Episode 46: Yes, We Can Improve Primary Care Access

Mike: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A spatchcocked monthly podcast for health care providers. I'm Mike Clark.

Heather: And I'm Heather Ward. Mike and I are practicing physicians who participate in the MaineHealth ACO.

Mike: Yep. Spatchcock. Anyway, our episode today features just one segment, Heather, but it is a good one. It's a meaty topic that tells an inspiring story of real-life health care transformation.

Heather: Awesome. All right, I'm ready to be inspired. Let's get to it.

Mike: One of the biggest problems that keeps primary care providers and administrators up these days is poor patient access. Here in northern New England, a shortage of practice staff and providers has collided with increased demand for patient care, and the result is long wait times for appointments, long hold times on the phone, and let's face it, some pretty stressed-out practice teams and unhappy patients.

Heather: Yeah, absolutely. And it's no surprise then that medical groups and practices are testing all kinds of tactics to get patients the care they need when they need it. It's too soon to see what the outcomes will be, but we do have an example of what can work right here in the MaineHealth system.

Mike: Yes, we do. And here to talk about it is Matt Dunn, chief medical officer at Memorial Hospital in North Conway. Now, a few years ago, before the pandemic, Matt began the push to improve primary care access at Memorial. Today, he's still pushing, but the increase in access that he helped engineer has been pretty amazing.

Heather: It really has been. This is a fantastic story. Matt spoke with our producer Paul Santomenna.

Paul: So, Matt, you've had some success in improving primary care access there at Memorial. Can you tell us at the beginning of this process, where were you? How was access and what was the situation?

Matt: Yeah, sure, Paul, thanks. Thanks for having me on. This was the summer/fall of 2020. We had been hearing both from our team in primary care (our providers, clinical team, registration team), that there were a lot of issues. We had certainly heard from our community that there are issues, mostly issues about getting in and getting follow ups. So, we all kind of took a pause and said, we really need to look at this holistically. So, at that time, we're a small rural health clinic here at Memorial Hospital, our primary care practice and about 10,000 patients. We had really significant issues getting our patients in. Our time to get new patients in was approaching nine months. All the traditional access metrics were, I'll say, they were very bad. Patients were waiting weeks, and weeks, and weeks to get in. Even for acute appointments, we didn't have the ability to see hospital follow up. We started to look at what is our quality performance in all of our quality metrics. So, the ACO Heat Map System Quality Dashboard. At that point, we had actually never achieved an ACO heat map metric out of our primary care office.

Paul: Can you just go back to the beginning and just give us a baseline? Like how big was the practice, how many providers, how many patients do you think you were seeing? And a little bit about the North Conway community there?

Matt: Yeah. So, we're based out of North Conway in New Hampshire, Carroll County. Our population in the county is about 50,000. And we also service western Maine. So about 20% of our patients come from the western Maine region, Fryeburg area mostly. Our practice at the time was about 10,000 patients. We were doing about 28,000 visits annually. At the time, we had a total of seven full time FTEs, a couple of part time FTEs in terms of providers. And that's just our, I'll say our true primary care. We also, within the practice have embedded endocrinology, behavioral health, and podiatry within the practice. Now, and so this is fiscal year 23. Last year we had 37,000 appointments from 28, and we're currently growing. We're adding about 150 new patients a month. You know, part of the strategy, obviously, if you're growing at that pace and you only have that many providers you have to recruit. Our total provider complement now is about ten FTEs. I just hired another primary care physician, three more APPs, and next year I'm recruiting for an additional 1.6 physicians. And honestly, the space is tight because we run seven days a week, and providers can work flexible scheduling. It allows us to do some unique things in terms of staffing and coverage. We are looking at doing full seven days a week, full days, all days. It'll take a lot, not so much for the practice, but registration and ancillary services. We want our patients to be able to get the same level of service Monday through Friday on the weekends that they get Monday through Friday.

Matt: Now we have about 11,500 patients growing at about 150 patients a month. Almost all of our panels are capped or very close to. It's been great. We've had tremendous success with access, but we're actually getting tight now, which has made it challenging. So, we made the decision there to also say, well, let's find out what our patients, what our consumers think about us. We hired an external firm to actually survey patients and key stakeholders in our community. I think we surveyed 200 to 300, so it was a pretty big survey. We had a really great response, and most of it centered around what I said earlier, people saying that they couldn't get in for an appointment. There were a lot of complaints about our phone system. We had a traditional phone tree, that if they did get through, they never got a call back, that we weren't messaging them back using MyChart, and that we had issues fulfilling patient prescriptions. It would take us sometimes a week when someone requested a refill just to get that through.

Matt: We also looked at our ED utilization for low acuity patients (i.e., patients that really could have been going to primary care), and we were one of the highest practices in the system at the time. So, we looked at a number of other things as well, but those are really the same issues that our provider team really said: I can't see my patients, we're having a challenging time communicating, I'm worried that we're not filling our prescriptions. And we said, we really need to tackle this. It was a combined team of, it was our whole senior leadership team, actually. The providers within primary care and the operational leaders from the primary care. We talked about all of the issues in a really open fashion. We let every single provider in the practice tell us what they felt their challenges were. And I'll say it was challenging for all of us to hear because a lot of us hear those things we immediately want to react or try to fix it, but it was important for them to be able to vocalize it. Once we're able to kind of get through, well, what are all of our issues, we started to focus on, well, what do we need to fix? And one of the things that became really apparent early on, which was pretty surprising to some people, is that the providers really, without question, said they want to see more patients. And a lot of us are thinking, well, they feel overwhelmed. They don't want to see patients. And it wasn't that they wanted to see more patients in the current environment. They felt like their patients couldn't get in and they weren't taking good care of them because of that.

Matt: So, we needed to figure out how we reduce the barriers to get the patients in. So, we looked at this project overall, this access project, in terms of what were the barriers to keep keeping patients from getting in, from allowing our primary care providers to see more patients, and how do we kind of close the loop on some of those issues? We met every week for 60 to 90 minutes. We had a really large, I'll say, kind of issue project tracker. We made decisions every week on things we were going to change, and we measured it and monitored it. Which allowed us to continually change and improve. And I'll say, this is still going on where we're two and a half years later, we meet every month. But the first year, year and a half, we made a lot of decisions, some that didn't work, some that worked really well. We allowed and encouraged the team to really chime in to take ownership. One of our MAs in a meeting said, well, why do you have a phone tree? If people don't like the phone tree, why do you have a phone tree? And we had gone through six different iterations of this phone tree trying to improve it. So, we literally made the decision to get rid of the phone tree. And if you call in now, you'll get a message that says if you want to leave a prescription, press this number. Otherwise, you actually go to a live operator. We went to all live operators and our phone answer rates since we've done that have been above 95%. And our goal now is about 98%. And we hit that almost every month. So that was an example of really having the whole team being able to give us ideas, ideas that we may not think about.

Matt: Some of the other things that we looked at; we did a workflow analysis really from the time that a patient calls to the time that they arrive to their appointment, they have their appointment, and they leave. So, we looked at the entire workflow through all of that, trying to streamline it. One of the things we realized is that an incredible amount of work was done during the patient visit that made it challenging for the provider to have enough time. So, we have a lot of rooming statistics, they were doing health maintenance activities, they were trying to determine immunization status, and our MAs were spending on average 12 to 14 minutes in the room in a 20-minute appointment, which left the providers feeling dissatisfied and as well the patients feeling dissatisfied. We've done everything we can to take most of those activities out of the visit. We developed what we call a patient outreach center, where we actively use EPIC to data mine for health maintenance activities (e.g., Things that we've missed or vaccinations, mammography, colonoscopy or colon cancer screening, and that is done outside of the visit). And we'll actively call and engage those patients. So, we were able to reduce the amount of time MAs were spending by over 50% initially, and now it's closer to 75%.

Matt: The other two areas that that are related, I mentioned patients saying I'm not getting my prescription and provider saying we're not giving our prescriptions. And no one's really messaging me back in MyChart. Our MyChart answer rate, our average response was five days and our average for prescription refill was six. And without getting into all the industry benchmarks, because Epic has them, I'll just say that was very bad and led to a lot of dissatisfaction. We did a pretty deep dive on our own in-basket workflow and realized that we were generating a lot of internal messages for every phone call we received. And so, one of the things we did with our live operators is we also had direct access to PSRs for scheduling as well as clinical RNs to answer clinical questions, with the goal that they would answer them on the spot and not generate in-basket messages. We also have signed up our patients actively for MyChart. We went from an activation rate of 55. We're at 87% now. So, we're close to the top decile on all of Epic. And even though we signed up more patients from MyChart, our overall MyChart utilization in terms of messages has gone down because we've reduced the amount of internal messages we're creating. Now our average turnaround time on a clinical message is 0.7 days and 100% of our prescriptions are filled by the end of the day. And that was our goal in the fall of 2020, and people thought that was crazy. But we continued to work on it and has become the standard.

Matt: The other part of what we've done is when we're looking at all these metrics and KPIs, these weren't secret. Everyone was included in them. Everyone participated in what we wanted to be measured. And there are dashboards in every pod which are available out in the open for everyone to see. This has really led to some innovation within each area, allowing them to address their issues. They understand what their gaps are, and they continue to push on that. I'll say one of the things that we did, and I know I discussed this in one of the other podcasts I was on, is we expanded our hours of operation. We were very traditional clinic, Monday through Friday, 8:30 to 4:30, which is work hours for everyone in our community. Our average unemployment rate is below 2%. Everyone had to take time off from work to come here, which was not popular. We went to ten-hour days, Monday through Friday, and we opened half days on weekends. That was directly from the provider group wanting to do that. They said we need to open weekends. And in order for us to do that, we created flexible scheduling. We have providers that are working three long days and some weekends, some that are working four days. This has allowed us to be flexible in our staffing as well as to continue to kind of push our access.

Matt: The key thing really in all of this, Paul, is the continued open discussion, listening, and being willing to try some ideas. Understanding that some of them aren't going to work. Some of them will work well. But continuing the effort, and we all know how health care is really busy. We all are doing a lot of things. As soon as you kind of look away and put your focus toward something else, inertia sets in, and things start to slowly break apart. This is why we continue to meet every month. We continue to look at our metrics, adding new metrics. When we started the formation of the partnership with Agilon called the HAC coding work, those became part of our dashboard. Now, just in the last couple of weeks, with Craig Smith becoming the VP for Physician and APP Services for the Medical Group, we're actually working on provider dashboards for each provider, which contains all of their productivity metrics, quality metrics, and Agilon metrics.

Matt: This is a request of theirs, so they can see it in one easy spot and identify their gaps as well as solutions. This has led us to a much better practice. Our engagement scores, because of it, are really improved. But there's still a lot to work on. I was just meeting with Craig today and he's like: God, I just feel like we just scratched the surface on this. I'm like, Yeah, I know. I think for us being continually willing to look at this, and we're trying to expand it across all of our practices, we didn't have quite the same access issues in our other practices. But because our primary care practice has grown, it's growing at about 15 to 16% per year right now, which is a lot. So, for us, that means at the end of a fiscal year, we've added almost another care team worth of patients, which is great. So, for me, that means we're starting to meet our community needs, which is what this was all about. This wasn't about productivity. This wasn't about anything other than we weren't meeting our community needs and we weren't taking great care of our patients. And now we can go back, and we can look at the ACO Heat Map metrics. And we're one of the top performers now. Every time we get those scores, the team is figuring out what they can do better. So, it's created a very different environment and it's nice. It's a place that I'll say a few years ago, you walk down there, you kind of wanted to almost not be in there because it was really challenging. Now it's just a very it's a very different place, it's a nice space. They're doing a fantastic job and they've really helped; they drove this and led this effort.

Matt: We also did something I'll say, that was very helpful with the way we created our schedule. We work with the providers to develop templates that were based really on access that they wanted to meet. We looked at our growth in our budget, but then we added about 10% additional open appointments. So, we actually have open appointment availability every day for same day. We monitor this every day, and we know that if we're not going to fill this, we actually will go back to those health maintenance activities, and we will pull patients into those open slots. This has allowed us to kind of push on annual wellness visits or physicals or other type of visits because we have open slots. Those open slots are locked so we don't schedule into them at all except for the 48 hours beforehand.

Paul: Right. So, I wanted to talk about retention of MAs, physicians, etc. It sounds like the morale is high and the things are humming along. Has there been, have you experienced that kind of problem? I assume retention may have been more of an issue at the beginning than it is now.

Matt: Yeah, we just like everyone, we had a lot of challenges with turnover a few years ago and still in health care. It's still a challenge. And, you know, when we started this, we had seven MA openings and a fairly small practice realizing that we weren't going to go anywhere if we didn't have clinical staff. We work with the local community college, and we developed an MA program that we provided some funding for. We actually, our first class had eight. We hired all eight of them. Also, in the state of New Hampshire, we're able to use EMTs as MAs. So, we also work with a local program to develop an EMT program to develop some clinical staff and then internal training, a six-week internal training program so all MAs can level set. So that's helped. Our turnover, our first-year turnover rate for those positions in that office has definitely gone down and our long-term retention rate after our first year, is about 7%. So, it's very low right now, which is great. It's kind of what you want to see.

Paul: To your point, it's not that people are afraid of being busy, right? It's that they, that what gets people down, is not being able to meet patient needs, it sounds like.

Matt: Yeah, that was it. And I just met with one of our providers. I've known her a long time. She's from this community and prior to this was pretty unhappy. And like I said, a lot of people in health care were feeling that. She's one of the providers that went to three days a week. She works a weekend a month. Her productivity has increased 40% and she's happier than she's ever been. So, to your point, it's not that people don't want to be busy. They want to be busy doing the work of taking care of their patients. And in my discussion with Craig earlier today, there are still a lot of things I think, that people are doing that they probably don't need to be doing. Do they need to be done? Absolutely. It's just a matter of where; how do we offload to allow people to spend more time taking care of the patients and getting more patients through the door.

Paul: Talk to me a bit more about the patient outreach center. That sounds like one of the major tactics, right, for taking things out of the office that don't belong in the office. How did you manage to do that? I can hear other providers or administrators saying, oh, that's really nice that you did that, but we don't have the resources to do that kind of thing or...?

Matt: Yeah, we started that when we were seven FTEs short. We trained one of our PSRs and we actually also trained PSRs in MAS in every practice on campus. So, if they had downtime, say, in our surgical office, they were logging into this system and they were running through these lists. Now, we did this initially as a temporary measure. We're like, okay, we're going to offload this, and we'll figure it out. But it was working extremely well, so we dedicated some time to streamlining our process, creating dashboards for every area that we were looking at. But the other thing that we noticed is that the patients really liked it. Because what it did was say, you know, like I'm a great example. I'm over 50. I know I need to go for a colon cancer screening. I'm like, I have a schedule. I'm too busy even though I work in health care. But we were calling them and saying: Hey, listen, we looked you're really, we need to screen your colon cancer. We need to check your cholesterol. We need to do this. And people were really happy to get those calls and say, oh, wow, you're paying attention. You know, I don't have to remember to schedule a mammogram. You're actively looking. I don't have to remember to get my vaccine, because previously, if they didn't come in, if they were a relatively healthy person, like I don't go to the doctor every year, I don't need to. I may miss some of those things because they're not happening during a visit, because I'm not going. But this allows us to pull all those activities out.

Matt: Now, do they look at them when they go in the room? You bet. They make sure MAs still run the list. The providers run the list, but it's really, really dramatically helped. Now we have a dedicated person, and we have a lead MA, who really oversees it. So, we're really well aware and we've added a number of different things to that. The next thing that we're going to add is low dose lung cancer screening for smokers. We're just kind of waiting for some more, some more details in that because it's just it's some of this stuff is just too hard to do in the room and know that you're getting it done every time. So, it's been a big success. And in this practice, 11,500 patients, we have about an FTE and a half doing that.

Paul: Well, that's, you know, being able to proactively reach out to people when appropriate must make those patients feel like they're being better cared for, I would think.

Matt: It does, I say originally, and this is one of our mistakes, is that we were we were looking at the I'll say the categories. So, we go in and say, oh, cholesterol, and we call everyone for cholesterol, and then we go in and say colon cancer. So, we'd be calling the same person, like, five times. And so, we took that feedback and they're like, hey, we know you really want me in there, but do you have to call me five times? Now we've cross-walked all those conditions per patient, so we can call once, ideally, and say: hey, there's these three things that you really would benefit from. So that was just part of a learning process.

Paul: Right. And tell me about this other sort of radical step, which was getting rid of the phone tree. Right. That sort of came from an MA, which is fantastic that someone sort of on the front line can say, well, why don't we try this thing no one had ever thought of? I would think to that that others might balk at that like, well we couldn't possibly get rid of the phone tree.

Matt: When I did speak about this at the last big Medical Group meeting I was at, know these are things that work well for us. They may not. They're really big practices out there that clearly need a phone tree. But this worked for us for a number of reasons. We dedicated an operator per pod, right. So, the operator, the PSR, the RNs, the clinical team, the provider, the MA, they were all connected. And this created a larger, a larger team that they all owned their pod and their patients as a whole in that care team. Initially, this was really challenging. We had a big volume. We didn't know how many operators we would need. We actually brought in some of our clinical staff to answer phones. And over time, we actually were able to cut back on the FTEs for our operators. Looking at our last set of data, our call answer rate is 97%. The average speed of answer is 13 seconds. So in our previous we were talking minutes, it was over, it was over 5 minutes for someone to actually get to a person. Now, the operator will then say, what do you need? You need to schedule an appointment. You'll go to the PSR. The PSRs have a call rate at 95%, so they will handle that immediately. They're at 40 seconds. So you haven't even hit a minute yet and you've gotten to two people. But the thing I think that was the most helpful is previously you'd leave a message on the phone tree saying, hey, I'd like to talk to someone about this or I have a sore throat or and you'd go you'd get an in-basket message to a triage pool that would go to someone.

Matt: And now we've actually, all of our RNs in the practice all have access to the phone system at all rings to their phones. We've put up live monitors for the phone system in every pod so we can see when calls are coming in, how they're coming in. And if someone calls for a clinical question, it immediately will get from the operator to an RN. The RNs answer rate is a little bit lower than the PSRs because they're also seeing patients. But the goal for them is to answer that clinical question right then and there. If they can, at all costs. So that has changed things a lot. Oh, you need a prescription, let's do it. Instead of putting a message in that goes to another pool or goes to someone else or you're coming in, I'm going to triage you right now. So, changing the expectation that we're going to handle these when they come in and that that really improved things over the phone tree was just so challenging to, A) to navigate, but B) for the team to sort out what to do with all the messages and all the various areas. This streamlined things a lot.

Paul: Plus, just made patients upset from the get-go, probably.

Matt: Yeah. I mean, they just set them off, right? And I was one of them, right? I mean, all of them, I mean, I am someone.

Paul: So finally, Matt, do you have any, do you have a single word of advice to others who are going down this road trying to improve primary care access?

Matt: You know, I think of all the things we've talked about, the thing that mattered the most is being willing to listen, listen to the team. Think of them as partners, as decision makers, and not customers. Without them, this would never have happened. It really wouldn't have. I mean, I'm an ER doc. I have a good sense of operations, but me trying to sort out and tell them what should happen in their practice just wasn't going to happen. Really listening. And sometimes you're hearing frustrations, but most of those frustrations are about wanting to do the right thing. And over time, that's what came out of all of this: being willing to really listen and bring them in as part of the team to work on this.

Paul: Great. Well, thanks for taking the time to to tell us about what you're doing.

Matt: Yeah. You bet. Thank you.

Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Heather: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thank you for joining us. See you next time.

Mike: See you next time.