Improving Access to Subspecialty Care in an Academic Medical Center Sam Weir, MD Warren P. Newton, MD, MPH University of North Carolina at Chapel Hill STFM Annual Meeting April 30, 2008

The Problem Access to specialist care drives payer mix/revenue, relations with referring doctors and patient satisfaction Many AHCs have significant problems with access Not many easy answers…

Objectives To describe an intervention to improve access to specialty care in an academic center To describe the role played by the Department of Family Medicine

Setting University of North Carolina Health Care UNCHCS provides comprehensive subspecialty care 65% of business comes from 6 area counties, but with large numbers of patients from all 100 counties Long wait for appointments in most divisions, yet overall demand expected to double in 10 years given rapid growth in the region A setting of rapid change in clinical infrastructure: scheduling, billing and clinical data system changes Integrated clinical record system (hospital, ancillaries, outpatient)

Department of Family Medicine Experience with practice redesign: open access, chronic disease, group visits (DM, Mothers, Well Children), e-medicine, as well as hospitalist/MCH

In the beginning… Strategic planning retreat of senior leaders discussing plans for growth…. Reality check—how can we grow when we’re not able to see our current patients? RFP for access improvement, implementation of new scheduling system Outside consultants OR Internal proposal developed by 3 MD faculty

Patient Access & Efficiency Initiative Three year project with goals: New patient evaluation in any clinic within 14 days. Reduce visit cycle time by 30% Implement enterprise wide scheduling system Learning collaborative model with three waves of improvement teams; all 54 clinics involved. Staff: Director, Redesign Change Managers, Data Coordinator, internal faculty (part time) Budget: Total of 3.2 million dollars, with contributions from the practice plan and the hospital Governance: Senior leader sponsors from both hospital and practice plan Started data team in 4/05; third wave started 11/07

February 2008: 63% of UNC clinics had appointments for new pts in < 15 days

Lessons Making the Case for Advanced Access Focus on new patients—improves revenue Offload return demand creates opportunity Service agreements between primary care and selected specialties improves understanding and collaboration PAcE has pushed OR & hospital throughput to a crisis point How will we organize quality?

Lessons Leading/Managing the Process Helpful to have friends (and patients) in high places Internal vs. External consultants Strategy of waves (get some early success) How to involve clinical leadership in subspecialties…

Lessons Role of Family Medicine QI Expertise, proven track record – and relationships Collaborating with other disciplines Opportunity knocks – being able to answer having the capacity to ‘share’ faculty time for an institutional role Spin offs/opportunities Care protocols (‘service agreements’) Uninsured care Financial support/Good will Downside Distraction from departmental work

Next Steps Incorporate new scheduling/tracking systems, address own services Extend to OR & ED throughput, linking ambulatory and inpatient care and community reorganization Key issue is sustainability, both in other departments and across the institution.