Elaine Hardman, MBA, Chief Operations Officer
Jackie Fantes, MD, Associate Medical Director
The Providence Community Health Centers
Providence, Rhode Island
August 16, 2013
Health Choice Network Quality Institute
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To reduce scheduling barriers for under-served
patients for improved access to care
High no-show rate (40%)
◦ Tried multiple ways to reduce
Reduced provider productivity/idle staff resulting
in inefficiencies
The work of tracking down patients that noshowed
Patients did not get care if they did not show up
Eliminate the perception of “too much” demand
Improve provider and staff satisfaction
The organization was ready to commit
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Do today’s work today
Access is a key determinant for consumers
choosing a health care provider (something
all of us CHCs will need to consider with ACA)
6 high level changes
◦ Match demand and supply daily
◦ Reduce backlog
◦ Simplify appointment types and times (apply
queuing theory)
◦ Create contingency plans
◦ Reduce demand for unnecessary visits
◦ Optimize the care team (no easy task!)
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Provider and staff resistance
Implementation takes up to 3-6 months due
to fluctuations in demand
Tracking demand – initially and constantly
Finding hidden capacity
Longer staff hours to reduce backlog
All staff need to work at their highest level
Disparity between efficient and non-efficient
providers
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Pre-work
Baseline Data
Establish a Call Center
Educate Patients
Work Down the Backlog
Reduce the Demand
Revise Schedule Templates
Staff Cross-training
Establish Safety Net
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Identify a team
Training staff on Advanced Access concepts
Establish timeline
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Baseline Data:
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Measure demand vs. capacity for each day of the
week for each provider
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◦ Generally 3 months out
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No show rate at each site
No show rate for each department
Panel size by Provider
3rd next visit for each Provider
Patient Satisfaction Surveys
Measure demand
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Worksheet for appointments
Sample of appointment capacity vs. demand
◦ Pediatrics, Internal Med, OB/GYN
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Sample of no-show rate
Need to tracking phone calls
Worksheet for tracking unmet demand
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Phones open 1 hour before start of
appointments
Phones routed to central area of clinic where
triage RN would also assist
Measure call volume by each hour of each day
◦ Sample Queue
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For each patient that arrived for their
appointment, we provided them with a
instruction sheet on advanced access
◦ Open Access is coming
◦ Call us the day you need appointment
◦ Call center opens at ….
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Approximately 3 months
Providers agreed to work extra hours to see
today’s demand
Guidelines on booking out into the future
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Transportation issues
Special interpreter needed
Patient insisted
Brittle patients that we needed to track more closely or
at risk to fall out of the system
At end of visit patients were given provider’s card
with his/her schedule and the date when they
should call for next visit
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Increase visit intervals
Have providers see their own patients
◦ Improved efficiency to see own PCP
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Give as much phone advice as possible for
the short period of time when many
appointments already pre-booked
Max-packing visits
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Simplify appointment types
◦ 4 visit types
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Pre-book Long (30 minute appointments)
Pre-book Short (15 minute appointments)
Open Long (30 minute appointments)
Open Short (15 minute appointments)
Schedules 30% pre-book and 70% Open
◦ Pre-Intergy open appointments could be set as
unavailable until the day of the appointment but
Intergy will not allow this feature
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Developed the roll of the Health Center
Assistant
◦ Allowed more flexibility to assigning staff from call
center to clinic support
◦ Allowed flexibility with vacations and variability in
volume
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Example of Hot List (get new one)
Scripts and Tips for Making Appointments
Recall and Reminder Policy
◦ Had difficulty re-establishing in electronic
environment
◦ Copy of our recall and reminder policy for everyone
FRONT DESK MUST DIRECT THE FOLLOWING CALLS TO THE NURSE
ALL PATIENTS:
Trouble Breathing/Asthma
Accidents
Bleeding from a wound
Question of a broken bone
Fell and hit head
Burn
Allergic reaction
Chest pain/Severe upper back pain
Confusion
Difficulty speaking/swallowing
Fever greater than 102
Left arm or jaw pain
Loss of consciousness/fainting
Severe headache
Severe Abdominal Pain
Seizure
Stiff Neck
Suicidal thoughts
Weakness of an extremity
POISONING:
Call Poison Control
@ 1-800-222-1222
PREGNANT WITH:
Trauma to abdomen
Accident/fall
Abdominal pain/contractions
Baby has less or no movement
Headache/dizziness
Think water broke
Vaginal bleeding/large fluid loss
Vomiting
CHILDREN:
Blue/grey color of lips or nails
Heart beating fast/skipping beat
Rash
Limp
Stomach pain/Back/kidney/pain when
urinating boy or girl
Vomiting projectile/bile/blood/diarrhea
Wheezing/breathing problem/cough
Headache/stiff neck
Overdue for or needs Immunization
SICK INFANT: (less than 3 months)
All sick infants under 1 month old
Irritable/won’t stop crying
Not eating as usual/decreased urine
Overly sleepy/too quiet
Rectal temp>100or AXtemp>99
Vomiting/diarrhea
Fast Breathing
VERY IMPORTANT!
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Any sick patient that wants to be seen today for sick visit and can’t be
accommodated must be transferred to Nurse.
If the patient’s complaint sounds unusual to you or you are not
comfortable with it or if the patient/parent thinks the patient is too sick to
wait, transfer the call to a nurse and wait for someone to answer.
Be sure to get the patients name, DOB and phone number.
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Need to manage the impulse for providers to prebook (providers that do not pre-book many patients
tend to see the patients of providers that pre-book a
lot – need to have clear guidelines for the call center)
Develop a good recall and reminder system especially
for chronic care and well child care
Manage panel sizes
Need to have a good system for tracking chronic care
and well child care
◦ Amalga can help, but no pediatric view yet
◦ Need to track immunization
 CLEAR can help
◦ Audit cancellations
 If patients < 18 months of age cancel their appointment then it
needs to be rescheduled, not asked to call back another day
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Demand management for sudden or prolonged
provider absence or big projects like implementation
of the EHR or seasonal fluctuations in demand (for
example, H1N1)
Managing unmet demand
Maxpacking is a great idea but the provider “spirit”
cannot handle 18-20 maxpacks daily which can be
difficult in a CHC setting
Need to have a very robust call center
Manage quick saturation of appointments
◦ All sick visits do need to be handled today (HC vs. Express)
◦ Well visits should be put on unmet demand list
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Need a detailed training for new providers
Strategies for Managing Patient Demand During EMR Go-Live
Draft 12/05/2011
Assumptions
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Go-live period will be 8 weeks in duration (eg, February 6 – March 30 for initial sites)
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Provider schedules will be reduced by as much as 50% during initial few weeks with gradual increase so as to
arrive at 100% at the end of eight weeks
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Similar demand reduction strategies will be needed during pre-Go-Live training weeks
IMED
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PEDI
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OB/Gyn
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Demand Reduction
PCHC/Site: Defer new patients for two
months Go-Live period (except those
assigned by NHPRI/UHC). Keep waitlist for
those requesting appts and contact post-GoLive.
PCHC/Site: limit prebooks during initial
month
Providers: extend follow-up intervals & use
recall
PCHC/Site: No PEs for children over 5 years
of age during initial month of Go-Live
PCHC/Site: limit prebooks during initial
month
Providers: develop guidance for call
center/RNs in order to triage/give advice for
issues provider visit may not be necessary
(eg, develop “cold list” of issues, like vomit
once, etc where further phone assessment &
advice would be appropriate)
PCHC/Site: Defer new patients for two
month Go-Live period (except those
assigned by NHPRI/UHC). Keep waitlist for
those requesting appts and contact post-GoLive.
PCHC/Site: No annuals for initial month of
Go-live (if calling for annual, ask if pt having
a problem instead)
PCHC/Site: limit prebooks during initial
month
PCHC/Site: Defer new patients for GYN for
at least initial month of Go-Live period.
Keep waitlist for those requesting appts and
contact post-Go-Live.
PCHC/Site: Continue to accept new patients
for Family Planning, pregnancy tests, OB
care throughout Go-Live
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Increase Capacity
Providers: reduce # of referrals/work-up
patients longer at site so RNs more available
to assist with history/initial record set-up
(this will increase capacity of support staff to
help enter date/history)
Site: Add hours/sessions for existing
providers
PCHC/Site: consider weekend/evening
make-up session for PEs (all Pediatrics or by
site)
PCHC: Increase Express capacity (add
provider hours) to meet demand for sick
care
PCHC/Site: r educe Colpo to 2x per month
(and free additional session for OB/Gyn)
PCHC/Site: add hours/sessions for existing
providers (by site or as a dept, eg, annuals
on Saturday)
All Sites: Actively record unmet demand via waitlist in Intergy. Review daily. Reinforce use with call center &
front desk staff.
Admin: In Dec/Jan, clearly explain to providers how productivity bonus will be affected/calculated during Go-Live
time period.
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No-show rate has dropped – was 40%
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Pediatrics < 10%
Adult Med 10-12%
OB/GYN 14-16% (OB greater than GYN)
Pre-books tend to no show greater than open
appointments
Improved access for patients
Improved productivity
Improved revenue
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Once the providers better understand the
recall and reminder system, their resistance
decreases
PCPs get to see their patients when the
patient needs them and especially for acute
needs which in a traditionally packed
schedule acute patients often get sent to
urgent care or ED and the provider is left
doing a full day of chronic or preventive care
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Elaine Hardman
◦ elaineh@providencechc.org
◦ Office: 401-444-0400 Ext 3112
◦ Cell: 401-226-3957
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Jackie Fantes
◦ jfantes@providencechc.org
◦ Office: 401-444-0400 Ext 3374
◦ Cell: 401-864-1951