Advanced Access: Decentralizing the Urgent Care

Presented by:

Jeremy Chrisman, DO, Medical Director

Thomas Sanchez, Chief Operating Officer

Agenda/Overview • Where is The Vancouver Clinic? • Who are we? • Why change? • Why did we do it? • How did we do it? • How did it turn out? • Where are we today? • What did we learn? • Benefits beyond dollars and data? • What’s next? • Questions?

Vancouver, WASHINGTON

Not B.C.

Where is The Vancouver Clinic?

Vancouver, WA

What do you call two straight days of rain in Vancouver?

What does daylight savings time mean in Vancouver?

What did the Vancouver native say to the Pillsbury Doughboy?

It only rains twice a year in Vancouver….

Who Are We? • Physician owned and governed, professionally

managed • Established in 1936 • Annual patient visits: > 1 Million • 6 sites, 35 Specialties • Compensation Model = ~100% production • 265 Providers

– 129 Primary Care – 136 Specialty Care

• 987 staff • Ancillary Services

Who Are We?

• Urgent Care

– 4 Sites

– 93,400 Annual Encounters

– 15 Providers

– 44 Staff

– Centralized model of care

– Same building as PC

Who are we?

• EMR and Practice Management

– Epic first implemented October 2010

• version 2010 – implemented March 2012

• Version 2012 – implemented March 2013

• Version 2014 – implementing June 2015

– MISYS 2004-2010

Why Change?

• Advanced Access implementation in PC

– Failed implementation 2009

Lessons Learned

• Continuity is king

• Understand panel size

• Tension between reserving capacity for panel and business that wants to fill the schedule

• How do you reserve a providers capacity for their panel while still guaranteeing a full schedule?

Advanced Access

– Restart implementation Fall 2011

– Fully implemented:

• Pediatrics 7/2012

• Internal Medicine 2/2013

• Family Medicine 5/2013

Panel & TNA

Panel Components

Trending Department

Trending Provider

Demand

Contingencies

1/7/15 1/14/15 1/21/15 1/28/15 2/4/15 2/11/15 2/18/15 2/25/15 1/0/00 TNA

87th Avenue 2 3 4 5 6 7 8 9 9

BIERMANN,K 1 0 1 100% - - - - - - - - -

BROOKS, EMI 566 667 (101) 85% 0 0 0 0 0 0 0 0 0

COFFEE,C 1535 1511 24 102% 0 1 2 1 4 0 0 0 0

HARSHMAN,KAT 502 489 13 103% 1 2 - 0 0 4 1 0 0

Michael Paul 100 69 31 145% - - 15 5 10 8 5 5 5

MOHANDESSI,S 2034 2651 (617) 77% 3 2 3 2 0 1 2 0 0

PARK,Y 1572 1734 (162) 91% 3 0 2 0 0 4 0 0 0

ODARICH, TET 1318 1548 (230) 85% 1 1 3 3 1 5 2 2 2

7 Providers Total 7628 8669 (1041) 88% TNA <3 4/6 5/5 3/5 5/6 4/6 3/6 5/6 5/6 5/6

Battle Ground

DOERFLER,E 1889 1952 (63) 97% 1 2 2 0 1 0 2 3 3

HAMPTON,J 2 0 2 100% - - - - - - - - -

HOLMES,R 1598 1952 (354) 82% 1 1 2 1 1 1 1 2 2

LOWER,C 3 0 3 - - - - - - - - - -

NIEHM,S 2070 2364 (294) 88% 3 3 3 2 0 2 0 2 2

RICHARDS,S 1 0 1 100% - - - - - - - - -

SHAVER, M 2 0 2 - - - - - - - - - -

SIMONS,A 1 0 1 100% - - - - - - - - -

VELAT,A 1540 1345 195 114% 6 7 5 5 5 5 3 2 2

WEED, M 1682 2082 (400) 81% 0 2 2 0 0 0 3 0 0

10 Providers Total 8788 9695 (907) 91% TNA <3 3/5 3/5 3/5 4/5 4/5 4/5 3/5 4/5 4/5

Columbia Tech

DROWN, A 10 0 10 - - - - - - - - - -

DRYNAN,KIMB 1304 701 603 186% 1 9 6 6 2 2 1 1 1

HOLZMAN, JES 1533 1692 (159) 91% 1 1 5 1 0 1 1 8 8

JORDHEN,L 5 0 5 - - - - - - - - -

KOH,S 2121 3104 (983) 68% 0 0 0 0 0 3 1 2 2

PAULL, RICA 87 67 20 130% - - 15 5 7 5 4 3 3

SUPPLITT,G 1297 1711 (414) 76% 0 0 0 0 1 0 0 0 0

7 Providers Total 6357 7275 (918) 87% TNA <3 4/4 3/4 2/5 3/5 4/5 3/5 4/5 3/5 3/5

Salmon Creek

DANSIE,M 1597 2295 (698) 70% 0 1 1 0 6 0 1 0 0

GREANEY,S 1846 2341 (495) 79% 1 1 0 1 0 1 0 3 3

RYAN, MINHUE 2 0 2 100% - - - - - - - - -

SHAH,M 1 0 1 100% - - - - - - - - -

TRAN,D 1416 1491 (75) 95% 2 3 2 3 2 3 1 2 2

VELYCHKO, I 1628 1913 (285) 85% 4 3 3 0 0 0 0 0 0

NASH,HEATHER 1266 1570 (304) 81% 2 2 0 1 0 0 0 0 0

7 Providers Total 7756 9610 (1854) 81% TNA <3 4/5 3/5 4/5 4/5 4/5 4/5 5/5 4/5 4/5

Washougal

NORTON, C 3 0 3 100% - - - - - - - - -

PEARSON,KATH 1300 1327 (27) 98% - - - - - - - - -

WALTON,E 996 1213 (217) 82% - - - - - - - - -

3 Providers Total 2299 2540 (241) 91% TNA <3 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0 0/0

Family Medicine Total 32828 37789 (4961) 87%

% to

Target

Over

UnderTargetPanel

Panel and Third Next Available

Family Medicine February - 2015

Thresholds Panel

<15% Open-green<90% Restricted-yellow

<95% Restricted-Red>=100% Closed- Black

Thresholds TNA

0 Green1-3 Yellow

>= 4 Red

Family Medicine 201403 201404 201405 201406 201407 201408 201409 201410 201411 201412 201501 201502

Patient Continuity 74% 72% 74% 75% 69% 71% 72% 72% 73% 71% 76% 76%

Provider Presence 78% 72% 75% 74% 69% 72% 73% 76% 76% 73% 79% 78%

201403 201404 201405 201406 201407 201408 201409 201410 201411 201412 201501 201502

DOERFLER,E 5% 3% 2% 1% 5% 4% 2% 3% 1% 2% 0% 1%

BG FAM MED 4% 5% 6% 6% 5% 6% 6% 4% 5% 4% 3% 3%

Family Medicine 6% 7% 8% 8% 9% 8% 5% 5% 5% 4% 3% 2%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

No Shows

Why Did We Do It?

• PC Providers’ anxiety

– 100% production based compensation

– The warehouse of patients

– Open and unused slots

• Implement “Urgent Care visit type” and expiring appointment.

Additional Benefits

• Build new PC panels

• Utilize providers on 1st year guarantee to do a percentage of Urgent Care work.

• Increases overall efficiency of our system

How Did We Do It? Patient checks in Urgent Care (UC) –

PSR checks for next available appointment with patient’s PCP

(anything that requires RN Triage stays in UC)

Schedule with PCP

Look for expiring appointment (5-30 minutes in future)

in Primary Care (PC)

Schedule UC visit (can be blocked and session

limits set) in PC Patient seen in UC

Available and acceptable to patient

Unavailable or unacceptable to patient

Available and acceptable to patient

Unavailable or unacceptable to patient

How Did it Turn Out?

0

100

200

300

400

500

600

700

800

900 UC Encounters seen in PC

How Did it Turn Out? Family Medicine Panel Numbers per FTE

1200

1300

1400

1500

1600

1700

1800

1900

2000

Pre Implementation

Where Are We Today?

• The shift of volume in Urgent Care using the UC visit types has allowed an overall growth in patients presenting to the UC.

• Two main factors in the year over year increase in patients presenting to UC:

– Decreased wait times

– Web appointments

Web Appointments

• Summer 2013: UC visit via website.

• Since inception, we have > 8,000 web appointments.

• This business continues to increase.

Where Are We Today?

0

2000

4000

6000

8000

10000

12000

14000

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

2012

2013

2014

Where Are We Today?

0

100

200

300

400

500

600

700

800UC Web Appointments

Where Are We Today?

• Work RVUs per FTE

0

1000

2000

3000

4000

5000

6000

7000

8000

2009 2011 2014

Family Medicine

Internal Medicine

Pediatrics

Urgent Care

Provider Satisfaction Targeting Improvement Map 2011

Provider Satisfaction Targeting Improvement Map 2013

Provider Satisfaction Targeting Improvement Map 2014

What Did We Learn?

• “Open slot” in PCP schedule did not always mean available

• Need to develop list of presenting problems that PCPs are comfortable with

• PCP’s communicating with UC staff directly around perceived problems

List of Criteria to Determine if Patient Stays in Urgent Care

• Elevated BP • Possible FX • Burns • Lacerations • Abscess • Blurred vision • Chest pain • Concussion • Shortness of breath • Dizziness, numbness or tingling

Benefits Beyond Dollars and Data

Opened up communication between department providers that would not have happened otherwise (much more cordial….It’s “our” patient, not “my” patient).

What’s Next?

• Ongoing maintenance

• Communication

• Continuous Improvement

Questions?