Practice and Provider Visit and Interval Scheduling Model

Introduction

The U.S. health care system is facing challenging times as more than 20 million people reportedly gained insurance and related medical service coverage under the Affordable Care Act (ACA), notwithstanding any changes that will occur under the Trump Administration’s and Republican Congressional efforts to reform or repeal certain and targeted provisions of the ACA. To accommodate this increased demand, we believe that primary and specialty medical practices will have to augment their traditional care delivery methods with other approaches such as new and establish patient access management, alternative site of service development, expansion of the use and utility of non-physician advance practice clinicians, use of alternative telehealth and e-visits, etc. Understanding these needed changes will be crucial for designing effective medical practice and provider visit and scheduling policies, procedures and processes to aid the appropriate management of patient and panel access, provider availability and affordability, while recognizing the need to balance the effective and efficient use of provider and practice resources.

Further, Logan Consulting Group has worked with its clients to demonstrate a deliberate and targeted “patient and panel centric” approach to patient access and interval management, along with provider and resource scheduling to improve and enhance patient access and availability and overall service and financial performance in general.

The Practice and Provider Visit and Interval Scheduling Model (“Model”)

Accordingly, the following provides a summary description of the approach and steps necessary to effectively develop a Practice and Provider Visit and Interval Scheduling Model (“Model”) for primary care and specialty practices. We believe the Model provides a specific approach to assist medical practice senior management in the development of its “practice and provider visit and scheduling approach”. This approach is tailored to their physician and provider preferences toward right placement, distribution and right provider intervention for New and Established patient requirements, frequency and interval follow-up visit planning for their patient service conditions and mix, and to achieve overall provider productivity and practice financial performance.

Step 1 - Getting Started: Understanding your current and existing provider practice patterns, patient and service mix, etc., for all initial and follow-up visits is the essential first step toward improving the provider and practice patient scheduling and visit improvement needed with your practice. Further, understanding and potentially eliminating or decreasing practice style variability among and between providers, practice locations and patient conditions among same specialties is equally important. Any improvements in patient access, provider scheduling and resource use and utilization hinges on altering the significant influences on provider behavior differences and bringing commonality among treatment modalities and protocols. However, the patient’s clinical and service needs should dictate the accessibility, availability and frequency interval of any medical service and treatment intervention, etc., and thus not be viewed as merely a “cookbook” approach.  Therefore, any patient visit and scheduling model should remain nimble and flexible to the specific patient and panel needs of the practice and result in desired and targeted patient clinical and patient safety outcomes. 

Provider characteristics, practice style and preferences and demographics are key drivers that affect patient access, availability and visit intervals. We have found that scheduling habits of most practices and providers may be unnecessarily contributing to the problems of limited access and availability, excessive follow-up utilization without consideration of commonality among and between medical conditions and needs among patients by diagnosis or multiple diagnoses, lack of understanding the importance of monitoring and managing new and established patient access benchmarks, underutilization of patient visit alternatives (i.e., advance practice providers, e-visits, telemedicine, group visits, etc.), and excessive costs, etc., without improvement in healthcare outcomes.

There are 4 obvious questions for any specific practice/provider:

1.)   Are patient new and established visits managed by the provider or “at will or request” by the patients to the practice?

2.)   Are these follow-up visits and their timing determined scientifically by the top 25 to 50 diagnoses treated or by convenience and habit of the practice/provider over time? 

3.)   Is there an evidence base to support a provider’s or various same specialty provider practice patterns?

4.)   If there is evidence to support the provider’s patterns and adherence to “best-practices” approach within the practice guidelines?

In approaching any practice improvement efforts, it is important to keep in mind that you must first, obtain the appropriate standard of performance; second, sustain the performance effort through appropriate provider consensus and changes to the operations and services; and, thirdly, maintain the effort by effective clinical and operational management and oversight.   

Step 2 - Targeting Patient Scheduling Optimization: Patient scheduling optimization is one of the most important steps in operationalizing and achieving effective and efficient delivery of care; physician, patient, and staff satisfaction; and for practice profitability. Four detailed tips to improve your scheduling process.

1.      Understand the Current Visit Types and Approach in Use in the Practice: Each patient visit has a different level of complexity, necessity and thus frequency requirement. Assign weight to the different visits and list them for reference by your schedulers with an approved scheduling template by patient type, diagnoses, practice locations and providers assigned within each location.

Approach: Identify the top 20-50 patient primary diagnoses treated by each office location and providers within the last two discrete 12 month periods (i.e., comparative 24 month periods). Using the top 25-50 diagnoses, identify the number of new patients and established patients by primary diagnosis, using E&M, consult and other appropriate CPT codes within the same two discrete 12 month periods. Finally, identify the estimated time to see for a.) each new patient (e.g., first and third available for routine, urgent and emergency); and, b.) for each established patient the follow-up visit frequency and interval.

Result: Based upon the above approach, each practice will have the ability to fully understand the following:

• New to established patient service ratio
• Time to see new patients by routine, urgent and emergent access and availability standard
• Time and frequency interval for patients by condition
• Patient scheduling and access variability by provider and office location

2.      Develop Consensus and Approach to Practice Visits: Once you have identified the current visit and scheduling approach in use in the practice, you can then begin to reflect on: a.) the desired new to established patient service standards by office location and provider; b.) the current and desired appropriate follow-up intervals for routine and chronic medical conditions of the patients; and, c.) review of current compliance with the new/established service ratios and follow-up and visit interval targets to the practice and providers.

Specifically, the practice providers should create triage and service standards for the top 25-50 diagnoses and/or symptoms of the practice by clinical criteria and consensus of the providers. The clinical criteria should include the symptom, appointment urgency and appointment length. Further, create service and visit codes for urgency and for appointment length, as well as potential assignment of visits and appointments to physicians or advance practice professional depending on the urgency, complexity and anticipated length of an appointment.

The triage and service standards development approach and direction of any practice and/or provider is predicated on a thorough and complete understanding of the specific patient profiles (i.e., patient panel specific demographics, medical conditions, medical necessity and care requirements, medical care setting facilities and provider and clinician insight and preferences, etc.) and should not be underestimated. Thus, once developed the triage and service standards can then be managed and compared to similar data for each provider in the practice, alternative practice locations within the employed physician network and publicly published period data by CMS and/or other third party payors over time and by other patient service standards such as patient and referring satisfaction, patient access and availability metrics, resource utilization and provider productivity and performance metrics.

Once established, the management team should then work with the schedulers and provider schedule templates to begin the management toward the desired state. Keep in mind the “obtain, sustain and maintain” approach to the improvement process indicated previously.  

3.      Working Toward Open Access Scheduling: The goal of any practice is to have the appropriate access, availability and distribution of service appointments among and between office locations and providers. One new standard that is being adopted across the country is “open access” scheduling. Open access scheduling is focused on seeing patients on the day they call when possible. Certainly, this is not always possible, and is often impractical outside of urgent care or emergency settings. Further, transitioning to open access scheduling will take months to achieve for practices already scheduled weeks ahead. Gradually reduce the pre-appointed visits to no more than 70% - 80% of the day, with even fewer on Mondays and after holidays, when urgent-access visits are in high demand. Maintain a list of patients who want to be seen sooner, and call them to in-fill or “compress” the schedule on the same day.

4.      Benefits of Follow-up Visit Frequency and Interval Management: A substantial portion of all ambulatory office visits are for follow-up visits. Further, over the years published literature suggests that the frequency and the interval of follow-up visit does not necessarily impact patient outcomes. Specifically, various and discrete studies have concluded that:

• Managing follow-up visits and intervals has the potential to reduce costs per person, improve access to provider patient panels without necessarily compromising or restricting care” to patients and potentially reducing no show rates;
• Patient health status does not dominate physician follow-up visits frequency and intervals; rather physicians appear to have characteristic scheduling tendencies that are acquired over time or by adoption of intra and inter peer scheduling templates that greatly influence the length of the re-visit intervals;
• Patients with chronic conditions necessitate seeing their providers for follow-up visits, however, anecdotally it appeared patients were perhaps being seen more often than may be needed; and,  
• Additionally, other services do not necessarily require provider training, such as nutrition classes, exercise classes or diabetic support groups, etc., which can and should be managed by other clinical staff within the practice.

The interval for a return appointment depends on the individual patient’s needs and on the discretion of the provider. Providers should consider what is necessary for the management of the patient, rather than "the usual" return visit interval. When medically appropriate, extending intervals for return appointments adds supply to the system because fewer future appointment slots are filled. Eliminate automatic return visits at standard intervals (e.g., all patients come back in one month). Instead, base the clinical decision of return interval on each patient's clinical condition.

Patients should be given a return appointment when it is needed and at an interval that is clinically meaningful. One way to reduce the variation among providers who see the same types of patients is to share information about return intervals to promote discussion and dialogue, not to impose and standardize arbitrarily.

Summary

In sum, the careful and deliberate development of a Practice and Provider Visit and Interval Scheduling Model (“Model”) for primary care and specialty practices provides for the right placement, distribution and right provider intervention for new and established patient requirements, frequency and interval follow-up visit planning for their patient service conditions and mix, and for achieving overall provider productivity and best practice financial performance.