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Optimize Your Patients’ Access to Care

Create a schedule model that fulfills patient scheduling needs, reduces no-shows, improves front staff workload, and allows provider flexibility.

By David J. Moore, MD, MS
Thinking from the health care administrator’s perspective, wouldn’t it be nice if a patient scheduling model and throughput existed that could:

  • Fill available schedule blocks;
  • Decrease no-show rates;
  • Reduce appointment handling and rescheduling workload;
  • Enhance provider schedule flexibility; and
  • Yield high patient satisfaction scores?

Thinking from the patient perspective, wouldn’t it be great if you:

  • Got dependably an appointment when you actually needed it;
  • Were seen reliably by your own provider;
  • Were treated respectfully by your doctor’s office as being competent and capable of managing your own appointment choices; and
  • Received regular follow-up reminders as necessary?

Take Care of Patients Who Take Care of Your Practice

Modified Open Access is a scheduling model developed in 2001 and aimed to achieve these goals of a patient-centered, sustainable, and viable practice model. The model strives to optimize care provider access and utilization through the creation and maintenance of intentionally open schedule templates at the start of each day. Originally developed by our quality improvement team, its goal is to capture—in a sustainable way—the innovative care scheduling ideals of the “Advanced Open Access model” (as developed and described in Murray and Tantau’s September 2000 publication, “Same-Day Appointments: Exploding the Access Paradigm”).
Like its Advanced Open Access predecessor, Modified Open Access pursues:

  • Same-day care access as the norm for a practice
  • A uniform schedule slot time length without special acuity limitations—slots are intentionally designated to average the time a practice needs per patient and to eliminate the need for special appointment handling around acuity issues
  • An emphasis on provider-specific continuity of care

The goal of Modified Open Access and Murray and Tantau’s model is to make the system’s first priority be to “take care” of the patients who are established with a practice and who ultimately are the ones who “take care” of the practice. As we considered implementation logistics, our team addressed the concern of how to prevent open schedules from refilling with new or transient clientele who may ultimately block out established patients. To address this concern and preserve an open and accessible schedule for established patients, Modified Open Access differs from the Murray and Tantau model in placing limits on the interval beyond “same-day” for when appointments may be booked. It then utilizes several simple policy tools to ensure that established patients can always get in when they call for either acute or follow-up care—these are tools to maintain the promise of established patient care access.

Offering Reliable, Limited Access Is Key

Like its predecessor, Modified Open Access achieves ready appointment access by intentionally having schedules two-thirds open at the start of any business day. Open schedules mean ready access for patients. Although it may seem counter-intuitive to pursue full schedules by intentionally opening two-thirds of a provider’s schedule, we found that patient throughput volume actually went up because the schedule allowed patients to see their preferred provider reliably. No-show rates markedly declined as a result of the time decrease between when the request was made to when the appointment actually occurred.
To achieve and maintain an open schedule, established patients are offered and encouraged to take same-day appointments, but are limited to appointments within seven days. To make established patients’ access top priority, new patients are limited to same-day access only; that is, new patients (patients never before seen by the particular provider) are only offered access to a provider on a same-day basis, and only after time slots for established patient care needs are addressed on that day. Limiting new patient access, as with traditional scheduling, supports and defends established patients’ access.

Use Tools to Support Open Scheduling

Tool No. 1: EPPA Time

A behind-the-scenes tool called the established patient priority access (EPPA) time supports priority access to established patients. The EPPA time is an internally set time on the clock each day. Before the EPPA time of the day, only established patients are allowed access to that day’s appointments. After the EPPA time passes, all patients, new and established, are given equal access to remaining appointments for that same day.
In our busy practice setting, the EPPA time is usually set at 11a.m., but remains flexible and can be altered as needed, even on a daily basis. Before 11 a.m., only our established patients have access to the day’s two-thirds open schedule, giving them priority status. After 11 a.m., both new and established patients are offered any remaining slots for that day.
New patients who call for appointments before the day’s established EPPA time are politely informed that no appointments are available at that time, and are offered a callback if an appointment becomes available after the set EPPA time. After the EPPA time, new patients have equal access to any remaining slots for the day and the call-back list also can be used to fill in remaining open slots in the day’s schedule.
The EPPA time may be adjusted to accommodate care demand trends observed by the practice. If the schedule is not filling, you can move the EPPA time to an earlier point in the day, effectively opening up the practice to more new patients. If established patient care demand rises—for instance, due to an influenza outbreak—then you can protect more established patient slots by moving the EPPA time to a later point in the day.
Central to the model’s success is that established patients may, at any point, book an appointment up to a week in advance, but at no point are new patients offered appointments beyond today. This not only defends and sustains the model’s openness, it satisfies new patient needs. We found that new patients are happy to accept or be called back for same-day appointments when they are available. Our new patient volume actually increased compared to our prior traditional scheduling model experience.

Tool No. 2: Receptionist Scripts

To support this method of handling care demands, receptionist phone protocol scripts were developed to aid our receptionists (see Figures A and B). Although the model protocol can be integrated into the practice management scheduling software, scripts for our receptionists remain a valuable tool for implementation and training. They are also useful for understanding the model’s flow of patient call handling.
Figure A:
Figure A
Figure B:
Figure B
The scripts encourage filling of first available slots, but our patient-centered emphasis remains on accommodating established patient appointment needs, up to the allowed full week’s advanced scheduling option. The scripts also introduce the next tool developed to support keeping the same-day access promise for established patients.

Tool No. 3: Pressure-valve Slots

Because patient care demand can be unpredictable in both volume and at what time, pressure-valve slots are a tool that allows for a second layer of capacity. Patients, who may not lock in appointments beyond one week in advance, need assurance that when they call, they have appointment access reliably. The pressure-valve slot tool is embedded in the model to ensure established patients can count on the availability of at least one same-day access option on any day.
Here’s how pressure-valve slots work: They are a scheduled interval of protected appointment slots built around the usual practice closing time that become available only if the day’s regular appointment slots have saturated. In our busy practice, pressure-valve slots span from one hour prior to our usual closing time to one hour after that time. These pressure-valve slots are available to established patients only, and always are open at the start of the day. If during any point of the day, no regular appointment slots remain open for an established patient calling for care, the pressure valve—closed till that point—then “opens,” allowing the first available pressure-valve slot only to be offered to that established patient.
The next available slot is only offered to a subsequent established patient requesting care. In our experience, pressure-valve slots rarely fill past usual closing time, but the capacity beyond the usual closing time allows responsiveness to care needs and demands of established patient clientele. In our primary care setting, pressure-valve care tends to be acute, urgent, and reflects the illnesses affecting the community; however, no limits are ever placed in the schedule on the nature of care requested. As the pressure-valve slots in a day progress across the interval, patients with lower acuity care needs tend to accept more readily the two-thirds open appointment options in the subsequent days.
Pressure-valve slots help to keep at least one appointment available around closing time to established patients, which honors the promise of access.

Tool No. 4: Follow-up Management Protocol

If appointments are not locked in beyond one week for established patients, how are follow-up appointments handled beyond one week?
To address this concern, a follow-up prompt and reminder system was developed using our existing practice management software capabilities. The reminder system’s foundation is based on the underlying principle: No matter what the scheduling model, it ultimately is the patient’s choice and decision whether to comply with the follow-up recommendations given by his or her provider. With this in mind, a three-tiered, follow-up reminder system was developed to encourage recommended return care interval compliance.
The system starts with the provider’s recommended follow-up interval being delivered to the receptionist desk while the patient exits from an existing appointment. The first tier is a general interval follow-up card given to the exiting patient (e.g., “follow up in early May”). The existing patient reminder system then triggers daily batch mailing reminder cards at the provider’s recommended follow-up interval. After allowing a response interval, if no appointment is initiated by the patient, a final reminder is generated and sent. Although initiation of an appointment request falls into the patient’s hands, follow-up compliance is tracked and providers are kept aware of all patient-specific lapses.

Appointment Accessibility Shows Favorable Results

The patient-initiated access and limited advanced scheduling aspects of the Modified Open Access model resulted in 50 percent or greater reductions of no-show rates versus our prior appointment model, or other site traditional appointment model users in our system. Front office staff reported dramatically improved workloads attributed to a significant reduction in appointment rescheduling. With no locked-in appointments beyond one week, provider schedules had a significant increase in flexibility. Most importantly, patient satisfaction with provider continuity and access has been high. Implementation challenges and caveats, as well as spin-off benefits of the model, continue to be noted, and opportunities for software-driven enhancements and streamlining still remain.

David J. Moore, MD, MS, has served in primary care community health for nearly 20 years and is an assistant professor at the University of Kentucky’s Center for Excellence in Rural Health. He has served in corporate medical director and site director roles in the University’s partner relationship with the North Fork Valley Community Health Center in Hazard, Ky. He is a graduate of Harvard University School of Public Health’s Masters in Health Care Management and a graduate of Wright State University School of Medicine and Family Medicine Residency in Dayton, Ohio.


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