Convenience care: a patient-centered model of scheduling.

As any experienced office manager knows, scheduling patients with health care providers and assuring a smooth patient flow through the clinic consumes almost all her time and energy. The tension usually arises from the patient's demand to see the health care provider as soon as possible.

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Several scheduling models have been devised to deal with this tension and several terms have circulated around the clinical office for a while--urgent care, fast track, same-day scheduling, walk-in patients, drop-in clinic, advanced access and open access.

All these terms, in one way or another, reflect the health care provider's point of view to decide who needs urgent care and who needs a scheduled appointment. When a patient decides to see a physician, he or she has a real need--although, from a strictly medical point of view, some needs are not medically necessary, such as filling out a form.

I propose the term "convenience care" to reflect that the patients evaluate their needs and schedule an appropriate kind of appointment on that same day.

Convenience care, in this context, is essentially similar to the concept of open access or advanced access proposed by Murray. (1) The difference is that it moves the mindset from the provider side to the patient side.

The challenge to the practice is how to adapt to the health care needs of the patients and not the other way around.

Three scheduling systems

The Institute of Health Improvement initiated a collaborative program called "Ideal Design of Clinical Office Practices" (IDCOP). (2) It aims at creating a comprehensive redesign of the clinical office system, with four major themes:

1. Access

2. Interaction

3. Reliability

4. Vitality 

Murray and Tantau (1) described systems of scheduling with three different models:

1. Traditional. "Do last month's work today." The schedule is completely booked several months in advance. Same-day urgent visits are squeezed between break time or lunch time.

2. Carve-out. "Do some of today's work today." There are some time slots reserved for same-day urgent care.

3. Advanced access. "Do today's work today." The schedule is truly open. There are some scheduled appointments, but the providers are ready to meet patients' needs on the same day.

Characteristics of a scheduling system

Table 1 compares these three scheduling systems, side-by-side, along these dimensions: easy access, continuity of care, interaction, capacity, stretching the system, value to patients and risk of losing patients.

There is no doubt that the convenience care model exceeds the other two models for easy access.

One objection typically raised against the open access and convenience care models is continuity. Actually, in a closed system, continuity is compromised, because when the patient calls in, if the provider's schedule is full, his appointment is put back at the end of the list, several months down the line.

Instead, in a convenience care model, when the patient calls in, if he has already had one primary doctor, he can be scheduled with her in the same day or the next few days at the most. In the case his primary doctor is not available, the patient can be seen by any other providers who still have capacity to accommodate this patient.

A drawback of the carved-out model is that providers are usually not willing to share the burden of non-scheduled patients. The variable show rate for each provider and the uncertain time of patient show-up at the clinic increase frustration for the providers and the whole staff.

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If all providers in one clinic session are organized to see any patients, there is no more fast track or urgent care subsystem and the whole scheduling system is simplified to only one.

Another objection about convenience care is that it allegedly stretches the practice system. Actually, the total number of patients that come to the clinic is rather stable over a specific period of time. If the practice usually sees 100 patients a day, there is no reason that the clinic will see 200 patients on certain days.

If there is any actual increase in the number of patient visits, this increase usually stretches slowly over a period of time and management has plenty of time to adapt necessary resources to this trend.

As anyone can attest, needs that are satisfied now bring more satisfaction than needs that are delayed into the future. This is the added value that convenience care brings to the patient. And in this time of fierce competition, it costs more to lose current, loyal patients than trying to acquire new, uncertain patients.

Supply and demand

An ideal scheduling system should match the demand from patients with the supply from providers. On the demand side, there are several factors to consider:

* How sick the patient is

* Pay structure status

* Frequency of visits

* Time of visit

On the supply side, there are also several factors:

* Time available to the provider

* Number of available providers

* Scope of practice

* Availability of exam rooms

Management has almost total control on the supply side but very limited impact on the demand side. Matching supply capacity with demand needs implies several corollaries.

The first part of solving this matching equation is to maximize capacity. All providers should be moved to convenience care by discontinuing all subsystems of care, such as fast track, urgent care or carved-out scheduling systems. Because everyone is supposed to see any patient, the show rate is meaningless. There is no more acrimony among providers about the issue "Why me?"

When a clinic practice moves from the carved-out model to the convenience care model, there will be some chaos and overwork for the first few months due to remaining scheduled patients from previous months.

The second part of solving this matching equation is to reduce demand. The practice can achieve this goal by several mechanisms:

* Decrease the frequency of visits, for example, from three months to four months, if medically possible.

* Follow up patients by phone or by e-mail, if medically possible, such as allowing patients to upload their logs of home sugar monitoring results.

* Refill medications over the phone, if the patient is wellknown to the physician.

* Provide alternative methods of delivery, such Web sites with frequently asked questions. common disease management or automatic telephone services and group teaching

Another way to decrease the number of unnecessary visits and improve the value to the patient is to increase the depth of services. The patient reserves a certain amount of time in his mind when he decides to come to see the doctor. If he has to wait for more than his expected time, he will be upset.

Because the doctor usually spends only a fraction of the patient's time with the patient, the other available portion of patient's time is wasted if it is not served, such as by the dietician, the health educator, the social worker. If the patient is really busy, he will say so. Otherwise, he is usually willing to have other services offered.

Another notion related to maximizing capacity is sunk time. If a provider is expected to see patients in 3.5 hours, from 9 a.m. to 12:30 p.m., with an average rate of four patients per hour, his total capacity is 14 patients in this session. Any hour passing without having patients seen by this provider is considered sunk time. This time is lost; and the capacity of this provider is decreasing with the passing time. At 11 a.m., his remaining total capacity is six patients. If by that time, he still has four patients being seen or waiting, he can only accommodate two more patients at the maximum.

Convenience care requires that patients who come first are served first, unless the provider decides to do differently, at his best judgment. Suppose Doctor A has four patients, one being seen and three waiting.

Doctor B, meanwhile, finishes with her patient and a new patient arrives. Common practice dictates that this newly arrived patient be assigned to Doctor B. However, this causes anger among patients because they perceive the unfairness of the newly arrived patient being served first while they are still waiting.

In this scenario, the patient number two in Doctor A's line should be given to Doctor B, and the newly arrived patient should be added to the last position in Doctor A's line. If patient number 2 still wants to see Doctor A, patient number 3 should be moved to Doctor B, and so on.

Because convenience care is not emergency care, there is always an opening hour and a closing hour. Usually there is no problem in the morning. The end of the day always causes some challenges. It is not productive to decide an arbitrary and fixed cut-off time, such as half hour before the closing time, after which time patients are not seen. This cut-off time should be based first on the remaining capacity of the providers, and secondly on other factors, such as first-time patients vs established patients and intake time. In other words, the cut-off time should be flexible and monitored closely.

All of this, of course, requires constant and effective coordination of activities and patient flow. The office manager or the chief nurse should be given full authority to conduct this corrdination and monitoring. Administration should not intervene itself in this function.

As most of the care occurs at the clinical office and competition becomes fierce, designing a scheduling system that meets patients' needs is a requisite for both good care and good business. The convenience care model satisfies patients' needs to be seen immediately, increases the clinic full capacity, simplifies the scheduling system, promotes continuity of care and interaction between patients and providers.

Table 1--Characteristics of the three scheduling systems

                            Closed Model  Carve-out Model  Convenience
                                                           Care Model

1. Easy access              +             ++               +++
2. Continuity of care       Variable      Variable         Variable
3. Interaction              ++            +                +++
4. Capacity                 +             ++               +++
5. Stretching the system    +             +++              +
6. Value to patients        +             ++               +++
7. Risk of losing patients  +++           ++               +

References:

1. Murray M. Tantau C. "Same-Day Appointments: Exploding the Access Paradigm." Family Practice Management, September 2000, pp. 45-50

2. "Idealized Design of Clinical Office Practices (IDCOP)." Institute of Health Improvement at http://www.ihi.org/idealized/idcop/index.asp

By Tai Huynh, MD

Tai Huynh, MD, is an attending at Mile Square Health Center and a faculty member of the Department of Family Medicine. College of Medicine. University of Illinois at Chicago. He can be reached at 312-413-8183 or [e-mail].