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PAs Team with NPs & RNs to Improve Veterans' Access to Care

Gastroenterology department succeeds in providing access to care within 7 days.

In June 2015, with "new patient consults" being scheduled 60 to 90 days out, the gastroenterology (GI) department of the Edward Hines Jr. VA Hospital set out to improve military veterans' access to clinical care. Our goal was to move toward achieving 30-day access to care for our nation's military veterans.

The GI clinic has open access scheduling, which means that any primary or specialty healthcare provider can initiate a new clinic consult by having their clerks schedule the patient to be seen in the clinic. 

At that time, there were 268 new GI clinic consults pending resolution: 146 of them (54%) were scheduled already; 104 of them (39%) still needed to be scheduled; and 18 of them (7%) required a signature on the final report before they could be considered completed.

Adding Clinic Hours Helps
In June 2015, the clinic was only open for one-half day each week, on Friday afternoons. It was staffed with one GI attending, four GI Fellows, one nurse practitioner, two nurses and two front desk clerks.

The department established six goals:

1.  rapid access into the GI specialty clinic;

2.  priority scheduling for urgent diagnostic evaluations;

3.  matching patient needs to appropriate services;

4.  developing a consult management plan;

5.  utilizing staff to their highest level of competency; and

6.  consult status reporting accuracy.

The process of achieving rapid access into the GI specialty clinic started with hiring a new GI nurse practitioner, as allowed by the Veterans Access Choice and Accountability Act of 2014.

Hiring the new NP allowed us to add a new clinic session, with six additional appointment times, on a different day.

On the new day, the clinic would also be staffed by an existing attending physician and a physician assistant.

Adding a new clinic session increased access to care for veterans traveling long distances and for those using VA transportation with fixed departure times.

Reprioritizing Patient Visits
Our second goal (priority scheduling for the most urgent diagnostic evaluations) was foremost in our minds as we began to schedule patients for appointments on the new clinic day.

We utilized the highest level of competency of our staff members by allowing the PA and NP to triage consults. The RNs were also authorized to prioritize scheduling of consults (either before or after the patient had been scheduled in our open-access system). In addition, the clerks were given the authority to discontinue consults if the patient declined the visit or stated that they preferred to see a private provider outside the VA system.

Consult Management Is Vital
The creation of a standard consult management plan played a major role in solving the current backlog and preventing future access limitations. The main points of the management plan included:

•  a daily review of new consults;

•  expedited scheduling based on clinical need;

•  identifying "special needs" consults, and arranging access to care outside of the normally established clinic hours;

•  recommending direct scheduling for procedures (as needed), instead of having an initial clinic visit and then scheduling for a procedure;

•  establishing the "GI E-consult" (answering clinical questions and recommending treatment without the need for a clinic visit);

•  conducting focused clerical reviews before initiating patient scheduling;

•  conducting "end-of-clinic" reviews, which identified no-shows, reviewed patients' ongoing needs and expedited rescheduling as needed;

•  establishing weekly "consult report reviews," to ensure that consults were connected to completed visits and were signed off on in a timely manner; and

•  making sure patients are referred back to their primary care providers if the patient declined to schedule a consult or had multiple "no shows."

To start the process, our PA, NP and RNs reviewed all of the 250 pending consults and "re-triaged" them.

Those with the most urgent diagnostic evaluations that were already scheduled but involved more than a 30 to 60 days wait time were moved into the open appointment slots. By moving a segment of routine follow-up appointments to the new day of clinic access, the patient load for Friday's half-day GI fellow clinic (which was a teaching clinic) was reduced. In turn, this teaching clinic became less congested and more efficient, allowing the fellows to better care for patients with more complicated cases.

This consult management plan then became the foundation of keeping the weekly "consult report review" accurate. The report no longer included: consults that patients did not want or keep; appointments that were scheduled not connected to a consult; or patients who had already been seen but whose reports were not completed with the appropriate signatures.

Once the patients who needed to be seen were identified, a new baseline for workload identification was established and the productivity flow improved.

Walk-Ins and E-Consults Provide Flexibility
To provide maximum flexibility for patient access, the department also established a GI walk-in clinic. Select consults were identified and re-scheduled for those veterans who had transportation or scheduling conflicts.

The GI E-consult is an e-mail based program that allows veterans to ask clinical questions of our staff members, and receive an electronic reply that answers the clinical question and recommends a courses of action for the patient without the need for a clinic visit.

As a result of these two initiatives, veterans no longer experienced such long wait times, and we eliminated the need for so many referrals to non-VA community providers.

As the backlog was reduced, the staff began to review each new incoming consult to ensure that every patient's needs were met with the proper resources. Another redirection tactic we employed was to schedule the veteran for the appropriate GI procedure instead of a bringing the veteran in for a clinic visit.

To give an example, for a one-month period (January 4 to February 4), 34% of the 83 scheduled consults were redirected into directly scheduled procedures by the referring providers. This step in consult management is critical to maintaining rapid and appropriate veteran access to care.

Teamwork Led to Success
In addition to the careful planning that went into overhauling the GI department's workflow, the main reason for success was that each team member identified their role in the consult management plan, and actively participated in the efforts to optimize the veteran's access to the GI clinic.

This may seem obvious and simple, but keep in mind that the RNs and clerks for the GI clinic were also staffing multiple other specialty clinics throughout the week --- giving them limited ability and time to support the GI clinic.

With this in mind, they designated specific time periods to complete certain tasks. The clerk identified those who needed to get scheduled, and either called the veterans or mailed letters to those they were unable to reach by phone.

The clerks also teamed up with the RNs to actively contact patients to offer them earlier appointments. Frequent communication with the GI providers made this a smooth scheduling transition for the patients.

Once this was done, both the RNs and clerks continued to conduct frequent reviews of upcoming appointments to ensure their appropriateness and timeliness. If a scheduling error was found, the appointment slot was opened up for a new pending priority evaluation. Until the backlog was cleared, this involved approximately 3 to 5 appointment slots each week.

Exceeding Our Goal
After 7 months of overhauling our workflow processes, we are pleased to report that military veterans in Hines, Illinois are experiencing rapid access to care at the Edward Hines Jr. VA Hospital's GI clinic.

By Feb. 1, 2016, only 81 consults were pending resolution --- we had achieved a 70% reduction. By February 5, only 5 (3%) of the consults needed to be scheduled, and there were 20 available appointments within the upcoming 30-day period.

Our consult status reports help clinic staff members identify our workload, which helps with staffing and resource allocation. Review and triage of all new consults entered into the open scheduling system delivered a 34% reduction in the number of consults that needed to be scheduled into the clinic --- an instant improvement allowing veterans easier access to care.

Our backlog was resolved. New incoming patient consults are being scheduled (and the patients are being seen) in a timely manner, and the paperwork for completed consults is being signed within a few days of the visit.

Toward the end of February, we discussed and implemented a proposal to reserve 3 Friday appointments for priority consults. With this proposal, the Edward Hines Jr. VA Hospital GI clinic successfully achieved access to clinical care for veterans within a 7-day time period --- thereby surpassing our original goal of 30-day access to care.

Thomas H. Hansen, Navy veteran and physician assistant, is the colorectal cancer coordinator for the gastroenterology department at the Edward Hines Jr. VA Hospital in Hines, IL.

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