THE CARE INTERVENTION SUBCOMMITTEE’S HIGH-PERFORMING PRACTICE STUDY IDENTIFIED SIX KEY ATTRIBUTES OF PRACTICES THAT WERE HIGH-PERFORMERS ON ED AND INPATIENT UTILIZATION. EFFECTIVE TEAMS RESPONDED TO PATIENT CONCERNS, CALLS AND INQUIRIES IN EXCEEDINGLY TIMELY WAYS. PATIENTS RECEIVED RESPONSES, OFTEN DIRECTLY FROM PCPS AND OTHER CLINICIANS AND ANSWERS TO THEIR QUESTIONS. THE FOLLOWING TOOLS WERE DEVELOPED TO ASSIST PRACTICES WITH IMPROVING RESPONSE TIMES TO PATIENTS.
In high-performing practices, it was very timely responsiveness to patient calls, queries and concerns that made the difference. Extended hours and same-day access were helpful, but were not useful to patients if they did not accommodate an urgent need. Time-sensitive clinician response to patient queries was much more important.
In some high-performing practices, the PCP directly returned patient calls for clinical guidance and then, if needed, nurses or other team members provided follow-up information and closed the inquiry. Additionally, PCPs in high-performing practices were often willing to accommodate patients that needed to be seen, even when available slots had been exhausted by extending their workday if needed.
The techniques that practices used to make patients aware of ways to access the primary care practice, “flip triage on its head” with direct PCP response to questions about clinical guidance and “flex their workdays” to accommodate patient needs are described below.
Robust Processes for Communicating with Patients About How to Access their PCP
High-performing practices educated patients continuously about ways to access the practice and clinical guidance. Most incorporated this in a new patient orientation or the patient’s first visit to the practice where the PCP would give the patient their direct phone line and/or email. Patients were told that they need not hesitate if an urgent problem arose that required clinical consultation. Ways to access the practice and clinical guidance were reinforced at
subsequent visits and if an ED visit or inpatient hospitalization occurred, follow-up calls included information and again emphasized ways that the patient can access their PCP if they have clinical questions.
When patients made calls for clinical guidance, several high-performing practices used an innovative approach to “flip triage on its head” with the PCP making the initial outreach instead of a team member. Practices found that often this closed the loop in a timelier way and in fewer steps.
Process Flow for “Flipping Call Triage on Its Head” with Direct PCP Clinical Guidance Calls
1. Patient calls requesting clinician guidance and advice were received by front desk.
2. The front desk was trained to collect key information including the patient “ask” (i.e., what the patient would like to know).
3. Front desk reminds patient to stay close to phone and to pick up the call when it is returned, providing a timeframe for call return when possible (e.g, within the hour, within two hours, etc.). The patient was also reminded to have the pertinent information for the call ready so that the call from their clinician could be productive.
4. The front desk used instant message feature within EHR to notify PCP and RN.
5. The PCP and RN received a “pop up” message in their EHRs about the patient call for clinical advice.
6. The PCP and RN used instant messaging to determine who will return the call, though in high-performing practices, most often the PCP would do so and could often provide the
7. patient with guidance and transfer the call to the front desk if an in-person visit was essential. If a return call to the patient was needed afterward, the PCP assured the patient that the RN, Care Manager or other staff member would be in touch shortly.
8. If necessary, the RN, Care Manager or other staff member called the patient to provide the follow-up information and close the inquiry.
Flex-scheduling to lengthen the workday to accommodate urgent patient requests
If spots held for same-day access were already used or patients could not be otherwise seen in slots that patients had cancelled, PCPs elected to “flex” their work schedules and stay if needed to see a patient after hours. This promoted patient trust in access to in-person cate when needed and could usually be accommodated quickly and directly after normal office hours. The high-performing practices prided themselves on “never turning away a patient that
needed to be seen the same day”.
Interestingly, the PCPs and practices report that patients did not call for frivolous reasons or initiate a call without a genuine concern about uncertainty regarding a new symptom or question regarding their condition. It seemed to the high-performing practices that patients valued their access to information and clinical guidance and were careful to not “bother the doctor” with a question that did not require the PCP’s involvement.