Improving Access to Care

Schedule Optimization

Optimizing schedules is a great way to see more new patients and ensure established patients can access care when needed. Optimization can ensure open slots are filled and, if desired, increase capacity on clinician schedules.

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Approach to Triaging Referrals

Triaging referrals can be used to ensure you are prioritizing patients who either have the greatest need for your services or to bifurcate patients that another specialty or PCP may better serve. Triage methods and things to consider include:

• Triage Line/Pathway for Referring Clinician: Set up a dedicated contact number or email address that referring physicians can use to contact a designated triage physician to determine if the patient needs to be seen urgently; the triage physician can be a dedicated or rotating position
• Chart Prep for Review Prior to Scheduling: Obtain records for patients coming from outside the health system for review and consideration
• Referral Review: Designate resources, which may be clinical, to review incoming referrals to ensure the practice can meet patient needs
• Referral Coordinators: Use referral coordinators who use a decision tree to prioritize and reach out to nursing staff when needed
• Identify Data Requirements for Referrals to Speed Review and Handling: Internal referrals can capture additional information with EHR templates, including desired subspecialty, which speeds scheduling
• Establish an Electronic Consult Process: This can streamline patients getting appropriate work-up prior to the exam and scheduling. Learn more
• Referral Workflow: Establish number of attempts to contact patients and workflow to communicate this with referring clinicians

Approach to Scheduling

There are many options for handling scheduling from patient self-scheduling to dedicated schedulers handling all requests to various hybrid approaches using a mix of both methods. Things to consider when thinking about scheduling:

• Centralize or Decentralized Models: Central call center scheduling vs. decentralized scheduling by patient support staff at the point of care
• Define Scheduling Rules: In-depth decision trees may be needed to determine what type of scheduling will be most effective
• Varied Scheduling Methods: Established patients can book through the portal, whereas new patients must schedule through a call center representative. Third-party scheduling solutions, such as member-recommended Acuity Scheduling, can also help patients schedule their own appointments
• Maximize Capacity: Pair APPs and MDs like a resident clinic to increase capacity and introduce patients to APPs at the initial visit
• Point of Care Scheduling: When necessary, a physician can schedule an appointment in the exam room with the patient in the exam room
• Establish an optimal wait time to maximize scheduling and minimize re-work
• When necessary, consider suggesting appointment times to patients instead of first asking for their schedule to reduce going back and forth to find a time

Approach to Overbooking

While most practices indicated it was the exception, not the rule, overbooking of appointments can be an effective method to offset the financial impacts of no-shows and last-minute cancellations. It can be essential to develop parameters and a process for overbooking. Strategies to consider include:

• Develop the process in collaboration with the provider
• Consider overbooking only certain types of appointments to minimize impacts to the remaining schedule
• Consider creating a process for when double-booked patients arrive
• Investigate and use EHR predictive technology for predicting arrival of certain patients

Approach to Cancellations and Waitlists

In addition to overbooking, there are other options to consider when trying to minimize the impact of short-notice cancellations. A wait list is a great way to fill in last-minute gaps in schedules. Things to consider include:

• Investigate EHR capabilities for managing a wait list workflow, e.g., member-recommended FastPass in Epic
• Explore external technology solutions, e.g., member-recommended Phreesia
• Dedicate sufficient resources to waitlist workflows to ensure functionality
• Use of Patient Communication Tools: Messages through the portal when an appointment becomes available
• No-show Policies: Too many no-shows may result in a fee or dismissal from the practice, however, consider the administrative burden of collecting a no-show fee, and certain payers don’t allow for these types of fees
• Specialized Workflows: A manual process where staff review and call patients can help triage urgency and ensure patients are scheduled correctly, but will likely need additional resources

Approach to Reminders

Varied ways to engage patients and remind them of upcoming appointments can also prove an effective tool in maximizing clinic schedules. Strategies and things to consider include:

• Use of Technology: Consider automated calls and text messages at various time intervals prior to appointments.
• Allow Patients to Interact with Reminders: Being able to confirm appointments and cancel or reschedule appoints directly through reminder platform can decrease no-shows
• Consider Integrated and Third-party Solutions: AAN members recommended using the patient portal or scheduling software like Phreesia and Televox

Group Visits

Some neurology practices are experimenting with group visits to improve access. The term “group visit” can be applied to a wide variety of visits designed for groups of patients, rather than individual patient-provider appointments. Group visits often focus on providing information that is general to all patients with the same diagnosis or neurologic issue and provide each participant with time to share their specific concerns and learn from both the provider and the other group members. The patients also have individual time spent with the clinician, but these individual appointments can often be of shorter duration as the general topics are covered in the group format. Clinics provide individual visits either completely separate from the group visit or by having an APP pull aside the patient for a quick individual encounter before returning to the group visit. Group visits are always voluntary for the patient. Practices should work closely with their coding team and ensure compliance with state and local laws as well as any insurance contracts.

Billing

There is no nationally accepted billing guidance or code for a group visit. Best practices include working with payers as they may use a variety of CPT codes including unlisted codes like 99499 (used when other codes are not available), 99078 (physician education in a group setting), and still others recognize traditional office visit codes (99212–99215). We recommend keeping the communications in writing. For additional information, visit the American College of Physicians page on group visit billing.

Examples

Headache

When faced with an increasing number of patients seeking treatment, the providers noticed they were saying the same things to every new patient and answering similar questions on topics, e.g., how sleep impacts headaches.

Initially, group visits were piloted for new patients to orient them to headache management, the clinic’s approach to treatments, and expectations of the patient. Patients that participated in this type of group visit first were given preference for scheduling an individual appointment, resulting in less wait time for the patient.

The clinic found more success with group visits geared towards return patients to discuss individual topics that impact headaches and treatment including nutrition, exercise biofeedback, neuromodulation, stress, medication overuse, bridge therapy options, and sleep. Depending on the topics, groups ranged from four to 12 participants. Patients are required to sign a consent form for the shared medical visit to address privacy concerns. Relying heavily on the group visits, the clinic was able to cut wait times while keeping the level of treatment and patient satisfaction at a high level.

Multiple Sclerosis
Group visits for patients with multiple sclerosis were scheduled for 90 minutes with eight to 10 patients selected for participation. The visit was staffed with one physician, nurse, and medical assistant. Prior to the visit, the nurses would review each patient chart to identify missing labs, gaps, or other items that may come up during the visit.

The goal of each visit was to educate patients on a physician-chosen topic and solicit patient input as appropriate. At the beginning of the visit, the medical assistant would perform a patient intake with each patient individually; using pre-printed forms the patient filled out aided in the documentation process. Then the physician would perform the group visit with the nurse assisting as needed. Finally, the physician would briefly check in with each patient while still in the group setting to discuss any concerns.

APP Integration

Adding advanced practice providers (APPs) to the team can be an effective way to increase access to neurologic care. Many academic and private organizations use APPs to expand capacity, efficiency, timely reply to portal messages, and research projects. The Practice Management and Technology Subcommittee compiled the following case studies of how APPs are integrated into care teams of neurology organizations of different sizes and settings. The case studies are not recommendations but examples of different APP models that have improved access to care for a particular organization.

Access Case Studies

General Considerations

• Recruitment/retention: AAN Staffing Challenges Guide
• Onboarding: AAN Team-Based Care Resources
  • Clinical Evaluation Template
  • Clinical Competencies Guide
  • Administrative Items Guide
  • Quick Reference― Working with APPs: talks about scope of practice, relationship with the physician
  • Understanding Billing and Coding for APPs
• On-going career growth
  
  • APP Fall Conference Pre-conference
• Benchmarking Guide

Increasing Efficiencies

Increasing efficiencies can reduce the burden and increase bandwidth for every member of the care team. Additional bandwidth can be used to add additional appointments to schedules, either in-person or virtual; to spend additional time connecting with patients via asynchronous methods, such as the patient portal; and to dedicate additional resources to managing referrals and other tasks.

The AAN has created and curated the following resources to help increase efficiency to improve access.