1. Advanced or Open Access FCC Arnold Goldberg MD, Donna Dupuis RN STFM November 2009

2. Introduction n Brown Fam Med Residency –39 Residents and 15 Faculty –3 Seperate Teams in a Continuity Practice –12,500 patients –35,000 visits/year n Piloted March 1, 2004 on Team C n Full Practice began Oct 1, 2004

3. Reasons for Trying n High No Show Rate n Frustration of patients, providers and staff on access –3 months for a follow up –No openings –Staff tearing out their hair to find openings n Triage Blockade: Nurses gate closers not gate openers

4. Reasons for Trying n Too many ER visits n Need to increase capacity n Innovation, Education

5. Open Access Scheduling n Patients call and are offered same-day appointment n “Do today’s work today” n Improves timeliness for appointments n Curtails triage system n Continuity should be preserved n No show rates decrease n Increased Patient satisfaction because of timely visits n Decreased ED visits

6. Hesitancy n Would destroy Continuity in Residency –Variable part time schedules n Practice too large and too complicated n Patients will hate it and too complicated –They will all show up at once and every day –No one will show up –Cherry picking of the Faculty

7. Value of Continuity n Valued more by women, those with less education, Medicare and Medicaid patients and those with lower health status (Pandi 2006, Nutting 2003) n Ranked third in patient priority in one study (Moore 2003)

8. Continuity Studies n Private Practice –Bundy 2004 improvement –Ahluwalia 2005, O’Connor 2006, Salisbury 2007 no change or a decline n Murray and Tantau 2007, 2003: Continuity is difficult to achieve for providers who work less than 6 out of 10 half days per work week

9. Continuity in Practice Programs n Phan 2009 Continuity decreased n Belardi 2004: Increased resident continuity n Kennedy 2003: Feedback suggests that continuity is higher

10. Our Program n Urban setting of a large city n Prior to this we had a carve out system n We have an EMR: Centricity n We open 3 to 5 working days before n There are 3 pre-books in AM:67% open and 2 pre-books in PM: 80% open n Maximum of 2 physicals per session n Schedules handed out to Patients and we try to be 3 months ahead

11. Our Program n Pre-books Ride Program,Procedures,Language,Patients with case-workers,Prenatals,Patients not able or willing to comply –We confirm Pre-books and all resident’s patients n Tickler system in the EMR n Secretaries make the appointments and emergency acutes are triaged by Rn

12. Our Program n If you call by 2:30 PM you will be seen for a follow up or acute! –Patients who call later however are usually able to be seen. >10 providers per session n Walk ins are not encouraged but are triaged and seen n We try to stay within the Teams but will cross if we have to

13. Myths Debunked n No major changes in pattern of patients n There does not need to be a Back log to spend down. We Flicked it on! –5 months preparation and 6 month pilot n Continuity was preserved and in some cases increased

14. Sessions per week n First years : 1.5 sessions per week n Second years: 3 sessions per week n Third years: 4.5 sessions per week n Faculty range from 1 session to 4 sessions per week

15. No Shows Improved Providers n Faculty n 3rd Years n 2nd Years n 1st Years BaselinePost-Open 16% 11% 21% 17% 24% 17% 22% 18% 22% DNS in Prebooks 15% DNS in OA slots

16. ED Visits and Cost PM: NHP n Visits/1000 & Cost n Sites Pre Open –FCC 537/1000 $9.02 PM –CHC 638/1000 $11.29 PM –Non CHC 575/1000 $11.03 PM n Sites Post Open –FCC 482/1000 $8.10 PM –CHC 632/1000 $11.41 PM –Non CHC 566/1000 $10.87 PM

17. Capacity Maintained Slightly hard to compare but, Pre Open Access for time period there were 26,096 visits for 49 physicians or average of 532 pts per physician Post Open Access for recent time period there were 27,062 visits or 520 pts per physician Not much difference Explained by changes in resident total providers, years and faculty changes.

18. Capacity n 86% of the appointments are filled by the end of the day on average. This varies by resident vs faculty

19. Surveys n Nurses –“It has made my job easier as I don’t get all the triage calls…It’s enabled me to do more patient care. It’s enabled me to become more involved in patient’s lives. The Team has become much more relaxed, more settled”

20. Surveys n Receptionists –“It’s made our Team work together. A lot of patients like it. It definitely makes it a lot easier. The Patients love it!” n On one survey 76% of 185 patients said they were able to get an appointment on the day they wanted it. 76% found it easy to make an appointment

21. Concerns n Return Visits –Have to have a Tickler System n Pre-Booked DNS n Must be consistent –Need to supervise physicians and staff so they do not slide back into old habits n Capacity cannot be allowed to decrease –Watch for too many schedule changes

22. Measure of Continuity n Numerous ways to measure continuity of care exist n The Usual Provider Continuity Index (UPC) n Ratio of the number of visits to the most frequently seen provider to the total number of visits to all providers

23. Measure of Continuity n The UPC index is simple to understand n Takes into account only the ratio of visits to the predominant provider n It does not reflect the total number of physicians seen n We excluded the Acute visits as patients are willing to see Team physician for acute care n Our system, but we try to keep acutes with predominant provider

24. Continuity Vs Acute Visits n Acute visits with the Non-PCP and Non- Continuity visits for routine visits are strictly defined for statistical evaluation and the patients and staff are respectful of these definitions.

25. Continuity: Baseline 3/1/2003 to 2/28/04, Post were times after 3/1/04 for Advanced Access Provider n Faculty n 3rd Years n 2nd Years n 1st Years BaselinePost Open 89% 72% 73% 75% 45% 72%

26. UPC for the Resident’s Practice n Pre: 18,813 visits –Continuity visits: 13,439 –Acute not to PCP and non-continuity visits: 5,374 UPC: 71% n Post; 36,277 visits –Continuity visits: 26,580 –Acute visits not to PCP and non-continuity visits: 9,697 UPC: 73%

27. Continuity for Total Practice n Pre Open Access: residents+faculty –Total visits: 26,096 Continuity visits: 19,893 Acute visits to Non-PCP and not-continuity visits: 6,203 –76% continuity UPC n Post Open Access: residents+faculty –Total visits: 43,138 Continuity visits: 32,711 Acute visits to Non-PCP and not-continuity visits: 10,427 –76% continuity UPC

28. Conclusions on Open Access n Open Access is doable in a Residency n It builds teamwork and enthusiasm n It improves No Show Rates though not as great as expected n It improves job satisfaction for everyone

29. Conclusions on Open Access n Maintains Capacity n Decreases ED Visits and Costs n Daily Access is Improved n Decreases the Length of Time to getting an appointment dramatically n The majority of Patients love it!

30. Conclusions on Continuity n Our findings are that Continuity in Open Access in our program for the residents was Maintained and overall slightly increased. 73% from 71% –Total Continuity was maintained at 76% n Our method of pre-books and using a 3 to 5 day window for booking, the patient’s knowledge of our schedules and the dedication of the staff and providers have maintained continuity

31. Continuity Conclusions n We are strict on the definition of an Acute visit and a non-continuity follow up, WCC, CPE, prebooks, prenatals, chronic pain visit n We use an EMR and electronic scheduling system n We have our own Family medicine hospital service n Our Team Nurses and administration and chair person have really supported us n Teams are essential to the success.