Implementing Advanced Access in California Physician Groups

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Implementing Advanced Access in California
Physician Groups
Neil Solomon, MD CQC and Health Net April 28,
2009
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Course Outline

• Learn AA concepts, how to implement program, data
  collection methods
• Review data collected, develop communications
  plan for practices
• Prepare to implement at demonstrator sites
• Review initial experiences, prepare for spread

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Format

• Teleconferences
• Teaching
• Share experiences
• Get your questions answered
• Work between sessions
• Collect information
• Gain comfort with concepts
• Test out with others in organization
• Ultimately, take it to the practices

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Todays Agenda

• Key change concepts
• Internal organizational resource required
• Characteristics of demonstrator sites
• How to collect the required data

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Its all about the LINE

• Lines form when supply and demand are mismatched
• Need to get S-D into balance to avoid lines
  forming, growing
• First need to eliminate the existing line
• Lines exist across healthcare, not just waiting
  for a physician appointment. This approach works
  on all of them.

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Key Change Concepts

• Measure and match supply and demand
• Commit to the conceptdo todays work today
• Increase supply (without working longer)
• Influence patient demand
• Work down your backlog
• Simplify your lines

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Change Concept 1

• Measure and Match Supply and Demand
• Calculate appointment slots (Supply)
• Include acceptable overbooks
• Count appointment requests prospectively (Demand)
• Externally driven
• Internally driven
• Review total predicted demand based on adjusted
  panel size
• Match by provider, clinic, organization day,
  season
• Track values and match over time
• Note This task is not the doctors
  responsibility
• Think office manager, site administrator, etc.

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Measuring Demand

• Use the tools to count how many people call, walk
  in, or are referred into the practice todayfor
  each MD
• Count how many patients are deflected to ER or UC
• May need to give tally sheets to multiple people
  in the office and collate at end of day
• Count each patient only once!
• Repeat for 2 weeks to see patterns
• Count number of return visits scheduled each day
  and add to demand total
• May wish to quantify other recurring
  time-consuming taskse.g. med refills, lab
  reviews, etc.

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Improve the Match

• Which days have greatest mismatch?
• (hint usually Monday)
• Schedule returns on slow days, early in day
• Train receptionist to offer these slots first
• Figure out how many slots to leave open at start
  of day, given expected demand
• Is it possible to accommodate all the demand
  given current schedule?
• Note Looks different for practices with lots of
  scheduled returns (e.g. well child checks)

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Common Worries

• Wont I get clobbered if anyone can get an
  appointment whenever they want it?
• Salaried MDs first concern
• What happens if no one calls and those spots go
  unused?
• PPO/IPA MDs first anxiety

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Problems with Measuring

• Significant investment of time before getting
  anything to actually happen
• Complicated process to collect data, especially
  for big offices
• Can lead to analysis paralysis

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Change Concept 2

• Do todays work today
• Commitment by physicians
• Dont push work to tomorrow, it just accumulates
• Appointments, documentation, electronic in-box
• Dont push extra work to others, it undermines
  the collective model
• Work comes right back, end up punishing efficient
  MDs
• Need for empanelment
• If we plan well variation from expected is small
• On average doctors go home a bit earlier

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Change Concept 3

• Increase Supply (without working longer)
• Optimize the care team
• Max-pack the visits
• Use non-traditional visits
• group visits
• secure messaging
• Schedule outbound phone visits of short duration
• Follow-ups

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Optimize the Care Team

• Medical Assistant roles
• Ensure all data available before MD sees patient
• Perform tasks beyond vitalsfoot exam, peak flow,
  smoking cessation counseling, checking for
  overdue prevention tests
• Calls back patients with normal lab results
• Use PA or NP for routine urgent, chronic care
• Everyone practices to the top of their capability
  and license. Take non-clinical work away from MD.

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Max-pack the Visit

• Go beyond the chief complaint
• Make it easy for doctor to do more during visit
• Are there any other future visits on the schedule
  that could be addressed today?
• Strongly induce continuity with same doctor
• Take care of preventive health during visits for
  other reasons
• This is all time permitting. MD uses judgment
  given idiosyncrasies of days work.

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Group Visits

• Concurrent medical visit for 8-12 people
• Involves real medical activity not a health ed
  class
• Typically need to overbook to get right number
• Visits last 60-90 minutes, intersperse 1-on-1
  medical encounters before, after session, and
  during a break
• Office space often a challenge
• All patients can have same chronic illness, or
  mixed
• Different persona for MD in this encounter
• Learned facilitation skills
• Patients tend to learn more from each other,
  sometimes hold each other accountable for health
  behaviors
• Has anyone tried this yet? What are your
  experiences?

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Secure Messaging

• Secure email with patients can be templated,
  batched, asynchronous
• Needs to have a financial model for most
  providers to be willing to engage in it
• Need to build into common workflow
• All experiences show patients do not abuse email
  access to their physician
• Several vendors with various products

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Change Concept 4

• Influence Patient Demand
• Actively edit schedule (combing)
• Extend interval between follow-up visits
• Resolve issue over phone so no need for visit
• Re-set patient expectations - colds are from
  viruses, and antibiotics wont help
• Are all those annual physicals necessary?
• Provide sources of information therapy
• Web sites
• Guides and handouts
• Local resources

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How to Comb Schedule

• Print out tomorrows schedule and look for
• Visits that can be averted with a phone call
  (e.g. normal lab results, rx refills)
• Just-in-case (i.e. stockpiled) visits
• Visits that require data to be fruitful--and be
  sure it is available (e.g. consult, hospital
  discharge summary, test result)
• Patients who are concurrently managed elsewhere
• Make sure one person is managing the problem
• Good example YouTube planned care huddle video
• http//www.youtube.com/watch?vWttxm7jAnb4

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Change Concept 5

• Work Down the Backlog
• Quantify number of appointments on the
  books--excluding returns you scheduled (good
  backlog)
• Important to know how much work it will require
• Devise a strategy to work down the backlog while
  still seeing current demand
• Give up half day off for several weeks
• Shorten lunch, start a bit earlier
• Use a moonlighter or internal locums doctor
• Do a call-a-thon of bad backlog patients to
  resolve issues quickly by phone
• Can be most painful part of AA, but it is
  temporary

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Change Concept 6

• Simplify the Schedule Template
• Multiple lines leads to inefficiency in waits
• Collapse all lines into one line
• Make all schedule slots one length (e.g. 15
  minute)
• Schedule all patients as X, 2X, 3X
• Fit 2X into first place with consecutive
  openings, etc.
• Eliminate special slots for physicals, new pts
  etc.

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Organizational Resources

• Board, leadership supportwalk the walk, talk the
  talk
• Internalize AA expertise
• Project leader - subject expert, system
  implementer
• Physician champion does it, can say it in MD
  terms
• Support data collection
• Support backlog reduction
• Subsequent training for new MDs and staff
• Empanelment, methods to preserve equity
• Rewards for achieving access goals, patient sat
• Strategies to further embed into organization

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Demonstrator Site Traits

• Physician open to innovative approach
• Partners wont dump onto demonstrator
• Strong office managerskills, influence
• Not implementing another big project (EHR)
• Backlog less than 30 days
• Practice will influence subsequent offices

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S-D Data Collection Tips

• Modify the tools to reflect your practices
• Train everyone who touches the patient
• Print and color code the days to avoid confusion
• One person is responsible for the project
• Forms, training, tallies

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Third Next Available

• Find the first, second and then third available
  appointment in the calendar
• Do not count slots frozen for same day
  appointments
• Count the number of working days from today until
  the third next available appointment (3NA)
• Do count half days, days off, days doing other
  work
• Dont count weekends (unless the office is
  typically open), holidays
• Repeat process for each appointment type
• Perform 3NA count at least monthly, on the same
  day of the week, same time of the day

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Work for Next Call

• Collect Measurements
• Measure 3NA for physicians at demonstrator sites,
  and all other candidate practices
• Measure supply and demand for potential
  demonstrator sites for at least one week
• Assess organizational readiness
• Board and senior leadership supportverbal and
  actions
• Have you identified a project manager? Physician
  lead?
• Look at compensation methods, empanelment
• Identify demonstrator sites
• Plan to present your work on the next call. Come
  back with questions that arise
• Next Call May 19 Review data collected,
  develop communications plan for practices

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Appendix
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Quickstart Method

• Incremental way to Advanced Access
• Builds upon frozen slots method
• Doesnt require data collection step
• Takes longer to get to Advanced Access
• Still have to deal with existing backlog
• Steps to Implement
• Leave open 2-4 slots at start of day for 1 week
  track time they are all filled each day
• At end of week add more open slots for next week
  if all same day slots taken before noon
• Iterate until close, then begin varying openings
  by day of the week

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Which Method to Choose