ACTIVITY DISCLAIMER Tools for Improving Access and Continuity Jean Antonucci, MD The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Jean Antonucci, MD Physician, Farmington, Maine Dr. Antonucci earned her medical degree from Temple University School of Medicine, Philadelphia, Pennsylvania, where she was a member of the Alpha Omega Alpha (AOA) Honor Medical Society. She completed her residency at the Maine-Dartmouth Family Medicine Residency, Augusta, as well as a fellowship in academic family practice at the University of North Carolina at Chapel Hill. A strong advocate for primary care, she has worked in various settings during the course of her career, including a hospitalowned practice, a federally qualified health center (FQHC), and a U.S. Department of Veterans Affairs (VA) hospital. For more than 12 years, she has run a family medicine practice in rural Maine that is high functioning and innovative, provides high-quality health care, and has low total resource use. At the Maine-Dartmouth Family Medicine Residency, Dr. Antonucci teaches in the practice management program and precepts in the model outpatient clinic. She has been an organizer of primary care physicians in her local community and statewide, and she has also written articles about the state of primary care. Currently, she is a board member and the project director for continuing medical education (CME) calls for the 501(c)(3) organization Ideal Medical Practices. She was a founding board member and previously served as the organization s treasurer. Learning Objectives 1. Describe the value of care continuity between the patient and the care team. 2. Identify appropriate and achievable methods to provide 24/7 access without compromising the quadruple aim. 3. Analyze opportunities for alternative access such as telemedicine, e-visits, group visits, etc. Tools to improve access and continuity Jean Antonucci MD jnantonucci@gmail.com 1
The 4 Pillars of Primary Care ---I can get care when I need it ---My doctor or nurse knows me ---My doctor or nurse in my primary care office provides most of my care over time ---My primary care office coordinates my care with other providers of care Patient and Family Drivers Key Attributes of Effective Primary Care I receive exactly the care I want and need exactly when and how I want and need it Moore LG, Wasson JH, JACM Vol 29, No 3, pp. 195-198 Strongly agree Disagree Strongly disagree Do you have: % agree %agree Continuity 95% 60% Access 85% 10% Efficiency 80% 20% Information 80% 20% Confident Self-Care 75% 15% Permission: John H. Wasson, MD Improved patient outcomes Improved experience of care Reduced per capita cost of health care Patient and family determinants of self care, self reflection learning, resilience Provider Care Team Drivers Patient and Family Centered Care Care Team Development Planned Care Access Efficiency Coordination Leadership Drivers Strategy and Prioritization Work Force Vitality Financial Viability Transformational Leadership Change management Building QI Capacity Health care policy and financing drivers Total dollars allocated to primary care Cost containment initiatives Eligibility and benefits variability Patient s Agenda and Experience Patient s agenda is a major driver of their behavior and outcomes Patient s experience is a major driver of their behavior and outcomes Poor relationship predicts lack of follow up with preventive recommendations and chronic disease management Poor continuity predicts hospitalization Poor experience of access or wasted time in the office predict no show Access means that patients say I can get care when and how I need it It includes open access scheduling and after hours call and texting and nontraditional visits and panel size management and office management 2
AES POLL QUESTION Which is not a barrier to access? 1. A practice that always is open to new patients 2. Phone trees 3. Specific telephone hours 4. Small functional teams Delays are costly Patient satisfaction Safety Why This Matters Delays are Costly No-shows Work arounds Who scheduled an X in a Y slot!?!?!?! Delays are costly Keeping up with the work is easier It s all about doing today s work today Thoughtful management of key variables plus flexibility make it possible Barriers to Improving Access Emotional burnout Lack of mentors/role model Lack of support technically/office staff Why We Cannot Get It Done Systemic issues Balancing supply and demand 3
Five Keys Areas for Improving Access 1. Manage first contact 2. Increase continuity 3. Open Access Scheduling 4. Offer alternatives to traditional visits *5. Improve overall office function It s your panel size How to Get it Right How to Get it Right It s your panel size It s what the front desk says on the phone How to Get it Right It s your panel size It s what the front desk says on the phone Minimize appointment types, saving slots, redline time, yellow line time and other devices Do today s work today How to Get it Right Part 2 Realize the system is set up to work against patient s and physician s needs It s our attitude You don t train patients Train staff and professionals Name the seven dwarfs (memory test) 4
Know your patients Know your providers Adjust panel size Closing and opening a practice is complex Demands increase as we are more accessible - let the source of dysfunction know Do more at a visit Do today s work today Flexing to the variation in demand AES POLL QUESTION Where is the weakest link in your own system? Key Variables Your total patient population (aka panel size ) Illness burden Scope of practice How much time you want to devote to work Composition of your team Reimbursement variables Vacation Employers Problems 5
Pitfalls of Planning for Open Access --Unrealistic view of what your supply really is When you are counting the number of days of provider time per year do not forget meetings (two Fridays a month you have 8 am meetings and start 1 hour later?) CME time,etc. --Be willing to work a bit harder before and after vacations OR (better) plan those times very carefully to prebook less good backup --be willing to work more on occasional busy days Fear not! This does not, if done well, put you back into the grind. But some flexibility is required. By doing today s work today you avoid what is even worse- today s work left over for next week! --Be willing to close your practice to stabilize demand --Keep it simple. Do not get stuck on multiple rules for staff OR for patients, or appointment types Keep It Simple TELL THE STAFF *NOT to have people call back *To put patients in that day. Prove what you do and see them the day they call. *To pre book some. Pre book not more than 1/3 of the visit time of your day. *To be clear to patients we will see you from 9 to 9:15 for knee pain Tell the staff to educate the patients TELL THE PATIENTS *Here are the days I am in- you can call on those days or see someone one else- we prefer you see your own doctor. She guarantees to see you the day you call. He will see you from 1 to 1:20 for the tick bite DEMAND How much have you been offering / is requested? - Look at your number of visits last year per provider. Many may be no shows or do overs Eg.:Oh- I cannot treat that wart while you are here, the liquid nitrogen is 22 steps and 10 min away, and I am too busy--come back. Or- I am not your doctor and I do not want to start HTN treatment-- come back. OR- I am not the usual provider and you have a pain contract with her. Come back. Look at your panel size. Consider how often each unique patient comes in- national average is 3.2 visits per patient per year. If all you see is acutes, can see all short visits more visits per year If all your practice is HIV care your panel size will be smaller and still fill the time. AES POLL QUESTION Name at least two non-traditional types of visits that improve access Think hard about why you bring people in every X months. There is no science to this - if you extend the re-visit interval because it is unneeded or because you use visits or a nurse call, you can improve access. How to start Work down the backlog. Not Measure a little bit how many people per day call to be seen that day? Are some days busier than others Keep it simple Pick a day in the future when the schedule is fairly empty. As of that day on the schedule you will not fill more than 50% of the day before it gets it here When it gets here the front desk is to say do you want to be seen today? Patients can be pre-booked for return visits but this increases no shows - a reminder card plus tickler works better IF you have done refills at visits, refills are your reminder 6
Worksheet for Open access SUPPLY -- What do you have to offer? 1. List the number of providers 2. List how many days a week each provider works 3. Multiply 1 x 2= 4. Weeks a year the provider is really in the office *TIP: Be careful to include CME, sick, vacation, conference meetings, duties at hospital, etc 5. Multiply answer 3 x 4= days of provider time per year 6. Multiply #5 answer by number of visits per day you think is realistic 7. *HINT: Limit the number of available kinds of slots. Use only 30 or 60 min slots. Use 20 min slots with multiples of these for longer visits. Avoid too many rules! Other Visit Types e-visits Transitional care visits CCM coding Telehealth E-Visits Please follow these FOUR easy steps: Any patient of the practice who needs care but does not need to come in to the office can do an electronic, or E Visit, without calling first. Just follow these instructions! 1. READ the E VISIT Information and Consent Information 2. CLICK on the PayPal Payment Button below 3. FILL IN ALL the white boxes and the check boxes 4. CLICK ON "SEND INFO" at the bottom. CHECK WITH YOUR PHARMACY! Your e visit will be answered some time today! Resources --www.ihi.org Search on Access --http://www.aafp.org/fpm/20000900/45same.html --Improving Timely Access to Primary Care: Case Studies of the Advanced Access Model Mark Murray, Thomas Bodenheimer, Diane Rittenhouse, and Kevin Grumbach JAMA 2003; 289: 1042-1046. --Advanced Access: Reducing Waiting and Delays in Primary Care Mark Murray and Donald M. Berwick JAMA 2003; 289: 1035-1040. --Lacy N, Pullman A,Reuter M, Lovejoy B, Why We Don t Come- Patients Perceptions on No Shows Annals of Family Medicine 2004 (5) pp 541-545 -- Open Access in Academic Practices Steinbauer et al Family Practice Management March 2006 pp59-63 7
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