1. Improving Access SHCPQI Learning Session September 2, 2009 Christine St. Andre

2. Objectives Define 2 methods for improving patient access without adding provider staff Describe the fundamentals of advanced access scheduling and how to get started Describe elements of group visits—logistics and benefits

3. Why Access? Waiting creates dissatisfaction and potential unwanted reduction in demand Delays in getting appointments lead to no shows and non-revenue provider time Inability to see one’s one provider compromises continuity  errors, rework, risk management issues Access and communication is one of the areas of focus for patient-centered medical home

4. What is Advanced Access ? NO delays for an appointment. No delays during the appointment (cycle time) CONTINUITY for patients and physicians. Doing today ’ s work today.

5. 5 5 What is your current Access? Who has tried to implement Access principles?

6. High Leverage Changes for Access Improvement Balance demand and supply daily Reduce backlog Reduce demand for visits Decrease appointment types Develop contingency plans Optimize the Care Team

7. Back–log reduction No substitution for hard work, start work is also important

8. “Work Hard” Strategies Include.. Develop a written plan and a date goal Add daily capacity  Working days off or parts of days off  Starting clinic early  Working over part of lunch  Saturday clinic  Evening clinic  Use of NP/PAs

9. “Work Smart” Strategies Include.. Look ahead into schedule/ remove demand Extend visit interval Maximize visit efficiency-max pack Support the team with tools and system improvements to allow them to be more effective and eliminate waste Track and display metrics

10. Next Steps for Advanced Access... Decrease appointment types Times = types Decrease variation Increase flexibility Eliminate the need to sort and match Eliminate “qualifying” criteria Makes scheduling easier

11. Project daily demand... External  Appointment requests, calls regardless of day appointed + Walk-ins + Other portals of entry + Deflections Internal + Returns booked today = Total Demand

12. Next Steps Once you project demand... Build enough open appointment slots to meet daily demand Develop contingency plans AND Shape demand (both during back-log reduction and steady state) so that you CAN match capacity with demand

13. Contingency Plans Match capacity and demand daily Time off policies Minimum # of provider policies Post vacation schedules Effective use of NP/PAs Unexpected is often predictable

14. Shaping Demand - Examples “Max Packing” (never let 1 visit turn into 2) See today’s demand today – try to avoid future scheduling Increase same day availability Find hidden capacity Challenge practice styles

15. Shaping Demand (continued) Guideline Use  Sore throats, UTI First a.m./p.m. appointment on time Shift procedures and follow-up appointments away from Mondays Daily huddles Proactive schedule management Work to the appropriate level Alternate visit types

16. Do More Per Visit--MaxPack Longer appointment slots if needed Document the increased visit intensity to code higher charges, turning level 3 visits into 4’s and 5’s Patients will need fewer overall appointments Opens capacity to see more patients Result: increased number of higher charge visits Note: type of reimbursement matters ©Tantau & Associates

17. Outpatient E&M Levels: Example of potential result Level of Visit Benchmark (eMD’s) HFM Adv. Access Team 15%<1% 26%3% 360%54% 428%37% 51%5%

18. If Supply Doesn’t Equal Demand …Tendency is to: Hire more providers Work harder Close panels Instead... Shape demand Increase supply  Optimize the care team  Identify and manage the constraint  Use of technology

19. Success hinges on... Willingness to try something new Willingness to take risks Physician champions Good communication Regular meetings “Next Tuesday” change mindset A lot of hard work Celebrate accomplishments

20. 20 Advanced Access is NOT Not about limiting patients’ ability to book in advance Not about prioritizing Access over Continuity Not about making doctors or team members ‘work harder’ Not about promoting a walk-in culture … Not about unleashing limitless demand

21. 21 Models

22. Group Visits-one way to shape demand

23. What is a group visit? Visits designed for groups of patients rather than a 1:1 patient-provider visit---shared medical appointment Include more than group education and support, generally including many aspects of the individual visit---a change in the care delivery system Takes the place of the regular provider visit Intended to validate patients as self-managers of care Voluntary; Interactive; Efficient and effective

24. Most common---CHCC (Cooperative Health Care Clinic) Started with frail elderly who were high utilizers/ multiple conditions--John Scott 1990 2 – 2 ½ hours, no more than 20 patients Includes individual sessions, plus education, and addressing group concerns and questions Scheduled at regular intervals, same group of patients Focused on like patients with chronic condition or other common health concern

25. What kind of group visits? Diabetes CAD/CHF Prenatal Well Child Newborn Flu shot School physicals Elderly Others

26. Potential Benefits of Group Visits Improved access Enhanced provider productivity Promotes patient self-management as well as using others as resources Leverages existing resources for operational efficiency Improve quality of care Improved patient satisfaction Provider satisfaction Improved bottom line 26

27. Getting started Start planning early (10-12 weeks) Enlist a champion Identify potential candidates Schedule provider and other staff/ determine frequency of the group Secure space (adequate for 30 people in circle or U-shape Formal written invitations, phone follow up Develop agenda Review charts/ create individual flowsheets

28. Patient selection Good candidates Need routine or follow up care People with similar problems requiring education Time-consuming patients Frequent visits Emotionally needy “Worried well” Not so good candidates Memory problems Language barriers Reluctance to attend First visit patients Communicable diseases Multiple medical problems

29. Agenda—2 hour group 15 min: Introductions (use name tags and allow each person to speak) 30 min: Topic of the day 30 min: Provider and nurse talk to each patient; vital signs; med refills 15 min: Q&A 15 min: Planning for next group/ topic selection 15 min: Individual 1:1 sessions as needed

30. Challenges with Group Visits Require good organization and planning Patients without a relationship to the provider Space Charting time Assuring quality care Confidentiality Interruptions Talkative physicians Not all patients interested 30

31. No-show and low-show rates and attrition Expect 1/3 to 1/2 of those invited to attend Patient selection Stress the visit is in lieu of regular visit, not just education Invitation by the physician Timing and frequency matter Invite family Refreshments and fun

32. Economics Maximizes use of educational, referral and other “specialty” resources. Creates openings in schedule to see more patients at other times. Need to maintain pre-determined minimum levels of patients to maintain leverage of provider time and keep the gains in productivity and efficiency. Need a minimum number of patients…(e.g. if provider spends 2 hours in a group and she usually sees 3 patients/hour, need at least 6 patients to break even, more to improve ROI). 32

33. Getting Paid—ask for forgiveness Some state Medicaid programs and other payors starting to pay for them—isolated cases. CPT panel: No defined code- use 99499 “Unlisted E&M service” CMS position: No prohibition on group members observing while a physician furnishes a medically necessary service to a particular patient. Most practices bill 99212, 99213, or 99214 based on complexity of the individual visit part of the group visit. Documentation is critical. Group Visits with no provider and no billing---may make sense for some patients if provider time can be freed 33

34. Resources-Access http://dms.dartmouth.edu/cms/toolkits/impr oving_access/ http://dms.dartmouth.edu/cms/toolkits/impr oving_access/ IHI.org

35. Resources- Group Visits Group Visit Starter Kit at www.improvingchroniccare.org www.ihi.org www.aafp.org http://www.impactbc.ca/practicesupportprogra m/resourcesforclinicalpractices/cdm/groupme dicalvisitsresources http://www.impactbc.ca/practicesupportprogra m/resourcesforclinicalpractices/cdm/groupme dicalvisitsresources 35