New Patient Access for Pediatric Specialties: Some Tools and Challenges Pauline Corso, BS, and Jay S. Greenspan, MD, MBA
O
ne goal of the “Triple Aim” is to improve the individual experience of care.1 Internal surveys at Nemours demonstrated that inadequate access to pediatric specialty care was the most commonly cited obstacle to patient and family satisfaction. We sought to enhance new patient access in pediatric specialties by ensuring that a new patient appointment was available within 5 business days. We address some tactics to enhance new patient access as well as obstacles encountered.
plates. We found a large variation in provider templates, even within the same division. Standardized templates were created with weekly standard clinic expectations for specialists adjusted for other responsibilities, such as administration, surgical time, inpatient load, and education, all with approval by the Division Chief and leadership. Optimizing templates included efficient clinic room and staff utilization during the 4-hour clinical sessions.
Tactics to Enhance New Patient Access
Optimize the Use of Non-Physician Providers Similar to optimizing physician templates, we optimized the templates for our physician assistants and nurse practitioners. We utilized these providers to offload follow-up visits from physician providers (thereby freeing them up for more new patient visits) and, in selected cases, we paneled the nonphysician provider independently so they could see new patients. For example, a neurology nurse practitioner runs the headache clinic for both new and follow-up patients. This releases the neurologists to see new and complex patients.
Determine the Optimal Follow-Up/New Patient Ratio to Optimize New Patient Slots Tactics for increasing new patient appointments available for scheduling include converting follow-up appointments to new patient slots. We determined the follow-up/new patient ratio for divisions and marked variability was observed. Weight management, for instance, had a new/ follow-up appointment ratio of 0.15 and gastroenterology was 0.35. Surgical specialties generally had a higher ratio than pediatric specialties, with otolaryngology showing the highest ratio at 0.43. We were able to reduce follow-up appointments in surgical specialties by utilizing postoperative phone calls and appointments with the medical home. For pediatric specialties, tactics varied, as many specialists manage children with chronic diseases requiring low new/ follow-up ratios. For a patient with cystic fibrosis, for instance, appropriate care could require up to 100 followup visits for each new patient (4-12 visits per year up to the age of 21 years). Attempts to increase the interval between follow-up visits have been met with mixed success.2 For many children with chronic disease, follow-up interval timing is not evidence-based. Although physician assistants and nurse practitioners can manage many follow-up cases, there are often complexities that require specialist intervention, and the specialist needs to have an abundance of follow-up appointments. Even though we were able to space out some of the follow-up visits without impacting patient safety or experience, these plans need to be well designed, and the impact on new patient access is limited. We acknowledge that reducing follow-up visits can place an additional burden on the medical home and may impact the physician-patient relationship in the specialty. Optimize Physician and Psychologist Provider Templates Increasing overall patient slots can be achieved by standardizing and optimizing the provider clinical schedule and tem-
Utilize General Pediatricians to Optimize Specialty Access Pediatricians can manage many of the complex issues that are often seen by fellowship-trained specialists. When we surveyed case loads of many specialists, we determined that 20%-40% of patients seen could be managed by a pediatrician if they were given appropriate time and specialist guidance to see the patient.3 Allowing and encouraging pediatricians to see patients with specialty issues can free up the specialist to see more complex cases. We have deployed an “access pediatrician” in gastroenterology (eg, functional abdominal pain, reflux, constipation), dermatology (eg, acne, warts), behavioral health (eg, autism, developmental delay), genetics, and several other specialties. The access pediatricians see new patients predominantly and are often embedded in a specialty clinic for rapid access to expertise, if needed. They have markedly enhanced access for new patients and maintain high family and referral provider satisfaction. They ensure quick triage to see a specialist when warranted.
From the Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; and Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA The authors declare no conflicts of interest. 0022-3476//$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.02.057
1333
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Optimize the Medical Home The need for follow-up visits can be reduced by returning the patients to their medical home while maintaining communication in case the specialty plans of care need amending. Many primary care providers are willing to manage the problem referred to the specialist after diagnosis and care plans have been established. This relationship between specialist and the medical home is enhanced with targeted education and care paths provided to the primary care provider. Enhancing the provider network’s capability encourages communication between the specialist and the medical home, and the other aspects of the medical home are advantageous for the patient. Encouraging this process of followup within the medical home enhances new patient specialty access. Consultative Models Divisions that were considerably backlogged (developmental medicine and psychology) were encouraged to consider adopting a consultative model. This allowed the specialist to see new patients primarily, diagnose them, develop a plan of care, and return them to a provider for treatment and follow-up care. Follow-up appointments are rare in this model and are reserved for patients who cannot be followed elsewhere. The divisions were challenged in developing a variety of community partners, including schools, to care for the child after a diagnosis and care plan were established. Close communication between the community support and specialist is necessary. Open Scheduling/Access Appointments Virtually all divisions required some new scheduling reserved for new patients that opened up a few days before the visit slot. These “access appointments” were made available and could be redesignated for follow-up visits if not filled within 48 hours.
New Patient Access Challenges Several important challenges to these scheduling changes need to be monitored and evaluated. The offer for a new patient appointment within 5 business days was only
1334
Vol. 166, No. 6 accepted 54% of the time. This varied with each division (ie, dermatology 21%, infectious diseases 58%, and pulmonology 70%). The next available appointments must be available at a reasonable time. Schedulers have to quickly find the available appointments and give immediate feedback to the division if slots are limited. Obtaining insurance approval is a challenge, and occasionally coverage is denied for failure to obtain approval prior to the visit. In addition, the community providers have to be engaged and supportive of the process, and they need the resources to assist a shift of follow-up care to the medical home. This requires additional training of and communication with the community providers. Monitoring and enhancing the interaction of the medical home with the specialty is critical and may require a change in thinking of specialists from fully working up a problem to encouraging a partnership with the primary provider.
Discussion We document tools to enhance new patient access to highdemand pediatric specialties. This requires careful planning and communication to the families, the medical home, the referring sources, and out to the community. This change cannot happen unless it becomes a clear organizational initiative. n Reprint requests: Jay S. Greenspan, MD, MBA, Nemours/Alfred I. duPont Hospital for Children, PO Box 269, Wilmington, DE 19899. E-mail: Jay. [email protected]
References 1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff 2008;27:759-69. 2. Bromage JS, Napier-Hemy RD, Payne SR, Pearce I. Outpatient follow appointment; are we using the resources effectively. Postgrad Med J 2006;82:465-7. 3. DiGuglielmo MD, Plesnick J, Greenspan JS, Sharif I. A new model to decrease time-to-appointment wait for gastroenterology evaluation. Pediatrics 2013;15:1632-8.
Corso and Greenspan
O
ne goal of the “Triple Aim” is to improve the individual experience of care.1 Internal surveys at Nemours demonstrated that inadequate access to pediatric specialty care was the most commonly cited obstacle to patient and family satisfaction. We sought to enhance new patient access in pediatric specialties by ensuring that a new patient appointment was available within 5 business days. We address some tactics to enhance new patient access as well as obstacles encountered.
plates. We found a large variation in provider templates, even within the same division. Standardized templates were created with weekly standard clinic expectations for specialists adjusted for other responsibilities, such as administration, surgical time, inpatient load, and education, all with approval by the Division Chief and leadership. Optimizing templates included efficient clinic room and staff utilization during the 4-hour clinical sessions.
Tactics to Enhance New Patient Access
Optimize the Use of Non-Physician Providers Similar to optimizing physician templates, we optimized the templates for our physician assistants and nurse practitioners. We utilized these providers to offload follow-up visits from physician providers (thereby freeing them up for more new patient visits) and, in selected cases, we paneled the nonphysician provider independently so they could see new patients. For example, a neurology nurse practitioner runs the headache clinic for both new and follow-up patients. This releases the neurologists to see new and complex patients.
Determine the Optimal Follow-Up/New Patient Ratio to Optimize New Patient Slots Tactics for increasing new patient appointments available for scheduling include converting follow-up appointments to new patient slots. We determined the follow-up/new patient ratio for divisions and marked variability was observed. Weight management, for instance, had a new/ follow-up appointment ratio of 0.15 and gastroenterology was 0.35. Surgical specialties generally had a higher ratio than pediatric specialties, with otolaryngology showing the highest ratio at 0.43. We were able to reduce follow-up appointments in surgical specialties by utilizing postoperative phone calls and appointments with the medical home. For pediatric specialties, tactics varied, as many specialists manage children with chronic diseases requiring low new/ follow-up ratios. For a patient with cystic fibrosis, for instance, appropriate care could require up to 100 followup visits for each new patient (4-12 visits per year up to the age of 21 years). Attempts to increase the interval between follow-up visits have been met with mixed success.2 For many children with chronic disease, follow-up interval timing is not evidence-based. Although physician assistants and nurse practitioners can manage many follow-up cases, there are often complexities that require specialist intervention, and the specialist needs to have an abundance of follow-up appointments. Even though we were able to space out some of the follow-up visits without impacting patient safety or experience, these plans need to be well designed, and the impact on new patient access is limited. We acknowledge that reducing follow-up visits can place an additional burden on the medical home and may impact the physician-patient relationship in the specialty. Optimize Physician and Psychologist Provider Templates Increasing overall patient slots can be achieved by standardizing and optimizing the provider clinical schedule and tem-
Utilize General Pediatricians to Optimize Specialty Access Pediatricians can manage many of the complex issues that are often seen by fellowship-trained specialists. When we surveyed case loads of many specialists, we determined that 20%-40% of patients seen could be managed by a pediatrician if they were given appropriate time and specialist guidance to see the patient.3 Allowing and encouraging pediatricians to see patients with specialty issues can free up the specialist to see more complex cases. We have deployed an “access pediatrician” in gastroenterology (eg, functional abdominal pain, reflux, constipation), dermatology (eg, acne, warts), behavioral health (eg, autism, developmental delay), genetics, and several other specialties. The access pediatricians see new patients predominantly and are often embedded in a specialty clinic for rapid access to expertise, if needed. They have markedly enhanced access for new patients and maintain high family and referral provider satisfaction. They ensure quick triage to see a specialist when warranted.
From the Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; and Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA The authors declare no conflicts of interest. 0022-3476//$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.02.057
1333
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Optimize the Medical Home The need for follow-up visits can be reduced by returning the patients to their medical home while maintaining communication in case the specialty plans of care need amending. Many primary care providers are willing to manage the problem referred to the specialist after diagnosis and care plans have been established. This relationship between specialist and the medical home is enhanced with targeted education and care paths provided to the primary care provider. Enhancing the provider network’s capability encourages communication between the specialist and the medical home, and the other aspects of the medical home are advantageous for the patient. Encouraging this process of followup within the medical home enhances new patient specialty access. Consultative Models Divisions that were considerably backlogged (developmental medicine and psychology) were encouraged to consider adopting a consultative model. This allowed the specialist to see new patients primarily, diagnose them, develop a plan of care, and return them to a provider for treatment and follow-up care. Follow-up appointments are rare in this model and are reserved for patients who cannot be followed elsewhere. The divisions were challenged in developing a variety of community partners, including schools, to care for the child after a diagnosis and care plan were established. Close communication between the community support and specialist is necessary. Open Scheduling/Access Appointments Virtually all divisions required some new scheduling reserved for new patients that opened up a few days before the visit slot. These “access appointments” were made available and could be redesignated for follow-up visits if not filled within 48 hours.
New Patient Access Challenges Several important challenges to these scheduling changes need to be monitored and evaluated. The offer for a new patient appointment within 5 business days was only
1334
Vol. 166, No. 6 accepted 54% of the time. This varied with each division (ie, dermatology 21%, infectious diseases 58%, and pulmonology 70%). The next available appointments must be available at a reasonable time. Schedulers have to quickly find the available appointments and give immediate feedback to the division if slots are limited. Obtaining insurance approval is a challenge, and occasionally coverage is denied for failure to obtain approval prior to the visit. In addition, the community providers have to be engaged and supportive of the process, and they need the resources to assist a shift of follow-up care to the medical home. This requires additional training of and communication with the community providers. Monitoring and enhancing the interaction of the medical home with the specialty is critical and may require a change in thinking of specialists from fully working up a problem to encouraging a partnership with the primary provider.
Discussion We document tools to enhance new patient access to highdemand pediatric specialties. This requires careful planning and communication to the families, the medical home, the referring sources, and out to the community. This change cannot happen unless it becomes a clear organizational initiative. n Reprint requests: Jay S. Greenspan, MD, MBA, Nemours/Alfred I. duPont Hospital for Children, PO Box 269, Wilmington, DE 19899. E-mail: Jay. [email protected]
References 1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff 2008;27:759-69. 2. Bromage JS, Napier-Hemy RD, Payne SR, Pearce I. Outpatient follow appointment; are we using the resources effectively. Postgrad Med J 2006;82:465-7. 3. DiGuglielmo MD, Plesnick J, Greenspan JS, Sharif I. A new model to decrease time-to-appointment wait for gastroenterology evaluation. Pediatrics 2013;15:1632-8.
Corso and Greenspan
