1. Cindy McHenry, RN BSN Jennifer Tieman, MD Darren Presley, MD Research Family Medicine Residency

2. ACTIVITY DISCLAIMER The material presented at this activity is being made available by the Society of Teachers of Family Medicine (STFM) for educational purposes only. This material is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed but, rather, is intended to present an approach, view, statement or opinion of the faculty that may be helpful to others who face similar situations. The STFM disclaims any and all liability for injury or other damages resulting to any individual attending this program and for all claims that may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented at these activities. Physicians may care to check specific details such as drug doses and contraindications, etc. in standard sources prior to clinical application. These materials have been produced. solely for the education of attendees. Any use of content or the name of the speaker or STFM is prohibited without written consent of the STFM. FACULTY DISCLOSURE The STFM has selected all faculty appearing in this program. It is the policy of the STFM that all CME planning committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

3.  36 Family medicine residents in Kansas City, Missouri  19 Faculty members, 50 clinic staff  Community based residency  We see critical to chronic patients at Goppert Trinity Family Care  Medicaid, Medicare, Commercial and HMO  Care provided by 3 teams and the Express Clinic

4.  The Goppert Express Clinic developed during the application process by our Clinic Efficiency Team to improve patient access  Already had same day appointments available through out the schedule  Already had extended hours in early morning and afternoon ◦ Monday thru Thursday 0830 to 1845 ◦ Saturday 0830 to 1200

5.  Our Patients seen in our clinic not at a doc- in-the-box retail clinic  Extended hours outside the regular clinic hours (before clinic and over the noon hour)  Have separate check in area  Same nurse to staff the clinic  Designated faculty to keep clinic flow going  Designated area of the clinic so patients would know what floor to go to

6.  Staffing Issues ◦ Nurses ◦ Physicians ◦ Front office personal  Did not have the ideal space  Not fully supported by hospital administration  No budget to advertise

7.  Goppert Express Clinic opening day September 7, 2010  Patients seen on the 3 rd floor  Same nurse working the clinic  Check in separate  List of what can and cannot be seen in clinic distributed through out clinic  Hours of operation 0815 to 1145  Flyers posted to Advertise clinic

8.  After the move, the clinic opened to a full day  3 rd year resident assigned to Express during their 2 weeks of office with Fridays covered by the 2 nd year  Same nurse works Express Clinic  Revamped what can be seen in Express Clinic

9.  Express Clinic Open Daily  Average number of patients seen daily in Express clinic – 20  PGY 3 resident has regular Friday morning clinic for continuity patients  PGY 2 covers Express on Friday morning  Available FTT  Can schedule patient seen in Express for follow up  Can schedule their OB patients if needed

10. AbrasionsRockhurst Students Allergy SymptomsSchool/Sports Physicals Asthma Shingles Back PanShortness of Breath Bug Bites/Bee StingsSinus Headache Chest CongestionSore Throat Chicken poxSprains/Strains ColdsTB Skin Test Cold/Canker SoresTetanus Shots ConjunctivitisVaginal Discharge/STD Check CoughsUTI’s Difficulty Breathing Earaches Ear Wax Removal Falls Fever Flu Symptoms Headaches Lice/Scabies Nausea/Vomiting/Diarrhea Poison Ivy Rashes Abdominal Pain Anxiety Any Bleeding Any Chest Pain Chronic Pain Chronic Conditions Depression Disability FMLA paperwork Follow up or recheck Any Head Injuries Joint Injections Invasive Procedures Lacerations Medication Refills Narcotic Refills Routine OB Tingling/Numbness/Slurred Speech Wart Removal Work Related Injuries ** If the patient is here and does not fit the criteria, the patient should be triaged by the Triage Staff.  Typical Express Clinic Symptoms  Symptoms Not Typically Seen in Express

11.  Patients – able to walk into clinic and be seen at their physicians office  We have access to their records (unlike other walk in clinic/ER where you have no records)  Residents learn how to see acute patient  Additional opportunity to add clinic numbers for residents

12.  Do not have same nurse working Express Clinic on a daily basis (Tried this twice and it failed both times)  Hard to find faculty when help is needed  Sometimes have to see patients who should not be in Express Clinic  Express located in back of Clinic takes longer for patients to get in a room  Does not have easy access to the lab due to location in clinic

13.  GTFC DNK rate had been running 20 to 30%  GTFC DNK rate now 10 to 13%  Decrease in DNK rate due to three contributing factors ◦ Express Clinic ◦ Nursing staff contacting patients when they do not show up for their scheduled appointment ◦ Hospital to Home (H2H)

14.  Excellent opportunity to teach residents how to prioritize and triage ◦ Patients often have chronic issues that also need to be addressed ◦ Patients may have more than one acute problem ◦ Patients occasionally misunderstand the purpose of urgent care ◦ Occasionally, patients need to be triaged to a different level of care – into the regular clinic with a provider who has more time, or to the ER

15.  Address urgent problem  Note other problems that need follow up  Encourage follow up with primary doctor  Able to ensure patients that their primary doctor has access to their express clinic records  Communicate to the primary physician any outstanding issues to be followed up

16.  As a practicing physician, ability to offer Express care to my patients a benefit  All of our clinic physicians, faculty and residents are part time, express clinic “fills the gaps”  Patients always know they can be seen the same day for an urgent need

17.  Faculty staff express clinic on Friday afternoons to allow residents to attend didactics  Opportunity to refresh our urgent care skills/procedure skills  Opportunity to appreciate our residents daily experience

18.  Excellent way to increase visit numbers ◦ 15-16 patients in a half day  Increase patient base  Learn to function independently  Learn to function quickly  Occasional emergencies occur similar to an Urgent Care setting