The UCSF Double Helix Curriculum: Facilitator Guide Time: 10 minutes Audience: First through third year residents Objectives: to understand your primary care clinic's access and how this differs from others, and changes over time. Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum:

Prompt Access to Care: The Basics Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: Adapted from the Center For Excellence in Primary Care

The UCSF Double Helix Curriculum: Lee Needs Access Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: CHOOSE EITHER ADULT OR PEDIATRIC CASE. FACILITATOR WOULD READ TO THE GROUP (OR COULD HAVE AUDIENCE MEMBER READ THIS OUT LOUD): Lee is a 57 year old woman with diabetes. She sees her physician every 3 months and has had trouble controlling her diabetes. She trusts her physician and enjoys their visits. In January, she is in a car accident. Her nephew is killed and she is hospitalized for 4 days. After the hospitalization, she experiences symptoms of post traumatic stress. Reliving the accident Afraid to enter cars Nightmares Frequent crying She calls her doctor’s office but is unable to get an appointment with her provider until their next scheduled appointment in 6 weeks Instead, she is scheduled to see the urgent care doctor, who she has never met. On the day of the appointment, the Lee is anxious about getting in a car to come in. She decides that this new doctor won’t be able to help her anyway, so she stays home and misses the appointment, wishing she could just talk with her regular, trusted physician about her fears. By the time of her next appointment, she has missed 6 weeks of work and lost her job.

The UCSF Double Helix Curriculum: Lee Needs Access Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: CHOOSE EITHER ADULT OR PEDIATRIC CASE. FACILITATOR WOULD READ TO THE GROUP (OR COULD HAVE AUDIENCE MEMBER READ THIS OUT LOUD): Lee is a 14 year old teenager with diabetes who lives with her 62 year old grandmother. She sees her physician every 3 months and has had trouble controlling her diabetes. She trusts her physician and enjoys their visits. In January, she is in a car accident. Her cousin is killed and she is hospitalized for 4 days. After the hospitalization, she experiences symptoms of post traumatic stress. Reliving the accident Afraid to enter cars Nightmares Frequent crying Lee’s grandmother calls Lee’s doctor’s office but is unable to get an appointment with her provider until their next scheduled appointment in 6 weeks Instead, she is scheduled to see the urgent care doctor, who she has never met. On the day of the appointment, Lee is anxious about getting in a car to come in. She decides that this new doctor won’t be able to help her anyway, so she stays home and misses the appointment, wishing she could just talk with her regular, trusted physician about her fears. By the time of her next appointment, she has missed 3 weeks of school.

The UCSF Double Helix Curriculum: What is access? Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: BB 8: Prompt Access to Care

Moving to Better Access Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: Advanced Access Better Access

The UCSF Double Helix Curriculum: Defining Access Patient lens – you are a patient and you have a rash and haven’t been sleeping; you call the clinic for care Clinician lens – you want to f/u with a patient who sent you an email stating “I am having trouble breathing and feeling dizzy. This is what it felt like when I had pneumonia.” Clinic lens – TNAA is 30 days for most clinicians and you need to balance schedules of part time FTE’s and a residency clinic. Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum:

The UCSF Double Helix Curriculum: But why isn’t Access FIRST! It’s SO IMPORTANT! Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum:

The UCSF Double Helix Curriculum: The Path Know your population before you decide how to staff what they need Empanelment/Data Team Based Care Population Management Access to Care Comprehensiveness and Care Coordination Redistribute the work before trying to match supply and demand Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: Refine the work of the team to improve care for patients Make sure patients can get appointments when they call Free up RN time by reducing triage need and standardizing low risk care

The UCSF Double Helix Curriculum: Why is it important? QUADRUPLE AIM! Patient Satisfaction Improved Patient Outcomes Reduced healthcare costs Increased Staff Happiness Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum:

The UCSF Double Helix Curriculum: Access & Outcomes Quality of Care Hosp. patients: 27% had out-patient workups recommended by hospital physicians  only 35% of these were completed (↑ time to PCP visit →less chance w/u done) Cost of Care Improve outpatient access associated with decreased ED visits & hospital admissions Patient Satisfaction Overall mixed results, but numerous observational studies showing dramatic improvement Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: Moore C, et al. Arch Int Med; 167(12):1305-11. Rose KD et al. Arch Intern Med. 2011;171(13):1150-9. Hudec JC et al. Can Fam Physician 2010; 56(10):e361-7. Newman ED et al. Arthritis Rheum. 2004;51(2):253-7.

The UCSF Double Helix Curriculum: Lee Gets Access Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: CHOOSE EITHER ADULT OR PEDIATRIC CASE. FACILITATOR WOULD READ TO THE GROUP (OR COULD HAVE AUDIENCE MEMBER READ THIS OUT LOUD): Lee calls the clinic to make an appointment with her physician. Because her physician has a right-sized panel, support from the team for chronic care tasks, and Open-Access slots every day, her own physician is able to see her within a week. On the day of the visit, Lee is nervous about getting into a car to see her physician. But she doesn’t want to let her physician down, and she is really looking forward to talking with her about what happened, so she asks her husband to drive her and sits in the back seat, where she feels safer. At the visit, before she even begins speaking, Lee breaks down crying. She describes the accident and her symptoms to her physician. “I feel like I’m going crazy”, she says. Her doctor is able to provide empathetic, supportive counseling. They arrange a follow up visit in a week, perform a warm handoff with a behavioral clinician, and discuss the possibility of temporary disability if she is unable to attend work.

The UCSF Double Helix Curriculum: Lee Gets Access Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: CHOOSE EITHER ADULT OR PEDIATRIC CASE. FACILITATOR WOULD READ TO THE GROUP (OR COULD HAVE AUDIENCE MEMBER READ THIS OUT LOUD): Lee’s grandmother calls the clinic to schedule an appointment with her physician. Because her physician has a right-sized panel, support from the team for chronic care tasks, and Open-Access slots every day, her own physician is able to see her within a week. On the day of the visit, Lee is nervous about getting into a car to see her physician. But she doesn’t want to let her physician down, and she is really looking forward to talking with her about what happened; her grandmother drives her and she sits in the back seat, where she feels safer. At the visit, before she even begins speaking, Lee breaks down crying. She describes the accident and her symptoms to her physician. “I feel like I’m going crazy”, she says. Her doctor is able to provide empathetic, supportive counseling. They arrange a follow up visit in a week, perform a warm handoff with a behavioral clinician, and discuss the possibility of home schooling if she is unable to commute to school.

The UCSF Double Helix Curriculum: Evaluation Transformation of High-Performing Primary Care in Education The UCSF Double Helix Curriculum: See evaluation sheet for thread objective