Assessing Effective Access and Availability Strategies for Today’s Cardiovascular Program

A guide for cardiovascular programs to improve access to care for new patients and recommendations on improving availability for existing patients.

By Ginger Biesbrock, PA-C, MPH, MPAS, AACC
 

An important emerging topic across the cardiovascular landscape is access to care. For cardiovascular patients, access to care has become a quality, market, and, in some cases, economic differentiator. Contemporary cardiovascular programs are focusing on access as a top priority, and this is challenging the traditionally accepted standard for appointment availability and wait times in the ambulatory setting.

Historically, the statistics on patient access to care have not been great. Data published by the Agency for Healthcare Research and Quality in 2016 showed that 12% of adults who needed immediate care for an illness, injury, or condition over the course of 12 months sometimes or never received care as soon as needed.1 Now, gone are the days when office phones are turned off at 5 PM with a message recommending an emergency department (ED) visit if the patient needs care. Today, a 4- to 6-week (or longer) wait for a new patient appointment with a cardiovascular specialist is unacceptable. Patient experience, the economic drive to provide care in the lowest-cost environment, and competitive markets have pushed these previously accepted standards out of the new normal. In this new normal, a > 5-day wait is too long, and patients must have 24/7 access to cardiovascular care outside the hospital. Many programs are finding these new standards challenging to accomplish. However, although contemporary programs require accessibility and availability, getting there does not necessarily mean increasing workloads or adding more staff. Success requires an understanding of the new goals and a focus on learning how to do “today’s work,” today.

Figure 1. A template of a sample schedule to improve access for patients. EST, established.

ACCESS FOR NEW PATIENTS

New patient access in the ambulatory clinic is the lifeblood of a program. A recent MedAxiom email survey question asked members to share their typical wait time for a new patient referral. Although the answers varied, a significant number of organizations answered 5 days, with one organization answering 2 days. This is consistent with our review of standards across the country; 5 business days has become the new standard of care. If a new patient cannot be seen in a cardiology clinic within 5 business days, there is high likelihood that the patient will go to another program if one is available. Two business days has become a market differentiator and will push market share in highly competitive markets. For programs with a significant internal network, there can be a false sense of security as far as market share capture. However, even internal network partners will refer outside of the network if access to cardiovascular care is challenging. The primary reason for referral leakage is typically poor access.

The ability to improve appointment times for new patients from 4 weeks down to 5 days will likely require a schedule overhaul. Programs must modify existing protocols to provide reliable access and an appropriate number of planned and protected slots for new patients that can accommodate expected patient volumes. Figure 1 provides a sample template for achieving this. To measure improvement progress, track and monitor the percentage of new patients to follow-up patients seen in a day. Programs that are improving growth are seeing this metric approach 25% to 30% (Figure 2).

Figure 2. Data from MedAxiom members indicate that programs moving toward improved access are seeing the percentage of new patient to follow-up patients seen in a day at 25% to 30%. PSA, professional services agreement.

Other solutions include disease-specific clinics with open access pathways, such as for atrial fibrillation, heart failure, or chest pain. Some programs will assign a physician of the day, with several protected slots for urgent same- or next-day new patient visits. The physician of the day function should also be available to take physician-to-physician calls and provide support for questions from noncardiology partners.

The theme of these solutions is the development of a proactive approach to meet the needs of the referral network and community. Oftentimes, programs describe a reactive “work-in” strategy as their solution to manage new patient access, which means that the patient is double- or triple-booked in an already full schedule that results in patients being rushed and left with a less than favorable experience. In this scenario, the practice is without adequate resources to effectively manage physician recommendations or orders, with many of these requests never being scheduled. The initial access availability may be several weeks out, and the offer to work the patient into an already full schedule is not provided that far ahead of the appointment date. In addition, if the program is struggling with new patient no-shows, it could be a sign that appointments are being offered so far in the future that the patient finds an alternative program for evaluation and does not call to cancel with the first program.

Managing the performance of patient access requires the development and monitoring of specific access goals. A great place to start is measuring the percentage of appointments offered within the new standard of 5 business days. In addition, programs should monitor new patient volume trends, the percentage of new patient visits versus return visits, rescheduling and cancellation rates, and market share growth or decline. These are good data points to better understand program accessibility as well as trends relative to new patients and program growth. The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) patient experience survey has several questions directed toward access, including the ability to get an appointment for care needed right away. CG-CAHPS or other patient experience surveys can provide great feedback as to the patient’s perspective on access to care.

AVAILABILITY FOR EXISTING PATIENTS

In addition to new patient access, cardiovascular programs are being pushed to become more available for their existing patients. Availability is the ability to proactively manage routine and urgent needs. Important availability objectives include routine follow-up management at requested intervals, urgent need management, results follow-up, and procedural availability. Lack of availability in any of these areas will create patient dissatisfaction, threaten quality outcomes, and delay necessary care.

Cardiovascular care includes a significant amount of chronic disease management, for which patients are managed for secondary prevention and disease progression. Many programs that have access issues also have challenges managing their active patients. Physicians begin to have sizeable wait lists or backlogs for patients needing routine care, which is often delayed for weeks or months.

To proactively manage availability for a physician’s panel, it is important to understand capacity versus demand. When the demand outweighs the capacity, wait lists form and patient care gets delayed. A great solution is the development of a team-based care model where the physician/advanced practice provider team can scale capacity to meet the demand. Simple calculations such as the patient per slot ratio can be very helpful in quantifying the need and determining how best to build the team to meet the need.

Urgent need management is another area that is often sacrificed when access becomes a challenge. With the changes in reimbursement and focus on value outcome—where quality and costs are both important—the need to be available for urgent need management in the ambulatory setting is becoming extremely important. There are two solutions that are invaluable.

First, the use of a registered nurse (RN) triage to manage patient calls for symptoms and questions can be valuable in averting ED visits and coordinating care to allow for urgent office evaluation or reassurance for nonurgent matters. Nurse triage with a direct answer line is important, as voicemail with a callback returned hours later can promote ED use and patient dissatisfaction. The RN triage role requires physician-developed protocols for appropriate escalation and patient management.

The second option is urgent clinic evaluation, which can be extremely effective in avoiding ED and hospital utilization. There are several options for offering these visits:

  • Protect several urgent patient slots on individual care team schedules to allow for continuity
  • Include urgent evaluations as part of the role of the physician of the day
  • Formalize an urgent care clinic that can be either a walk-in clinic for cardiovascular patients or a same-day access clinic for triage nurses to direct patients when a face-to-face evaluation is required

Timely follow-up and management of test results is another area of availability for established patients. A proactive approach to managing test results is a patient satisfier and a protection against liability. Abnormal results that are not managed in a timely fashion set the program up for significant liability. A great solution is for the test results to be managed in the testing facility, with escalation based on normal, abnormal, stable, and abnormal unstable. Ideally, programs escalate same-day abnormal stable results to allow for effective clinical decision-making and care. Additionally, programs should develop a written cardiovascular testing results policy (Figure 3) to ensure effective, timely management of the data.

Figure 3. An example of a cardiovascular testing results policy.

In addition to diagnostic testing results management, procedural availability and access is also important for timely care and patient satisfaction. Based on MedAxiom community feedback, industry trends suggest that the typical referral to procedure time line is 4 to 6 weeks for elective structural heart procedures, 2 to 4 weeks for elective advanced electrophysiology ablations, and within the same week for elective interventional cardiology procedures. Any wait times longer than these, especially for structural heart and electrophysiology procedures, may leave opportunity for patients to go elsewhere.

Availability performance management requires that administrators monitor procedural backlogs or wait lists, referral to procedure wait times, and nurse triage turnaround times. In addition, several CG-CAHPS questions are directly related to the ability to meet urgent needs in a timely fashion, follow-up on test results, and evaluate timeliness of patient question follow-up.

CONCLUSION

The cardiovascular landscape is under increasing pressure to be more accessible and available. Competitive markets, value/outcome–based reimbursement models, and utilization tracking are all pushing for timely access and availability. Programs are responding with shorter wait times for new patients, nurse triage functions, reliable testing follow-up, and rightsizing physician staffing to allow for timely access to care.

Performance management is key to ensuring appropriate access and availability. Measuring wait times, turnaround times, and patient experience survey results will provide a foundation for scaling and responding to patient needs and market pressures. Programs that have not developed a strategy for managing accessibility and availability are undoubtedly losing market share and will likely find themselves on the higher end of patient care costs. Now is the time to understand the current state and redesign the delivery model to meet industry standards and patient needs.

1. Agency for Healthcare Research and Quality. 2016 national healthcare quality and disparities report. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr16/final2016qdr-cx.pdf. Accessed July 17, 2019.

Ginger Biesbrock, PA-C, MPH, MPAS, AACC
Senior Vice President, MedAxiom Consulting
Neptune Beach, Florida
gbiesbrock@medaxiom.com
Disclosures: None.

 

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About Cardiac Interventions Today

Cardiac Interventions Today (ISSN 2572-5955 print and ISSN 2572-5963 online) is a publication dedicated to providing comprehensive coverage of the latest developments in technology, techniques, clinical studies, and regulatory and reimbursement issues in the field of coronary and cardiac interventions. Cardiac Interventions Today premiered in March 2007 and each edition contains a variety of topics in a flexible format, including articles covering various perspectives on current clinical topics, in-depth interviews with expert physicians, overviews of available technologies, industry news, and insights into the issues affecting today's interventional cardiology practices.