build enough open appointment slots to meet

daily demand

Develop contingency plans

AND

Shape demand (both during back-log reduction and steady state) so that you CAN match capacity with demand

Contingency Plans

Match capacity and demand daily Time off policies Minimum # of provider policies Post vacation schedules Effective use of NP/PAs Unexpected is often predictable

Shaping Demand - Examples

“Max Packing” (never let 1 visit turn into 2)

See today’s demand today – try to avoid future scheduling

Increase same day availability Find hidden capacity Challenge practice styles

Shaping Demand (continued) Guideline Use

Sore throats, UTI First a.m./p.m. appointment on time Shift procedures and follow-up

appointments away from Mondays Daily huddles Proactive schedule management Work to the appropriate level Alternate visit types

Do More Per Visit--MaxPack

Longer appointment slots if needed Document the increased visit intensity to code higher charges,

turning level 3 visits into 4’s and 5’s Patients will need fewer overall appointments Opens capacity to see more patients Result: increased number of higher charge visits Note: type of reimbursement matters

©Tantau & Associates

Outpatient E&M Levels:Example of potential result

Level of Visit

Benchmark(eMD’s)

HFMAdv. Access Team

1 5% <1%

2 6% 3%

3 60% 54%

4 28% 37%

5 1% 5%

If Supply Doesn’t Equal Demand …Tendency is to:

Hire more providers Work harder Close panels Instead... Shape demand Increase supply

Optimize the care team Identify and manage the constraintUse of technology

Success hinges on . . .

Willingness to try something new Willingness to take risks Physician champions Good communication Regular meetings “Next Tuesday” change mindset A lot of hard work Celebrate accomplishments

2020

Advanced Access is NOT

• Not about limiting patients’ ability to book in

advance

• Not about prioritizing Access over Continuity

• Not about making doctors or team members

‘work harder’

• Not about promoting a walk-in culture …

• Not about unleashing limitless demand

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Models

Group Visits-one way to shape demand

What is a group visit?

Visits designed for groups of patients rather than a 1:1 patient-provider visit---shared medical appointment

Include more than group education and support, generally including many aspects of the individual visit---a change in the care delivery system

Takes the place of the regular provider visit Intended to validate patients as self-managers of

care Voluntary; Interactive; Efficient and effective

Most common---CHCC (Cooperative Health Care Clinic) Started with frail elderly who were high utilizers/

multiple conditions--John Scott 1990 2 – 2 ½ hours, no more than 20 patients Includes individual sessions, plus education, and

addressing group concerns and questions Scheduled at regular intervals, same group of

patients Focused on like patients with chronic condition

or other common health concern

What kind of group visits?

Diabetes CAD/CHF Prenatal Well Child Newborn Flu shot School physicals Elderly Others

Potential Benefits of Group Visits

Improved access Enhanced provider productivity Promotes patient self-management as well as

using others as resources Leverages existing resources for operational

efficiency Improve quality of care Improved patient satisfaction Provider satisfaction Improved bottom line

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Getting started

Start planning early (10-12 weeks) Enlist a champion Identify potential candidates Schedule provider and other staff/ determine

frequency of the group Secure space (adequate for 30 people in circle or U-

shape Formal written invitations, phone follow up Develop agenda Review charts/ create individual flowsheets

Patient selection

Good candidates Need routine or follow up

care People with similar

problems requiring education

Time-consuming patients Frequent visits Emotionally needy “Worried well”

Not so good candidates Memory problems Language barriers Reluctance to attend First visit patients Communicable diseases Multiple medical

problems

Agenda—2 hour group

15 min: Introductions (use name tags and allow each person to speak)

30 min: Topic of the day 30 min: Provider and nurse talk to each patient;

vital signs; med refills 15 min: Q&A 15 min: Planning for next group/ topic selection 15 min: Individual 1:1 sessions as needed

Challenges with Group Visits

Require good organization and planning Patients without a relationship to the provider Space Charting time Assuring quality care Confidentiality Interruptions Talkative physicians Not all patients interested

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No-show and low-show rates and attrition Expect 1/3 to 1/2 of those invited to attend Patient selection Stress the visit is in lieu of regular visit, not just

education Invitation by the physician Timing and frequency matter Invite family Refreshments and fun

Economics

Maximizes use of educational, referral and other “specialty” resources.

Creates openings in schedule to see more patients at other times.

Need to maintain pre-determined minimum levels of patients to maintain leverage of provider time and keep the gains in productivity and efficiency.

Need a minimum number of patients…(e.g. if provider spends 2 hours in a group and she usually sees 3 patients/hour, need at least 6 patients to break even, more to improve ROI).

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Getting Paid—ask for forgiveness

Some state Medicaid programs and other payors starting to pay for them—isolated cases.

CPT panel: No defined code- use 99499 “Unlisted E&M service”

CMS position: No prohibition on group members observing while a physician furnishes a medically necessary service to a particular patient.

Most practices bill 99212, 99213, or 99214 based on complexity of the individual visit part of the group visit. Documentation is critical.

Group Visits with no provider and no billing---may make sense for some patients if provider time can be freed

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Resources-Access

http://dms.dartmouth.edu/cms/toolkits/improving_access/

IHI.org

Resources- Group Visits

Group Visit Starter Kit at www.improvingchroniccare.org

www.ihi.org www.aafp.org http://www.impactbc.ca/practicesupportprogra

m/resourcesforclinicalpractices/cdm/groupmedicalvisitsresources

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