Clinic Scheduling

1
Clinic Scheduling

• 16 APR 2005
• W. Paul Crum M.D.
• MAJ, MC
• Faculty, FPRC Womack AMC
• Ft. Bragg, NC

2
Agenda

• Scheduling Templates
• Traditional, Advanced Access and Open Access
• Traditional Scheduling
• Wave Scheduling, Modified Wave Scheduling, Carve
  Out Scheduling
• Acute Care Access
• Contingency Plans
• Special Clinics
• Saturday Clinics
• PM Clinics
• Procedure and PAP clinics
• Factors to Consider
• Empanelment, Administration Support, Access and
  Demand
• PCM management of panel

3
Scheduling Types

• Traditional Access
• 4 Appt Types WELL, EST, ROUT and ACUTE (Tricare)
• Access standards for each type
• Loads most of todays work for tomorrow creates
  Backlog (good and bad)
• Patients and Providers familiar with model
• NO-SHOW rate
• Can be up to 20 for EST and ROUT appointments
• WELL appointments may actually be higher NO-SHOW
  rates
• 4 week backlog for appointments is common
• Difficult to cancel clinics
• Most Clinics can plan using demand (typical
  distribution)
• ACUT 20-40
• ROUT 20
• EST 20-40
• WELL 20

4
Scheduling Types

• Advanced Access
• Describes both Open Access and Same Day Access
• 100 appointment availability
• See todays work today, no front loading
• Easy to plan for surges and demand
• Overflow may happen
• Needs a fall back contingency plan for heavy
  utilization periods
• Patients and Providers variably familiar with
  model
• NO-SHOW rate is less than 5
• Doesnt allow for acute follow up 1 week, 2
  weeks, etc.
• Easy to cancel appointments

Murray, M. and C. Tantau. Same-day appointments,
exploding the access paradigm. Fam Prac Manag.
Sep 2000 45-50.
5
Scheduling Types

• Open Access
• Lets Practice flow dictate demand
• Easy to cancel clinics
• Less pre-booked appointments
• Provider Satisfaction run your own schedule
• Buy in to see extra patients important
• Provider engagement required
• Shortens patient waiting time for appointments
• Less NO-SHOW appointments than Traditional Access
• Typical Template
• EST 20-40
• ACUT 60-80

Larsen, R. Open Access Implementation Manual.
Advanced Access Coordinator. Tricare Europe. 2
May 2003.
6
Traditional Scheduling
0800 ROUT 0820 EST 0840 WELL 0900
ROUT 0920 EST 0940 ACUT 0955 ACUT 1010
WELL 1040 EST 1100 ACUT 1115 EST 1135
ACUT 1150 ACUT

• Standard Scheduling
• Easiest to understand for central booking
• No contingency when appointments run out
• Patients showing up late create a problem
• Clinic wait time for patients is low
• Provider sees a fixed number of patients every
  day
• Doesnt allow for extended visits (unmodified)

Zazove, P. Clinic scheduling and access. Clinics
in Family Practice. 54. Dec 2003.
7
Traditional Scheduling
0800 ROUT 0800 ROUT 0830 EST 0830
EST 0900 ROUT 0900 ROUT 0930 EST 0930
EST 1000 ACUT 1000 ACUT 1015 EST 1030
EST 1100 WELL 1100 ACUT 1115 ACUT

• Wave Scheduling
• Book 2 appointments for every 30 minutes
• 1st patient to show up is seen first
• Allows patients to be early or late
• Wait time in clinic may be longer
• Allows Provider to see large number of patients
  (q15 min)
• Doesnt allow for extended visits (unmodified)

Zazove, P. Clinic scheduling and access. Clinics
in Family Practice. 54. Dec 2003.
8
Traditional Scheduling

• 0800 EST
• 0800 ACUT
• 0815 ACUT
• 0830 EST
• 0900 WELL
• 0900 ACUT
• 0915 ACUT
• 0930 EST
• 1000 WELL
• 1000 ACUT
• 1015 ACUT
• 1030 EST
• 1100 EST
• 1100 ACUT
• ACUT
• 1130 EST

• Modified Wave Scheduling
• Book a long and short appt at top of hour
• Book a short appt at 15 after
• Book a long appt at 30 after
• End of hour is catch up time for Provider
• Allows patients to be early or late
• Wait time in clinic will be longer
• Allows Provider to see large number of patients
• Allows for Extended appts
• Difficult to communicate with central booking
• One sicker acute patient can throw off entire
  half-day.

Zazove, P. Clinic scheduling and access. Clinics
in Family Practice. 54. Dec 2003.
9
Traditional Scheduling

• Carve Out Scheduling
• Carve out a block of time for Acute Care
• Standard booking
• Acute care appointments are attractive for
  Providers to use for 1 week or 2-3 day follow up
• Acute access for entire clinic can be degraded by
  nibbling
• Doesnt allows patients to be early or late
• Wait time in clinic is shorter
• Allows Provider to see fewer patients
• More downtime is attractive for Providers
• Doesnt allow for extended visits
• Least efficient of last three options for
  Provider and Nursing time.

0800 WELL 0820 EST 0840 ROUT 0900
WELL 0920 EST 0940 ROUT 1000 EST 1020
ROUT 1040 ACUT 1055 ACUT 1110
ACUT 1125 ACUT 1140 ACUT
Zazove, P. Clinic scheduling and access. Clinics
in Family Practice. 54. Dec 2003.
10
Advanced Access Scheduling

• Same Day Pure
• All Patients calling for appointments are seen
  that day
• PCM is unavailable, patient is still seen
• Can also use Wave or Modified Wave to book
• 4 appointments per hour v.s. 3.
• Chart Room responsiveness
• Nursing cant plan for acute needs
• Phone line intensive
• Has potential to become overwhelmed
• Unused demand days look like availability for
  empanelment
• beware of un-booked appointments
• Provides no assurance of acute follow up
• 1-2 days or 1-2 weeks

• 0800 SDA
• 0815 SDA
• 0830 SDA
• 0845 SDA
• 0900 SDA
• 0915 SDA
• 0930 SDA
• 0945 SDA
• 1000 SDA
• 1015 SDA
• 1030 SDA
• 1045 SDA
• SDA
• 1115 SDA
• 1130 SDA

Murray, M. and D. Berwick. Advanced access,
reducing waiting and delays in primary care.
JAMA. 2898. 26 Feb 2003.
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Advanced Access Scheduling
0800 EST 0815 EST 0830 EST 0845
OPAC 0900 OPAC 0915 EST (PCM booked) 0930
EST (converted) 0945 EST (PCM booked 30
min) 1015 EST (converted) 1030 OPAC 1045
OPAC 1100 EST 1115 OPAC 1130 OPAC

• Open Access (OPAC)
• All Patients calling for appointments are seen or
  booked
• Can also use Wave or Modified Wave to book
• 4 appointments per hour v.s. 3.
• Chart Room responsiveness degraded
• Nursing can plan, partially
• Allows patient to book future appointments
• Minimizes unused availability
• Best method to meet acute and chronic need
• Patient offered choice, SDA v.s. PCM appt.
• Maximizes PCM booking

Larsen, R. Open Access Implementation Manual.
Advanced Access Coordinator. Tricare Europe. 2
May 2003.
12
Advanced Access/Open Access

• Terms used interchangeably
• Advanced Access describes open access (OPAC) and
  same day (SDA) scheduling
• Terms need clarification
• Regardless of term used
• Need for EST appointments is recognized under
  OPAC plan
• Number of EST appointments is practice dependant
• These EST appointments are intended for PCM only
  appointments
• EST for non-PCM patients, under Advanced Access
  are supported
• Under Open Access as described, they are not
• Open Access
• PCM Driven allows provider to affect template
• Allows for daily Provider Driven decisions about
  care
• Takes Provider away from seeing patients
• Allows Providers to potentially degrade acute
  care access
• When reviewing the literature remember be aware

13
Acute Care Access

• Study demand on day by day basis
• Highest acute care demand - Monday, Tuesday and
  Friday
• Highest routine care demand also on these days
• Active management of Acute Care access is
  important
• Plan for contingencies
• Sick Provider
• Lack of nursing support
• High demand months Dec-Feb
• Local concerns Reservists and NG soldiers
• Summer understaffing for Providers
• Schedule Providers or template to meet demand
• More ACUT on Mondays and Fridays
• Can be up to 60 of workload after Holidays or 4
  day weekends

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Acute Care Access

• Acute Care Provider/MOD
• Possible Solution assign one or two Providers
  to acute care only
• Effectively establishes an Acute Minor Illness
  Clinic within practice
• Does not support PCM ownership of acute care for
  panel
• Does not support PCM awareness of acute care for
  panel
• Can be overwhelmed if not properly staffed
• Provider is taken away from managing their panel
  while providing acute care for everyone
• Nursing Intensive tasking. Labs, IVs,
  Nebulizer treatments
• Nursing support will need to be higher for these
  providers
• Planning can match
• What happens when MOD is sick?

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Acute Care Access

• Contingency Plans when system fails
• Book Acute Care Earlier
• Open up 0700-0800 time for 4 appointments per PCM
  or designated provider, booked the night before
• Book Acute Care through lunch
• Open up 1200-1300 time for 4 appointments per PCM
  for their patients or designated Provider
• Book Acute Care in PM
• Open up 1600-1700 time for 4 appointments per PCM
  for their patients or designated Provider
• Make PCM aware and work patient in during
  existing clinic, see after hours or triage over
  phone
• PCM ownership v. being a designated Provider

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Acute Care Access

• Nursing support needed for contingency plan
• Clerical Staff support needed for contingency
  plan
• Adding clinical time or stealing lunch hour has
  its costs
• Will Command Support?
• Will Providers Support?
• Will Union Support?

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Saturday Clinics

• Goal 1
• Open up Routine Appt access for patients
• Patients dont often know about these clinics
• Patient demand for routine Saturday Access low
• WELL and EST appointments typically go unbooked
  or NO SHOW
• Goal 2
• Open up Acute Appt access for patients
• Becomes an offload the ER function fairly soon
• Many of Minor Illness patients from ER are not
  enrolled to clinic
• Staff Concerns
• One less clinic during the week
• Nursing, chart room and phone support
  requirements
• Many practices have been able to stop Saturday
  Clinics
• Providing data to support that they are seeing
  their patients during the week

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PM Clinics

• Goal 1
• Open up Routine Appt access for patients
• Patients dont often know about these clinics
• Patient demand for routine PM access is low
• WELL and EST appointments typically go unbooked
  or NO SHOW
• Staffing for WELL exams is difficult
• Goal 2
• Open up Acute Appt access for patients
• Patients will preferentially book later
  appointments
• If opened too early, they will fill up quickly
• Acute appts earlier in day go un-booked
• ER can be tempted into trying to access
• Staff Concerns
• Provider Coverage (start clinic later or longer
  clinic)
• Physician supervision of Residents and Extenders
• Nursing, chart room support

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Special Clinics

• Procedure Clinics
• Need 1-2 monthly for every procedure credentialed
  provider
• Minimize filling with fluff
• Cryotherapy should be done at time of visit
• Minor Biopsies 1 site, can usually be done at
  visit
• Save these for meaningful Procedures
• Encourage PCM self scheduling or fill with demand
• Avoid scheduling on Monday or Friday
• Minimizes conflict with Acute Access
• Maintain standard of access
• Wait lists should be avoided
• If procedure cannot be performed in 30 days,
  recommend referral to specialty care

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Special Appointments

• PAP Clinics (an option)
• Need 1-2 monthly for every provider
• Nursing awareness of PAP Clinic
• Nursing likes planning, streamlines support
• 20-30 minute visits
• Easy to template, difficult to cancel
• Easy to plan for Provider shortages
• During Active Duty Provider under-lap in Summer
• No PAP Clinics (JUN/JUL), hold down the fort and
  refill medications
• PPF Provider Palatability Factor
• Doesnt Support PCM Ownership of PAP appointments

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Empanelment

• Watch for Over Empanelled Providers
• Doesnt matter what scheduling method used
• Demand gtgt Supply
• Means they cant see all their patients
• NP/PA Extenders
• Ancillary support
• Acute Care and Routine Access to assist
  Physicians
• Uncomplicated patients
• Visits should be Staffed with PCM
• Watch their empanelment hard
• or- dont empanel them

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Empanelment

• Over-empanelled MD Providers are at risk
• Watch and Support
• Being a good or patient friendly doctor does not
  equal being asked to do more
• Watch Popular M.D. panels harder than others
• Requests for movement to new PCM Who will MD
  give up?
• PCM Ownership Reinforcement at every visit

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System Supports

• HHS/Administration
• Follow Metrics ask for numbers
• Number seen by PCM and team for clinic
• Number of no-shows by appointment type
• Number of patients who cant be seen by clinic
  (overflow)
• Or were seen by someone else (AMIC/ACC or ER)
• Number of T-cons by PCM
• Coding by PCM
• Hospitalization Rates by PCM and Team/Clinic
• Patient Satisfaction Surveys
• OTSG Tool online
• Flawed only asks patients who actually were
  seen by the Provider
• Developing a clinic tool is not discouraged (PIP)

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Access and Demand

• Appointment Availability
• Appointments must be available at the right time
• Running out is not an option
• Planning and Contingencies
• Dont be afraid of ROUT, WELL or EST access
• Convert appointments from SDA/OPAC as they are
  booked
• Demand is fairly predictable
• Structure to plan availability
• Structure to plan contingencies
• Structure to plan for special situations
• Structure to plan for deployments
• Structure to plan for sick providers
• Structure to plan for nursing shortages
• Structure to plan for training missions
• Be Prepared as OIC to handle the lost and angry
  patient at the front desk

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Access and Demand
What we are afraid ofwe cant see all of these
patients in appointments
6 month totals JUL-DEC 04
FPRC, WAMC Resident Workload by Year Group
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PCM Ownership

• Reinforce PCM at every visit
• Other Providers, Nursing, Clerical and Phone
  Staff need to support this mission
• New PCM in a clinic
• Proactively engage more chronically ill
• Easier to do from beginning for PCM
• Verification of patient information at every
  visit
• Clerks, checked by nursing, verified by Provider
• POC is PCM reinforced through systems
• POC is PCM reinforced by Providers
• Less demand for inappropriate follow-up
• Telephone management assistance
• T-con forwarding to PCM as standard

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Review

• Scheduling Templates
• Traditional, Open Access and Advanced Access
• Traditional Scheduling
• Wave Scheduling, Modified Wave Scheduling, Carve
  Out Scheduling
• Acute Care Access
• Contingency Plans
• Special Clinics
• Saturday Clinics
• PM Clinics
• Procedure and PAP clinics
• Factors to Consider
• Empanelment, Administration Support, Access and
  Demand
• PCM management of panel

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Questions