Knowing your Population and Enhanced Access in The Patient Centered

Medical Home

Xavier Sevilla M.D. FAAPWhole Child Pediatrics

Manatee County Rural Health Services Inc.

Samoset Pediatrics 1999 Lots of patients “Walk in” Already Saturated schedule at 8

am Phone ringing off the hook Staff and Physician dissatisfaction Lots of No-shows Angry, Frustrated Patients Patients waiting > 70 minutes Getting home very late

Our practice was sick

Enhanced/Advanced Access Decrease No shows and

Cancellations Decrease staff phone time for

Triage and scheduling Increase staff and patient

satisfaction Decrease Overtime Improve continuity

Terms Demand: What the patient wants.

A Continuous relationship with a clinician (face to face visits to the doctor, phone calls, email)

Supply: What we provide ( face to face visits, phone calls, email)

Our Business is matching demand with supply.

Terms Backlog: Waiting list, Queue, e.g.

number of days/weeks until your next physical available.

Constraint/bottleneck: The rate limiting step

Examples in other Industries Toyota: matches supply and

demand within seconds Panera Bread: Matches supply and

demand within 6 minutes Fast Food: McDonalds

Every 6 seconds of wait represents 1% of market share

Is improving access important?

Access is #1 in Customer satisfaction Decreased waits improve staff

satisfaction Reducing appointment delays

improves clinical outcomes ( Pediatrics 116,1 7/05)

Delays Cost a lot of Money Large waits = large No shows Nurses time( triage), Receptionist (time) It takes 30s to say Yes, 9 minutes to say

NO Gives the impression of lack of resources

The place to start… If the heart of the Medical

Home is a continuous relationship over time between Patient/Family and the Practice Team…… then we must provide a mechanism for allowing that relationship to happen in our systems.

The Cornerstone of the Patient Centered Medical Home is

KNOWING YOUR POPULATION…

Knowing your Population

1. Assess Supply and Demand

2. Provide a systematic way to allow patients to have their own Primary Care Physician/Team.

Knowing your population

3. Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, self-management status, community and family need.

3. Use panel data and Registries Maintain a database (Registry) that

includes key information on important patient groups within a practice population.

Monitor the database to identify and reach out to those needing service.

3. Use panel data and Registries MY JOURNEY Registry

Florida Shots Practice Management System

Asthma patients Well Child Checks

Key Changes: Enhanced Access

1. Ensuring 24/7 continuous access

2. Help patients attain and understand insurance

3. Provide scheduling options that are patient centered

1. Ensuring 24/7 Continuous Access

Extended hours at the office Stay open past 5pm and weekends

Alternate offices or teams Early opening for labs Stay open at lunch (alternate lunches)

After hours care by phone or email Accessibility of the Medical Record

after hours

2. Help patients attain insurance coverage Clerical staff that can fill insurance

applications on site Social Worker/Financial counselor

can address health insurance coverage

3. Provide scheduling options that are patient centered Patients can access the practice

when THEY need it Advanced or Open Access

High leverage changes for Advanced Access

1. Balance demand and Supply2. Assign patients to PCP3. Reduce the Backlog4. Reduce appointment types5. Reduce demand6. Increase supply7. Develop Contingency Plans8. Decrease waiting in the office

1.Balance Demand and Supply

o Predict Same Day Demando Have your front desk make a daily list

of:o Appointment requests calls for todayo Walk ins or work inso Patients that used the ER during office

hourso Patients sent to other sites

o The Total is your Daily Same Day demand

1.Balance Demand and supply Predict Supply Determine the Patients/hr a typical

Clinician in the practice can see Determine # of hours each

clinician works at the office. Patients/hr x Hours per day=

Total Supply

1.Balance Demand and Supply If Demand > Supply every day

there is no system in the world that can make it work: Hire another FTE Hire a part-timer to cover peaks

Or...

1.Balance Supply and Demand Balance supply and demand For each day calculate how many Same

Day appointments you need to cover total Same Day Demand

Distribute supply ( physician/hours) looking at covering peaks such as Monday morning and Friday afternoons.

Also distribute time off looking at the demand for appointments.

Supply : P. PediatricsAM PM Total

Monday 15 15 30

Tuesday 15 15 30

Wednesday 15 15 30

Thursday 19 0 19

Friday 15 15 30

Same Day Demand:P. Pediatrics

AM PM Total

Monday 6 2 8

Tuesday 5 3 8

Wednesday 4 3 7

Thursday 6 Closed 6

Friday 6 2 8

2. Assign patients to PCP Continuity is KING!!!! Assign patients who already have a

PCP Assign patients who don’t have a

PCP using the 4 cut method

27

4-Cut MethodCut Patient Assignment

1 Only ever seen 1 provider Provider seen

2 Seen 2 providers, with 1 provider majority

Provider seen the majority of times

3 Seen a few providersProvider who

performed last physical

4 Seen many providers Last provider seen

28

Practical Steps(starting as if no patients are assigned)

1. Assign all patients who have only ever seen 1 provider to that provider

2. Develop a list of patients with their last 3-5 providers seen

3. Assign patients who have seen a provider the majority of times to the majority provider

4. Allow clinic teams to talk through the rest of the patients and where they belong

3. Work down the Backlog Measure the extent of your backlog. # of days until you have the third

available non urgent appointment. Good Backlog

Follow ups, WCC booked in advance Bad Backlog

Pts wanted to be seen earlier but were deflected into the future because of no availability

3. Work down the Backlog

HARD WORK!!! Add daily capacity

Set a day to Start Backlog reduction Add a few more slots per Doctor

per/day Bring patients from the future

schedule into today Add locums or extend hours

temporarily

4. Reduce appointment types Reduce number of appointment

types Use only 1 or 2 types of appointments Eliminate distinction between urgent

and routine Standardize length of

appointments Consider having one 10, 15 or 20

minute standard slot. Short appt is one slot and a long appt is two slots.

4. Reduce appointment types MY JOURNEY Two types standard (short) 15 mins

and long (2 slots) 30 mins. Last appointment of the morning

30 mins prior to lunch. Last appointment of the afternoon 430pm (730pm late)

Every slot is available for any type of appointment

Scheduling is an art… Demand for appointments is

predictable Sell early (morning), Sell late

(week)… Appointments we can control:

Follow ups Chronic care monitoring Wellness/ Physicals

5. Decrease Demand Maximize each visit Use alternative methods of

communication: Phone for follow-ups and refills Protocols for triage

Increase intervals for visits Otitis Media from 2 weeks to 3 months

Decrease no-shows Increase continuity

15% Reduction in demand

5. Decrease Demand: Decrease No-Shows

Sell the return visit “If you can’t make this

appointment you’ll let me know right?”

Make cancellations easy Reminder call system. Call 24-48

hours Know your chronic no showers

After 3 no shows do not schedule

6. Increase Supply ARNP/ PA Clinicians to add

appointments Nurse Visits:

RN/LPNs for simple visits ( sutures, BP)

Group visits Vaccination clinics

7. Contingency Plans Anticipate for expected

supply/demand mismatch. Decreased supply

Vacation, Sick clinician, Increased Demand

Flu Season, School physical time Develop protocol for unusual but

expected events.

7. Contingency Plans Clinician Time off/Vacation

Block off vacation time period The Week after vacation block off half

the day When clinician returns then open the

blocked time

8. Decrease waiting in the office First AM and PM appts start on time Huddles at the start of the day to go

through the schedule Dictate/type your note during the visit Co-locate staff to enhance work and

communication flow

Things I can do next Tuesday…

1. Have a Team huddle2. Alternate Lunch between teams3. Measure 3rd available appointment 4. Look at your Same day demand5. Block enough slots in the

schedule for your Same day demand

Resources AAP

http://www.aap.org/visit/openaccess.htm

AAFP http://www.transformed.com/resource

s/Access.cfm Qualis Health PCMH

http://www.qhmedicalhome.org/

Questions ?????