Knowing your Population and Enhanced Access in The Patient Centered Medical Home Xavier Sevilla M.D. FAAP Whole Child Pediatrics Manatee County Rural Health Services Inc.

Samoset Pediatrics 1999 Lots of patients “Walk in” Already Saturated schedule at 8 am Phone ringing off the hook Staff and Physician dissatisfaction Lots of No-shows Angry, Frustrated Patients Patients waiting > 70 minutes Getting home very late

Our practice was sick

Enhanced/Advanced Access Decrease No shows and Cancellations Decrease staff phone time for Triage and scheduling Increase staff and patient satisfaction Decrease Overtime Improve continuity

Terms Demand: What the patient wants. A Continuous relationship with a clinician (face to face visits to the doctor, phone calls, ) Supply: What we provide ( face to face visits, phone calls, ) Our Business is matching demand with supply.

Terms Backlog: Waiting list, Queue, e.g. number of days/weeks until your next physical available. Constraint/bottleneck: The rate limiting step

Examples in other Industries Toyota: matches supply and demand within seconds Panera Bread: Matches supply and demand within 6 minutes Fast Food: McDonalds Every 6 seconds of wait represents 1% of market share

Is improving access important? Access is #1 in Customer satisfaction Decreased waits improve staff satisfaction Reducing appointment delays improves clinical outcomes ( Pediatrics 116,1 7/05) Delays Cost a lot of Money Large waits = large No shows Nurses time( triage), Receptionist (time) It takes 30s to say Yes, 9 minutes to say NO Gives the impression of lack of resources

The place to start… If the heart of the Medical Home is a continuous relationship over time between Patient/Family and the Practice Team… … then we must provide a mechanism for allowing that relationship to happen in our systems.

The Cornerstone of the Patient Centered Medical Home is KNOWING YOUR POPULATION…

Knowing your Population 1. Assess Supply and Demand 2. Provide a systematic way to allow patients to have their own Primary Care Physician/Team.

Knowing your population 3. Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, self-management status, community and family need.

3. Use panel data and Registries Maintain a database (Registry) that includes key information on important patient groups within a practice population. Monitor the database to identify and reach out to those needing service.

3. Use panel data and Registries MY JOURNEY Registry Florida Shots Practice Management System Asthma patients Well Child Checks

Key Changes: Enhanced Access 1. Ensuring 24/7 continuous access 2. Help patients attain and understand insurance 3. Provide scheduling options that are patient centered

1. Ensuring 24/7 Continuous Access Extended hours at the office Stay open past 5pm and weekends Alternate offices or teams Early opening for labs Stay open at lunch (alternate lunches) After hours care by phone or Accessibility of the Medical Record after hours

2. Help patients attain insurance coverage Clerical staff that can fill insurance applications on site Social Worker/Financial counselor can address health insurance coverage

3. Provide scheduling options that are patient centered Patients can access the practice when THEY need it Advanced or Open Access

High leverage changes for Advanced Access 1. Balance demand and Supply 2. Assign patients to PCP 3. Reduce the Backlog 4. Reduce appointment types 5. Reduce demand 6. Increase supply 7. Develop Contingency Plans 8. Decrease waiting in the office

1.Balance Demand and Supply o Predict Same Day Demand o Have your front desk make a daily list of: o Appointment requests calls for today o Walk ins or work ins o Patients that used the ER during office hours o Patients sent to other sites o The Total is your Daily Same Day demand

1.Balance Demand and supply Predict Supply Determine the Patients/hr a typical Clinician in the practice can see Determine # of hours each clinician works at the office. Patients/hr x Hours per day= Total Supply

1.Balance Demand and Supply If Demand > Supply every day there is no system in the world that can make it work: Hire another FTE Hire a part-timer to cover peaks Or...

1.Balance Supply and Demand Balance supply and demand For each day calculate how many Same Day appointments you need to cover total Same Day Demand Distribute supply ( physician/hours) looking at covering peaks such as Monday morning and Friday afternoons. Also distribute time off looking at the demand for appointments.

Supply : P. Pediatrics AMPMTotal Monday15 30 Tuesday15 30 Wednesday15 30 Thursday190 Friday15 30

Same Day Demand: P. Pediatrics AMPMTotal Monday628 Tuesday538 Wednesday437 Thursday6Closed6 Friday628

2. Assign patients to PCP Continuity is KING!!!! Assign patients who already have a PCP Assign patients who don’t have a PCP using the 4 cut method

27 4-Cut Method CutPatientAssignment 1 Only ever seen 1 provider Provider seen 2 Seen 2 providers, with 1 provider majority Provider seen the majority of times 3Seen a few providers Provider who performed last physical 4Seen many providersLast provider seen

28 Practical Steps (starting as if no patients are assigned) 1. Assign all patients who have only ever seen 1 provider to that provider 2. Develop a list of patients with their last 3-5 providers seen 3. Assign patients who have seen a provider the majority of times to the majority provider 4. Allow clinic teams to talk through the rest of the patients and where they belong

3. Work down the Backlog Measure the extent of your backlog. # of days until you have the third available non urgent appointment. Good Backlog Follow ups, WCC booked in advance Bad Backlog Pts wanted to be seen earlier but were deflected into the future because of no availability

3. Work down the Backlog HARD WORK!!! Add daily capacity Set a day to Start Backlog reduction Add a few more slots per Doctor per/day Bring patients from the future schedule into today Add locums or extend hours temporarily

4. Reduce appointment types Reduce number of appointment types Use only 1 or 2 types of appointments Eliminate distinction between urgent and routine Standardize length of appointments Consider having one 10, 15 or 20 minute standard slot. Short appt is one slot and a long appt is two slots.

4. Reduce appointment types MY JOURNEY Two types standard (short) 15 mins and long (2 slots) 30 mins. Last appointment of the morning 30 mins prior to lunch. Last appointment of the afternoon 430pm (730pm late) Every slot is available for any type of appointment

Scheduling is an art… Demand for appointments is predictable Sell early (morning), Sell late (week)… Appointments we can control: Follow ups Chronic care monitoring Wellness/ Physicals

5. Decrease Demand Maximize each visit Use alternative methods of communication : Phone for follow-ups and refills Protocols for triage Increase intervals for visits Otitis Media from 2 weeks to 3 months Decrease no-shows Increase continuity 15% Reduction in demand

5. Decrease Demand: Decrease No-Shows Sell the return visit “If you can’t make this appointment you’ll let me know right?” Make cancellations easy Reminder call system. Call hours Know your chronic no showers After 3 no shows do not schedule

6. Increase Supply ARNP/ PA Clinicians to add appointments Nurse Visits: RN/LPNs for simple visits ( sutures, BP) Group visits Vaccination clinics

7. Contingency Plans Anticipate for expected supply/demand mismatch. Decreased supply Vacation, Sick clinician, Increased Demand Flu Season, School physical time Develop protocol for unusual but expected events.

7. Contingency Plans Clinician Time off/Vacation Block off vacation time period The Week after vacation block off half the day When clinician returns then open the blocked time

8. Decrease waiting in the office First AM and PM appts start on time Huddles at the start of the day to go through the schedule Dictate/type your note during the visit Co-locate staff to enhance work and communication flow

Things I can do next Tuesday… 1. Have a Team huddle 2. Alternate Lunch between teams 3. Measure 3 rd available appointment 4. Look at your Same day demand 5. Block enough slots in the schedule for your Same day demand

Resources AAP AAFP cess.cfm cess.cfm Qualis Health PCMH

Questions ?????