At AdvantageCare Physicians, a multidisciplinary practice providing specialty and primary care in the New York City and Long Island areas, a pilot study was done to see if a comprehensive care team around a specialist could improve quality of patient care, physician productivity and patient access. This was done by measuring the impact of care team implementation in cardiology practices on an array of performance indicators that reflect access, quality and productivity.
Training protocol
The Department of Cardiology implemented care team extenders, including medical assistants (MAs) and a cardiac procedure coordinator (CPC). Two MAs were trained to support the physician practice by prepping patients prior to the clinical workday via a clinician huddle. They were trained to provide reports to the clinician for a 15-minute decompression period at the end of the day prior to the following day clinic. During this huddle and decompression, missing tests and reports were identified as necessary to improving the clinical workflow. During the clinic day, the MAs would oversee obtaining vitals and EKGs, providing check-in forms and checking out the patient, including scheduling any follow-up visits and testing.
The CPC is a care team extender who facilitates pre- and post-operative processes and helps patients and providers coordinate procedures. CPCs are responsible for organizing pre-surgical testing, communications with external facilities and patient assistance as needed. They were trained to instruct patients and coordinate appointments, place and remove heart rhythm monitors, manage device-check schedules and follow-up appointments, and schedule echocardiograms and stress tests. No-show appointments or canceled appointments were appropriately documented by these extenders.
The study was a retrospective analysis of two cardiologists’ practices located in Long Island and Queens. Cardiologists were compared during two time periods: July to September 2015, prior to care team implementation, and July to September 2016, after care team implementation. Cardiology service line staff trained the care team extenders, and key performance indicators were assessed prior to and after implementation.
Of note, both practices did not have a nonphysician provider in place at the time of this study.
The key performance indicators for procedural and clinical volume were higher with a care team with respect to an increase in wRVUs and more echocardiograms completed.
Protocol implementation
Both cardiology practices were measured pre- and post-implementation of the care team with regard to productivity, quality, access and patient satisfaction. Metrics that were measured included Press Ganey, new consult to follow-up ratio, no-show rate and third next available appointment. Productivity was measured in terms of RVUs and the number of cardio-diagnostic studies that were performed, including echocardiograms. Press Ganey provided patient satisfaction survey management reports for integrated healthcare delivery systems to utilize and measure changes in the patient satisfaction and healthcare quality provided. The absolute number of initial consults is a performance measure and reflective of access provided to new patients. As a rule of thumb, the higher the number of consults, the more likely a significant proportion of a clinician’s time was being taken up with new patient appointments. Reducing unnecessary follow-ups was part of improving new patient capacity of the health service. The case mix was an important indicator and it should be noted that both new patients and follow-up patients were given 15-minute slots.
The no-show rate is also a performance indicator that was averaged from July to September 2016. Personal calls were made by the CPC, and an automated reminder service was utilized to improve patient visit compliance. The automated reminder service was provided prior to the care team extender intervention.
The third next available appointment is a performance indicator that is used to measure the delay patients experience in accessing providers for a scheduled appointment. It is often measured as the average length of time in days between the day a patient makes a request for an appointment with a physician and the third available appointment for a new patient visit or return visit examination. This quality indicator is a measure of access for patients and can be a surrogate to help identify where to preserve same-day access more effectively and to triage patients to the right appointment at the right time by decreasing the third next available appointment results.
Results
Providing care team extenders is a model of care for specialists that should be supported in accountable care organizations (ACOs) to improve provider performance and the quality of healthcare provided. AdvantageCare compared provider 1 and provider 2 patient visits from July to September 2015 and July to September 2016. The visit volume and the number of echocardiograms were measures of productivity from a clinical and procedural volume standpoint.
Provider 1 performed 174 visits prior to the extended team and 351 patients after implementation, a 102% increase. Provider 1 also completed 85 echocardiograms prior to care team implementation and 135 echocardiograms post-implementation, a 59% increase.
Provider 2 performed 280 visits prior to the extended team and 364 patients thereafter, a 30% increase. Provider 2 completed 120 echocardiograms prior to care team implementation and 174 echocardiograms thereafter, a 45% increase.
The number of new consults was also assessed as a marker of increased access to the cardiology practice. Provider 1 completed 237 new consults in July to September 2015 and 268 in July to September 2016, representing a 13% increase in new patient access.
Provider 2 completed 303 new consults in July to September 2015 and 355 in July to September 2016, a 17% increase. The two providers together averaged a 15% increase in new patient access.
The work RVUs (wRVUs) were surrogates for combined clinical and procedural volume. The procedural volume reflected was more comprehensive, including event monitors, Holter monitors, stress echocardiograms, electrocardiograms and plain treadmill stress tests. The average of three months from July to September 2015 and July to September 2016 were reported. This measure of productivity showed provider 1 increased by 265.7 wRVUs over a three-month period. This can be annualized to an increase of 1,062.80 wRVUs. This reflected a 13% increase for provider 1. Provider 2 showed an increase of 418.43 wRVUs over a three-month period, which can be annualized to an increase of 1,674 wRVUs. This reflected a 15% increase for provider 2.
The no-show rate for provider 1 from July to September 2016 was 6%, while the no-show rate for provider 2 from July to September 2016 was less than 1%.
The third next available appointment was compared from August 2015 to July 2016 as a performance indicator about access. Provider 1 went from 24 days to four, an 83% improvement. Provider 2 went from 37 days to 20, a 46% improvement in access.
Patient satisfaction needed to be assessed to ensure that despite an increase in patient and procedural volume, the quality of care was not significantly affected. The absolute values for providers 1 and 2 were recorded for May 2016. Study limitations did not allow for access to 2015 Press Ganey data for comparison. Provider 1 scored 100 for “care received during visit,” 87.5 for “likelihood of recommending care provider,” 81.30 for “likelihood of recommending practice” and 91.70 for “wait time at clinic.” Responses for provider 2 in the same categories were 100, 100, 100 and 87.50, respectively. These reflect high qualities of care and satisfaction for both providers with higher volumes and care team support.
Conclusion
In a Patient-Centered Medical Home setting, implementation of a specialty-specific cardiology care team support structure improved efficiency, access, quality and productivity in a multispecialty integrated healthcare delivery model.
The key performance indicators for procedural and clinical volume were higher with a care team with respect to an increase in wRVUs and more echocardiograms completed. Enhanced productivity was also evidenced by an increase in visit volume. Patient access was notably improved with an increase in the number of new consults and a reduction in the number of third next available appointments.
During this pilot study, while an improvement was evident in the productivity and access, there was no loss of quality evidenced by Press Ganey scores. Our cardiology care team model showed an improvement in quantity and quality of healthcare for an ACO.
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