Episode 55: Memorial Hospital Improves Primary Care Access

Mike: This is BACON, brief news from the MaineHealth Accountable Care Organization. A 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: So, Heather, in this episode, as we wind down this year, we decided that we would revisit one of the most popular interviews we did this year. That discussion we did with Dr. Matt Dunn about a successful project at Memorial Hospital in North Conway to increase primary care access.

Heather: Back in February, when we recorded this, Matt was the CMO at Memorial. He is now the CMO for MaineHealth's Mountain Region.

Mike: That's right. So let's have a listen.

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 is 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, where were you, how was access and what was the situation?

Matt: Yeah, sure, Paul. Thanks for having me on. This was the summer fall of 2020. You know, we had been hearing both from our or 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 were issues, mostly issues about getting in and getting follow up. So, we all kind of took a pause and said, we really need to look at this holistically. So, at that time we had about we're a small rural health clinic here at Memorial Hospital and our primary care practice at about 10,000 patients. We had really significant issues getting our patients in. Our time to get new patients in was was approaching nine months. All the traditional access metrics were, I'll say, they were very bad. You know, 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's 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 some like a baseline, like how big was the practice? How many how many providers? How many patients do you think you were seeing? And a little bit about the community, the North Conway community there. Yeah.

Matt: So we're based out of North Conway, 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. 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 you know, fiscal year 23, last year, we hit 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've just hired another primary care physician, three more APPs, and next year I'm recruiting for an additional 1.6 physicians. And you know, 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, ancillary services.

Matt: 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. 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 2 to 300. So it was a pretty big survey. We had a really great response. And, you know, 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. We weren't messaging them back using MyChart and that we had issues fulfilling patient prescriptions. It would take us sometimes, you know, a week when someone requested a refill just to get that through. We also looked at our ED utilization for low acuity patients, 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 within 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, you know, it's I'll say it, it's 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 do 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, 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. 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? Like 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 we made the decision to get rid of the phone tree. And if you call in now, you'll get a you'll get a message that says if you want to leave a prescription, press this number.

Matt: Otherwise you actually go to a live operator. It went to all live operators and our phone answer rates, since we've done that, have been above 95%. And our our goal now our goal is about 98%. And we hit that almost every month. So that was an example of really, you know, having the whole team being able to give us ideas, ideas that we may not think about. 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 arrived 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 is and 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. So, we've done everything we can to take most of those activities out of the visit. So, we developed what we call a patient outreach center, where we actively use Epic to data mine for health maintenance activities.

Matt: So 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%. The other two areas that that are related, I mentioned patients saying I'm not getting my prescription, and providers saying we're not giving our prescriptions, and no one's really messaging me back in MyChart or 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 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, so we went from an activation rate of 55 or at 87% now. So we're close to the top decile in all of Epic.

Matt: And even though we signed up more patients for MyChart, our overall MyChart utilization in terms of messages has gone down because we've reduced the amount of internal messages we're creating. So 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 this fall of 2020. And people thought that was crazy. But we continued to work on it and has become the standard. The other part of what we've done is when we're looking at all these 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. And this is 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. And I'll say one of the things that we we did, and I know I discussed this in one of the other podcasts I was on, is we expanded our hours of operation. So we were a very traditional clinic Monday through Friday, 830 to 430, which is work hours for everyone. You know, in our community, our average unemployment rate is below 2%. So everyone had to take time off from work to come here, which was not popular.

Matt: So we went to ten hour days Monday through Friday, and we opened half days on weekends. And 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. So, we have providers that are working three long days and some weekends, some that are working four days. And this is allowed us to be flexible in our staffing as well as to continue to kind of push our access. 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 health care is really busy. We're all doing a lot of things, and as soon as you kind of look away and put your focus towards something else, inertia sets in and things start to slowly break apart. So this is why we continue to meet every month. We continue to look at our metrics, adding new metrics. So when when we started the formation of the partnership with agilion, all the HCC 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, agilion 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. So this is 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. 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. Um, so it's just, I think for us being, you know, continually willing to, to look at this and we're trying to expand it, you know, across all of our practices. And, you know, we didn't have quite the same access issues in our, 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. So we're which is which is great. So for me that means we're starting to meet our community needs, which is what this was all about. This this wasn't about productivity. This 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 Heat Map metrics. And, and we're one of the top performers now.

Matt: And every time we get those scores, the team is figuring out what they can do better. So it's it's created a very different environment. And it's nice that 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 it was really challenging. And now it's, it's it's just a very it's a very different place. And it's a nice it's a nice space. They're doing a fantastic job and they've really helped. You know, 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 and that we work with the providers to develop templates that were based really on access that they wanted to meet. And we looked at our growth and our budget, but then we added about 10% additional open appointments. So we actually have open appointment availability every day for same-day. So and 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 in to those open slots. So this has allowed us to kind of push on annual wellness visits or physicals or other type of visits, because we have open slots and those those open slots are locked. So we don't we don't schedule into them at all except for the 48 hours beforehand.

Paul: Right. So I wonder too about retention of MAs, physicians, Et cetera. It sounds like, you know, the morale is high and the things are humming along. I mean, has there been have you experienced that kind of problem? I assume retention may have been more more of an issue at the beginning than it is now.

Matt: Yeah. We just like everyone we we had a lot of challenges with turnover a few years ago, you know, and still in health care, it's still a challenge. And you know, when we started this, we had seven MA openings in a fairly small practice, realizing that we weren't going to go anywhere if we didn't have clinical staff. We worked 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 were 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 could level-set. So that's helped. Our turnover, our first-year turnover rate for those positions in that office is definitely gone down. And our our long term retention rates are after our first year is about 7%. So it's very it's very low right now which is 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 you know, that was it and just met with, you know, one of our providers. I've known her a long time. She's from this community and prior to this was pretty unhappy, you know, challenging. Like I said, a lot of people in health care were feeling that. And 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's still a lot of things, I think, that people are doing that they probably don't need to be doing because 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: Well, talk to me a little 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 how did you manage to do that? I could just I can hear other providers or administrators saying, oh, that's really nice that you did that. But like, 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, we trained one of our PSRs, and we actually also trained PSR and 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, and I'm a great, great example. Like I'm over 50, I know I need to go for a colon cancer screening. I'm like, I'm not going to schedule. Like 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 you for colon cancer. We need to check your cholesterol. We need to do this. And and people were really happy to get those calls and say, wow, you're paying attention. You know, don't have to remember to schedule a mammogram. You're actively looking don't have to remember to get my vaccine because previously, if they didn't come in, if they were, you know, relatively healthy person, like, don't go to the doctor every year.

Matt: I don't need to. I may miss some of those things because they're not happening during a visit because I don't I'm not going. But this allows us to pull all those activities out. Now, do they look at them when they go in the room? You bet. They make sure we're still the run the list, the providers run the list. But it's really, really dramatically helped. And now we have 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, you know, 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 it's been a big success. And this practice, you know, 11, 11,500 patients we have about an FTE hour 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 say originally, and this is one of our mistakes, is that we were we were looking at the, the I'll say the categories. So we'd go in and say, oh, a cholesterol and we call everyone for cholesterol. And then we'd go in and say colon cancer. So we be calling the same person like five times. Um, 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 crosswalked 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. Um, so that was just part of a learning process. But yeah.

Paul: Right. And tell me about this other sort of radical step which was getting rid of the phone tree. Right. That that sort of was, came out 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, too, that that others might balk at that, like, well, we couldn't possibly get rid of the phone tree.

Matt: When I did kind of speak about this at the last big Medical Group meeting was at, you know, these are things that work well for us. They may not like 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, you know, an operator per pod. Right. So the operator, the PSR, the RN, clinical team, the provider, the MA, they were all connected. Um, and this created a larger, a larger team that all owned their pod and their patients as a whole. And that care team, um, initially this was really challenging, right? 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. I'm 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 five minutes for someone to actually get to a person. Now the operator will then say, you know, what do you need? You need to schedule an appointment. You'll go to the PSR. The PSR is have a call answer rate at 95%. So they will handle that immediately. They're at 40s. 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 poll 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. It 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 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. Um, oh, you need a prescription, let's do it. Instead of putting a message in that goes to another pool that goes to someone else, or you're coming in, I'm going to triage you right now. Um, 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. So this, this streamline things a lot.

Paul: Plus just made patients upset from the get go. Probably. Yeah.

Matt: Mean just set them off right and was, I mean lot of them.

Paul: So finally, Matt do you have any you know 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, think of all the things we've talked about. The thing that that matter 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 happened. I mean, I'm an ER doc. I have a, you know, 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, um, 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. So 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.

Heather: 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 would love to hear from you. Please email us at bacon@mainehealth.org. That's Bacon@mainehealth.org.

Mike: Bacon is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. See you next time.

Heather: See you next time.