Clinic Access, the Orientation Visit, and Same-Day-Clinic

1. Clinic Access, the Orientation Visit, and Same-Day-Clinic 6/29/06 Tom Miller Robb Malone Paul chelminski

2. Tom Miller, MDClinic Access

3. Interventions Developed to Date • Interventions implemented late February 2006: • Revised procedures for scheduling acute visits. • “E” slots or acute slots were eliminated from templates. • “N” slots were eliminated in favor of using two adjacent “R” slots for NEW patients. • PBAs manually note “N” or “R” status in A2K. • PBAs schedule adjacent appointments to preserve consecutive slots for NEW patients, and start scheduling with the first opening of the clinic session. • There is no limit to the number of NEW patients a provider can see in a clinic session. • This intervention has since been revised.

4. Interventions Developed to Date (cont’d) • Further interventions developed and implemented in mid-March 2006: • Began new patient group visits for new patients scheduled with residents. • Reviewed Attendings who no longer accepted NEW patients and revised decision not to take NEW patients. • Began to “work” Televox reports and mail postcards to patients who had incorrect contact information.

5. Interventions Developed to Date (cont’d) • Further interventions developed and implemented in mid-May 2006: • Began to educate patients on Televox interaction. • Use educational handouts. • Implement appointment reminder cards at check out and mail reminders “remotely”. • Encourage patients to call and cancel/reschedule

6. Assessment of GIM Clinic Access • In an effort to assess GIM clinic appointment utility and access we have developed the following run-charts. • These charts are used to develop and assess interventions to improve appointment utility and clinic access.

7. Resident Appointments

8. Resident New Appointments

9. Resident New Appointments (Cont’d)

10. Resident Return Appointments

11. Resident Return Appointments (Cont’d)

12. Attending Appointments

13. Attending New Appointments

14. Attending New Appointments (Cont’d)

15. Attending Return Appointments

16. Attending Return Appointments (Cont’d)

17. No Shows for All Physicians

18. Physician Appointment Utilization Utilization rate is defined as completed visits/total openings. Productivity is defined as completed visits/scheduled visits. Scheduling rate is defined as scheduled visits/total openings.

19. Improved Press Ganey Results

20. Robb Malone, PharmDOrientation Visit

21. Goal of Orientation Visits for Resident New Patients • Problem: • 40% No-show rates for resident new visits • Goals: • Orient patients to clinic policies and procedures • Decrease no show rates for resident new patient appointments • Decrease wait time to new patient visits with residents

22. Who gets an Orientation Visit? • If a new patient is SELF-PAY or has MEDICAID ONLY, must have orientation visit. • If acute need, recommend continue to see previous PCP. • Make orientation visit if plans to come afterward. • If a patient is seen in the orientation visit, but no shows for their new patient provider visit, they must return to the orientation visit before receiving another appointment.

23. Who does not get an Orientation Visit? • NO orientation visit if new patient referred from ED by a Hospitalist. • NO orientation visit if new patient for anticoagulation clinic. • NO orientation visit if assigned to an attending • If new patient has MEDICARE, PRIVATE INSURANCE, or MEDICARE & MEDICAID; • Schedule with Attending if availability within 2 weeks. • Schedule orientation visit if no appointment is available.

24. Utilization of Orientation Appointments

25. Orientation Availability

26. Assessment of Orientation Visits (OV) Objective: • Assess the impact of the OV on no show rates and patient clinic utilization prior to implementation of Same-Day-Clinic. Results: • Assessed 49 consecutive patients scheduled for the OV. • 57% scheduled, attended the OV. • Of those who did not attend the OV, 1 patient made and attended a new patient appointment by other means. • 100% of those who attended received an appointment with a GIM provider at the time of OV attendance. • Of those who attended the OV, there was a 32% no show rate for the initial provider appointment.

27. Paul Chelminski, MDSame-Day Clinic

28. Internal Medicine Same-Day Clinic (SDC) • The Urgent Care Clinic (UCC) will close on 6/30/06. • Date of Initial SDC Operations: July 3, 2006 • Purpose: • The SDC will provide timely and efficient care to patients with acute internal medicine and primary care needs. • The SDC will replace the IMC walk-in doctor. • The SDC will function differently from the UCC in terms of; • patient source, • access by specialty referral, • hours of operation, • and staffing.

29. Potential SDC Patients • Established IM and Geriatrics continuity patients with acute needs. • New patients from the Orientation Visit. • These patients will be added to the continuity panel of the resident first involved in their care, with exception being Medicine & Pediatrics residents rotating through SDC. • New patients referred from Hospitalists. • Patients discharged from ED by Hospitalists do not require Orientation Visit. • Our goal is to be able to provide follow-up within 3 days.

30. Potential SDC Patients (cont’d) • Patients seen in the ACC-based Occupational Health Clinic (OHC) may be referred by OHC providers for same-day services. • IM Attendings will be available to provide consult services for OHC patients. • Same-day consults from other specialty clinics, primarily those located in the ACC, provided these specialties will provide reciprocal expedited consultation services in their clinics. • Dermatology • Orthopedics • Ophthalmology

31. Location of SDC • ACC IM clinic, East Wing (3200 suite). • 4 exam rooms with flexibility to expand up to 6 depending on room demand. • 3205 will serve as the consult room for SDC operations.

32. SDC Staffing • Nursing: • One additional RN FTE. • SDC staff and nurses will fall under the authority and policies of the IM Clinic and its medical director.  • Administrative: • One additional PBA FTE (Front Desk).

33. SDC Provider Staffing • Attendings: • Current IM faculty and fellows. • Residents: • 2.4 to 3.4 resident FTE’s/month. • Goal is to have two residents at all times. • Accommodations will be made for vacations, alternate duty, continuity clinics etc. • Continuity Elective Residents: • Will staff SDC 4 half days per week over 2 months

34. SDC Hours of Operation and Templates • SDC will operate from 8:30 AM until 6 PM • Lunch: Noon to 1 PM • AM Session: • Template starts at 8:30 AM and last patient scheduled at 11:30 AM. • PM Session: • Template starts at 1:00 PM and last patient scheduled at 4:30 PM. • No evenings, weekends, holidays.

35. SDC Scheduling • Scheduled slots available today, tomorrow, and the next day. • Walk-In patients will be seen according to room and template availability. • If no appointments are available the PBA will contact the triage nurse who will discuss the patient with the SDC Attending. • Patients should not be sent away unless the Attending has been involved in the decision making process • Referral to ED will be last resort after Attending consultation and if appropriate, offered appointment next business day. • The Hospitalists will facilitate the direct admission process.

36. SDC Scheduling (Cont’d) • The SDC resident can schedule SDC follow-up. • Non-SDC providers can schedule SDC follow-up • Staff will be available at 8 AM to schedule patients who left messages or are calling for appointments. • Schedulers will try to fill unused slots including cancelled visits in the continuity clinic and at the same time keep adequate volume in the SDC. • In scheduling for the SDC, PBA’s will use the most immediately available half day.

37. Billing & Attending Involvement • The Attending will see all patients and bill at level that service and documentation support. • No “primary care exception”. • The Attending will independently evaluate patients seen by medical students and also during periods of high volume and acuity.

38. SDC Teaching • Teaching conference from 8 to 8:30 AM. • Curriculum: • The morning attending is responsible for topic germane to management of acute medical issues commonly encountered in outpatient internal medicine. • With proviso that for first two months Drs. Chelminski, Colford, and Miller will assume teaching responsibilities on mornings—except Thursday—when Dr. Meyerhoffer is attending. • Revolving curriculum to be developed over first few months of SDC operations.

39. Questions