Advanced access is a model of care delivery aimed at reducing waiting and delays for outpatient care. By redesigning your delivery systems, reducing waiting times is possible, without adding staff. The Amarillo VA Health Care System (Amarillo, Texas, USA) was able to decrease the overall wait for primary care appointments from 76 days to the level of 20 days, by using the Advanced Access concepts.
The staff at the Amarillo VA Health Care System reorganized Primary Care in January 2000 based on the principles of Advanced Clinic Access. The Walk-In Clinic was eliminated and the staff reorganized into an additional primary care team, adding capacity to the system. The principles of Advanced Clinic Access were taught to providers at a one-day retreat in March 2000. During breakout sessions teams were challenged to find ways to put the theories into practice and identified the ten key changes below. After the retreat, the entire department began testing cycles of change and implementing the best of the ten key changes into everyday practice.
This report includes some of the areas where key changes in primary care were made at the Amarillo VA Health Care System to realize the gains of Advanced Access.
1. Work Down the Backlog
One of the first steps towards improving access in primary care is to know the extent of the waiting times for your patients. This can be done by determining the average wait time until the next available appointment for your patients. The VA has a database that contains a monthly summary of wait times, encounters, and appointments. This data can be pulled for a range of clinics within a DSS identifier and then further refined to division specific information. In January 2000, the waiting time for primary care appointments at the Amarillo VA Health Care System was over 70 days.
One of the methods used to work down the backlog in appointments at the Amarillo VA was to disband the Walk-In Clinic in January 2000. Patients want the opportunity to see their own physicians when they have urgent health care needs. If they are seen by an unfamiliar provider (as was done in the Walk-In Clinic), this often results in a second visit with their own provider within a day or so of the urgent care visit, resulting in rework for the health care system. In order to best serve our patients and work down the backlog, we asked that providers see their own patients who have urgent care needs. The providers running the Walk-In Clinic were redirected into a new primary care team and primary care panels were reviewed and evenly distributed among all providers. New schedules contained three slots per day, per provider, for walk-in patients. By March 2003, we were able to reduce the waiting time for primary care appointments at the Amarillo VA Health Care System to 20 days.
2. Reduce Demand
To help reduce demand, we maximized activity at each appointment. Nurses share responsibility by completing some clinical reminders. New patients attend a new patient orientation class prior to receiving their first clinic visit. The orientation class, started in May 2002, gives the patient an overview of the VA Health Care System. Patients are instructed to fast for the first new patient visit so that a complete work-up including labs, EKG, and X-rays can be done. Providers extend return appointment intervals for follow-up of healthy patients. In February 2003, we implemented registered nurse screening of walk-in patients. Nurse screening allows needs such as medication refills and paperwork to be met without the patient requiring a face-to-face encounter with their provider.
Another strategy that we are employing to reduce demand is creating alternatives to traditional face-to-face interactions. A diabetic group visit clinic was implemented starting in February 2003 in order to educate a large group of diabetic patients about different aspects of their disease and optimize patient involvement in their care.
Service agreements with specialty care clinics and education of providers on treatment of common conditions, and the appropriate work-up before referral, led to a decreased demand for subspecialty care.
3. Understand Supply and Demand
One strategy that we used to better align the supply and demand was to reduce the number of no shows because this represented a lost opportunity for both the patient and the provider. Under the old system, new patients were often automatically assigned a primary care appointment after a visit to the Life Support Unit. Ninety percent of these patients were subsequently no shows for their first appointment. Now patients are given the number to Telephone Triage and an appointment is scheduled at their request. No-show rates have dropped to 10 percent overall.
Panel sizes were standardized for physicians and mid-level providers and are tracked closely using Primary Care Management Module (PCMM) software. New patients are allocated to providers depending on their current panel sizes. The information can also be used to support staffing decisions by the clinic manager, as the standardized tools in PCMM allow determination of overall clinic capacity and provider efficiency.
Another strategy to align supply and demand was to assign primary care providers to ambulatory care only without emergency room or inpatient responsibilities, thus maximizing the continuity of care and preventing disruptions in service. Providers also were empowered to take care of patients during any type of visit, even an urgent care visit, in order to get all necessary work done during the same visit. This is part of the concept of “doing today’s work today.”
4. Reduce Appointment Types
Standardized appointment lengths have been established for follow-up, walk-in, and hospital follow-up patient visits. By standardizing the time employed for each of these different appointments, providers can use the appointments slots interchangeably as demand changes.
5. Plan for Contingencies
Demand variations are managed proactively by anticipating staffing shortages and reacting accordingly. In the event of illness or emergency leave team members provide cross-coverage. A standard Leave Policy for all team members requires advance notice of vacation and requires the rescheduling of cancelled appointments within two weeks of the original appointment date.
6. Manage the Constraint
Before the elimination of the Walk-In Clinic the physician to mid-level supervisor ratio was a less than optimal at 1:5, a potentially rate-limiting step for the mid-level providers. Redistributing the providers from the disbanded Walk-In Clinic reduced the ratio to 1:3. Taking advantage of natural turnover, mid-level providers were replaced with physicians further decreasing the supervisory ratio to 1:1. Capacity has been increased and mid-level providers no longer wait to present a case.
Vacant exam rooms are used when possible (e.g., when another provider is on leave). A future construction proposal requests expansion of ambulatory care facilities to allow two rooms per provider to enhance our efficiency and allow the providers' work to flow more smoothly.
7. Optimize the Care Team
We have partnered with the other services represented in primary care to ensure that all roles in the practice are maximized to meet the patient’s needs using the team approach to care for the patient. Our goal is to have one nurse per provider and one mid-level provider per supervising physician. Each care team also has one registered nurse to oversee, facilitate, and triage urgent needs and walk-in patients. Each team of four to five providers is also supported by three Team Associates.
Standardized protocols are used by the Telephone Triage nurses to coordinate the patient’s needs. Questions related to routine medical issues, medication refills, and appointment information are answered by Telephone Triage. A progress note is entered into CPRS (non-urgent), with the provider receiving a “view alert,” while urgent / emergent calls are transferred directly to the team nurse.
8. Synchronize Patient, Provider, and Information
In order to synchronize the patient, provider, and clinical information, patients are scheduled into a “Nursing Assessment Clinic” 30 minutes prior to their primary care visit. This allows the team nurse to screen the patients and allows adequate time for the nurse to complete their assigned clinical reminders before the provider appointment. Nurses can complete those portions of the clinic visit that do not require the physician’s presence (e.g., preventive vaccinations, diet and/or smoking education, etc.).
9. Predict and Anticipate Patient Needs
The clinic manager, outpatient nurse manager, and administrative supervisor coordinate coverage on a daily basis. There is daily communication between all members of the health care team in primary care. The use of regular “huddles” allows the clinic as a whole to anticipate and plan for contingencies.
10. Optimize Rooms and Equipment
We have chosen to standardize supplies in the provider’s rooms and ensure the rooms are well stocked as one way of optimizing rooms and equipment.
In summary, utilizing these ten key changes described has helped Amarillo VA Health Care System achieve our first aim of reducing our clinic waits below 30 days. The next step is reaching true Advanced Clinic Access, which offers appointments the same day. This is best described in the following quote: “The core principle of advanced access is that patients calling to schedule a physician visit are offered an appointment the same day. Advanced access is not sustainable if patient demand for appointments is permanently greater than physician capacity to offer appointments.” (Murray M, Berwick DM. Advanced access: Reducing waiting and delays in primary care. Journal of the Amercian Medical Association. 2003;289(8):1035-1040.)
Nolan T, Schall M, Berwick DM, Roessner J. Reducing Delays and Waiting Times Throughout the Healthcare System. Boston, Massachusetts: Institute for Healthcare Improvement; 1996.
Murray M, Berwick DM. Advanced access: Reducing waiting and delays in primary care. Journal of the Amercian Medical Association. 2003;289(8):1035-1040.
Murray M, Bodenheimer T, Rittenhouse D, Grumbach K. Improving timely access to primary care: Case studies of the advanced access model. Journal of the American Medical Association. 2003;289:1042-1046.