Placing the pieces
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Managing follow-up appointments, acute care, and extender use can lead to a more efficient practice schedule

Despite all the changes in health care over the previous decade, access to care remains at or near the top of the most important issues faced by dermatologists today. The American Academy of Dermatology and other physician and patient organizations have reported growing wait times for patients even with acute problems. Taking a closer look at scheduling, according to practice managers and physicians who have tried to address the issue, can help a practice allocate appointment slots more efficiently and extend access to more new and acute patients.

Finding time

Massachusetts General Hospital dermatologist Alexa Boer Kimball, MD, MPH, found that her clinic was experiencing issues of access. While she had no problem hiring physicians, her clinic had reached its staff capacity for the space it had. With this scenario, the clinic found itself with a months-long waiting period for new patients and extra difficulty accommodating acute care patients.

“We were struggling with long wait times for patients, and there were two important issues. One, there were long wait times for routine appointments, but there were also not obvious ways for patients with acute needs to get in,” Dr. Kimball said. “They were being squeezed in, but there wasn’t a regular way to manage that. We needed to tackle both of those problems at once.”

Once Dr. Kimball and the rest of a task force convened to tackle the issue delved into it, they found that the biggest factor to be addressed was the frequency and volume of follow-up visits.

“When we started to do some analysis of how our clinics were set up, there were some substantial surprises for me. The first was that the proportion of patients who, once they converted to being follow-up patients, remained our follow-up patients was very high — about 85 percent over a three-year period. The other thing that was interesting to me was that although the queue to see us was quite long in terms of number of patients, when you compared it to the actual volume of patients we could see in any given week, it wasn’t an overwhelming amount,” Dr. Kimball said. “It meant that our clinics were being clogged with follow-up visits, and that the biggest lever to open up appointments without adding additional staff or other options was to figure out how to change how we were managing our follow-ups in order to open up appointments for new patients or patients with acute needs.”

The findings, she said, informed what she perceived as the best approach to opening these new appointments — re-thinking the follow-up scheduling system.

“Most of us determine our follow-up assignments based on what we were taught, some sort of gestalt, and habit,” Dr. Kimball said. “Being more thoughtful about how we thought about this issue was one of the key strategies we used.” [pagebreak]

Scheduling follow-ups

Dr. Kimball and her colleagues recommended slightly extending the time between follow-up appointments for a number of non-urgent issues. The current body of evidence, she said, supports the thinking that the follow-up system may be adjustable, and that it’s important for physicians and administrators to recognize that a too-high proportion of unnecessary follow-ups causes problems for new and acute patients and the physicians who need to keep up with this increased demand.

“When we started to think about the evidence base on follow-up intervals, we found that with the possible exception of melanoma, there was essentially no evidence base on the appropriate time frame to see a patient. So I think that it’s a plausible argument that whether you see an acne patient three times a year or four times a year, it’s unlikely to have a significant impact on the outcome,” Dr. Kimball said. “We ultimately want to test this in an evidence-based way but that was the assumption going in. And if that’s the case, and you can see them once less per year, and acne is a common visit, if you change that pattern of follow ups, you can make substantially more appointments available.”

Pamela Matheny, a board member for the Association of Dermatology Administrators and Managers and the administrator for the University of Missouri Medical School department of dermatology, said that her clinic does its best to plan for a balanced proportion of new patients with follow-up visits, though their acute care is handled by overbooking.

“All of our people have the same master schedule of 10 and 20 minute appointment increments for returning and new patients. We have a 14 percent no-show rate, and we do overbook for urgent cases,” Matheny said. “Patients have learned that they should call when there’s an urgent case. Our physicians work very hard, but this way we can accommodate the referral base in Columbia. We don’t turn down new patients. We try to get them in, because we know they are crucial to the practice. It’s a little more challenging for the doctors, but it’s necessary,” she said, noting that Columbia provides the majority of access to dermatologic care for the 16 surrounding counties.[pagebreak]

Employing extenders

In addition to engineering a more efficient follow-up system, a number of practices are using non-physician clinicians to relieve the follow-up responsibilities on dermatologists. Matheny said that using physician assistants (PAs) and nurse practitioners (NPs) to address established patients with stable issues allows her department to make the most of its limited physician resources.

“Our NP sees simple follow-ups for acne, warts, and other simple problems. She also does biopsies, which frees up the physicians to see another patient. It’s difficult to recruit to academics, so we handled access by adding an NP to our practice,” Matheny said. “We have an open schedule for her,” she said, meaning the practice only schedules the NP two weeks in advance. This ensures that the practice can always offer patients who need or want to be seen sooner than a physician’s schedule allows the option of being seen by the NP. “We also use her schedule for urgent patients that can’t be overbooked,” she said. “It’s really helped access.”

Melinda Lomax, practice manager for the Dermatology Center of Atlanta, a three-physican practice in Johns Creek, Ga., also uses the NP in her practice to ease the load of simple follow-up patients on the physicians in her practice.

“It’s not unusual for acne and warts to be followed up by the midlevel. We usually do that. I’ve got one physician in the practice who will send pretty much all of her follow-up warts and most follow-up acnes to our nurse practitioner, because that’s what she excels in,” Lomax said. “She sees almost any of the problems that come in, within reason. She has a good aptitude for follow-up patients. She’ll see rechecks for warts and acne pretty easily, and sometimes her schedule isn’t quite as full, and she’ll be able to see same-day appointments, which is what we really like. If we can get them in the door today for something she can deal with, that’s a big advantage.”

Dermatologist Christen Mowad, MD, who practices at the Geisinger Medical Center in Danville, Pa., takes a similar tack, and finds that simply being told they’ll be seeing an extender before they show up to the office eases most patients into the idea.

“Most objections can be nipped in the bud if the patient is told when they’re being scheduled that they’re going to be scheduled with a non-physician clinician or a resident,” Dr. Mowad said. “You can prevent potential dissatisfaction when the scheduling occurs by letting the patient know exactly how their visit will be conducted.”

Dr. Kimball agreed with the use of extenders after the physician has established a diagnosis and the patient has a relationship with the practice. This, she said, seems on its face to offer a more efficient use of non-physician clinicians than other models of extender scheduling.

“I think we ought to put the dermatologists up front to see most of the new patients. It’s important to have the derm establish the diagnosis, make sure there’s not a rare thing that needs to be managed differently, then assign routine follow-up to people to manage. The physician can see the bulk of the new patients, and the more challenging ones,” Dr. Kimball said. “I tend to not like the other model, to use the PAs and NPs as triaging. You ultimately may create more work that way, because there may be several appointments in between figuring out how they need to be triaged. You might have a higher likelihood of success by establishing the diagnosis and handing it to the team to manage. This is something definitely worth testing.”

In addition to extenders, many teaching hospitals employ residents assigned to attending physicians for acute care cases that go beyond the scope of non-physician clinicians. At Geisinger, Dr. Mowad’s department assigns a resident every day to cover acute care cases. This resident is paired with one of several rotating physicians whose job it is to supervise the resident’s acute care visits. This too, Dr. Mowad said, can require some patient education at the outset.

“We block a resident’s schedule for urgent care every day. That resident is then staffed by one of the physicians on a rotating basis,” Dr. Mowad said. “What we encounter with some frequency is a patient wanting to know why they’re being seen by a resident and not, quote, a real doctor.’ It’s a teaching moment to let them know that they’re indeed licensed physicians going through a teaching program.” [pagebreak]

Communicating with patients

While less-frequent follow-up appointments might elicit some doubts from patients, Dr. Kimball has found that patients don’t react to the interval between their appointments as much as whether they leave with one scheduled.

“For the routine acne or other problems, patients don’t really tend to recognize the difference I don’t get any questions. Where you do see some shifting views, which aren’t worth fighting about, is when you say to someone you don’t need to come in every year how about 18 months?’ And they comment back that they would like to be seen in 12.” But sometimes the reason they wanted their follow-up within a year is because they were worried they would not get back in. “We’ve actually adjusted our schedule to be able to take 18-month follow-up appointments as a result of this,” Dr. Kimball said. “They want to leave the office with an appointment an 18-month appointment solves that problem for them.”

Some may worry that patients would be less willing to see physician extenders for follow-up appointments, but both Lomax and Matheny have encountered little to no resistance to their tactic of scheduling simple follow-ups for their NPs.

“If they need to be seen, they usually don’t care who is going to be seeing them as long as I can get them in the same day,” Lomax said. “The way we tell them is Dr. Gray would certainly see you, but her next available time for this problem’s going to be next month. Our nurse practitioner could see you tomorrow.’ Usually, that works out.”

For patients who remain resistant to the idea of fewer visits, Dr. Kimball advised adjusting to their unique needs. Not every patient can be, or necessarily needs to be, convinced.

“When I say I don’t think I need to see a patient every year, most of them are relieved. But there is the occasional patient who says no, I really would rather see you every year,’ and I say okay,” Dr. Kimball said. “If I can shift 80 percent of people into longer intervals that I think are medically appropriate, I can have a lot of impact on the schedule.”

Operational model of outpatient scheduling

Boston dermatologist Alexa Boer Kimball, MD, MPH, outlined the following model of outpatient scheduling in a May 2011 paper for Practical Dermatology along with co-authors Anne James Goldsberry, MD, MBA, and Patricia M. Sullivan. It was conceived following collection of data on 2,428 patient visits to Massachusetts General Hospital’s department of dermatology during 2005, 2007, and 2008, with the latter accounting for the majority of the data.

Dr. Kimball’s operational model demonstrates the ratio of new patients to existing follow-up patients during a given time period. At its base are two key equations — one for practice capacity and one for a steady practice state, defined as a state where the parameters remained fixed over time, including a consistent established patient pool.

C = Capacity

EP = Established patient

EPAR = Established patient appointment rate

EPER = Established patient exit rate

NP = New patients

NPER = New patient exit rate

Capacity equation: C = EP x EPAR + NP

Steady state equation: EP = EP (1 EPER) + NP (1 NPER)]

Using these equations, it is possible to calculate the proportion of new patient appointments to established patients necessary to achieve a steady state, allowing a practice to determine how many new patients it can accommodate by altering the rate at which it schedules follow-ups for established patients.

New patient week

At Massachusetts General Hospital, Alexa Kimball, MD, MPH, and her colleagues routinely face long patient waiting lists, a problem common in dermatology practices across the country. Dr. Kimball proposes a novel solution.

“The concept here is that my queue, which is five-and-a-half months long, is only essentially equivalent to a volume of five weeks of patients or less. So let’s say that we had roughly 3,000 patients in our queue, but were seeing about 800 patients a week. If you could convert a large number of patients in any given week into new patient appointments, you could actually make a substantial impact,” Dr. Kimball said. So, she said, about once a quarter any remaining empty appointment slots in the next two or three months are assigned to new patients. “Other clinics have managed the problem by adding in extra sessions to see their new patients, but what we like about this approach is that you can integrate it into practice without having to add anything additional.”



Operational model of outpatient scheduling
New patient week