Castro Mission Health Center’s (CMHC) solution to access issues, after a lot of research by their management team, was to restructure their schedule to allow for same day appointments.  Although their system does not solve all access problems, CMHC views it as a vast improvement for patients and for providers, compared to how things were functioning before.  “Everyone means something different when they use the term open access, and it is important to adapt the concept to your own site”, says Dr. Jane Bailowitz, Medical Director at CMHC.  She describes her experience with open access below. 

Q: Why did you start open access scheduling?
A: In 2002, we were concerned about high no show rates and not enough availability for urgent care needs.  We read articles from Kaiser and spent a day at a site that was attempting open access scheduling – Bellevue, New York – and learned from their experience.  We didn’t work down the backlog.  We just started with a 50/50 split of open appointments and pre-booked appointments.  We allow a 36-hour window for scheduling the appointments, to allow enough access for people who need to be seen.  They always get filled.  Some providers have almost 100% open access scheduling because they have a large number of nonliterate patients, who would no-show if booked in advance.

Q: What challenges do you have?
A: It is still a struggle to ensure that patients see their own primary care provider.  The patients have to call early, or the appointments will fill.  We put flags on people who miss appointments frequently, and they are only allowed to schedule same-day appointments. 

We still have trouble with phone access – it sometimes is more work for patients to get through on the phones, and some patients do come in physically to schedule the appointments.

We don’t offer open access to new patients – when we allowed new patients access to the same day schedule, we got too many people requesting controlled substances.  So we control the number of new patients who can be scheduled on any given shift.

It is very important to have an adequate phone system.  Our old phone system did not allow queuing, so it would not have worked.  Our new phone system allows us to answer in the order the patients call.

Q: What do you think of the argument “but how do you make sure your patients come back”?
A: Future appointments are a terrible tracking tool.  If you schedule appointments just to make sure that you review the chart in three months if a patient doesn’t show, it means you have created more work for the staff, and you have created a disorganized schedule with a high no show rate.  We use cohort lists as a tracking tool, so you can tell your patient to call in October for an appointment, and give them a card to remind them, and track them if you are worried they will not show up.  The other way to track is to only give them enough refills to last until you want to see them again.  When we get the fax from the pharmacy, we can assess whether or not the patient needs to be seen.

Q: How is it working now?
A: I think it is working well, and it is easier for patients to get in to see their own provider.  We have simplified the scheduling template, so we only have four appointment types – youth clinic new appointments, new patients, returns, and “open access” which are blocked and only scheduled within 36 hours.    A few patients find it frustrating, but the majority of the patients are happy with the new system.  The providers are happy as well because we have improved continuity, and the day goes more smoothly since there are not as many no shows, or as many last minute fit-ins.

Our no show rate used to be 35%, and now it is 17% overall, and 22% for primary care.

Q: What type of training is required?
A: We did a lot of training for phone staff.  In the old system, they would spend a lot of time negotiating with patients; we had to train them to do no triage – just give the appointment; the patient doesn’t have to prove they need it.   If we run out of appointments, we offer them the chance to speak with the nurse.    We also worked closely with our providers to make sure everyone was on board.

Q: Is there a down-side to making the decision to start the program without working down the backlog?
A: Many open-access proponents advocate working down the backlog, and continually measuring supply and demand, because otherwise you will have delays until the next available scheduled appointment, even if there is available same day access.  In our case, there are sometimes delays of a month for patients who want to schedule an appointment, and because of staffing, sometimes patients have to call repeatedly on the morning they want an appointment, or even have to walk in to schedule it.

However, since we are not in a closed system and there is frequent movement of patients between clinics, we decided to use the carve-out model. Otherwise, our concern was that we would see influx of too many patients from other sites, since we would have more availability at our site.  We did find that when we offered open access to new patients, we were besieged with patients from other sites looking for pain medication.