How teamwork can help improve primary care access

In the Department of Public Health (DPH) clinics in San Francisco, CA, demand for doctor’s appointments far outweighs supply. This has been especially dramatic in clinics that have switched to “open access” scheduling, an innovation that allows patients to schedule same-day or next-day appointments. Open access is meant to eliminate long waits for appointments, but the reality is that often dozens of patients call for a limited number of appointments. Fifteen minutes into each day, receptionists have to tell patients that there are no more appointments available.

In January of this year, as part of my work with the Center for Excellence in Primary Care at the University of California, San Francisco, I teamed up with one of these open-access clinics, Southeast Health Center, to work on their access issue. Other DPH clinics had piloted telephone visits to reduce demand for face-to-face appointments but had had a hard time sorting out which patients or issues were appropriate for a telephone visit. Still, we knew that many patients had issues that could be resolved over the phone, maybe even some of the patients that called after all the appointments for the day had been booked. So that month, I helped the Southeast team try to replace denied appointment requests with team-based telephone visits. After a few weeks of trial and error, our team came up with a nice system.

Each Thursday morning, Willetta West, a clerk at Southeast, fields phone calls from patients requesting an appointment for Friday’s open-access slots. Once all of Dr. Elsa Tsutaoka’s appointments have been booked for the next day, Willetta asks Dr. Elsa’s patients if they would like their “care team” to call them back the following day between 8:00 and 8:30am. Willetta then records on a log sheet their contact information and reason for calling if they are willing to disclose it. The following morning, Elsa and Suzanne Huang, a medical assistant who teams up with Elsa when she is in clinic, meet each morning in a room that has two available computers and phone lines. Elsa looks over the list of patients to be called and “quarterbacks” the responsibilities of the following half hour.

For patients requesting medication refills or lab results which we know to be normal, Elsa asks Suzanne to call the patients to tell them of their lab result or to notify them that Elsa will fax in a refill request to the pharmacy. For patients complaining of acute symptoms or those that do not disclose a reason, Elsa calls them back herself. If patients have issues that cannot be resolved over the phone, Elsa asks the patient to come in for a drop-in appointment or schedules them in a “save” appointment slot. This process happens in place of what would have been the first appointment of the day. The “phone access” period ends for Suzanne when she leaves to take vital signs for the first patient; Elsa leaves to see the first patient a few minutes later.

Even after two months, we had remarkable results. Each day that we practiced the intervention during that period, Willetta recorded between four and 11 patients to be called back. A little more than half of these patients had their issues resolved over the phone without a face-to-face appointment. The others were given an appointment in a “save” slot or asked to visit a drop-in clinic.  Elsa and Suzanne teamed up to take care of an average of more than six patients in the time it would have taken to room and begin to see the first patient of the day. Both tell me they prefer this system to usual care. Willetta says she appreciates being able to tell patients something other than, “Sorry there are no more appointments today.”

My role in this whole operation? Cheerleader, facilitator, secretary, log-sheet maker … whatever it took to help get the innovation off and running. As a student, I had the time and opportunity to get to know the frustration felt by each member of this primary care team. For Willetta, it was saying “no” to patients every day; for Suzanne, having a role limited to taking vital signs and putting patients in rooms; and for Elsa, knowing that most of the patients in her panel struggled to get access to care. Together, we turned these frustrations into a solution.

At Southeast Health Center, as in most primary care clinics in this country, access remains a problem. Returning phone calls as a team is not the complete answer to this problem, but it is a good start.

David Margolius is a primary care resident who blogs at Primary Care Progress.

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  • Margalit Gur-Arie

    This is good stuff, but I don’t quite understand the term innovation. In most well-run practices, there is a time set aside when physicians return non-urgent calls (some have a system where this is done between patients, maybe not as efficient, but still, it gets done).
    As to renewal requests, I don’t see why these necessitate a phone call (two phone calls actually). Patients should be instructed to call the pharmacy, which will then sent an electronic request to the practice EMR and standing orders should be in place for staff to deal with these messages electronically.

    • buzzkillerjsmith

      Right. I’ve been doing this kind of stuff for about 24 years. Every clinic I’ve worked in. Have the MA call the pt and set up and appt if not urgent. Have the MA call for normal labs. Get the pt in for something acute.

      Maybe this resident is a bit wet behind the ears.

      • southerndoc1

        He’s no more wet behind the ears than the MD on the same day appointments thread .

        Somedays reading this stuff, I feel like I’ve fallen down the rabbit hole.

        • Margalit Gur-Arie

          Here is a bit more depth to the rabbit hole: a new Health Affairs article examining reasons for increased inpatient utilization in Medicaid and uninsured patients, finds that having a completely open-schedule (i.e. all same-day appointments) causes so much trouble and uncertainty for folks who have to arrange for transportation and off-work time in advance that they rather just go to the ER instead:
          “Medicaid also provided free public transportation passes. However, this required advance notice, which was challenging because many clinics offered only same-day appointments. This system of open-access scheduling was viewed as unaccommodating by patients: “You have to call that same morning, and a lot of times the line is busy with all the other people calling at the same time. By the time I get through, they’re booked. And I just wasted a day off from work!””

          • buzzkillerjsmith

            I love it.

            The sociologist Peter Rossi formulated the semi-humorous Iron Law of Evaluation: “The expected value of any net impact assessment of any large social program is zero.” I would submit it has some application here.

            In other words, if it works, it is due to chance because if it really worked, we would have already done it.

            Feel free to apply to education reform, crime reform, welfare reform, you name it.

          • cmtyhlthwkr

            I think it depends on who your patient population is. For example: for individuals who may be experiencing homelessness or housing instability, same day appointments often are a better and more effective option for getting people in to their medical home, rather than urgent care or the ER. I think it depends on the community you’re serving, and my guess is that open access scheduling, or at least some amount of it is probably exactly appropriate for SEMC.

            It’s true, innovation may not be the correct term, but it does sound like an successful QI project for this specific clinic, and step in the right direction towards more effectively caring for their patients.

          • buzzkillerjsmith

            Believe it or not, physicians, over the past 2000 or 3000 years or so, have actually tried to figure out what works for our pts!

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