3101 — Challenges to Increasing Access and Continuity in a Large Academic Primary Care Clinic Implementing the Patient-Centered Medical Home

Robinson CH, VA Center for Clinical Management Research; Harrod M, VA Center for Clinical Management Research; Kerr EA, VA Center for Clinical Management Research, University of Michigan Department of Internal Medicine; Forman JH, VA Center for Clinical Management Research; Tremblay AS, VA Center for Clinical Management Research, University of Michigan Department of Internal Medicine; Rosland AM, VA Center for Clinical Management Research, University of Michigan Department of Internal Medicine;

Objectives:
Increasing timely access to care while maintaining patient-provider continuity is a core goal of patient aligned care teams (PACT). The PACT initiative has focused on accommodating urgent access requests from established patients to their usual Primary Care Provider (PCP), in particular by rewarding performance on an urgent access performance measure. We examined factors that affected the efforts of a large academic Primary Care clinic to meet the emphasized access measure while implementing other aspects of PACT.

Methods:
We conducted 20 semi-structured interviews with Primary Care staff (physicians, residents, nurses, and administrative clerks) early in PACT implementation (2012-2013) and observed 19 coaching sessions designed to help Primary Care teams improve access and continuity. Descriptive codes were applied and findings were developed via consensus.

Results:
Challenges faced in meeting the urgent access performance measure that uniquely impacted this clinic included the part-time availability of PCPs, increased reliance on team member and non-face-to-face care which was not recognized by the performance measure, high volume of patients making it difficult to open urgent appointment slots, large number and varied locations of schedulers, and multiple simultaneous access improvement goals.

Implications:
Early in PACT implementation, a performance measure that incentivized same-day access to the usual PCP created challenges and some unintended consequences at a large academic clinic. Early formative evaluation of performance measure implementation has potential to rapidly inform and improve efforts to enact PACT goals while continuously improving how we measure PACT success.

Impacts:
Those designing performance measures will need to consider what actions facilities are likely to take to try to meet them and how organizational structures may affect these actions. VHA leadership had the foresight to plan and fund formative evaluations of the early implementation of PACT, which it is using to adapt scheduling protocols and access measures, and to continually improve the PACT program. As the VHA and other health systems work on further initiatives to enhance patient access, we should continue to evaluate how these changes affect large clinics' ability to provide meaningful patient-centered care to their patients.