Primary Care Clinic Increases Access Without More Providers

“When you want to fix patient access, you have to look at your entire system,” says a general internist in a Saint Louis University physician group. “It’s not just adding more appointment spots. You have to be able to get the patients into the appointment slots that you have.”

Even when something is clearly not working well, it can be daunting to dig into the problem, identify a solution, and push for change. That is especially true when hospital staff have already learned to work around a chaotic process within a large, busy medical clinic.

But the benefits of doing so can be substantial. An overhaul of front-office procedures at the Saint Louis University General Internal Medicine primary care clinic (SLUCare GIM) led to a 9 percent increase, on average, in the scheduled appointments per month and more than $260,000 in increased annual payment.

The effort, spearheaded by a physician leader and a system-level administrative executive, started with the goal of reducing long hold times for patients calling the office and a high rate—more than 30 percent—of calls in which patients got tired of waiting and hung up. The solution included adopting an interactive voice response (IVR) phone system, changing the master schedule, and outsourcing the scheduling function to a third-party vendor. The results: Fewer incoming calls, fewer patients hanging up in frustration, and quicker access to appointments for new and existing patients.

“When you want to fix access, you have to look at your entire system,” says Jennifer Schmidt, a general internist in the SLUCare Physician Group and chief of ambulatory general internal medicine at Saint Louis University. “It’s not just adding more appointment spots. You have to be able to get the patients into the appointment slots that you have.”

The changes also allowed the clinic’s medical assistants who previously spent a lot of time fielding phone calls to be redeployed to patient care, prompting improvement in quality scores. Writing about their initiative in NEJM Catalyst, Schmidt and her co-author said staff turnover and absenteeism among medical assistants improved as a direct result of the new phone and scheduling systems (Schmidt, J.M. and Kosydor, A., Creating a Holistic Approach to Patient Access,” NEJM Catalyst, May 3, 2018). “…Both clinic staff and providers are now able to focus on delivering high-quality care, rather than apologizing for the poor phone access and difficulties in scheduling appointments,” they wrote.

Transforming SLUCare

SLUCare Physician Group, the university’s academic medical practice, includes more than 600 healthcare providers throughout the St. Louis region. In early 2017, the university launched Transformative Excellence in Academic Medicine (TEAM), an initiative to position the physician practice and the entire academic medical system for growth.

The TEAM steering committee identified six focus areas, one of which is patient access. The patient access focus area has two initiatives—optimize clinical capacity and reduce cancellations and no-shows.

Schmidt and Ali Kosydor, SLUCare chief of clinical transformation, are among the patient-access “initiative owners,” and one of their first projects was the GIM primary care clinic where Schmidt works.

Tackling the Status Quo

The clinic, with 16 providers, had traditionally assigned medical assistants to answer incoming telephone calls. While this may have worked well at some point, Schmidt says, by 2017, the system had reached a crisis. The three medical assistants serving as switchboard operators were unable to field the onslaught of incoming calls; patients often waited at least 40 minutes on hold and phone abandonment rates were more than 30 percent.

The medical assistants had not been consistently trained, and the clinic lacked policies and protocols on how to handle various types of calls. Thus, they often were unable to schedule appointments, process medication refills, or address other routine requests during patients’ first calls, requiring patients to call back repeatedly—which increased the volume of calls.

Other problems:

• Because the main clinic phone number had such long wait times, triage nurses often gave their “back line” number to patients, adding to the nurses’ workloads, sometimes unnecessarily, and increasing ad hoc responses to patient requests by staff other than the medical assistants.
• Absenteeism and turnover among the medical assistants was high with nine employees leaving between April 2016 and January 2017.

The patient-unfriendly phone system had been a source of frustration to clinic staff for quite some time, Schmidt says. While no one advocated that it was working well, no one was responsible for figuring out a solution. When Schmidt joined the clinic in mid-2016, she brought fresh eyes to the situation and recognized the need to get system-level resources for a process-improvement initiative.

“When you are in the middle of something, it’s hard to step back and see that things could be improved,” she said. “As an outsider coming in, that was a perspective I was lucky to have.”

Identifying the Solutions

Understanding the scope of the problem was difficult for two reasons. First, the clinic’s telephone technology did not collect data that allowed Schmidt and Kosydor to understand important data points such as average hold times, average handling times, and average lag time between calls. Second, because triage nurses had coached patients to call their back lines to avoid long holds on the clinic’s main line, the total volume of calls coming into the clinic was unknown.

The department’s telephone system did capture some data points—the total number of calls coming to the main line, the number of calls answered, and the percent of calls abandoned—that gave Schmidt and Kosydor a rudimentary understanding of the problem. They supplemented that information by interviewing all clinic staff members who had administrative responsibilities to get a full picture of the situation. 

“We sat down with every clinic staff member in a two-to-one fashion to talk about what they do every day,” Schmidt says. “We tried to empower them to share where they felt improvements were needed because they had information we couldn’t get anywhere else. They were really important to our efforts.”

Those interviews revealed, for example, that many incoming calls were from patients asking for straightforward information like the clinic’s fax number or address. That made phone-tree technology—a menu-driven system that routes callers to specific information or individuals, based on their responses to questions—emerge as a potential solution. “There’s no need for somebody to wait 40 minutes to get a fax number,” Schmidt says. “So a phone tree seemed like an easy fix to alleviate that stress on the system.”

That decision had ramifications throughout the clinic. 

Medical assistants could be redeployed to clinical care. Schmidt and Kosydor interviewed staff members to develop a list of all clinical tasks that needed to be performed and a roster of each staff member’s skills and credentials. That allowed them to create standardized roles and responsibilities for medical assistants.

The clinic needed a new scheduling process. Clinic leaders chose to outsource scheduling to a vendor, which eliminated the need to hire, train, and supervise the scheduling staff.

“Having to create and manage an entirely new phone access group (for scheduling) and to provide the quality assurance that was needed was much more than just hiring three or four people,” Schmidt says.

Outsourced scheduling required a new master schedule. The off-site schedulers need to easily slot patients into the right appointment type at the right time, requiring uniform scheduling protocols.  

Historically, the GIM clinic had more than 30 different appointment types (although most of those types were rarely used). Also, each provider set the parameters for his or her own schedule.

“A provider might have had different templates for Monday afternoon, Tuesday afternoon, the fourth Tuesday afternoon of the month,” Schmidt says.

Two changes were needed to allow off-site schedulers to efficiently and accurately schedule appointments. First, the clinic established just five appointment types: 

• Regular appointment for established patient
• New patient visit
• Extended appointment for established patient
• Transitions-of-care appointment used for patients recently discharged from the hospital
• Urgent care visit

Second, all providers’ schedules were set in four-hour blocks. “We tried to make the scheduling template as uniform as possible to minimize errors,” Schmidt says.

Scripts were written for off-site schedulers to ensure consistency. During each call, schedulers encourage patients to arrive early for appointments, to sign up for access to the patient portal and pre-register.

The interventions—the phone tree, outsourced scheduling, and redefined roles for medical assistants—were implemented simultaneously in January 2017.

Measuring Progress

The number of incoming calls fell by more than 300 percent when comparing the four months after the phone tree system was implemented with the previous four months. The call-abandonment rate fell from 34 percent to 5 percent. Patients’ concerns were addressed on the first call, so they didn’t need to call back repeatedly, Schmidt says. 

SLUCare Physician Group Patient Access Transformation Results

Other measures of success: 

• The median number of days from a request for a new-patient appointment and the appointment fell from 37 days to 31 days.
• The median number of scheduled appointments increased from 600 per week to 638 per week.
• The median number of new-patient appointments increased from 69 per month to 79 per month.
• The increased number of scheduled appointments each month yielded an estimated $269,201 in annual revenue to the clinic, while outsourcing the scheduling function cost just $5,532 a year more than in-house schedules, so the return on investment, extrapolated to 12 months, was $263,669.
• Only one medical assistant left in the eight months after the new systems were implemented, compared to nine in the previous eight months.

A surprise result: Because medical assistants no longer have phone duty, they have more time to attend to tasks that improve quality of care. In the six months after the changes, the rate of depression screening during patient-rooming increased to 95 percent, up from 51 percent. 

Learning from the Front Lines

The move to off-site schedulers and a uniform master schedule was difficult for some providers to adjust to. “I can’t just walk down and ask someone to make me an appointment—now I have to call somebody else and I don’t even really know who they are,” Schmidt says, recalling the frustration expressed by some providers. “That was a huge shift but that is something that is necessary as we move forward and grow.”

Having a physician champion who works in the clinic was essential, she says. “Rather than having a top-down approach where the leadership says, ‘Just do this,’ I was there to help address concerns immediately,” she says. “And I wasn’t asking anybody to do anything that I, myself, didn’t have to do.”

Also, collaborating with an administrative executive who knew what data needed to be collected to support decision making and how to calculate the return-on-investment was key to the initiative’s success. Equally important, she says, was empowering the front-line workers to help with decision making.

“We went to their staff meetings every week and said, ‘This is what we’re thinking about. What do you think would work? What do you think won’t work? What are some potential pitfalls that you see?’” Schmidt says. “That helped us get the information that we really needed.”

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Lola Butcher is a freelance writer and editor based in Missouri.

Interviewed for this article:

Jennifer M. Schmidt , MD, general internist, SLUCare Physician Group; chief of ambulatory general internal medicine and associate program director, Internal Medicine Residency Program, Saint Louis University.