PCHC Experience With Advanced Access Scheduling Elaine Hardman, MBA, Chief Operations Officer Jackie Fantes, MD, Associate Medical Director The Providence Community Health Centers Providence, Rhode Island August 16, 2013 Health Choice Network Quality Institute

Why PCHC Implemented Advanced Access Scheduling To reduce scheduling barriers for under-served patients for improved access to care High no-show rate (40%) Tried multiple ways to reduce Reduced provider productivity/idle staff resulting in inefficiencies The work of tracking down patients that no- showed Patients did not get care if they did not show up Eliminate the perception of “too much” demand Improve provider and staff satisfaction The organization was ready to commit

Principles of Advanced Access Do today’s work today Access is a key determinant for consumers choosing a health care provider (something all of us CHCs will need to consider with ACA) 6 high level changes Match demand and supply daily Reduce backlog Simplify appointment types and times (apply queuing theory) Create contingency plans Reduce demand for unnecessary visits Optimize the care team (no easy task!)

Challenges to overcome Provider and staff resistance Implementation takes up to 3-6 months due to fluctuations in demand Tracking demand – initially and constantly Finding hidden capacity Longer staff hours to reduce backlog All staff need to work at their highest level Disparity between efficient and non-efficient providers

Steps to Implementation Pre-work Baseline Data Establish a Call Center Educate Patients Work Down the Backlog Reduce the Demand Revise Schedule Templates Staff Cross-training Establish Safety Net

Steps of Implementation – Pre-Work Identify a team Training staff on Advanced Access concepts Establish timeline Generally 3 months out Baseline Data: No show rate at each site No show rate for each department Panel size by Provider 3rd next visit for each Provider Patient Satisfaction Surveys Measure demand Measure demand vs. capacity for each day of the week for each provider

Steps of Implementation – Baseline Data Worksheet for appointments Sample of appointment capacity vs. demand Pediatrics, Internal Med, OB/GYN Sample of no-show rate Need to tracking phone calls Worksheet for tracking unmet demand

Steps of Implementation – Establish a Call Center Phones open 1 hour before start of appointments Phones routed to central area of clinic where triage RN would also assist Measure call volume by each hour of each day Sample Queue

Steps of Implementation – Educate Patients For each patient that arrived for their appointment, we provided them with a instruction sheet on advanced access Open Access is coming Call us the day you need appointment Call center opens at ….

Steps of Implementation – Work Down the Backlog Approximately 3 months Providers agreed to work extra hours to see today’s demand Guidelines on booking out into the future Transportation issues Special interpreter needed Patient insisted Brittle patients that we needed to track more closely or at risk to fall out of the system At end of visit patients were given provider’s card with his/her schedule and the date when they should call for next visit

Steps of Implementation – Reduce the Demand Increase visit intervals Have providers see their own patients Improved efficiency to see own PCP Give as much phone advice as possible for the short period of time when many appointments already pre-booked Max-packing visits

Steps of Implementation – Revise Schedule Templates Simplify appointment types 4 visit types Pre-book Long (30 minute appointments) Pre-book Short (15 minute appointments) Open Long (30 minute appointments) Open Short (15 minute appointments) Schedules 30% pre-book and 70% Open Pre-Intergy open appointments could be set as unavailable until the day of the appointment but Intergy will not allow this feature

Steps to Implementation – Staff Cross training Developed the roll of the Health Center Assistant Allowed more flexibility to assigning staff from call center to clinic support Allowed flexibility with vacations and variability in volume

Steps of Implementation – Establish Safety Net Plan Example of Hot List (get new one) Scripts and Tips for Making Appointments Recall and Reminder Policy Had difficulty re-establishing in electronic environment Copy of our recall and reminder policy for everyone

Lessons learned Need to manage the impulse for providers to pre- book (providers that do not pre-book many patients tend to see the patients of providers that pre-book a lot – need to have clear guidelines for the call center) Develop a good recall and reminder system especially for chronic care and well child care Manage panel sizes Need to have a good system for tracking chronic care and well child care Amalga can help, but no pediatric view yet Need to track immunization CLEAR can help Audit cancellations If patients < 18 months of age cancel their appointment then it needs to be rescheduled, not asked to call back another day

Lessons learned (cont.) Demand management for sudden or prolonged provider absence or big projects like implementation of the EHR or seasonal fluctuations in demand (for example, H1N1) Managing unmet demand Maxpacking is a great idea but the provider “spirit” cannot handle 18-20 maxpacks daily which can be difficult in a CHC setting Need to have a very robust call center Manage quick saturation of appointments All sick visits do need to be handled today (HC vs. Express) Well visits should be put on unmet demand list Need a detailed training for new providers

Benefits of Advanced Access for PCHC No-show rate has dropped – was 40% Pediatrics < 10% Adult Med 10-12% OB/GYN 14-16% (OB greater than GYN) Pre-books tend to no show greater than open appointments Improved access for patients Improved productivity Improved revenue

Benefits of Advanced Access for PCHC Once the providers better understand the recall and reminder system, their resistance decreases PCPs get to see their patients when the patient needs them and especially for acute needs which in a traditionally packed schedule acute patients often get sent to urgent care or ED and the provider is left doing a full day of chronic or preventive care

Contact us with questions Elaine Hardman elaineh@providencechc.org Office: 401-444-0400 Ext 3112 Cell: 401-226-3957 Jackie Fantes jfantes@providencechc.org Office: 401-444-0400 Ext 3374 Cell: 401-864-1951