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Improving Access
SHCPQI
Learning Session
September 2, 2009
Christine St. Andre
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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
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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
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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?
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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
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Back–log reduction
No substitution for hard work, start work is also important
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“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
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“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
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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
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Project daily demand...
ExternalAppointment requests, calls regardless of
day appointed+ Walk-ins+ Other portals of entry+ Deflections
Internal+ Returns booked today
= Total Demand
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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
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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
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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
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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
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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
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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%
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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
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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
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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
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Group Visits-one way to shape demand
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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
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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
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What kind of group visits?
Diabetes CAD/CHF Prenatal Well Child Newborn Flu shot School physicals Elderly Others
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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
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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
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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
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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
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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
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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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