Improving Patient Access to Primary Care with Open Access Scheduling

In the United States, many primary care offices are affected by an overwhelming patient demand due to primary care provider shortages.(1) The average wait time for a new routine visit with a family practice provider is 24 days.(2) As a result, patients often receive nonurgent care from emergency departments and urgent care centers, which can cause a disruption in continuity of care, as well as decreased revenue for the primary care practice.(1) Studies show that a large portion of these patients (10%–60%) can be managed using primary care.(3) Treatment in the urgent care setting often is delivered without the conveniences of a complete medical history, or the capability to ensure follow-up, which results in episodic and fragmented care.(4) Timely access to primary care can reduce health disparities, improve health outcomes, reduce emergency department and urgent care visits, and, ultimately, decrease the cost of healthcare.

The urgent care center is not an optimal setting for patients to receive primary care, because it is less cost efficient.(4) In 2020, the average cost for an urgent care visit for acute primary care diagnoses such as acute otitis media, pharyngitis, or a urinary tract infection is $155. A visit to the emergency department costs approximately $1233, with the average copay being $50 to $100. In contrast, a copay for a primary care office visit is an average of $15 to $25, and the cost of an established, Level 3 patient visit averages $104.(5) Due to barriers such as limited office hours and limited same-day availability in primary care, patients often seek alternate forms of care.(6)

Access to primary care commonly is measured by the third next available appointment (TNAA).(2) TNAA is considered a more accurate way to measure, because the first and second available appointments usually are last-minute openings that became available as a result of patient cancellations.(1)

To address the modifiable barriers to access of primary care, evidenced-based literature supports the use of open access or same-day scheduling.(7) According to the Institute for Healthcare Improvement,(8) the third next available primary care appointment should be zero days (i.e., same day) to ensure timely access to care. The purpose of this quality improvement project was to improve same-day patient access in a primary care setting using evidenced-based open access (OA) scheduling.

The Problem

A Northwestern U.S. family practice’s TNAA was an average of 22 days. This was above the practice goal of zero to five days and far above the national benchmark of zero days.(8) This delay in access to primary care resulted in an office average of 22% of patients per month being referred to urgent care. One of the modifiable barriers this practice faced was the practice’s current scheduling process, which had a daily designated “on-call” provider for same-day appointments. These appointment slots were being filled weeks and even months in advance. Patient satisfaction also was affected. Only 58% of patients rated ease of scheduling an urgent appointment as excellent. Additional barriers to timely access to primary care included provider shortages, high volume of patients with chronic conditions, and no after-hours availability.(9)

Open Access Scheduling

To address the modifiable barriers to access of primary care, evidenced-based literature supports the use of open access or same-day scheduling.(7) Advanced access scheduling—also referred to as open access or same-day scheduling—is one of the most feasible and economical approaches to improve access to primary care appointments.(7) OA scheduling focuses on reducing and eliminating delays without adding additional staffing resources.(7)

About 65% to 75% of the provider’s schedule is completely open at the start of the day. Office staff offer an appointment to the patient on the same day he or she calls. Appointment lengths are standardized to 15- to 20-minute acute visits.(7)

Evidence Review

Several studies in the literature have addressed the topic of improving patient access to care and offer information on OA scheduling to decrease time to TNAA. A systematic review by Ansell et al.(7) looked at 11 studies focused on this outcome. Overall, the researchers found that there was a mean reduction in wait time of 11.3 days when OA scheduling was implemented.(7) A pilot study by Bundy et al.(10) consisted of four primary care clinics in North Carolina that expressed interest in quality improvement (QI) and implemented OA scheduling. The average time to TNAA was decreased from 36 days (95% confidence interval (CI): 20, 44 days) to 4 days. In addition to a decrease in TNAA, patient satisfaction increased by 16%, from 45% to 61% (95% CI: 0.2%, 30%).(10) Mallard et al.(11) conducted a pilot study to assess the implementation of OA and its effect on patient wait time, no-shows, new patient appointments, and provider productivity. The average wait time for TNAA was 46 days. After initiation of same-day scheduling, the time to TNAA decreased to 5 days (p <.0001).(11)

Mehrotra et al.(1) conducted a case series including five primary care practices to assess the effect of OA scheduling on time to TNAA, no-show rates, and patient satisfaction with appointment availability. After four months of OA scheduling, the average time to TNAA for all five practices decreased from 21 days to 8 days for short visits and from 39 to 14 days for long visits.(1)

A qualitative analysis performed by Dixon et al.(12) evaluated the impact of advanced access scheduling on patient access to primary care. Time to TNAA with a provider decreased by almost 60%, from 3.6 to 1.5 days.(12) Cameron et al.(2) performed a QI project to implement OA scheduling to decrease time to the TNAA. Data were collected nine months pre-implementation and nine months post-implementation. Following the implementation of OA scheduling, time to TNAA decreased from a mean of 13.7 days to 3.6 days (p <.0001).(2)

Methods

Ethical Review

This project was evaluated by the Medical University of South Carolina’s institutional review board (IRB) guidelines for quality improvement. IRB submission was not required for this project, because as it was designated as a certified QI project. There was no increase in patient risk, and HIPAA guidelines were maintained throughout the data collection process. Patient information was depersonalized and maintained on a password protected-computer.

Study Design

This quality improvement initiative was based on pre- and postintervention data. Pre-intervention data were collected from April 2019 to July 2019. Post-intervention data collection ran from August 2019 through February 2020. Primary data collected were on time to TNAA and percent of urgent care referrals monthly.

Translational Framework

The RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework was highly applicable to this project, because it is widely used in quality improvement projects. Use of this framework helped translate research into practice in a systematic and organized manner. Buy-in from providers and staff was secured and maintained by frequently meeting with providers, administration, and office staff to address barriers or concerns. Data were presented to key stakeholders on the intervention and its success at monthly provider meetings, helping to improve the project’s sustainability.(13,14)

Setting and Population

The clinical site was a primary care practice with a broad patient population. Staff consisted of six physicians, one nurse practitioner, and two physician assistants. The population setting for this project included all patients who were calling to request a same-day appointment. The patients were primarily Caucasian, ranging in age from newborn to elderly, with acute and chronic illnesses. The office receives an average of 100 calls per month requesting same-day appointments.

Intervention

An OA schedule policy was developed in collaboration with the clinic’s providers, administration, and the project coordinator. The policy initially included keeping 50% of each day’s appointment slots open for the on-call provider; however, two months into implementation, 50% of these appointments opened three days prior and the remaining 50% opened the morning of to accommodate subacute and acute needs. The OA slots for the daily on-call provider were intended for urgent or acute needs and were not to be used for routine or chronic visits. This was a change from the previous scheduling process, in which the on-call provider’s schedule was already fully scheduled on most days.

Education for staff was provided by the project coordinator via PowerPoint presentation. Patients were educated on the new scheduling process via flyers, text messages, and email reminders. Implementation occurred over seven months, with data collection weekly. Meetings with staff and key stakeholders initially took place biweekly to gain feedback, address concerns, and discuss progress, and then progressed to monthly.

Measures and Data Collection

The primary outcomes were reductions in urgent care referrals and in TNAA. The secondary outcome was to improve patient satisfaction regarding ease of scheduling an urgent appointment. Urgent care referrals were tracked within the EHR. The outcome of each call received by the triage nurse was followed and documented. TNAA was tracked by the project coordinator. Once weekly, the number of days between a request for an appointment with a provider and the TNAA with that provider was counted. The TNAA appointment was calculated for each provider and then averaged to make up the total practice TNAA. The practice site’s patient satisfaction survey, consisting of 12 questions, was provided via email to every patient after each appointment.

The time to TNAA was compared pre- and postintervention (Figure 1). The postintervention TNAA was tracked weekly to assess for trends. An additional primary aim was to decrease the number of patients referred to urgent care. Postintervention urgent care referrals were tracked biweekly, comparing pre- and postintervention via the EHR (Figure 2). A secondary aim was to improve patient satisfaction regarding ease of scheduling urgent or same-day appointments. The pre- and postintervention response to the patient satisfaction survey regarding ease of scheduling urgent appointments was tracked. The following descriptive information was collected: number of patient calls requesting same-day appointment; reason for appointment; outcome of call; and patient’s primary provider.

Figure 1. Third next available appointment. Office average pre- and post-intervention.

Figure 2. Urgent care referrals pre- and post-intervention.

Results

A total of 898 calls were evaluated, pre-intervention (n=189) and post-intervention (n=709). Significant improvements were seen in time to TNAA and number of urgent care referrals. Patient satisfaction improvements were not clinically significant. The average time to TNAA decreased from 22 days to 10 days postintervention. Percent of patients referred to urgent care also decreased, from 22% to 6% monthly. Patient satisfaction regarding ease of scheduling an urgent appointment increased slightly, from 58% to 59%. This increase may have been affected by an increase in patient response rate to this question postintervention.

Discussion

Despite the extensive healthcare system in the United States, wait times to see a primary care provider are still delayed, with an average of 24 days. These delays lead to patients seeking care in urgent and emergent settings, increased health care costs, decreased patient satisfaction, decreased continuity of care, and negative effects on healthcare outcomes.(1,3,7) OA scheduling has been shown to be a cost-effective way to reduce time to TNAA.

This quality improvement project focused on decreasing time to TNAA and reducing the number of patients referred to urgent care. The project demonstrated that use of a modified version of OA scheduling can accomplish both goals. Time to TNAA decreased from 22 days to 10 days after the seven-month intervention period. Urgent care referrals decreased from 22% to 6% per month. The improvement in access to care had a great impact on the clinic’s patients. The reduction in time to TNAA is similar to that of other studies that have been performed in family practice settings. There is a high probability for sustainability due to the length of the postintervention. Over a period of seven months, a total number of 898 phone calls were received from patients requesting an appointment for acute needs, and staff and providers were receptive to the intervention.

Limitations

This project may not be applicable in all family practice settings. This specific clinic designates one physician each day to be the “on-call” provider. Information from the literature was applied to the “on-call” physician’s schedule. Differing scheduling practices may affect the generalizability of this project. Secondly, new front desk staff were hired during the intervention period who were not familiar with the new scheduling process. Frequent education was provided to compensate for changes in staffing. A third limitation was that a new provider was hired at the start of the intervention period. This provider’s availability may have improved the office average for time to TNAA.

Conclusion

Implementing a modified version of OA scheduling decreased the time to TNAA and the number of patients referred to urgent care. However, the time to TNAA is still above the office goal. It will be beneficial to continue to trend and monitor the number of calls received each month and adjust open slots accordingly. Making more open slots available during the cold and flu season and less during the months where not many same-day appointments are needed will be most cost efficient. New staff hired to work the front desk should be well trained in the scheduling process to ensure open slots are used appropriately. Evidence-based interventions intended to reduce time to TNAA and reduce urgent care referrals should be used to increase access to care, improve continuity of care, decrease health care costs, and improve patient outcomes. Further research is needed to look specifically at urgent care referrals that are the result of a lack of access to primary care.

Acknowledgement: The author thanks Dr. Cormack and Dr. Fowler for their contributions to the project, as well as the administrative team at the project site, Mike Cummins and Luise Wyatt, for their assistance in project implementation.

References

1. Mehrotra A, Keehl-Markowitz L, Ayanian JZ. Implementation of open access scheduling in primary care: a cautionary tale. Ann Intern Med. 2008;148:915-922.

2. Cameron S, Sadler L, Lawson B. Adoption of open-access scheduling in an academic family practice. Can Fam Physician. 2010;56:906-911.

3. Coster, JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24:1137-1149.

4. Weisz D, Gusmano MK, Wong G, Trombley J. Emergency department use: a reflection of poor primary care access? Am J Manag Care. 2015;21(2):e152-e160.

5. Fay B. Doctor’s visit costs. Debt.org . 2019. www.debt.org/medical/doctor-visit-costs/ . Accessed April 3, 2019.

6. Villasenor S, Krouse HJ. Can the use of urgent care clinics improve access to care without undermining continuity in primary care? J Am Assoc Nurse Pract. 2016;28:335-341. DOI: 10.1002/2327-6924.12314

7. Ansell D, Crispo JA, Semard B, Bjerre LM. Interventions to reduce wait times in primary care appointments: a systematic review. BMC Health Serv Res. 2017;17(295). DOI 10.1186/s12913-017-2219-y.

8. Third next available appointment. Institute for Healthcare Improvement. www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx .

9. Corscadden L, Levesque JF, Lewis V, Strumpf E., Breton M, Russell G. Factors associated with multiple barriers to access to primary care: an international analysis. Int J Equity Health. 2018;17(28). doi.org/10.1186/s12939-018-0740-1.

10. Bundy DG, Randolph GD, Murray M, Anderson J, Margolis PA. Open access in primary care: results of a North Carolina pilot project. Pediatrics. 2005;116:82-87.

11. Mallard SD, Leakeas T, Duncan WJ, Fleenor ME, Sinsky RJ. Same-day scheduling in a public health clinic: a pilot study. J Public Health Manag Pract. 2004;10:148-155.

12. Dixon S, Sampson FC, O’Cathain A, Pickin M. Advanced access: more than just GP waiting times? Fam Pract. 2006;23:233-239.

13. RE-AIM. What is RE-AIM. www.re-aim.org/about/what-is-re-aim/

14. White K, Dudley-Brown S, Terhaar M. Translation of Evidence Into Nursing and Health Care, 2nd ed. New York: Springer Publishing Company; 2016.