Challenges of Advanced Access in a Residency Clinic

Bernadette Kiraly by Bernadette Kiraly

“Any provider with less than a 60% clinical presence hasn’t got a prayer at creating appropriate access for their patients.”  This was one presenters dire opinion of how Advanced Access will or will not work at a recent conference on Transforming the Primary Care Practice hosted by the Institute for Healthcare Improvement (IHI).   I am the medical director of two combined family medicine residency training and faculty practices.   This, of course, describes almost our entire provider group.  How will we ever accomplish Advanced Access?  The answer, thankfully, came later in the talk:  Team Based Care.

Advanced Access (AA), the gold standard in access,  can be defined as set of principles that lead  to patient centered care through which a patient can get the care that they want, the care that they need and the care when they need it (Tauntau 2009).  A practice knows they have to achieve this standard when they can state “our patients can see their provider, or another provider on their care team, today if desired.”  This level of patient access is good for patients by reducing delays and wasted time (such as calling the office more than once in search of a needed appointment), and is good for providers by improving  quality and provider satisfaction.  The financial impact for a practice is substantial by reducing no shows and providing room for  new patient growth as capacity is increased.

Some of the steps toward achieving AA  include panel management, monitoring  third next available appointment, measuring and managing continuity rates with the PCP (Primary Care Provider), matching  supply (appointments) and demand (patient appointment requests), and by reducing demand for visits through optimization of  care teams.  How our practice will achieve this goal is beyond the scope of this blog post; however, I will highlight some aspects of the transformation process and the specific challenges a residency program faces in this process.

Panel management is one of the first steps towards AA.  This includes measuring each provider’s panel, consistently and accurately assigning patients to provider panels, and monitoring on an ongoing basis.  Our institution and electronic medical record (EMR) allow for the designation of allied health professionals and residents as the PCP of record.  Therefore our residents have their own panels which has its benefits.   The challenge we face every spring is how to manage the graduating resident’s patient panel.  We want to honor patient preferences and desires to select their personal PCP, but also need to be realistic about the need for rapid reassignment of these patients for population management.  For the last few years we have tried different iterations of patient hand-off, but none feel rapid, accurate, or wholly patient-centered.

Another element of AA that is a challenge to a residency program is matching supply and demand.  Residents and faculty are drawn in numerous directions and have competing demands  such as hospital rotations, hospital rounding, teaching/learning obligations, and other non-clinical work.  AA  requires measuring appointment demand and matching  appointment supply to this.  Schedule management makes this difficult.   Giving the ambulatory practice and patient care the highest priority is necessary, but unrealistic given all the other demands, some of which if are unmet, jeopardize accreditation.

Optimizing the care team and developing a robust team based care process is essential to proclaiming “our patients can see their provider, or another provider on their team, today if desired.”  This means creating a schedule where at least one member of the  care team is in the clinic at all times.  It also requires available appointments in that schedule.

Operationalizing care teams with residents, and ideally with them in a leadership role, is challenging.  Again, the inconsistent presence in the ambulatory clinic is the main issue.  We are striving to create care teams that communicate effectively without face-time, can accommodate learners, and still provide high quality care that patients value and find satisfying.  We haven’t developed the solution to these issues yet, but are exploring models with physician assistants as the “backbone” in our care team.

There was no magic formula presented at the IHI conference that will bring our clinic to advanced access gold standard status, however there was excellent guidance on the steps needed to achieve this.   Developing robust team based care and managing the challenges of resident schedules will be the key to our success.

Bernadette Kiraly, MD is an Assistant Professor in the Department of Family and Preventive Medicine. She is also the Medical Director for the University of Utah Sugarhouse and Madsen Family Health Centers where the Family Medicine residents train.

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