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Challenges to Increasing Access and Continuity in a Large Academic Medical Center Implementing PCMH
Robinson CH, Harrod M, Forman JH, Tremblay AS, Kerr EA, Rosland A. Challenges to Increasing Access and Continuity in a Large Academic Medical Center Implementing PCMH. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.
Title: Challenges to Increasing Access and Continuity in a Large Academic Medical Center Implementing PCMH
Authors: Claire Robinson, Molly Harrod, Jane Forman, Ann-Marie Rosland, Adam Tremblay, Eve Kerr
Background: A core goal of the patient-centered medical home (PCMH) model is to increase timely access to primary care while maintaining patient-provider continuity. While definitions of access vary, it is often operationalized as receiving a same-day appointment with the patient's usual provider. For example, the Department of Veterans Affairs (VA) has implemented a national performance measure examining receipt of same-day appointments with the patient's usual primary care provider (PCP). Large academic primary care clinics face unique challenges in providing prompt access to a patient's usual provider, particularly because many of these clinics are staffed by providers and residents who are in the clinic only a few hours each week ('part-time providers'). We examined factors affecting efforts to increase prompt access and provider continuity in a large VA academic medical center that was in the process of implementing PCMH. Among the medical center's 78 PCPs, 59 were available in clinic half-time or less. We have previously shown that part-time providers at this medical center were less likely to meet the national access measure.
Methods: We conducted 20 semi-structured interviews with primary care staff (physicians, residents, registered nurses, licensed practical nurses, and clerks), roughly one and a half years into PCMH implementation. We also observed more than 25 hours of coaching sessions designed to help newly formed primary care teams redesign their delivery processes to improve their access and continuity measures. We coded interview transcripts and coaching observation field notes with descriptive, non-hierarchical, grounded codes that emerged from the data and developed findings via group consensus.
Results: We identified two main barriers to improving same-day access for patients of part-time PCPs. The first of these was lack of flexibility in scheduling face-to-face and telephone visits. Part-time providers were often scheduled to other duties during their time away from clinic. While many part-time PCPs had partners or team members who could see patients when they were not in clinic, these encounters did not count toward the access measures. Second, the volume of patients requesting a same-day appointment was high, and because part-time PCPs had limited clinic hours, it was difficult for these patients to be seen on the same day with their assigned PCP. Even with open access, slots reserved for same-day appointments were filled quickly. In addition, other pressures, like seeing patients who were recently discharged, and the volume of new patients, decreased availability for same-day access.
Conclusions: The large number of part-time primary care providers and residents combined with the large volume of patients made same-day access with the patient's usual PCP challenging. Increased flexibility to schedule non face-to-face visits during part-time PCP's non-clinical duties could help improve access. However, strategies that promote a team approach to access are likely the only long-term solution if we are to improve access while continuing to support providers who choose or need to work part-time. More information is needed on patient needs and preferences for prompt access and continuity in academic environments, so these new strategies can be tailored to patient-centered goals.
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