7 Ways to Improve Access and Reduce No-Shows
with Dianna Prachyl, Vice President, Community Health, JPS Health Network, Fort Worth, TX
When JPS Health Network—a 537-bed acute care public hospital with 15 affiliated primary care clinics and 100 contracted primary care providers—went live with an electronic medical record 18 months ago, volumes plummeted while docs got up to speed thanks to fewer scheduled appointments. But when ED visits continued to rise with lower practice volumes over time, JPS did a deep dive to understand why and launched a comprehensive access plan in April 2013.
"Our scores on CG CAHPS access also validated this as a real problem for our patients," said Dianna Prachyl, vice president, community health at JPS. "We were averaging 100 days for next available appointments across some clinics with less capacity and Board members wanted to know why." One culprit? A no-show rate that averaged 28 percent across clinics, leaving appointment slots unused, but also unavailable.
Because JPS is also in the midst of implementing a Primary Care Medical Home model of care, it adopted a multi-faceted approach to addressing the problem, resulting in a $1.3 million return on investment by halving the number of no-shows alone1. Next available appointments have dropped to an average of 55 days, with 40% of primary care clinics currently under 30 days. The goal for 2014 is 100% of primary care clinics at 30 days or less, with a goal of 14 days for 2016.
How JPS Did It
#1: Patient-centered care.
JPS runs everything from proposed changes in patient flow to the design of its electronic patient portal by real patients at its Patient Family Advisory Council meetings. "We stopped assuming we knew what was best for our patients and asked them instead," says Prachyl. "They really do know what best meets their needs. When we asked about reasons for our high no-show rates, they told us that patients didn't feel like anyone cared if they missed their appointment...that some were afraid as they may not have had medical care in a while."
#2: Pre-calls to patients.
Based on Council input, JPS began "warm" pre-visit calls by staff to patients one week in advance of appointments to collect history, ask if they need help with transportation, answer questions, and reschedule appointments if necessary. There was a particular emphasis on new patients. Three days out, all patients receive an automated TeleVox call confirming the upcoming visit. Since data showed the most likely no-shows were visits scheduled for months out, it was particularly important to touch base with these patients.
#3: Welcome Clinics.
The Welcome Clinic is a 30-minute visit for patients new to JPS and enrolled in its charity program. Newly enrolled patients receive a welcome flyer explaining the clinic and encouraging them to make an appointment. The clinic, staffed with registered nurses and patient navigators, briefs new patients on availability and locations of extended hours and when to use the ED. High risk patients are seen by their new primary care provider within one to two weeks while other patients are scheduled further out. With high positive feedback and few no-shows, JPS is expanding the program.
#4: Reward and recognition.
At JPS, CG CAHPS scores for individual providers are posted where patients can see them—in the main hallways of each clinic. Yet, there's little physician pushback due to JPS' culture of high reward and recognition. All medical directors participate in Leadership Development Institutes and steering committees to review policies before they are rolled out. A physician champion also validates the data and Prachyl publicly recognizes high performers. "I had one physician who said she'd never succeed because her patient population was different," she says. "But when she exceeded the 57th percentile, it was like she received an Academy Award!"
#5: Centralized, standardized scheduling.
By changing the reporting structure of registration staff to report to a centralized administrative team, training and standards for scheduling were streamlined and standardized across all the primary care clinics. JPS reduced types of visits (e.g., newborn, well visit) for more provider availability and fewer barriers for patients. When providers could view the real data for access challenges in their clinics, they agreed to adjust their schedules to meet a standardized schedule template that includes two walk-in appointments daily and allows time to respond to patient email for follow-up visits that have been moved to the electronic portal.
#6: Individualized patient care.
In October 2013, JPS introduced a standardized individualized patient care card that every patient receives upon checking in. On the front, the patient's arrival and appointment times are noted. Patients are requested to ask for an update if a practitioner does not see them within 15 minutes of their appointment time (which correlates to the CG CAHPS wait time question of 15 minutes).
On the back of the card, patients are asked to check the reason for their appointment to ensure their needs are met (e.g., prescription refill, form for work, referral). Nurses then use the cards to validate these actions were taken. In addition, every patient who waits 15 minutes or more receives a postcard after his or her visit apologizing for the wait and expressing JPS' commitment to improvement.
#7: Track results!
Prachyl keeps a current dashboard with key performance metrics for each clinic that includes volumes, slot utilization, percentage walk-ins, no-show rates, days until 3rd next available appointment, overall provider rating and wait times. Baseline data are color coded red or green with a target and action plan for each clinic.
"I think the key to our success has been high engagement with our affiliated physicians," said Prachyl. "When we make changes that might seem difficult, we sit down with them and ask, 'How can we achieve this goal and still meet your needs?'"
1$1.16 million ROI based on reducing the number of primary care no-shows from 71,691 to 32,926 over six months. Revenue is based on an average collection rate of $30 per visit.