Lynda Greene, MPA, LDN Scott Hewitt, MA

1. Collaboration between Wood River Health Services and PCMH Practice Transformation Facilitators: Successful Implementation of Same Day Access Lynda Greene, MPA, LDN Scott Hewitt, MA Wood River Health Services Brown Primary Care Transformation Initiative

2. Wood River Health Services PCMH Transformation • Community Health Center – Primary Care, Dental, Social Service, Behavioral Health, WIC, Sliding Fees • Achieved Level 3 NCQA PCMH 10/2013 • 63 employees, 10,000 -patients • Long tenured high quality providers • 7 Medical Providers: 3 Family Practice, 1 Adult Medicine, 1 Pediatrician, 2 Nurse Practitioners • 2 Dental Providers ; 3 Dental Hygienists • Converted to Electronic Health Record on September 2012 • Began working with the Brown Primary Care Transformation Initiative in 7/2012 and joined RI-CSI in 10/2013

3. Same Day Access • Wood River decided to overhaul same day availability in March 2013 • Previously had some same day appointment slots but they were not being used as such • Wood Rivers same day access goals and purpose : • Seeing a patient when they need to be seen • Keeping patients out of urgent care/ER • Provider satisfaction (being able to see your own patients) • Manageable workflow • Consistency • Great customer service/Improve patient care

4. Context for Change Critical contextual elements for successful implementation: Practice-wide commitment Wood River’s PCMH Steering Committee consists of representatives from areas of the practice. Each committee member has equal input into all PCMH initiatives. Committee members act as a liaisons between the steering committee and their respective area.

5. Context for Change Critical contextual elements for successful implementation: Engaged Leadership Practice leadership consistently demonstrates support for and investment in PCMH transformation and communicates its importance to the practice Initiative Champions Champions such provider champion Dr. Lisa Manlove, Operations Manager Patty Martin, and Head of Nursing Bonnie Cooper drove the necessary changes needed for success

6. Collaboration with Practice Facilitators Practice Facilitators worked with Wood River’s PCMH Steering Committee to develop a Same Day Access Implementation Plan. Practice facilitators discussed and reviewed concepts and methods essential to successful implementation: • Ensuring balanced provider panels • Establishing start date/working through the pre-scheduling backlog • Measuring supply versus demand for same day appointments • Managing same day appointment slots in the schedule • Strategic scheduling

7. Same Day Access Implementation Plan Pilot Phase: Wood River implemented a pilot phase, during which same day availability was not advertised to patients. The implementation plan consisted of several key elements: Daily measuring and tracking of supply and demand • Number request for same day/next day appointments • Number of patients that could not be scheduled • Number of same day patients seen by their PCP

8. Same Day Access Implementation Plan Establishing a start date to begin reserving same day appointment slots Wood River began reserving 3 slots per day per provider in April 2013 and steadily increased the number of same day slots in the ensuing months • April - 3 same day appointments per day/per provider • May - 4 same day appointments per day/per provider • June - 5 same day appointments per day/per provider • July - 5 same day appointments per day/per provider • August - the number same day appointments was determined based on supply and demand data.

9. Same Day Access Implementation Plan Strategic Scheduling Literature: Same day appointments opened in the middle of the day makes the most sense as they are the least desirable time for pre-booked appointments Staggering same day and pre-booked appointments allows for scheduling flexibility and adaptability

10. Same Day Access Implementation Plan Full Implementation Phase: In August 2013, Wood River ended the pilot period of its same day access plan and began advertising same day access to patients, encouraging them to call the practice before going to the urgent care or the ER, when appropriate.

11. Outcomes Wood River has developed a same day access policy that: Maintains same day availability while minimizing unfilled appointment slots: • Same day appointments open before the phone room shuts down at night • Morning huddles are used to ensure the same days are open. • Same day appointments are reserved for acute, sick visits until 12pm, after which they may be used for other types of patient appointment requests. Is informed by data driven improvement: • Wood River continually tracks and reviews data on same day appointment supply and demand as well as percentage of patients seen by PCP.

12. Outcomes Preserves continuity of care • Same day appointments are scheduled with a patient’s PCP or Care Team whenever possible Focuses on Patient Satisfaction • Patients are presented with all scheduling options to best meet their needs

13. Outcomes Wood River has been able to accommodate nearly all of its patients’ same day requests Same Day Access

14. Outcomes Improved Employee Satisfaction: Despite the added burden tracking same day access, Wood River’s phone room staff have reported higher satisfaction by having less encounters with patients upset over not being able to be seen when needed.

15. Challenges The implementation plan evolved over time and required many iterations Adherence to same day access policy Providers with “over-subscribed” patient panels Anticipating fluctuations in same day demand

16. Next Steps Wood River will modify its same day access policy so that no patient in need of a same day appointment will be turned away CAHPS Score?

17. Resources Mark Murray, MD, MPA Same-Day Appointments: Exploding the Access Paradigm http://www.aafp.org/fpm/2000/0900/p45.html Mark Murray, MD, MPA Answers to Your Questions about Same Day Scheduling http://www.aafp.org/fpm/2005/0300/p59.html http://www.aafp.org/practice-management/pcmh/patient-care.html