Open Access Appointing in Army Primary Care Clinics

Military Medicine, May 2005 by Aiello, Kimberlee

The open access model, also referred to as advanced or sameday appointments, is a new concept in managing patient appointments. More than 70% of the Army's primary care clinics currently use an antiquated system that inherently provides for a delay of medical services and lacks continuity of care. Although many providers and administrators believe delay and the lack of continuity of care are associated with a lack of resources, many studies prove otherwise. Open access is predicated on the principal that providers do today's work today. Patients calling to schedule an appointment with their provider are offered a same-day appointment. To achieve this, clinic chiefs and administrators must conduct an in-depth analysis of their true demand and current resources. Clinic staffs who have a strong commitment to change will be able to convert to an open access model whereby they are able to increase patient and provider satisfaction.

Introduction

Have you ever called to make a doctor's appointment only to be told to call back in 1 week when the clinic had open appointments or your appointment was scheduled for 5 weeks out? Maybe you attempted to "sell" your medical problem to the scheduler so you could be seen immediately. Imagine calling your primary care clinic and being asked, "Can you come in today?" This initiative, referred to as open access, advanced access, or a same-day appointment, is the modernized version of the U.S. Army's primary care appointment management system. Currently, only 40% of the Army's primary care clinics offer open access to its beneficiaries as noted by MG Farmer, Deputy Surgeon General of the Army, in a memorandum dated June 23, 2003. The Army's method of booking primary care appointments is moving toward open access and MG Farmer established a goal of another 20% of clinics booking appointments using the open access model.

Health care scholars define open access many different ways. The emerging definition is "the ability of a patient to seek and receive primary care with the provider of choice at the time the patient chooses."1 The two critical elements of open access are the patient's ability to choose his provider and the appointment time. Placing this definition in the context of Army primary care clinics, open access refers to "the concept of providing a same day appointment to military managed care priority beneficiaries regardless of the type of [medical] complaint."2 Open access should not be confused with walk-in appointments or sick-call, which are still common in the Army's health care system. This methodology of making an appointment, by using open access, is a philosophy change that allows the patient (demand) rather than the appointment schedule (supply) to be the determining factor of when the patient receives care.3 Simply put, open access is predicated on "doing today's work today."

Open access is similar to the basic tenants of economics: supply and demand. COL Robert Larsen, the spearhead of open access in Europe, claims, "access is the outcome of balancing supply and demand." Dr. Mark Murray, the founder of open access, explains that patients serve as the demand function, whereas the clinic serves as the supply function or capacity, based on the number and type of providers available on any given day.4 The variability between supply and demand leads to the delay from the time a patient calls for an appointment to the delivery of patient services. However, supply and demand ultimately reaches equilibrium, therefore the delay in appointments becomes consistent.4 Open access tests the current system's need to have a built-in delay of appointments. Dr. Murray and COL Larson contend that facilities resourced appropriately, that use an open access model, can absorb the variability of demand on a daily basis rather than having the patient absorb this through the delay for an appointment.4,5 By providers doing today's work today, the patient is able to see his provider on the day he calls with a problem.

This article examines the concept, analysis, and implementation stages of an open access model in Army primary care clinics. The model enables the patients, not an appointment type, to define the need for care while allowing providers to focus on their empaneled patients as opposed to an appointment schedule. Each day, private sector health maintenance organizations are using innovative processes to entice employers to choose their health care plan while continuing to decrease use and increase continuity of care. To stay competitive, military primary care clinics must focus on providing high quality care with increased access as defined by our beneficiaries.

Background

There was a time when people viewed long waits to see a provider as an indication of the provider's status and competence within a community.5 When patients began to complain, providers rarely made modifications to their business practices.5 Not until the early 1990s, when the U.S. health care delivery system underwent changes as part of the transition to managed care, did organizations make attempts to modify their appointment systems.5 Health care organizations tried to integrate the basic tenants of managed care: cost, quality, and access. Primary care clinics, such as Kaiser Permanente, under the leadership of Dr. Murray, realized that to meet the tenants of cost, quality, and access, the access system must incorporate continuity, the ability to ensure the patient is seen by the same provider, and capacity, availability on the provider's schedule.5 This continuity ensures that the provider is completely knowledgeable of all of the patient's medical issues and is therefore better prepared to address them appropriately.