More doctors tell patients, 'we'll see you today'

Physicians who offer open access report happier patients and healthier revenues

From the November ACP Observer, copyright © 2006 by the American College of Physicians.

By Lola Butcher

Elizabeth L. Fabens, ACP Member, remembers the quizzical looks she received from patients when she introduced the idea of same-day scheduling.

Although many patients were frustrated with long waits for appointments, the opportunity to be seen on the day they called sounded too good to be true.

"It was counterintuitive," said Dr. Fabens, a partner with Greenhouse Internists, a four-physician primary care practice in Philadelphia. "If we couldn't get them an acute appointment for a week, how were we going to get them in immediately?"

Dr. Fabens and her colleagues worked extra hours for a few weeks to reduce the schedule backlog. But, a year after adopting open-access scheduling, the system is running smoothly. "For staff, doctors and patients, it's been a positive experience," she said.

Greenhouse is one of many primary care practices that have moved to a scheduling strategy-sometimes called open access, advanced access or same-day scheduling-designed to make it easier for patients to see their physicians. Much ballyhooed a few years back, open access scheduling is still relatively rare, but interest appears to be growing among physicians.

Five years ago, physicians who signed up for the Institute for Healthcare Improvement's (IHI) programs on open access "didn't have a clue," said Marie W. Schall, director of office practice and outpatient settings at IHI. "Now we get people who are very sophisticated," she said. Instead of asking "should I be doing this?" they want to know "how can I do this?"

Getting started

Physicians define "open access" in various ways—from completely opening up their schedule and filling in appointments as the day progresses to offering early morning and evening walk-in clinics. Some practices set aside blocks of time—or a percentage of slots-each day for patients who call in early to snap up a same-day appointment, while others promise that every patient who calls the practice will be seen that day.

The IHI definition of open access emphasizes the importance of continuity of care. A patient should be able to see his or her own physician or a member of the "care team"—two or three clinicians plus medical assistants and perhaps others—who share responsibility for a group of patients.

"The issue of continuity is central to the concept and practice of advanced access," Ms. Schall said. "It isn't that the patient can come see someone they don't know."

Meeting that standard can be discouraging, said Charles M. Kilo, FACP, an early proponent of open access.

"If you look at most groups across the country who've tried to get there, they were overly myopic about the changes that were necessary," said Dr. Kilo, chief executive officer of GreenField Health, a primary care clinic in Portland, Ore. "In fact, if you try to do open access in isolation of doing a lot of the other things you need to do, you will fail."

For example, Healthcare Partners Medical Group, a Los Angeles area practice with more than 400 physicians in dozens of locations, initiated open access as part of a complete overhaul of its practice protocols five years ago.

"We started by re-designing our clinical flow with the care team process and then we proceeded to open access," said Francis L. Yemofio, FACP. "We are now implementing our electronic medical record system."

Step one was assigning caregivers—two or three physicians, each with two medical assistants—to a "care team" and reconfiguring space so that team members worked closely together. That allows patients to become acquainted with other members of their physician's care team—and for the caregivers to share work as the need arises.

Overcoming barriers, reaping rewards

A common error, Dr. Kilo said, is focusing on eliminating the backlog of scheduled patients rather than changing the staffing pattern to accommodate patients on they day they call in.

"People would go about working down the backlog of patients, and putting a lot of extra work into that, but not being able to sustain that extra work," he said. "So they try to get back to normal, and then the backlog just builds up."

Those who have converted to open access report advantages ranging from happier patients and staff members to increased job satisfaction for physicians—and financial benefits.

L. Gordon Moore, MD, a solo family medicine practitioner in Rochester, N.Y., and an IHI consultant, said some practices appear to have jam-packed schedules but also can have no-show rates of up to 40%. "We can cut that at least in half, if not more, by moving to 'I can see you today,'" he said.

The move to open access scheduling prompted Greenhouse Internists to start billing for no-show appointments, which the partners had been reluctant to do when appointments were scheduled far in the future. Additionally, Dr. Fabens said, open access has increased the percentage of acute-care visits in her patient mix, which boosts revenue by enabling her to see more patients per day.

At Healthcare Partners in California, the secondary motivation for open access—after patient satisfaction—was to allow physicians to increase the size of their panels, said Dr. Yemofio. That has panned out well, he said, adding that except for a handful of physicians with closed panels "everybody is ready to take on more patients."

At Evans Medical Group, a four-physician practice in Evans, Ga., launching a walk-in clinic has been a financial boon, said partner Robert J. Lamberts, ACP Member. The clinic is open for only three hours a day—7:30 a.m. to 9 a.m. and 5:30 p.m. to 7 p.m.—but accounts for 25% of the practice's revenue. The "quick sick" visits go quickly, Dr. Lamberts said. In addition, one HMO with a capitation contract pays Evans Medical extra for treating patients after normal business hours.

An ounce of prevention

Dr. Moore uses the increased acute-care contact with his patients to stay on top of screenings and other preventive care, such as counseling about smoking cessation, glaucometer use, diet and exercise.

"That activity is compensable; therefore, it increases the weight of the visit and the coding," he said. "I do it, I document it, I get paid for it."

Others agreed that easier access to the primary care physician promotes higher quality care.

"I like to be able to ask, 'how's that diet going?' when a patient comes in for an acute visit," said Joann Falkenburg, MD, head of the family medicine department at the Palo Alto Medical Foundation's clinic in Fremont, Calif.. Under traditional scheduling, she explained, her patients frequently were treated by other providers when they needed immediate care.

Some practices are adopting open-access scheduling as a competitive advantage, said Ms. Schall. Others see it as a way to increase patient satisfaction scores, which are emerging as a metric in some pay-for-performance programs.

That was true at the Palo Alto clinic, said Dr. Falkenburg. "We immediately saw our (patient satisfaction) scores go to 100% on scheduling."

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Follow these tips for a successful transition to open access

Staffing

• Analyze the needs of your patients as a group. "What do we know about them in terms of their chronic conditions, their age and sex breakdown?" said Charles M. Kilo, FACP, chief executive officer of GreenField Health in Portland, Ore. "Go much deeper than that, and it gives us a huge amount of information about what they need."
• Determine the mix of caregivers needed to take care of those patient needs. Traditionally, the medical assistant escorts patients to the exam room and helps with some of the paperwork, vital signs, calling in refills, etc. while the physician does the rest of the work, said Dr. Kilo, who headed the Institute of Healthcare Improvement's open-access project before he opened his own practice in 2001. Increasing the assistant-to-physician ratio or adding other caregivers to the team might add efficiency. "A very significant part of (the work) could be done by somebody else, not the physician," Dr. Kilo said.
• Front office schedulers are freed up when they no longer spend their days rescheduling patients and calling with appointment reminders. They may be able to introduce efficiencies that make open-access scheduling easier.
• If you work in a group practice, develop a care team that shares responsibility for patients. At Healthcare Partners Medical Group in Los Angeles, each team includes two or three clinicians and two medical assistants per provider, all of whom share a work space. "Patients get to know the members of the team," said Francis L. Yemofio, FACP. "So if I don't have an opening, they see members of my care team. Open access cannot work in a traditional office where providers have their own offices and are operating independent of other clinicians next door."

Backlog elimination

• Brace yourself for resistance. When Palo Alto Medical Foundation moved to open access in 2003, Joann Falkenburg, MD, head of the family medicine department at the Palo Alto Medical Foundation's Fremont Center, found that some physicians were reluctant to embrace the change, necessitating a lot of coaching to get on board.
• Prepare your patients—and yourself—for the transition. Greenhouse Internists, a four-physician practice in Philadelphia that converted to open access scheduling in 2005, introduced the idea of same-day scheduling months before it went into effect. "Starting three months out, we gave people a card that said 'mid-October' instead of an actual date for their next visit," said Greenhouse partner Elizabeth L. Fabens, ACP Member. As patients started calling for same-day appointments, the physicians worked longer hours or extra days to see patients already on the schedule.
• Be patient. The time it takes for the backlog to be eliminated depends on a physician's patient mix. At Healthcare Partners, some physicians erased their backlog in one month, while others took six months. Pediatrics was the easiest transition to open access, Dr. Yemofio said, and geriatrics was the most difficult.
• "Double-up" appointments during the transition period. If a patient comes for a same-day visit for acute treatment, peek in the schedule to see if a chronic care appointment is on the schedule, Marie Schall, a director at the Institute for Healthcare Improvement, suggested. If so, try to handle both matters in a single visit.

Get help

• Consider hiring consultants. The planning, training and hand-holding needed to move to open access may be more than a practice can handle on its own. "A medical group cannot do this by themselves, just saying 'OK, here's the manual. Let's go do it,'" said Dr. Yemofio, whose 400-member medical group made the leap in 2001. "It's important to have someone work with your team to implement and teach the program. It is really intense and very broad-based in terms of the people who are trained and how to put it all together."

Open access in the real world

• You're in a seasonal business. Open-access practices see more patients in the winter cold and flu season, noted Dr. Falkenburg at Palo Alto Medical Foundation. Summers get busy when some physicians go on vacation and others must fill in. But some slots may not fill in spring and autumn months, and the unpredictability can be unsettling. "Physicians are famous for being control freaks," she said.
• Taking time off on short notice may upset the system. "I've got to be very accurate about what I can offer the practice a month, two months out in the future so that the supply (of physicians) can be predictable," said L. Gordon Moore, MD, an IHI consultant and family medicine practitioner. Telling a colleague he or she cannot take time off when they want to can be uncomfortable.
• First days back from vacation are killers. "Some patients will be holding out for you and when you return back to work, you can be deluged," Dr. Yemofio said. "So when I come back after a week's vacation, I have half a day blocked for the next three days, to accommodate this temporary back-log."

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