Advanced Access; What s it All About?

Advanced Access; What s it All About? CATHERINE TANTAU TANTAU & ASSOCIATES POB 179, 111CHICAGO PARK CALIFORNIA 95712 530-273-6550 CT@TANTAUASSOCIATES.COM 1

Objectives Begin to understand the best work currently being done to dramatically improve appointment access and continuity for patients. Learn what research has told us for years about the value of Continuity between patients and PCP s. Recognize where you are on the access continuum and how to distinguish between Traditional, Open and Advanced Access models. Understand why access is a pillar of the Medical Home model and why it s not about just working harder. 2

Every system is perfectly designed to get the results it gets. 3

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Academics Weigh in Key Elements of a Medical Home Barbara Starfield, 2004 Accessible Person focused Comprehensive Coordinated Barbara Starfield, MD, MPH Director, Primary Care Policy Center Distinguished Professor, John Hopkins University Schools of Public Health and Medicine 5

NCQA PCMH Standards Standard 1: Access and Communication Standard 2: Patient Tracking and Registry Functions Standard 3: Care Management Standard 4: Patient Self-Management Support Standard 5: Electronic Prescribing Standard 6: Test Tracking Standard 7: Referral Tracking Standard 8: Performance Reporting and Improvement Standard 9: Advanced Electronic Communications

I had to think about this for awhile before I jumped in. I realized everything in medicine has changed steadily constantly looking for better ways to diagnose and treat patients. But, office flow has stayed the same for 50 years. It is about time we pay attention to it. Patrick Macken M.D., Luther Middlefort Waiting list of 4 months for 26 years eliminated in four months 50% now booked same day, 50% next day Phone abandoned rate reduced from 20% to <1% Protocols to refill common meds Anticipate need for x-rays, complete pre-visit 7

Minor changes in flow can help greatly with a very busy schedule Steve Smith M.D., Olympia Washington 3 rd next available 15 days to 5 days in 4 months Reduced appointment types from 7 to 3 Start on time Chart preparation the day before Pre-history form Huddles 8

I have seen that it works in other places so we have adapted the principles in our service. Marc Lowe M.D., Urology, Group Health Cooperative Achieved access goals in 5 months. Phone abandoned rate reduced 25% to 5% Late and missing encounter forms reduced from 151 per month to 0 in four months Standardized exam rooms and stocking lists Patient clinic discharge form allows MA/LPN to complete visit and fill out majority of paperwork 9

What if. you could offer your patients an appointment with the physician or provider of their choice at a time that was convenient for them? 10

Access An access problem is a delay problem An access problem is a system property 11

Constraints Demand from pts Request for primary service constraint Access to that service constraint Delivery of that service constraint Access to specialty service 12

The longer patients/families wait, The harder we work. New Patient Calls (1/wk/MD) Switchboard Established Patient Calls (Most) PCP Receptionist (4) # Admin. - Q & A - Page Pedi MA - Assist patient Hold Busy N.A. Answer Appt. req. recept Note: - No triage on phone - Occas. triage walk in + - Book it w/pcp - Overflow MD if walk in when avail min. -- hours or lost Bounce to others when PCP recept. fall Q & A Sick? Not sure Mesg. To MD MD calls patient Q & A Check insur. & confirm on 2 systems new patients longer - Next avail. w/pcp + - Book it - Add on sooner - Occas. Msg to MD or 30" - hrs. Advise Appt. Emerg. - ED Note: Always see pts. Admin. to resolve - non PCP - 1st available 13

Advanced Access AA is No delays for an appointment. CONTINUITY for patients and providers. Doing today s work today AA is Not Holding appts in anticipation of same day urgent demand. A Walk in Clinic or Urgent Care Clinic. 100% open schedule each day Telling pts to all back tomorrow 14

Advanced Access is the ability of a practice to Offer patients/families an appointment with the provider of their choice at a time that is convenient for them. 15

Start with an Aim The Gold Standard Primary Care: Offer an appointment today for any problem (urgent or routine) with the PCP or teammate in the absence of the PCP.* Specialty Care Offer an appt this week for any problem (urgent or routine) with the specialist of record or teammate in the absence of the specialist of record. WHY??? Tantau & Associates.com 16

Feeling overwhelmed? 17

Gold Standard: Why Today???? Constant tension between medical definition of Urgent and patient definition. Nice for pts. Transformative for the practice Work doesn t pile up Room to grow practice TODAY. Competitive advantage 18

Gold Standard: Why Continuity? Poor Continuity More hospitalizations Longer Length of Stay More referrals to specialists More prescriptions More ER visits More testing, studies Increased Demand More costs for everyone Lousy access 19

4/17/2002 4/24/2002 5/1/2002 5/8/2002 5/15/2002 5/22/2002 5/29/2002 6/5/2002 6/12/2002 6/19/2002 6/26/2002 7/3/2002 7/10/2002 7/17/2002 7/24/2002 7/31/2002 8/7/2002 8/14/2002 8/21/2002 8/28/2002 9/4/2002 9/11/2002 9/18/2002 3rd NEXT AVAILABLE PHYSICAL Carillion Medical Group Team 1 160 140 120 100 80 60 HARCUS LEWIS PRINCE STAMBAUGH YOUNG ZIMMER 40 20 0 20

Delay the Anchor Measure What s a 3rd Next Available? 21

Anchor Measure for Access Tool #1: How to Measure Delay for 3 rd next available appt. Delay for a Routine Appointment for each Provider Number of calendar days to third next available routine appointment. Pick appt type or length most delayed (physical?) to track Or, measure Long appts and Short appts. If that is more meaningful to you. 3 rd Next Available a reliable reflection of system s availability. 1st or 2nd appt likely due to cancellation or random event. Use your scheduling system; computerized or manual. Count number of days from today to the day when 3 rd next appointment is available. Measure for each Provider. Measure same day and time each week 7:30 Monday morning is good. Plot the number of calendar days to the third 3 rd next available appointment, each week An example of a Delay run chart.. 22

10/4/99 10/18/99 11/1/99 11/15/99 11/29/99 12/13/99 12/27/99 1/10/00 1/24/00 2/7/00 2/21/00 3/6/00 3/20/00 4/3/00 4/17/00 5/1/00 Days Delay for a Physical Exam 3rd Next Avail. Appt. for PE Appt. with PCP 30.0 25.0 20.0 15.0 10.0 5.0 0.0 23

5/31/05 6/30/05 7/31/05 8/31/05 9/30/05 10/31/05 11/30/05 12/31/05 1/31/06 2/28/06 A different time, a different place, a very different group, same access aim, similar results NUMBER OF CALENDAR DAYS UNTIL 3RD APPT 100 80 60 40 20 0 PEDI OB/GYN I MED Source: Providence CHC s, Rhode Island 24

Capitol Hill CHC Providence, Rhode Island Decrease No Show rate CHHC NO SHOW RATE 2005-2006 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% PEDI OB/GYN I MED APRIL MAY JUNE JULY AUGUST SEPT OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY Aug Sept Oct Nov Dec 25

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YKHC Physical Therapy Reduction in Delays for Appointments Stopped serial Booking of returns Third next appointment -PT 40 35 30 No. of Days 25 20 15 RH KH HJ 10 5 0 10/27/05 11/16/05 12/07/05 12/19/05 01/13/06 01/18/06 01/27/06 02/06/06 (*)3/7/2006 03/17/06 03/29/06 Date 27

Critical Access Design Elements 1. Continuity / familiarity 2. Appointment capacity 3. Demand and Supply equilibrium 28

Range (Max_Min) %VG/EX 1. Continuity Satisfaction Ratings 90 Comparison of Provider Ratings (Qs 56-65) by Demographics 1996 100 Ethnicity Gender Age Educ Health Status Care Type # of Visits Tenure 80 70 Range PCP Familiar Stranger 90 60 80 50 70 40 60 30 20 50 10 Am Africian Hispani White Chines Filipino Japane Other Indian Am. c e se Asian Other Male Female < 18 18-34 35-44 45-64 65+ LT 12 H School Post- Sec. College Grad G. Sch. Poor Fair Good V. Good Excelle Prevent Routine Contin Emerg Urgent nt ive uing ency 1 2-3 4-5 6+ LT 1 1-2 3-5 6-10 11+ 40 Range 19.8 21 23.3 20.6 20.5 22.9 23.3 22.7 22.1 20.6 22.1 27.2 18.4 19.3 16.6 14.5 19.7 22.3 22.1 21.4 20.6 21.6 21.9 22.5 21.9 22.2 19.5 20.7 21.4 20.7 16.6 16.7 20.3 22.1 24.1 21.5 23.6 22.2 21.24 20.14 PCP 78.5 81 79.5 84 72 75.7 80.8 71.3 80 82.6 81.4 85.7 73.4 79.3 81.5 82.3 78.1 80.7 82.9 81.4 84.4 76.6 74.5 77.5 83.8 88.3 81.4 82.4 83.8 79.6 78.4 78.9 81 82.2 83.2 80.9 80.8 80.1 81.99 82.67 Familiar 71.9 75 69.1 78 64.5 67 70.5 61.4 72.8 76.3 74.8 71.1 70.3 73.2 78.9 82.2 73.8 73 75.6 75.4 78.7 73.4 70 71.8 76.9 79.4 77.1 75.6 79.8 70.3 75.4 73 74.5 75.4 76.3 70.1 69.3 72.8 75.45 77.98 Stranger 58.7 60 56.2 63.4 51.5 52.8 57.5 48.6 57.9 62 59.3 58.5 55 60 64.9 67.8 58.4 58.4 60.8 60 63.8 55 52.6 55 61.9 66.1 61.9 61.7 62.4 58.9 61.8 62.2 60.7 60.1 59.1 59.4 57.2 57.9 60.75 62.53 29

Gold Standard: Why Continuity? Poor Continuity More hospitalizations Longer Length of Stay More referrals to specialists More prescriptions More ER visits More test, studies Increase Demand More costs for everyone 30

2. Capacity 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% % Open Next Four Weeks Sep-99 O ct-99 Nov-99 Dec-99 Jan-00 Dr. S Dr. T Dr. V 31

3. Demand and Supply Equilibrium Demand Evidence of a stable reservoir??? DELAY Supply Costs: No Shows, Triage, Rework, Call backs, Messages, Testing, Rx s 32

Access Continuum Traditional Model Carve Out Model Advanced Access Model 33

Traditional Model Saturated schedules Triage & rework use expensive resources (MD and RN) Multiple appointment types Urgent, Routine juggled Capacity: Overbook and over there Continuity: delayed 34

Open Access; Carve Out Model Marv Smoller,MD Predict demand for Urgent appts based on history. Reserve space for Urgent demand (carve out) Routines delayed; no space for intermediate care Continuity: fair to poor Capacity: Future filled or held 35

Carve Out Model Flaws Call back Black market Self destruct Do some of today s work today 36

Advanced Access Paradigm shift: No distinction between Urgent & Routine Evidence of stable reservoir Backlog eliminated (good vs. bad) Continuity: System property Primary Care panels Specialty care Case loads Capacity: Future is open Pull vs push 37

Advanced Access Today and the future are open and available for booking appts. Yesterday we did yesterday s work. Last week we did last week s work. Last month we did last month s work. Today we do today s work. We don t need to freeze, restrict, hold appts. We us tools to predict daily appt demand. 38

Advanced Access Fears: Saturated schedules Demand is insatiable Panel size Pitfalls: Panel size Supply side variation Do today s work today. 39

Traditional and Carve-outs In order to protect today, we push work to tomorrow. Vs Advanced Access In order to protect tomorrow, we pull work into today. 40

Results of Advanced Access Reduced delays for appointments Decreased Urgent Care and ED visits Improved continuity for patients and physicians Improved clinical outcomes Enhanced compliance with guidelines Growth opportunities and financials Increased patient, physician and staff satisfaction. 41

Nov 9-13 Dec 7-11 Jan 4-8 Feb 1-5 Mar 1-5 Mar 29-Apr 2 April 26-Apr 30 May 31-June 4 June 28 - Jul 2 Aug 2-6 Aug 30-Sept 3 Sept 27-Oct 1 Oct 25-29 Nov 22-26 Dec 20-24*** Jan 17-21 Feb 14-18 Mar 13-17 Apr 17-21 Delay for Appointments Before Advanced Access Wisconsin Group 1 Days to 3rd Next Available Appointment 10 9 8 7 6 5 4 3 2 1 0 After Advanced Access Target Level 42

Days til 3rd Available Routine Appointment 43

Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 May-00 Jun-00 Jul-00 Aug-00 Sep-00 Oct-00 Nov-00 Dec-00 Appointment Availability Family Medicine Clinic Average Percentage of Appointments Open at 8:00 a.m. 60% 50% 48% 46% 49% 51% 56% 40% 37% 40% 42% 30% 28% 33% 35% 29% 20% 18% 10% 7% 10% 7% 0% 4% 44

Emergency Department Visits ER Visits per 1000 Patients in Panel 20 18 16 Group 2 14 12 10 8 Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Group 1 Wisconsin Group 45

Patient / Provider Continuity Family Medicine Patient / Provider Continuity 90% 80% 70% 60% 75% 66% 77% 70% 60% 60% 66% 75% 69% 65% 69% 70% 77% 50% 53% 40% 36% 30% 20% 17% 24% 10% 14% 0% Jul-99 Sep-99 Nov-99 Jan-00 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 46

Lipids Colorectal BP - diag. Tetanus Influenza Pneumovax Breast Ca Cervical Ca Tobacco Use Tobacco users advice % of serv. Complete Improved Clinical Outcomes 120% 2000 1Q 110% 100% 90% 80% 88% 1999 Q4 97% 94% 97% 96% 88% 86% 98% 99% 86% 93% 70% 60% 50% 40% 30% 1998 Q4 20% 10% 0% Interventions: 1998 Q 4 1999 Q4 2000 Q1 Lipids 59% 92% 88% Colorectal 50% 74% 97% BP - diag. 88% 100% 94% Tetanus 50% 80% 97% Influenza 52% 100% 96% Health prompt Pneumovax 65% 92% 88% Breast Ca 69% 70% 86% Cervical Ca 76% 95% 98% Continuity Tobacco Use 70% 97% 99% Tobacco users advice 93% 90% 86% % of serv. Complete 60% 87% 93% 47 Advanced Access

Visits Change in Visit Utilization April 1995 - March 1997 Sacramento 250,000 2.250 Visits 194,305 200,000 Visit Rate 170,746 2.200 2.150 150,000 100,000 Impaneled Members 86,896 83,867 (-8.3 %) 2.100 2.050 50,000 2.000 - Initiated Second Generation End Year 1 End Year 2 4/95 to 3/96 4/96 to 3/97 Year Primary Care Visits Avg. # Impaneled Visits / Impaneled Member 1.950 48

Over and Under Appointments 49

Improved Finances Average per month over 1 year 440 429 420 400 380 360 378 Office Visits per Physician Decrease of 11.9% 340 385 380 375 370 365 360 355 350 345 340 April 98-March 99 April 99-March 00 355 50 379 April 98-March 99 April 99-March 00 Work RVU per Physician Increase of 6.8%

Improved Finances Average per month over 1 year $200,000 $190,000 $180,000 $170,000 $160,000 $150,000 $16,500 $16,000 $15,500 $15,000 $14,500 $14,000 $13,500 $167,560 April 98-March 99 $14,654 $196,521 April 99-March 00 $16,054 April 98-March 99 April 99-March 00 Net Revenue per Month Increase of 17.3% Net Income per Month Increase of 9.6% 51

Getting Started.. 52

High Leverage Changes for Access Improvement Balance demand and supply daily Reduce backlog Decrease appointment types Develop contingency plans Reduce demand for visits Optimize the Care Team 53

Advanced Access Sequencing Steps Foundation Steps Set Access Aim Gold Standard Empanel pts to PCP in Primary Care Measure delay 3 rd next available routine appt Measure Continuity with PCP Measure Appt Demand, Supply, Actual Match Demand, Supply, daily and weekly Action Steps Reduce Backlog Simplify appt types/times Contingency planning Reduce Demand for visits Optimize the Care Team At every step Track, display, discuss data weekly. Celebrate successes and failures! 54

XXXX Last Chance? What s next???????? 55

References Tantau, Catherine, Accessing Patient Centered Care Using the Advanced Access Model, Journal of Ambulatory Care Management, Winter, 2009 Managing the Unexpected, Karl E. Weick and Kathleen M. Sutcliffe, University of Michigan Business School, 2001 Kilo, C.M., Triffletti, P., Tantau, C., & Murray, M. (2000). Improving access to clinical offices. The Journal of Medical Practice Management, 16(3):126:132. Tantau, Catherine. Same-Day Appointments Create Capacity, Increase Access. Executive Solutions for Healthcare Management, February 1999. Tantau, Catherine, Murray, M., Sept 2000. Same-day appointments: Exploding the access paradigm. Family Practice Management, 7(8):45-50. Retrieved January 15, 2004: huttp://www.aafp.org/fpm/20000900/45same.html. Raddish M, Horn S, Sharkey P. Continuity of Care: Is it Cost Effective? American Journal of Managed Care. 1999:5:727-734. Jon O. Neher, MD; Gary Kelsberg, MD; Drew Oliveira, MD, Improving Continuity by Increasing Clinic Frequency in a Residency Setting, Family Medicine Journal, Vol.33, no. 10 p 751, November - December 2001 John W. Saultz, Jennifer Lochner, Interpersonal Continuity of Care and Care Outcomes: A Critical Review, Ann Fam Med 2005;3:159-166. DOI: 10.1370/afm.285. 56