Improving Primary Care Access
Managing panel size and the scope of the practice allows a team to balance supply and demand and ensures that they can do today’s work today. Panel size is the number of unique patients for whom a care team is responsible; it is a measure of the equity of the work. Panel size can be measured by calculating the number of unique patients seen by a specific provider within a specific time frame — usually the past eighteen months. An appropriate panel size is an outcome of an optimal access system, not a goal or end in itself. The goal is good panel management: clinicians and their care teams being responsible to, and caring for, a designated population of patients.
From the physician’s perspective, having an equitable and appropriate panel size ensures that he or she will be able to offer good care in a timely way to a reasonable number of patients. Panel size drives demand. An agreed-upon panel size range for each primary care provider ensures the physician who is working to improve his or her access that the demand for services will not exceed the supply.
Another way to evaluate panel size is to use "average visits per week" as a proxy of the clinic's work. Determine the number of visits per week that can be supported based on current supply, and use this as a proxy for the total of visit and non-visit work. As the clinic adopts a model of care based on continuous healing relationships, non-visit work will increase and clinics will need to adjust panel size targets.
Changes for Improvement
Limit the Scope of the Practice
Practices can shape their demand by limiting the types of services and procedures they are prepared to offer patients. For example, a primary care practice with greater demand than supply may decide to send patients needing blood draws or other simple diagnostic tests (that had traditionally been done in the office) to a lab or phlebotomy service. Physicians (in partnership with specialists) may also begin referring patients for simple procedures, such as removing skin lesions, to a dermatologist rather than provide that level of treatment themselves.
Improve Continuity for Appointments and All Clinical Work
One of the most powerful change ideas to reduce demand is to promote continuity with the primary care provider (PCP) and the care team at all times. When a patient is deflected to Urgent Care, or even to another provider on the team, they may often be instructed to check back with their PCP, or choose to do so on their own, thus creating a second demand on the system. The PCP is in the best position to "max-pack" at that visit, possibly reducing future demand even more.
Practices can promote continuity by first committing to it. Once providers, nurses, and appointment staff all view continuity with the PCP as a priority, then scheduling and nursing staff can script the appointment interaction. The only situations in which a patient should be deflected to an alternate provider or to Urgent Care is if the PCP is absent, or if the patient prefers this option because he or she cannot wait. Sometimes it is helpful for a mid-level provider to carry a smaller panel of patients and be the first provider assigned to see a patient for a provider who is absent.
A good example of how practices have improved continuity is to route all patient-related work to the PCP/care team. To do this, consider all members of the care team when planning a patient visit (e.g., nurses can be responsible for flu shots or physician assistants for some post-procedure follow-up). This helps to reduce demand for appointments with the physician. Be careful to schedule the patient for the appropriate level of care the first time. For example, if a patient's needs require him or her to see the physician, schedule the appointment with the physician instead of the physician assistant (PA) to avoid creating demand for two appointments. Conversely, if the level of care indicated dictates that a nurse or PA can meet the patient's needs, it is not necessary to schedule an appointment with the physician.
Once clinical teams have fixed panels of patients, the practice should devise a streamlined process for connecting incoming work with that team. Practices using paper charts might label their charts with colored tape as a signal to reduce time spent finding the answer to the question, "Who gets this work?"
Improve Patient Self-Management
Clinics that promote patient self-management achieve better overall management of the patient’s condition. Self-management for chronic diseases also reduces unnecessary demand for visits.
Establish Input Equity
Panel size is based on clinical full-time equivalents (FTE) or clinical supply (availability for appointments), and a full-time provider will have a larger panel size than a part-time provider. When two full-time providers have very disparate panel sizes (and thus very different levels of demand), efforts should be made to make the panel size equitable for each provider. An equitable panel size can be achieved by either actively redistributing patients from a larger panel to a smaller one, or by temporarily closing the larger panel to allow new patients to fill the smaller panel, thereby decreasing the larger panel by attrition.
At some point, each clinical team will reach its limit of supply and will need to reduce the patients entering the practice to balance those leaving the practice. New patients that cannot be absorbed by a team with a full practice should be deflected to teams capable of accommodating the demand. At some point the entire practice may reach its limit. At this point the practice must come together to discuss whether to deflect new patients to other practices (closing temporarily or permanently to new patients) or to grow the practice by adding more clinical teams.
Create and Implement Service Agreements Between Primary Care and Specialty Care, and with Diagnostic Entities
Service agreements between primary care physicians and specialists define the list of conditions that should be taken care of in primary care, and the process for making a prompt referral to specialty care if needed. Service agreements also define the appropriate work-up needed so that the patient arrives at their specialty care appointment with all necessary tests completed and ready for review. Agreements also help to stipulate the expectations for the specialist so that he or she knows what the patient has been told about the referral, what the primary care provider suspects about the patient's condition, and when the primary care provider expects to have their patient returned to their care (possibly after the work-up and diagnosis, or after the patient is stabilized on treatment).
Service agreements benefit both primary care physicians and specialists. Primary care physicians are ensured that their patients will be treated promptly by a specialist — either by appointment (ideally within 24 hours, typically within a week) or by an immediate phone consult if more appropriate. Specialists are assured that they will see only those patients who require their services, and those patients will be ready for their review, diagnosis and treatment plan. Service agreements are not guidelines or referral criteria unilaterally disseminated from specialists to primary care providers; rather, they are built-in partnerships between primary care and specialty care.
Service agreements between primary and specialty care should also include an understanding of when a patient is transferred back to the primary care physician following a specialty referral.
Service agreements between clinical areas and diagnostic services are also very important to ensure that the patient’s journey is fast and smooth as they move from primary care to a diagnostic study, and then either back to primary care or on to a specialty referral. Because diagnostics are key in the patient’s care journey, it is essential to have agreements established to expedite the process.