September 2003

### A Publication of the Primary and Ambulatory Care Strategic Healthcare Group

Pages- Inside This Issue

+---+------------------------------+----+-----------------------------+
| 1 | Message: Office of Primary & | 9  | Kidney Disease Outcome      |
| - | Ambulatory Care              |    | Quality Initiative          |
| 2 |                              |    |                             |
+---+------------------------------+----+-----------------------------+
| 2 | Proposed Reorganization of   | 10 | Advanced Clinic Access      |
| - | the Office of Patient Care   |    | National Coaches meeting    |
| 3 | Services                     |    |                             |
+---+------------------------------+----+-----------------------------+
| 4 | Making Advanced Clinic       | 10 | The National Center for     |
| - | Access Work                  |    | Health                      |
| 8 |                              |    |                             |
|   | At the Amarillo, VA          |    | Promotion and Disease       |
|   | Healthcare System            |    | Prevention                  |
+---+------------------------------+----+-----------------------------+
| 9 | Ambulatory Care Conference   | 11 | Editorial Board             |
+---+------------------------------+----+-----------------------------+

*(Continued from page 1)*

We will continue to publish this newsletter, update our Primary and
Ambulatory Care website and distribute information via our e-mail
distributions. Staff will continue to serve on task forces, special
projects and respond to congressional inquiries as required. We will
continue to offer monthly conference calls, which we share with Renee
Parlier and the Advanced Clinic Access Conference call. This office will
continue to support the VISN's, facilities and other program offices.

Let me take this opportunity to express my deep appreciation for your
past support and in anticipation for your continued interest and
advocacy.

######## 

######## Reorganization of the Office of Patient Care Services

These schematic focuses on the specific changes proposed for PCS. It
shows the four SHGs affected by the reorganization.

The current organizational structure of the Office of Patient Care
Services and the proposed changes are:

**OLD STRUCTURE NEW STRUCTURE**

**Office of Patient Care Services**

**Organizational Chart**

**Current and Proposed**

This schematic displays the current and proposed organizational
structures for PCS.

**Current Structure**

![](media/image3.wmf)

**Proposed Structure**

![](media/image4.wmf)

[Making Advanced Clinic]{.underline}

Access Work At the Amarillo

VA Healthcare System

# By Brent Armstrong MD, MSHA, CHE,

# Anne Kreutzer and Mary Cresap

**Introduction to Advanced Access:**

![](media/image5.wmf)Advanced access is a model of care delivery aimed
at reducing waiting and delays for outpatient care. By redesigning your
delivery systems, reducing waiting times is possible, without adding
staff (1). The Amarillo VA Health Care System was able to decrease the
overall wait for primary care appointments from 76 days to the current
level of 20 days, by using the advanced access concepts.

The staff at the Amarillo VA Health Care System reorganized Primary Care
in January of 2000 based on the principles of Advanced Clinic Access.
The Walk-In Clinic was eliminated and the staff reorganized into an
additional primary care team --adding capacity to the system. The
principles of Advanced Clinic Access were taught to providers at a
one-day retreat in March 2000. During breakout sessions teams were
challenged to find ways to put the theories into practice. Appendix A
contains a sample of the Key Changes Worksheets from one of the many of
these breakout sessions. After the retreat, the entire department began
testing cycles of change and implementing the best of the 10 key changes
into everyday practice.

This case report includes some of the areas where key changes in Primary
Care were made to realize the gains of advanced access, based on the 10
key changes (2).

1.  **Work Down the Backlog:**

One of the first steps towards improving access in primary care is to
know the extent of the waiting times for your patients. This can be done
by going into the VISN Support Service Center (VSSC) database (3) to
determine the average wait time until the next available appointment for
your patients. The VSSC database contains a monthly summary of wait
times, encounters and appointments and can be pulled for a range of
clinics within a DSS identifier and then further refined to division
specific information. In December 1999, according to VSSC, our facility
waiting time for primary care appointments was **76 days**. With
implementation of the 10 key changes it decreased to **20 days as of
March 2003**.

One of the methods used to work down the backlog was to disband the Walk
In Clinic in January 2000. Patients want the opportunity to see their
own physicians when they have urgent health care needs. If they are seen
by an unfamiliar provider (as was done in the Walk In Clinic), this
often results in a second visit with their own provider within a day or
so of the urgent care visit, resulting in rework for the healthcare
system. In order to best serve our patients and work down the backlog,
we asked that **providers see their own patients** who have urgent care
needs. The providers running the Walk In Clinic were redirected into a
new primary care team and primary care panels were reviewed and evenly
distributed among all providers. New schedules contained three slots per
day, per provider, for walk in patients.

2.  **Reduce Demand:**

To help reduce demand, we **maximized activity** at each appointment.
Nurses share responsibility by completing some clinical reminders. New
patients attend a **new patient orientation class** prior to receiving
their first clinic visit. The orientation class, started in May 2002,
gives the patient an overview of the VA Healthcare system. Patients are
instructed to be fasting for the first new patient visit so that a
complete work up including labs, EKG, and x-rays can be done.

Providers **extended return appointment intervals** for follow up of
healthy patients. In February 2003 we implemented registered nurse
screening of walk-in patients. **RN screening** allows needs such as
medication refills and paperwork to be met without the patient requiring
a face-to-face encounter with their provider.

Another strategy that we are employing to reduce demand is by **creating
alternatives to traditional face-to-face interactions**. A diabetic
group visit clinic was implemented starting in February 2003 in order to
educate a large group of diabetic patients about different aspects of
their disease and **optimize patient involvement in their care**.

**Service agreements** with specialty care clinics and **education** of
providers on treatment of common conditions, and the appropriate work-up
before referral, led to a decreased demand for subspecialty care.

3.  **Understanding Supply and Demand:**

One strategy that we used to better align the supply and demand was to
reduce the number of **no shows** because this represented a lost
opportunity for both the patient and the provider. Under the old system,
new patients were often automatically assigned a primary care
appointment after a visit to the Life Support Unit. 90% of these
patients subsequently no-showed their first appointment. Now patients
are given the number to Telephone Triage and an appointment is scheduled
at their request. No-show rates have dropped to 10% overall.

**Panel sizes were** **standardized** for providers and mid levels and
are tracked closely using Primary Care Management Module (PCMM)
software. New patients are allocated to providers depending on their
current panel sizes. The information can also be used to support
staffing decisions by the clinic manager, as the standardized tools in
PCMM allow determination of overall clinic capacity and provider
efficiency.

Another strategy was to assign primary care providers to ambulatory care
only without emergency room or inpatient responsibilities, thus
maximizing the continuity of care and preventing disruptions in service.
Providers also were empowered to take care of patients during any type
of visit, even an urgent care visit, in order to get all necessary work
done during the same visit**.** This is part of the concept of "**doing
today's work today**" (3).

4.  **Reducing Appointment Types:**

S**tandardized appointment lengths** have been established for
follow-up, walk-in and hospital follow-up patient visits. By
standardizing the time employed for each of these different
appointments, providers can use the appointments slots interchangeably
as demand changes.

5.  **Plan for Contingencies:**

**Demand variations are managed proactively** by anticipating staffing
shortages and reacting accordingly. In the event of illness or emergency
leave team members provide cross coverage. A standard **Leave Policy**
for all team members requires advance notice of vacation and requires
the rescheduling of cancelled appointments within two weeks of the
original appointment date.

6.  **Manage the Constraint:**

Before the elimination of the Walk-In Clinic the physician to mid-level
supervisory ratio was a less than optimal 1:5, a potentially
rate-limiting step for the mid levels. Redistributing the providers from
the disbanded Walk-In Clinic reduced the ratio to 1:3. Taking advantage
of natural turnover, mid-level providers were replaced with physicians
further decreasing the supervisory ratio to 1:1. Capacity has been
increased and mid-levels no longer wait to present a case.

Vacant exam rooms are used when possible (e.g. when another provider is
on leave). A future construction proposal requests expansion of
ambulatory care facilities to **allow 2 rooms per provider** to enhance
our efficiency and allow the provider's work to flow more smoothly.

7.  **Optimize the Care Team:**

We have partnered with the other services represented in primary care to
ensure that **all roles in the practice are maximized to meet the
patient's needs** by using the team approach to the care of the patient.
Our goal is one nurse per provider and one midlevel per supervising
physician. Each team also has one RN to oversee, facilitate and triage
urgent needs and walk-in patients. Each team of 4-5 providers is also
supported by three Team Associates.

**Standardized protocols are used by the telephone triage nurses** to
coordinate the patient's needs. Questions related to routine medical
issues, medication refills and appointment information are answered by
Telephone Triage. A progress note is entered into CPRS (non urgent),
with the provider receiving a "view alert," while urgent/ emergent calls
are transferred directly to the team RN.

8.  **Synchronize Patient, Provider, and Information:**

In order to synchronize patient, provider and the clinical information,
patients are scheduled into a "Nursing Assessment Clinic" 30 minutes
prior to their primary care visit. This allows the team nurse to screen
the patients and allows adequate time for the nurse to complete their
assigned **clinical reminders before the provider appointment.** Nurses
can complete those portions of the clinic visit that do not require the
physician's presence (e.g., preventive vaccinations, diet and/or smoking
education, etc.).

**9. Predict and Anticipate Patient Needs:**

The clinic manager, outpatient nurse manager and administrative
supervisor **coordinate coverage** on a daily basis. There is daily
communication between all members of the health care team in primary
care. The use of regular "huddles" allows the clinic as a whole to
anticipate and plan for contingencies.

10. **Optimize Rooms and Equipment:**

> We have chosen to **standardize supplies** in the provider's rooms and
> **ensure the rooms are well stocked** as one way of optimizing rooms
> and equipment.
>
> In summary, utilizing the 10 key changes described above has helped
> Amarillo VA Health Care System achieve our first aim of reducing our
> clinic waits below 30 days. The next step is reaching true advanced
> clinic access, which offers appointments the same day. This is best
> described in the following quote; "The core principle of advanced
> access is that patients calling to schedule a physician visit are
> offered an appointment the same day. Advanced access is not
> sustainable if patient demand for appointments is permanently greater
> than physician capacity to offer appointments." (2)

\(1\) Guide to Reducing Delays and Waiting Times. Nolan, T, Schall, M,
Berwick, D, Roessner, J. Boston: Institute for Healthcare Improvement;
1996.

\(2\) "Advanced Access: Reducing Waiting and Delays in Primary Care"
Murray, M and Berwick, D. JAMA. February 2003; 289:1035-1040.

\(3\) ACA-ICI website: http://www.ihi.org/clients/va/access/changes/

\(4\) VSSC website:
[http://klfmenu.med.va.gov](http://klfmenu.med.va.gov/)

Other resources:

"Improving Timely Access to Primary Care: Case Studies of the Advanced
Access Model" Murray M. et al. JAMA. February 2003; 289: 1042-1046.

Appendix A: Improving Clinic Waiting Times Key Changes Worksheet-Access

Appendix A

**Improving Clinic Waiting Time**

KEY CHANGES WORKSHEET -- ACCESS

+-----------------------------------+-----------------------------------+
| Key Changes for Improving Access  | Describe changes you are planning |
|                                   | to test in the next two months    |
+-----------------------------------+-----------------------------------+
| #### GAIN CAPACITY                |                                   |
+-----------------------------------+-----------------------------------+
| 1\. Carve out: Hold appointment   |                                   |
| slots each day for same day needs |                                   |
+-----------------------------------+-----------------------------------+
| 2\. Open Access: Working on doing |                                   |
| all today's work today            |                                   |
+-----------------------------------+-----------------------------------+
| #### WORKING DOWN BACKLOG         |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Adding more appointments      |                                   |
+-----------------------------------+-----------------------------------+
| 2.  Doing more for patients at    |                                   |
|     each visit                    |                                   |
+-----------------------------------+-----------------------------------+
| 3.  Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| #### APPOINTMENT TYPES            |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Reduce the number of          |                                   |
|     appointment types             |                                   |
+-----------------------------------+-----------------------------------+
| 2.  Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| #### CONTINGENCY PLANS            |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Adding more appointment time  |                                   |
|     as needed                     |                                   |
+-----------------------------------+-----------------------------------+
| 2.  Adding providers as needed    |                                   |
+-----------------------------------+-----------------------------------+
| 3\. Making temporary changes in   |                                   |
| clinic flow and staff             |                                   |
| responsibilities                  |                                   |
+-----------------------------------+-----------------------------------+
| 3.  Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| #### REDUCE DEMAND FOR VISITS     |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Match patients with providers |                                   |
+-----------------------------------+-----------------------------------+
| 2.  Phone follow ups              |                                   |
+-----------------------------------+-----------------------------------+
| 3.  Group visits                  |                                   |
+-----------------------------------+-----------------------------------+
| 4.  Extend visit intervals        |                                   |
+-----------------------------------+-----------------------------------+
| 5.  Doing more for patients at    |                                   |
|     each visit                    |                                   |
+-----------------------------------+-----------------------------------+
| 6\. Referral agreements between   |                                   |
| specialists and primary care      |                                   |
+-----------------------------------+-----------------------------------+
| 7\. For specialty care, use       |                                   |
| work-up and treatment guidelines  |                                   |
+-----------------------------------+-----------------------------------+
| 8\. Other                         |                                   |
+-----------------------------------+-----------------------------------+

### KEY CHANGES WORKSHEET - EFFICIENCY

+-----------------------------------+-----------------------------------+
| ## Key Changes for Impr           | Describe Changes You Are Planning |
| oving Efficiency and Patient Flow | to Test in the Next Two Months:   |
+-----------------------------------+-----------------------------------+
| #### BALANCE CAPACITY AND DEMAND  |                                   |
+-----------------------------------+-----------------------------------+
| 1\. Predict daily demand and      |                                   |
| match provider availability to    |                                   |
| prediction                        |                                   |
+-----------------------------------+-----------------------------------+
| 3.  Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| **SYNCHRONIZE PATIENT, PROVIDER,  |                                   |
| AND INFORMATION**                 |                                   |
+-----------------------------------+-----------------------------------+
| 1.  First AM and PM appointment   |                                   |
|     start on time                 |                                   |
+-----------------------------------+-----------------------------------+
| 2.  Chart-check prior to visit    |                                   |
+-----------------------------------+-----------------------------------+
| 3.  Rooming criteria to prepare   |                                   |
|     patient for exam              |                                   |
+-----------------------------------+-----------------------------------+
| 4.  Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| **ANTICIPATE PATIENT NEEDS AT     |                                   |
| TIME OF APPOINTMENT**             |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Staff huddles to plan for     |                                   |
|     contingencies                 |                                   |
+-----------------------------------+-----------------------------------+
| 2\. Align physician and staff     |                                   |
| expertise with patient needs      |                                   |
+-----------------------------------+-----------------------------------+
| 3\. Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| #### OPTIMIZE ROOMS AND EQUIPMENT |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Maximize flexibility of rooms |                                   |
+-----------------------------------+-----------------------------------+
| 2\. Standardize supplies and have |                                   |
| rooms stocked at all times        |                                   |
+-----------------------------------+-----------------------------------+
| 3\. Other:                        |                                   |
+-----------------------------------+-----------------------------------+
| #### MANAGE CONSTRAINTS           |                                   |
+-----------------------------------+-----------------------------------+
| 1.  Distribute work among all     |                                   |
|     providers and staff           |                                   |
+-----------------------------------+-----------------------------------+
| 2.  Use protocols to optimize     |                                   |
|     other providers               |                                   |
+-----------------------------------+-----------------------------------+
| 3\. Separate responsibility for   |                                   |
| phone, patient flow, and paper    |                                   |
| flow                              |                                   |
+-----------------------------------+-----------------------------------+
| 4\. Other:                        |                                   |
+-----------------------------------+-----------------------------------+

Ambulatory Care Conference

**By Mildred Eichinger, RN, MPH**

*Clinical Program Manager, Primary Care*

For those of you who were unable to attend the Ambulatory Care
Conference held in the Doubletree Hotel, Crystal City, VA. June 24-26,
2003, the agenda is now posted on the primary care website along with
some slide presentations or handouts: <http://vaww.va.gov/primary> (see
Primary and Ambulatory Conference.)

There were over 200 attendees at the conference. This conference was
jointly sponsored by EES Northport, (Dr. Rivkah Lindenfeld), and the
Primary Care Office. It was open to CMO recommended participants to
represent the VISN and/or facility. Dr. Perlin delivered the keynote
speech: Challenge to Maintain Quality in Times of Growth. Dr. Kussman
discussed the Cardiac Campaign. There was a panel discussion on
Discipline Specific Interface between Primary Care and Specialty Care
and a panel discussion moderated by Dr. Elwood Headley on Integrated
Primary Care in the Ambulatory Care Setting. Concurrent sessions
addressed: Patient Health Education, Primary Care Panel Size, Telephone
Access and Replacement Scheduling Application (RSA) Support of Advanced
Clinic Access. The agenda has been condensed and there are interlinks
for some slide presentations and handouts to facilitate access. Slide
presentations are available for:

Advanced Clinic Access Current Challenges Adapting to

New Demands: Renee Parlier, RN, MPA

Action Plan for Cardiology Care: Dr. Michael Kussman

Clinic Process Evaluation Overview of Role and Utility: Dr. David Reagan

Delivering Integrated Primary Care: Mary Schohn, PhD.

Group Clinics Range of Modalities: Dr. Paul Heineken

Office Based Functional Assessment: Dr. Thomas Edes Patient Education
TEACH for Success: Rose Mary Pries, PhD

Report of the Primary Care Subcommittee: Dr. Michael Mayo-Smith

RSA Support for Advanced Clinic Access: Dr. Peter Woodbridge

The Old Folks are Sneaky: An Approach to Weight Loss

in the Elderly: Dr. Thomas Edes

VHA Physician Productivity and Staffing Advisory Group: Dr.
Michael-Mayo-Smith

VHA Physician Productivity And Staffing Task Force: Dr.
Michael-Mayo-Smith

VA Mental Health Primary Care Integration: Dr. Laurent Lehmann

Women's Program Handouts: Carole L. Turner, RN, MN, CNAA

VERA: Paul Kerns

There were many posters representing information for both patients and
providers. If you wish additional information, feel free to contact the
presenters. A summary of the evaluations indicates that participants
felt that the conference was worthwhile. Positive comments included:

"I would recommend this program to a friend or

co-worker."

"Outstanding in all respects."

"Make it available to more people twice a year."

"Fantastic conference. Great faculty and

attendees. Well done."

"Well organized. Excellent speakers."

"All the participants I spoke with have favorable

comments. Well done."

"Compelling thoughts, new ideas and to take

home."

Thanks to all who contributed their time and efforts towards making this
an excellent conference.

\*\*\*

**[Primary Care Conference Calls]{.underline}** are scheduled for the
third Wednesday of each Month @ 1 p.m., Eastern Time. These calls are
scheduled through December 2003. 1-800-767-1750; Access Code 28097. \*
ACA calls.

  -----------------------------------------------------------------------
  \*September 17

  October 15

  \*November 19

  December 17
  -----------------------------------------------------------------------

###### **Practice Management Guide**

The Practice Management Guide, Volume II, is available on the primary
care website: <http://vaww.va.gov/primary>.

Kidney Disease Outcome

Quality Initiative

**By Thakor G. Patel, M.D.,** *Chief Renal Diseases*

Kidney Disease Outcome Quality Initiative (K/DOQI) of National Kidney
Foundation came out with guidelines that have chronic kidney disease in
5 stages with action plan based on estimated GFR(eGFR). VA has released
a patch that can provide the eGFR, but each center has to install it.
Whenever you order serum creatinine, you should get eGFR done for you
without having to ask for it. The reference for K/DOQI guidelines is:
Annuals of Internal Medicine 2003;139:137-147.

We have three websites that have patient and provider information.
Please visit these sites and let us know if you need more information.
The diabetes website has links to NDEP website which has translated
information for patients in the various languages such as Hispanic,
Samoan, etc. The kidney website has an easy link to GFR calculator.

<http://www.va.gov/kidney>

<http://www.va.gov/diabetes>

<http://www.va.gov/cancer>

Advanced Clinic Access National Coaches meeting

**By Renee Parlier, Director***, VHA Advanced Clinic Access Initiative*

When you ask him why he adopted Advanced Clinic Access into his primary
care clinics, Dr. Rich Stark says, "Desperation! We knew we had problems
with waiting times and were not able to put a dent in it. We saw the *NY
Times* article on Mark Murray's efforts a few years back and it seemed
to make sense. We felt we had nothing to lose and everything to gain, so
we went for it, starting on a small scale in a CBOC so if it turned out
to be a disaster we wouldn't be too far-gone. Once we saw how successful
it was, we rolled it out to other sites as fast as we could."

Dr. Stark is an Advanced Clinic Access National Coach. Advanced Clinic
Access National Coaches are people who have implemented Advanced Clinic
Access principles in their clinics, have achieved and sustained
significant improvement and are willing to teach others how to do what
they have done. Presently there are 55 ACA National Coaches; 16 in
primary care alone.

October 28 and 29^th^, 2003, the ACA National Coaches will meet at the
Hyatt Regency in Phoenix, AZ.

If you are interested in joining the national coaches group and you meet
the description outlined above, please contact Renee Parlier, Director,
VHA Advanced Clinic Access Initiative, at <renee.parlier@med.va.gov> or
call her at 612-970-5869 to find out more.

The National Center for Health Promotion and Disease Prevention

The National Center for Health Promotion and Disease Prevention
encourages you to access National Health Observances for the remainder
of Calendar Year 2003, by visiting <http://www.health.gov/nhic/pubs/>
Contact Lewis, Susi NCHPDP@DURVAMC for further information.

## Schedule for MAP articles

  ------------------ ---------- ------ ------ ---------- ----- ----- ----------- ----- ---------
  FLOW               **4^th^                  **1^st^                **2nd^st^         
                     Q/2003**                 Q/2004**               Q/2004**          

                     July       Aug    Sept   Oct        Nov   Dec   Jan         Feb   March

  Articles Submitted 18                       15                     21                

  Distribute to                 8                        5                       11    
  Board Members                                                                        

  Comments to OPAC              29                             23                      3

  Final Presentation                   10                      17                      17
  to 112                                                                               

  Electronic & Hard                    17                      24                      31
  Copy Distribution                                                                    
  ------------------ ---------- ------ ------ ---------- ----- ----- ----------- ----- ---------

Articles may be submitted electronically at any time to Mildred
Eichinger and/or Renee Hodges.