When Sumi Sexton first set up shop with three fellow family physicians — Jennifer Gorrelick, Hey-Jin Kong, and Julia Stanford — back in the spring of 2003, she absolutely insisted that, along with using computerized medical records, the practice employ an open-access scheduling model to see patients. “She pretty much made us do it,” says Kong, chuckling. Four years later, Kong fully agrees with Sexton’s stipulation. “It’s working out very well.”
Before launching Premier Primary Care in Arlington, Va., the four had been working at a satellite office practice of Georgetown University Hospital, where they experienced firsthand the frustrating repercussions of working with traditional scheduling. “Despite the manager’s best efforts, patients just couldn’t get in,” says Sexton. “It was so inefficient.”
“Open access” means patients can call the doctor and be seen that day, or perhaps the next day, regardless of the reason. Sometimes known as “advanced access,” the open-access concept was conceived back in the early 1990s by Mark Murray and Catherine Tantau, a physician and nurse at Kaiser Permanente, who wanted to improve patient care by being more immediately available. Applying the axiom “Do today’s work today” to scheduling, Murray and Tantau reduced their 55-day appointment backlog to just one day. They also found themselves much more responsive to their patients’ acute and chronic needs, and they discovered that they’d greatly increased the odds of each group’s physicians seeing their own patient panel, thus improving continuity of care. Patient satisfaction soared.
Today, more and more physician practices like Premier Primary Care are embracing open access. Is it time to consider such a model for your own practice? Do you have a backlog of appointments weeks long? A harried front-desk staff that scrambles daily to appease a demanding public? Physicians who see their own patients only once out of every three visits? If so, a new scheduling model might be just what the doctor ordered to improve the daily goings-on of your practice.
The doctor will see you now
Open-access implementations vary considerably. Sexton says that Premier Primary Care uses a hybrid approach by combining both open-access and traditional scheduling concepts. “True open access is staying as late as needed to see all patients. We’re four working moms — we can’t do that,” she says. “The way our system works is you can be seen today or tomorrow, with a certain number of openings that patients can schedule in advance.”
Out of the 32 appointment slots available per physician each day, Sexton says the schedulers are trained to “leave 20 open” for same-day/next-day call-ins. She gives an example: “On Wednesday morning, the schedulers start scheduling Wednesday and Thursday, but not Friday. Friday was full a month ago.” By “full,” she means the dozen slots set aside for known purposes — a regular diabetes checkup, perhaps, or any other chronic condition needing regular monitoring.
So that’s just one derivative; perhaps it will also work for you. Or consider this rendition invoked three years ago by the six physicians and four nurse practitioners at Prime Care Medical Center in Selmer, Tenn. Here, the practice splits open-access and scheduled appointments about equally. Early-bird scheduled appointments are generally reserved for chronically ill patients, while “most others come after 10 a.m.,” says Jim King, a family physician at the practice. “We try to see all the people we can.” This means about 35 to 40 patients per provider per day, from a “monthly average” viewpoint. On a daily basis, though, you must accept the unpredictable nature of open-access scheduling, says King. “Some days I’ll be extremely busy, and other days I’ll sit around and wonder why people don’t love me.”
For the semantically exacting, it must be noted here that Prime Care’s setup is not technically a bona fide “open-access” model, as the majority of appointment slots are not reserved for open-access appointments. Rather, this model is known as a “carve out” — traditional scheduling with some open access included (carved out). Still, 50 percent is a significant chunk, allowing an overall higher physician response to patient concerns than with purely conventional scheduling.
Doin’ what comes openly
Regardless of the exact scenario you choose, expect trickle-down benefits to permeate your practice after adopting open-access scheduling, including the following:
- Continuity of care can become a reality for your patients; indeed, this was one of the driving reasons King switched over. “With traditional scheduling, I wasn’t seeing my own patients. They’d come in for something, and I’d find out they’d been in for bronchitis or whatnot,” he says. Even though he knows his patients were receiving good care from the other physicians in his group, King says that open access has strengthened the physician/ patient bond because he’s involved with all issues, both acute and chronic.
Why does this matter? Because if your patient can’t see you when he needs to, you risk both undermining his sense of having a medical home if he seeks care elsewhere, such as a retail medical clinic, and potentially missing some chain of events relevant to a new diagnosis.
- Efficiency is another area of positive impact. Just as professional organizers endorse handling the tidal wave of paper flooding our mailboxes daily, likewise with patient requests. Advance scheduling puts the onus on your staff to make reminder calls when future appointments come due — not necessary if Mrs. Bernstein can just come in today at 10 to have that annoying sebaceous cyst on her back removed. Minimize repeat contacts and shunting the patient to this or that staff person, advises practice management educator Elizabeth Woodcock. “Every hand-off, every new form reduces the time that staff can productively spend in patient care,” she says. “It is more efficient to spend time on patient visits instead of finding ways to keep them out of the practice.”
- Cost reduction is always attractive, and open access won’t disappoint. Schedule a little extra time in your appointment slots to address multiple issues during one visit, suggests Dennis O’Hare, a family physician for Allina Hospitals & Clinics in the Minneapolis area. Consider Mrs. Bernstein’s cyst: “In the ‘old world,’ you wouldn’t have time to take that off, but in the new way, you might get it all done in one visit,” says O’Hare. The vice president of two of Allina’s hospitals, Mercy and Unity, calls this “max packing,” saying, “Everybody wins: The patient saves himself another visit. The doctor can code a higher charge and can see more patients. The insurance company pays for fewer visits.”All this can certainly build a healthier bottom line. But the concept of “too much of a good thing” does apply to open access, especially since filling appointment slots can only be estimated, not guaranteed. “We try to see all the people we can,” says King, but he likes the financial security that scheduled appointments afford. I can’t have too much open access.”
- Supply and demand in terms of patient load will become more manageable. A backlog of patient appointments sometimes gives a physician the misleading impression that the demand for his services is limitless. But is this really true? Take a hard look at your appointment access gaps over time. If patients consistently waited 35 days on average for an appointment for the past two years, then your demand is actually stable. There’s no reason you can’t eliminate this chronic blockage through open access. Back in 1998, O’Hare’s clinic — the largest of Allina’s 42 clinics, with about a 100-physician staff — found this to be true. “We had gridlock,” he says. “The ability of getting into our clinic [that same day] was about a 10 percent chance, and the chance of seeing your own doctor? About 15 percent.”
The clinic’s previous 30-day backlog is now essentially zero. What’s more, O’Hare says, the clinic, due to an unexpected balance in patient supply and demand, stopped actively recruiting additional providers — previously thought necessary to accommodate an escalating crush of patients that didn’t, in fact, exist. Without recruiting costs or an additional partner, the practice now finds itself both calmer and richer.
