Improving Primary Care Access

Backlog consists of appointments on the future schedule that have been put off due to lack of space on the schedule to do this work sooner; working down the backlog recalibrates the system to improve access. This backlog of appointments clogs clinic schedules, taking up slots that could be used for patients requesting appointments with their providers. The traditional office practice scheduling philosophy has been to push out appointments into the future to protect today's schedule, creating backlog. Improved access calls for pulling today’s requests into today in order to protect the future, eliminating backlog. A practice cannot successfully improve access without working down the backlog and recalibrating their system of access to care.

It is sometimes useful to think of backlog as a reservoir of unmet demand. Water flows into the reservoir (patient demand), and water goes out of the reservoir (supply/services provided). If water comes in at the same rate as it goes out, then the level of water in the reservoir remains constant. If somehow the reservoir could be drained, then the water would flow smoothly with no need for a reservoir. Working down the backlog is like draining the clinic's reservoir of built-up demand. Once the reservoir of appointments has been reduced, there will be no delay in access as long as demand and supply are in balance.

Not all appointments on the future schedule are considered backlog:

• Provider discretionary return appointments for more acute problems
• Appointments made by patient choice (patient calls in today, but wants an appointment in the future)
• Provider generated interval follow-ups for planned care to manage chronic conditions and patients, for preventive tests such as yearly physicals, and for age-specific appointments

Changes for Improvement

Create and Use a Backlog Reduction Plan

It is imperative to create a deliberate and actionable plan for reducing backlog. The backlog reduction plan should include the following steps:

1. Gain immediate supply the easy way. Physicians and the care team can review the schedule of patients with future appointments to see if there are ways to meet their needs other than with an office visit. Ask the following questions about patients with future appointments:
    
• There's a patient on my schedule next month that I'm seeing today. Can I take care of that patient's needs today so that next month's appointment is not needed?  When I see them, can I safely and effectively extend their return interval? If yes, then I can schedule a return appointment (if necessary) in three to four months.
• Can this patient's needs be met with a phone call, or by handling the care in a different way such as by compressing multiple follow-ups into one visit? Can this patient be seen by someone else on the care team? 
• Does this patient really need a scheduled appointment? For example, a patient who only needs a medicine refill, had a recent office visit, is in the hospital, or who sees another provider as their primary physician might have his or her needs met in other ways.
  
2. Temporarily add appointment slots and try to do increasingly more of today’s work today.  Preventing new backlog by not putting today's work off into the future involves reducing future demand and gaining supply in the system. Clinics can prevent future backlog by temporarily adding appointment slots to the schedule (e.g., by adding weekend or evening appointments, or extra appointments during the day). Additional staff members are sometimes needed on a temporary basis to reduce the backlog and prevent future backlog from being created. Gaining supply allows the clinic to do more of today's work today, thereby reducing the amount of work that is being put off into the future and preventing new backlog from being created.
   
3. Set a start date to begin reducing the backlog and determine an end date when backlog reduction will be completed. By determining these two important dates, you set the pace for backlog reduction. Be careful to gain and add enough supply that backlog reduction is not a prolonged process. It is also important that the pace for backlog reduction is not too rapid to avoid the risk of burning out providers and staff.
   
4. Before you start, confer with senior leaders to be clear about organizational support for various options for working down the backlog. For example, will the organization pay overtime? Will there be additional compensation for providers working extra sessions/hours? Are locum tenens (temporary help providers) an option? Can part-time providers add hours? Explore all the options with your leaders before you engage the team members.

Measure the Backlog

The backlog that needs to be reduced consists of patients waiting to be scheduled or patients whose appointments have been put off into the future. Often in primary care, the backlog consists of patients waiting for physicals, new patient visits, or follow-ups. In specialty care, the backlog includes patients waiting for an initial consult with the specialist, or awaiting a timely return visit.  There are two important ways to measure the extent of the backlog.

• The third next available appointment is the average length of time in days between the day a patient makes a request for an appointment with a physician and the third next available appointment for that appointment — whether it is a new patient physical, routine exam, or return visit exam — without using “frozen” or held appointment slots. The “third next available” appointment is used rather than the “next available” appointment since it is a more sensitive reflection of true appointment availability. For example, an appointment may be open at the time of a request because of a cancellation or other unexpected event. Using the third next available appointment eliminates these chance occurrences from the measure of availability. This helps determine where availability on the schedule begins.

• Count the number of backlog appointments: Many groups have counted the number of backlog appointments (i.e., work the practice pushes into the future) by reviewing the future schedules and actually counting the number of appointments that represent backlog. Add the number of patients on a wait list to that count to get the total number of backlog appointments.