Transitioning to Open Access

1. Transitioning to Open Access Andrea Haffty August 23, 2010 Generations Community Health Center Willimantic, Norwich, Danielson & Putnam CT

2. The waiting room • What about the population served at a typical community health center makes waiting times so excessive? • What does this mean for the center, its providers, and the care provided?

3. Who does the Generations Health Network serve? • Generations Willimantic provided 16, 037 medical visits and 8, 721 dental visits in FY2007 • The center also has a mobile dental van through its “Across the Smiles” program that visits area schools • The patient population is 50% Hispanic, 41% White, 6% Black, and 3% Other • Willimantic's patient population is the most diverse of the four centers

4. A little history... • In the late 1930s, unrelenting mill bosses responded to strikes in the towns' mills by luring large numbers Puerto Rican immigrants to the area to take the place of striking workers. The work was not steady and many families soon found themselves stranded and jobless. This trend, which continued through the 1980s, partially contributes to Willimantic's current rampant heroin problem.

5. Who does Generations serve? • Generations Norwich, which is housed in Backus Hospital provided 10,582 visits in FY 2007 • The Norwich site also operates a mobile van which provides primary care and mental health services to local soup kitchens and shelters

6. Who does Generations serve? • Generations Danielson provided 7, 792 medical visits in FY2007 • With funding from Healthcare for the Homeless, the center also provides care to the 60-bed shelter across the street

7. What contributes to missed medical appointments? • Families living at or below the poverty line often have multiple family members working multiple jobs with non-regular hours, several children, and in some cases, unreliable transportation.

8. Why is the current scheduling system flawed? • In a traditional scheduling system, the provider finds his or her schedule full at the outset of each day • The typical wait time to see a provider, for a non-acute case, can be months • In the community health center world, the day is likely to involve no-shows, walk-ins, and double booking. Despite scheduling, actual flow of daily appointments involves some guesswork. • At Generations, some providers run up to two hours behind on a semi-regular basis, despite double-booking and working through lunch.

9. The backlog • The combination of a large patient backlog and missed appointments creates an apparent need for more staff and more physicians. Time, resources and money become increasingly devoted to triage, phones, and managing the backlog of appointments itself. (Murray and Tantou, 2000)

10. Problems with the traditional scheduling system • In the traditional booking system, capacity is “found” within an already saturated schedule • Urgent visits are squeezed in and providers are double-booked • The routine appointments require a complex naming system (male/female physical, DM F/U, pre-op, etc) • Leads to high no show rates, disrupts the patient-provider relationship and is very costly (Murray and Tantou, 2000)

11. Advanced Access Model • Advanced access requires a paradigm shift in which “today's work is done today.” • Only 35% of the providers' schedules are booked. These bookings represent: • Well-infant/child visits • Those patients who could not make it in the days (referred to as “good backlog”)(Murray and Tantou, 2000)

12. Advanced access model • When patients call in, as opposed to being asked the reason for their visit, they are simply asked who their primary care provider is. The naming system for appointments is simplified to 3 types: - Personal visit (1:1 with clinician) - Team visit (multiple clinicians) - Unestablished (new patient) (Murray and Tantou, 2000)

13. Open Access Staff Commitments • Maximize time with patients -Take care of routine follow-up -Richer visits lead to higher patient satisfaction and higher CPT codes -Staff culture questions deferring patient care (“is this follow-up appointment really needed?”) • Develop contingency plans -Perhaps have a mid-level “floater” for times of high demand, particularly at outset (Murray and Tantou, 2000)

14. Open Access Staff Commitments • Reduce unnecessary follow-up, such as for UTIs • Institute group visits where appropriate and productive, for issues like diabetes education or smoking cessation (Murray and Tantou, 2000)

15. Benefits of Open Access • At CA's Kaiser Permanente, the following benefits were realized within one year -Average wait for appointment: 55 days to 1 day -Patients' satisfaction ratings skyrocketed, largely due to consistently being booked with their own clinicians -Decreased number of visits/patient/year by 10% (Murray and Tantou, 2000)

16. Where to begin? • How does a health network implement these kinds of changes? • The literature suggests that health networks must measure supply and demand as closely as possible (AHRQ 2008)

17. The time study • Generations Health asked that I complete a simple time study which involved following a patient from sign-in to sign-out, documenting vitals time, time for an interpreter to arrive when paged, time with provider, and time with LPN/MA or case management following the visit

18. Current total appointment times On average: • Willimantic: 76m (10 m – 4 h +) • Danielson: 51m (30 m- 1h, 20m) • Putnam: 70m (1 h, 5m-1h, 18m) • Norwich: 58m (13 min – 1h, 55 min)

19. What was significant about these findings? • More than any other factor (site, time of day, type of appointment, need for MA post-appointment, need for translation, etc) the most definitive factor in patient wait time was provider • This factor will transcend any booking system • Biggest implication is training providers to communicate to patients when they are running behind.

20. Implications for Generations • Generations will benefit from reduction of backlog and the elimination of the walk-in system through implementation of same-day appointments. • Less efficient providers must communicate with their patients; perhaps schedule less patients with these providers • Wait times of more than 1 hours must be eliminated

21. Suggestions for OA implementation • Institute a mid-level provider to deal with the overflow of less efficient providers • Have medical assistants interrupt practitioners when a certain period of wait time has elapsed for the next patient • Have an automatic same-week scheduling when a certain wait time has elapsed • Hire more administrative staff to help with specialty providers (such as with HIV staff)

22. References Agency for Healthcare Research and Quality (2008) Open Access Scheduling for Routine and Urgent Appointments http://www.cahps.ahrq.gov/qiguide/content/interventions/OpenAccessScheduling.aspx Forjuoh SN, Averitt WM, Cauthen DB, et al. Open-access appointment scheduling in family practice: comparison of a demand prediction grid with actual appointments. J Am Board Fam Pract 2001;14(4): 259-65. Murray, M., & Tantau, C. (2000). Same-day appointments: Exploding the access paradigm. Family Practice Management, 7, 45-50, 69-70, insert 2p. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=20 00069282&site=ehost-live