Objectives To describe the 20-year evolution of Aurora Medical Group within Aurora Health Care To identify the cultural characteristics necessary to improve patient access from the patient s perspective To apply specific tactics and processes that improve patient access To implement monitoring techniques and follow-up action planning to assure compliance with patient access expectations. 2
Full Disclosure Brent R. Phillips, FACMPE, has no actual or potential conflicts of interest in relation to this presentation Stephen Francaviglia has no actual or potential conflicts of interest in relation to this presentation Mary Beth McDonald, CMPE, has no actual or potential conflicts of interest in relation to this presentation 3
Aurora Health Care 1991 Strategic Plan Aurora will expand its geographic coverage within Wisconsin to achieve its mission to: Establish strong affiliations with additional acute care and specialty hospitals Expand ambulatory care network through additional clinic affiliations Form a comprehensive integrated regional system with a complete continuum of care 4
Aurora Health Care Today 15 hospitals Eastern third of WI & Northern Illinois 1600+ employed physicians and 500+ APPs in 200 clinic locations Visiting Nurse Association 80 retail pharmacies 30,000 employees 92,000 inpatient discharges 3.6 million ambulatory care visits Revenue = $4.2 billion; 82% driven by the physician groups 5
Primary & Specialty Care Family & Community Services Prevention and Early Detection Pharmacies End-of-Life Care Home Care Behavioral Health Care Rehabilitation Emergency Care Hospital Care Continuum of Care 6
Aurora Medical Group Growth in Number of Physicians Nurse Practitioners, Physician Assistants, Nurse Midwives and CRNAs in 2011: 433 FTEs 7
Dyad Leadership Model President & Sr. VP Physician VP & COO Administrator Vice President Physician Vice President Administrator Vice President Physician Vice President Administrator Vice President Physician Vice President Physician Vice President Administrator Physician Management Committee/Administrative Teams 8
AMG s Priority Focus Areas Enhancing the Patient Experience Operational Readiness and Excellence Financial Performance 9
AMG s Priority Focus Areas Enhancing the Patient Experience Operational Readiness and Excellence Financial Performance 10
Validation From the Institute of Medicine Institute of Medicine s Principles: Effective Efficient Safe Timely Patient Access Patient-centered Equitable 11
Key Patient Access Principles Understand supply and demand 1,2,4 Reduce appointment types 2,3,4 Reduce scheduling rules 3 Physician and staff buy-in and accountability 1 Predict anticipated needs 2 Optimize supply by allowing caregivers to work at their highest training level 4 1. Improving Healthcare Access Virtually, Marshfield Clinic Indianhead Center Institute for Healthcare Improvement Link www.ihi.org 2. Making Advanced Clinic Access Work at the Amarillo VA Health Care System, Institute for Healthcare Improvement Link www.ihi.org 3. Improving Access to Pediatric Subspecialty Care: Initial Failures and Lessons Learned, Maria T. Britto et al Quality Management in Healthcare Vol 17, No 4. pp.320-329 4. Improving Healthcare Access Virtually, 2005 Marshfield Clinic Indianhead Center Institute for Healthcare Improvement Link www.ihi.org 12
Traditional Patient Access Models Triage Model Appointment types Urgent and Non-Urgent Diverts flows out of office Urgent Care and Emergency Department Creates more appointments with providers to re-establish continuity of care Time consumed with triage Carve-Out Model Reserved time blocked for Urgent cases Dysfunction in matching Demand with Supply Advance Access Reducing Waiting and Delays in Primary Care Mark Murray and Donald M. Berwick JAMA, February 26, 2003 Vol 289, No8 13
Advanced Patient Access Model Do today s work today Same day appointments - reduce time and work spent on triage Same day appointments - reduce provider interruptions caused by triage Same day appointments - with your provider improves efficiency and continuity of care Same day appointments - reduces no show rate and the need to overbook Advance Access - Reducing Waiting and Delays in Primary Care Mark Murray and Donald M. Berwick, JAMA, February 26, 2003 Vol 289, No8 14
AMG s Access Journey INSPIRE, PROVIDE MEANS, MEASURE Goal, Communication, Measurement Tools Enhanced Contact Hours Time-Starved Family Initiative Physician Schedule Revisions Standardized Appointment Types Same-Day Access Accountability Secret Shopper Monitoring Caregiver Merit Impact Results 15
AMG s Access Journey Goal: 100% of our patients will receive same-day access for primary care acute appointments Each provider will accomplish this in collaboration with an associate provider or Urgent Care facility (Urgent Care access can only account for less than 10% of patient access) 16
Communication Plan A detailed communication plan was developed that included the following: Written communication to all AMG providers that described the importance of the initiatives and their goals to all physicians/apps/ caregivers of AMG Videos from the physician President and VP & COO of AMG to all physicians/apps/caregivers of AMG stating the same message that was distributed verbally Messaging on Aurora s intranet (video and written message) for all Caregivers of AHC to hear F/U meetings in individual Markets within Aurora to review the message and its goals 17
Communication Plan 18
Measurement Tools AMG discussed which measurement tools to use to determine physician/app availability Third Next Available Appointment vs. Secret Shopper. AMG decided on using Secret Shopper as its primary measurement (less capital-intensive strategy) AMG contracted with a marketing firm to make patient calls for Same Day Access 19
Appointment Volume AMG s Access Opportunity 7am noon 6pm 20
Time-Starved Families Pilot Time-starved Families Single parent or two parents with children living in the home and busy working professionals Non-traditional Hours Monday-Friday Monday-Thursday Saturday 7am to 8am 5pm to 7pm 8am to Noon Ancillaries available during extended hours (e.g., lab, pharmacy, diagnostics) Extended-hours primarily for well-care visits family members schedule physicals on days off or after work Designed to establish a long-term relationship with a physician 21
Time-Starved Families Pilot Results 80% of available visits filled 92% of visits = busy working households 82% of users are commercially insured working household patients 172,311 claims during extended hours $34M in charges 5,437 new patients 75% TSF = commercial insurance 22
Enhance Contact Hours Standardize and enforce contracted hours established clear expectations Reduce the use of blocking, holding and freezing schedules Improve management of providers paid time off Normalize availability during day (early morning, lunch-time and early evening) 23
Enhance Contact Hours Design optimal appointment length and numbers to reach the 50th percentile in productivity Measurement system put in place to identify providers with Patient Access below the 50th percentile in productivity Implementation of the auditing system 24
Enhance Contact Hours Sample Report 1 2 3 4 6 7 A G H I P R Y AF AH AJ AK Physician or Provider YTD WRVUs MGMA YTD WRVU Productivity Tier MTD WRVUs MGMA MTD WRVU Productivity Tier Third Next Appt: Visit 13 Wk Avg <2 MTD Available Sched Hrs % Booked MTD Proj WRVUs at Avail Hrs Avail MTD WRVU Productivity Tier Physician 1 1,266.17 75% to 90% 268 > 90% 6.8 171.00 87% 309 > 90% Physician 2 1,007.88 < 30% 187 < 30% 0.7 87.25 68% 275 < 30% Physician 3 3,792.63 75% to 90% 766 75% to 90% 35.9 143.50 87% 876 75% to 90% Physician 4 2,795.77 75% to 90% 605 > 90% 0.3 132.00 31% 1,933 > 90% Physician 5 593.77 30% to 50% 152 30% to 50% 0.6 125.50 57% 265 50% to 75% 25
Standardize Appointment Types Reduced 153 to 9 core Visit Types (ongoing process): New Patient Same Day Visit Office Visit Well Child Complete Physical Complete Physical with pap First Prenatal Follow-up Visit Extended Follow-up Visit 15 additional visit types (examples include: nurse, return to work, pre/post op) are used, but the above 9 are used to measure access. 26
Standardize Appointment Types Benefits: Improves patient access and productivity Promotes flexible scheduling and removes barriers to access Improves accuracy of patient access data Reduces staff time associated with schedule management Simplifies the scheduling process and supports cross training Conducive to Internet patient portal self scheduling and centralized scheduling 27
Accountability Secret Shopper Monitoring Initiative Caregiver Merit Impact 28
Secret Shopper AMG contracted with a Marketing firm to Secret Shop Same Day Access Use specific scripts - objective and subjective (attitude, professionalism, etc.) were documented on spreadsheets A list was provided with the PCP names who were under 50% MGMA productivity The spreadsheet Info that was obtained was distributed to senior AMG leadership and the local markets for review/appropriate f/u could be taken Initial Results In July of 2010, the initial "Secret Shopper" calls revealed that only 54% of "callers/patients" who requested Same Day Access were actually given Same Day Access with the requested PCP provider, an associate or an Aurora Urgent Care facility 29
Secret Shopper AMG contracted with a Marketing firm to Secret Shop Same Day Access Use specific scripts - objective and subjective (attitude, professionalism, etc.) were documented on spreadsheets A list was provided with the PCP names who were under 50% MGMA productivity The spreadsheet Info that was obtained was distributed to senior AMG leadership and the local markets for review/appropriate f/u could be taken Initial Results In July of 2010, the initial "Secret Shopper" calls revealed that only 54% of "callers/patients" who requested Same Day Access were actually given Same Day Access with the requested PCP provider, an associate or an Aurora Urgent Care facility 30
Secret Shopper Since the Access initiative began in 2010, monitoring was expanded (1/11) to PCPs whose production was greater than 50% MGMA productivity, as well as select sub-specialties Initially there was fluctuation in Access as the emphasis in the beginning of the initiative was on the providers with lower productivity (>50%/MGMA) Accountability and expectations required additional review and reinforcement The latter half of 2011 demonstrated improvement 31
Caregiver Merit Impact 100% of same-day appointment accommodated Minimum of 90% being offered the requested provider or partner No more than 10% being offered walk-in or urgent care Impacts 10% of Caregiver s merit. 32
Results: Third-Next Available Problems with measurement Multiple site physicians Schedules built in advance of physician starting Physicians on leave remain in data Departed physicians remain in data Too many visit types included in data collection Results ignored Led to better measures of access 33
Appointment Volume Results: Post Time-Starved Family Initiative 7am noon 6pm 34
Results: Scorecard Example: Same-Day Access AMG Providers >50% September YTD September YTD Target Same Day Access Provider and/or Partner 18 190 62% 68% >90% No SDA except urgent care 9 160 31% 21% <10% No SDA offered 2 33 7% 12% 0% 29 383 100% 100% Incomplete Call 5 5 AMG Providers <50% September YTD September YTD Target Same Day Access Provider and/or Partner 34 525 83% 76% >90% No SDA except urgent care 6 102 15% 15% <10% No SDA offered 1 66 2% 10% 0% 41 693 100% 100% Incomplete Call 2 2 35
First Six-Month Results for Same-Day Access Initiative Percentage of "Secret Shoppers" who were given Same Day Access through a PCP or Urgent Care in 2010 100 90 80 70 102 168 97 86 92.5 139 60 50 40 86 85 % yes to provider, partner and/or U/C 30 54 20 10 0 July August Sept October Nov Dec 36
First Six-Month Results: Medical Group Visit Growth 12.00% 10.00% 8.00% 6.00% 4.00% 10% 2.00% 4.08% 0.00% YTD July 2010 Aug-Dec 2010 Visits 37
First Six-Month Results: Medical Group Visit Growth Visits 250,000 240,000 230,000 2009 2010 1.8% Increase in Visits in September over August 220,000 210,000 200,000 190,000 180,000 170,000 160,000 6% Increase in Visits in August over July 150,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec AMG Total: September 2010 38
Results Medical Group Visit Growth 250,000 AMG Visits 2009- November 2011 2009 2010 2011 225,000 200,000 175,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 39
Same Day Access Offered with a PCP Provider or Urgent Care Facility/Provider (7/10-12/11) 100 90 80 70 Percentage 60 50 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 2010 n=714 calls (8/1 to 12/31) 2011 n=974 calls (1/1 to 9/30) 40
Results: Financial Impact Impact of a 1% increase in visits for Aurora Medical Group and its affiliates results in $22,678,267 additional revenue to AMG and affiliated clinics and Aurora hospital. 41
Results: Financial Impact 1% increase in visits $6.9 M Annualized Net Revenue Impact on AMG/Affiliates Impact on AHC $22.7 M 5.9% increase in visits $40.71 M $133.93 M 42
Results: Productivity Improvement 250 25.7% increase in access and productivity 200 69 150 60 100 50 161 59 fewer Physicians 111 0 July 2010 Dec 2010 <30% >30%-<50% 43
Results: Patient Satisfaction 44
Patient Access Initiative Summary: First Six Months There were 59 fewer physicians under the 50th percentile Same day access (per Secret Shopper) increased from 54% to between 85%-97% During the final 6 months of 2010, visits increased 10% or 107,981 actual visits over the monthly average of 4.08% increase for the first six months of 2010 The Aurora Medical Group s annualized net revenue impact was $40.7M Aurora Health Care s system wide annualized net revenue impact was $133.9M 45
Creating a Culture of Patient Access Establish clear expectations and accountability Accountability drove discipline in behavior and process Discipline led to cultural shift Journey of Patient Centered Culture 46
Challenges and Lessons Learned 1. Many of the foundations for Best Practices related to Access already exist in previous research 2. Communication is critical. The Physicians, APP s and all caregivers must understand the rationale and plan for any initiatives. Do not assume that the message has reached the stakeholders; there must be a multitude of ways to deliver the message. 3. Accountability is the key. There must be clear cut items that can be measured and evaluated on a regular and consistent basis. 4. Knowing who and what someone is responsible for is a key to managing any process, but is crucial to accountability 5. Third Next Available Appointment s value in assessing access is limited 47
Challenges and Lessons Learned (continued) 6. Simplicity in the type of appointments is key. Scheduling must be easy and quick to improve access. 7. Physicians, APP s and all caregivers must not only understand why an initiative is important, but must also understand or buy-in to its value to improve the chance for success 8. The physicians are not the only people who may be blocking schedules, all other caregivers may be equally as guilty for their own personal reasons 9. An assumption was made that improved access would generally lead to improved patient satisfaction. This has not been true in all cases. 10.The more diverse the organization, the more difficult it is to standardize processes. It is a journey that does not happen overnight. 48
Challenges and Lessons Learned (continued) 11. Caregivers at all levels must have some skin in the game to make any initiative successful 12. Site management is critical to holding everyone accountable. The variation in managers can lead to different levels of success, even in a standardized process. 13. Relationship management is key. Difficult discussions occur everyday. Positive outcomes may hinge on these relationships. 14. Physicians must be part of the process. This is a basic concept, but again, critical to any initiative s success. 15. Remember, no matter what initiative is started, it must be about the patient first. This is what should drive us. 49
Next Steps in the Journey Visit Closure Referral Integration 50
THANK YOU Questions?