Memorial Hospital Cogdell Family Clinic

Project Name: Category 1 – Expansion of Primary Care Healthcare Services and Access Our Project has been focused on mediating the Severe Primary Care Provider Shortage in Scurry and surrounding counties, reducing Excessive Appointment Wait Times, and Reducing Now Show Rates that were twice the national Primary Care Average

Project Baseline 2011 Our area had a Reduction of the number of Primary Care providers due to illness and retirement brought the number of Primary care providers to 6 to service our geographic area 4 Physicians + 2 Physician Assistants The Wait time for an appointment for a chronic or acute condition exceeded 2 weeks. Due to the excessive wait time for acute appointments, patients were feeling better by their appointment date or they had sought treatment out of town and they would not show for their appointments. “No Show” rates at one point reached 28%.

Proposed Resolutions / Goals CN.1 - Severe primary care provider shortage, wait time, expense, lack of insurance, access to care Train/Hire additional Primary Care Providers and staff making a total of 8 for Cogdell Family Clinic Shorten Wait time for Appointments – implement EHR, revamp schedules, training for support & clinical staff, Reduce the overall wait time for the patient while in the clinic Decrease number of “No-Show” appointments Increase access to Primary Care services resulting in an increase in Primary care visits to the Clinic

Train/Hire additional Primary Care Providers Recruitment of Physicians and Mid-level Providers began in 2012 Original Goal: add 2 additional providers Results: 2 new physicians were employed by the clinic beginning in Aug additional Mid level providers were added to the clinic staff as well. 1 physician was a new Graduate / 1had been in practice for 9 years – both FP/OB 1PA-C honorable discharged from the military / 1 FNP new graduate “returning home” to the community she grew up in. Overall added 4 new providers to the Family Clinic

Shorten Wait time for Appointments Original Goal: reduce wait time for appointments to 2-3 days Results: Patients with Acute Care conditions are seen within 24 hours of contacting the clinic Chronic Care appointments seen as soon as possible or within provider directed parameters Processes: Templated Schedules were implements instead of free form scheduling Acute Care appointments were reserved with each provider Templated Schedules offered an increased number of appointments 53% of patients were seen in the clinic within 24 hours of contacting the clinic – the other 47% were non-acute type appointments – (well checks, annual exams, DOT physicals, or other chronic care follow up appointments) * Original Goal was exceeded – Acute care pts are seen within 24 hours instead of 2-3 days – a large improvement over 2+ weeks

Reduce the overall wait time in the clinic Problem: Patient’s total time spent waiting on providers or staff in the reception area, exam room, when added to the time spent seeing provider became excessive. Some visits times exceeded 2.5 hours from the time the patient checked in to the time they checked out. Goal: Increase time spent with provider while decreasing wait time Process: Templating the provider’s schedule with acute care and chronic care appointment types increased the number of patients that could be seen and reduced provider down time between patients and increased the available time for the provider to spent with patients. Results: Total Average Encounter time from check in to check out is under 60 minutes, without reducing face to face time with the provider.

Decrease number of “No-Show” Appointments Problem: No-Show (NS) Appointment rate was more than twice the national average. Highest monthly NS rate reached 28% Goal: Reduce NS rate by half to 14% Process: 1.) Reduce wait time for appointments so patients were seen before they recovered on their own or sought care outside the area. 2.) for appointment greater than 48 hours in the future a reminder call was made. Also the patient is pre-registered at this phone call, reducing check in times. Result: No-Show rate was decreased to an average of 10% for all of 2014.

Increase access to Primary Care services Problem: Inadequate Access to Primary Care services resulting from Antiquated processes and outdated facilities Goal: Increase capacity to see more patients locally instead of the patient having to travel out of the area for services. Goal was to increase the total number of monthly visits by 125 visits or 2,125 a month. Process: In addition to the previous points that made the clinic processes more efficient the physical facilities needed to be upgraded to compliment the updated processes. Result: This facilities upgrade included building a new 15,000 sq. ft. clinic that was attached to the hospital instead of down the street. The new process and facility have enabled the clinic team to see an average of 2835 patients per month in This increased volume resulted in almost 7000 additional pt visits in 2014 over 2013.

New Clinic

Project Challenges and Lessons Learned Challenges Need to recruit medical providers to rural West Texas New processes for how tasks are accomplished are usually met with resistance from staff Lost confidence by the community members in the clinic’s ability to deliver timely efficient care. Large increases in pt visits have necessitated the recruiting, hiring and training of additional nursing and support team members. Lessons Learned It is always better to take a sufficient amount of time to find a provider with not only the correct professional skill set but a personality (and family) to match a small community’s pace and style of living. When the clinical and non-clinical team members involvement, process changes are still painful but team support makes it easier. Time is not just a proverbial healer, but time and continually improving the community’s experiences with the clinic continues to restore their pride in, and support of Cogdell Family Clinic. Community Support and involvement in process change is helpful and aids in identifying missed opportunities to serve patients.

Continual Quality Improvement CQI Projects that have been implement as a result of this project * Report tracking for various metrics that include: 1.) Type of appointment being seen in the clinic 2.) New Patient vs. Established pt 3.) How many pt visits occur within 24 hours of pt contacting the clinic 4.)Tracking of NS appointments by appointment time (am vs. pm clinic) provider and pt demographics. By tracking NS appointments with minute detail we are able to target efforts more effectively Involving the entire clinic team in understanding the goals and the way the results are tracked was invaluable to our success. The Medical Providers are given weekly updates to their CQI project results – Provider involvement has inspired the Provider & Nurse teams to have competitions with other teams to see who can improve their pts’ experience the most. Also, by seeing the overall clinic stats encourage improvement because no provider team wants to have the worst stats. In our Clinic, “friendly CQI competition” has resulted in positive interactions with our community and improved pt experiences.

Patient Comments “It so wonderful to be able to stay home and see my local doctor instead of spending half the day traveling.” “The new clinic is so beautiful and efficient – it is great to see the nurses, doctors and staff smiling and enjoying their jobs.” “When I’m sick, I don’t want to spent time traveling or in a waiting room, I love the new clinic – in and out in under and hour and home to rest!” “The convenience of getting an appointment the same day is a great change to how it has been in the past.”