Low tech innovations in primary care (and why they are so important)

1. Low tech innovations in primary care(and why they are so important) Anton J. Kuzel, MD, MHPE Department of Family Medicine and Population Health

3. Connecticut: Health Enhancement Program Lower monthly premiums, no deductibles No copayments for most medication No copayments for office visits for chronic conditions Incentive payments for compliance with HEP requirements

4. Interesting early trends: Interesting early trends

5. Secret to PC success? Access Continuity Comprehensiveness Coordination

6. NCQA’s elements

7. The current reality Overworked, underpaid PCPs Small fraction are at level 3 PCMH status No idea of how to get to an idealized model without special financing

8. More reasons to worry Med students not going into primary care in sufficient numbers More referrals from PC → higher costs 1 million more Virginians with insurance Population getting heavier and older

9. What to do? Large healthcare systems—Sentara story Independent practices? Get paid for actual work Team care model Rapid access scheduling

10. What is rapid access scheduling? AKA Open access, advanced access, same day scheduling A way to support continuity A way to let patients get care when they want or need it Matches supply with demand Does today’s work today

11. Typical scheduling model Fully booked when day starts (filled with appointments made one to several months ago) Acute care is added on – skip lunch, stay longer, rush routine visits “Do last month’s work today”

12. Carve-out model Portion of slots held for acute care same day Consequences • Patients with non-urgent needs still are delayed • Harder to predict urgent demand vs. total demand • Tendency to “borrow” future “frozen” slots, and you are back to traditional model • Still requires triage

13. Why bother? B.A.U. causes: Delays in care Poorer continuity of care (risk of lower quality, lower coding and reimbursement) Spending resources on triage Higher risk of no-shows = lost opportunity for revenue Frustrated patients, staff, and physicians

14. More on downside of B.A.U.: Risk of hiring too many staff and physicians, with resulting higher overhead Higher patient use of urgicenters and EDs for routine care—higher costs, more risk for harm (over testing)

15. Steps to follow Determine panel sizes Determine demand Match supply with demand Create contingency plan Simplify appointment types Stop creating future work Work down backlog

16. ≈ 2000 patients per FTE (assumes 2.5 visits per year per patient) Determine panel size Critical—over-panelled Docs cannot do RA Must determine each patient’s PCP • Physician who always sees patient • Physician who usually sees patient • Physician who did last physical • Physician who did most recent visit

17. Move some of those patients to physicians who have capacity What if a doc has too many patients? • Hire additional clinicians • Implement team care model to increase existing physicians’ capacity

18. Determine demand Options • Look at past appointment volume and reduce it by 10% • Have receptionists use tick sheets to determine number of calls per day for appointments • Use accurate panel sizes to estimate demand for appointments (2.5 – 3 pp/py)

19. Match supply with demand Right number of appointments per day Account for vacations and other absences • Half of demand will remain, half will wait • More appointments for those covering • More appointments for a day or two upon return Adjust for variation (MF vs. TWT)

20. KISS with appointment types Simpler for staff Maximized capacity— any patient can have any appointment When longer time is required and anticipated, use two slots (lengthy procedures) Physicians develop a rhythm, and are more likely to stay on time

21. Stop creating/start reducing future demand Only schedule two weeks out for any follow up Consider using an acute care visit as an opportunity to do CDM that was schedules for a later date Consider doing some follow up “visits” by email or phone rather than face to face Use evidence-based intervals for CDM

22. Since you have stopped creating unnecessary future demand, the volume of backlog work will diminish quickly and be gone in 6-8 weeks Work down the backlog Acute care appointment requests won’t go away Work through lunch or into early evening Consider doing this during the slow time of the year for the practice (July or August)

23. Common questions What about OB or well-child visits the first year? • OK to pre-book What about people who have to schedule time off from work well in advance for routine visits? • OK to pre-book Multiple part-time physicians? • May have to accept continuity with team

24. Common questions Do previsits work the day before? • Maybe not—may have to do it in mini-batches throughout the day Why bother with RA – why not just make it a walk-in clinic? • Would create waits at the time of the appointment, even though there wouldn’t be wait for an appointment Can one physician do RA in a group while the others stick with carve out or conventional models? • Could only do this if teamlet is insulated from other teamlets

25. Common questions What about patients who might not remember to call for an appointment in 3 or 6 months? • Use tickler file What about patients who have to schedule time off from work well in advance? • Two week lead time is usually enough, but if not, accommodate them

26. Usual causes of failure of RA Lack of leadership Inaccurate measurement of demand or supply or both Lack of physician engagement Lack of engagement of team

27. Impact: continuity Happier patients and physicians Higher quality of care Higher coding at time of visit Reduced patient demand for services, which leads to higher panel sizes (2014; blended payment models) Reduced overall costs of care (urgicenter and ED effects reduced; prepare for ACO environment)

28. Freed up nursing time can be devoted to taking non-physician work away from physician (team care model) Impact: staff resource Triage is eliminated

29. Impact: my own practice Happier patients and Doc Improved coding distribution TNA few days, instead of months Larger panel size

30. Team care Takes non-paying work away from clinicians (as much as 50% of effort) Better use of talent on team Improves quality, efficiency, team satisfaction, bottom line

31. Delegate to clerical staff Non-clinical parts of forms Sending results letters to patients Scanning documents to EMR

32. Delegate to MA/Nurse Attention to prevention, chronic disease management Protocol driven medication refills Some of clinical portion of forms Historical data (range) Rest of data entry (vs. scribe)

33. 1.5-2.5 MA/Nurse per CFTE clinician Staffing, financing Rapid access scheduling cut no shows in half, created space in schedule • More revenue Spending 1-2 hours less per day on non-clinician level work allows for 2 more patient visits per day (at least) • $$$

34. Training MA/Nurse Clerical • Use protocols for PSD, CDM, med refills; look at who is coming in tomorrow; med reconciliation, update FHx, SHx; vaccination standing orders; consider training on taking history • Demo and give feedback

35. Thank you