Neurology Access Clinic

Abstract

Background and Objectives

Delays in access to neurologic care are a major problem. In this pilot program, we aimed to evaluate the effectiveness of a novel staffing model for neurology outpatient clinic within an academic neurology center to increase access to neurologic care, while incorporating such a model into a growing academic neurology department.

Methods

We created a new model for provision of access to neurologic care that could be introduced in an academic neurologic department, the access clinic. One attending was assigned to staff the access clinic for 1 week at a time. This was introduced as rotation equal to conventional on-service inpatient rotations. Descriptive analyses were performed to characterize the access clinic's performance characteristics. Comparisons were made to the previously established traditional faculty clinic model.

Results

A total of 5,917 access clinic visits were compared with 6,000 traditional clinic visits. Lead time dropped from 142 to 18 days for new patients and from 64 to 0 days for return visits. Although total readmission rates were similar during both clinic periods, readmission through the emergency department was less for access clinic patients. The access clinic resulted in significant improvement in patient satisfaction ratings. The access clinic model was financially profitable.

Discussion

Our findings suggest that introducing an access clinic as service rotation for neurology faculty is both effective in offering enhanced access for patients to neurologic care and for patient satisfaction. Future studies may test this model in other centers and should address the effect on provider satisfaction.

Providing timely outpatient appointments is a principal component of access to care and patient-centered care. Delays in access to neurologic care are a recognized problem.^1,2 Although the shortage of neurologists is a main factor contributive to these delays,³ organizational optimization of outpatient referrals and appointments is also of utmost importance. Lead time, the time from referral placement until actual appointment, is used as a standard means to quantify the timely occurrence of outpatient appointments.⁴ Lead time varies with the type of medical care sought and subspecialty, geographic circumstances, and type of insurance. Difficulties with access to timely medical care and a desire to decrease lead times have prompted health care systems to explore a variety of approaches, and set goals, to improve access.⁴ Most of these were explored in primary care, where one of the most economical techniques to improve access has proven to be the use of open access or same-day scheduling.^5-7 Other models include extended practice hours⁸ or incorporating general practitioners into specialty clinics to enable access for low to moderate complexity referrals.⁹ Reported experience and models for neurology clinics are scarce. One successful model introduced a physician–advanced practice provider team model with drastic reduction of lead times and preserved patient satisfaction.¹⁰ We report our experience of a new neurology clinic model that we created in our academic neurology department to enhance access to subspecialty neurology outpatient care while engaging subspecialty academic faculty.

Methods

Setting

The setting of this study was an academic neurology department at a tertiary care center in north central Florida with a full spectrum of outpatient neurology services. The primary service area encompasses north central Florida, but referrals are routinely received from the entire state as well as the states in the southeastern region of the United States.

Intervention

With the aim to improve access to patients in need of ambulatory care from neurology-trained physician neurology faculty members, the Neurology Department at the University of Florida piloted a novel clinic model from January 2017 through December 2019. A new service rotation for neurology faculty was created and named access clinic. The access clinic was designed to function as a service rotation equivalent to 1 week of general inpatient consult service through assigning 1 faculty member per week. Each assigned physician would be able to provide general neurologic care and, if needed, subspecialty-specific neurology care, which was taken into consideration during the scheduling process. The week consists of 10 half-days, consisting of 9 half-days of clinic, 2 sessions per day Monday through Friday, from 8:00 am to 5:00 pm with additional availability from 5:00 pm to 6:00 pm for urgent appointment requests scheduled on the same day, and 1 half-day administrative time. While counting as a service week, the access clinic week would not entail any weekend obligations or night calls. For 1 half-day during this week-long rotation, the assigned faculty would staff a resident clinic in which residents would evaluate a patient and then present to the faculty for supervision and staffing. From a practice perspective with regard to the individual clinic session, the traditional clinic and access clinic staffed by an attending faculty are comparable to each other—the attending treats patients within the scope of their neurologic specialty training as well as seeing general neurology patients, (i.e., referrals for common neurologic problems without a priori assignment to a subspecialty clinic.) The key difference between the traditional clinic and the access clinic is the schedule as outlined above. Attending faculty with predominant interest in outpatient neurology were given the opportunity to volunteer for the access clinic rotation in lieu of in-hospital service time and were preferentially assigned to this service.

Scheduling

All incoming new general neurology referrals were offered a timely appointment within the access clinic. Subspecialty referral requests from other neurologists were not included in this intervention. Scheduling is handled both centrally and locally at both clinic sites by clerical staff. UF Neurology has a Patient Access Center where 6–9 agents receive calls Monday through Friday from 8:00 am to 5:00 pm with voicemail option availability. When clerical staff are not interfacing patients, they are available to schedule patients and fill in empty slots on the clinic schedules to assist with addressing last-minute cancellations.

Comparison to Traditional Faculty Clinic

The cohort for this study duration contained all the patients seen through the access clinic from January 2017 to December 2019 (pilot period). The control group was drawn from the neurology service line outpatient visits by random selection of 6,000 unique patient referrals during the traditional clinic duration from January 2016 to December 2016.

Attending faculty agreed to make the access clinic weeks part of their annual clinical expectations with UF Neurology. The traditional clinic and access clinic occurred within the same 52 yearly calendar weeks in conjunction with one another. A total of 5,017 access clinic patients and 6,000 traditional clinic patients were seen within the same 36-month period. Six thousand unique patients from the traditional clinic were pulled from all traditional clinic visits from January 2016 to December 2016 to compare varying lead times, readmission rates, and patient satisfaction to access clinic patients.

Data from the pilot period were compared with prepilot, traditional academic neurology clinic (with faculty assigned to their respective subspecialty clinic days). Resident clinic (as its own entity) was not included in the pilot or comparison group.

Outcome Measures

Four evaluation parameters were used to ensure that health services were delivered as effectively via the access clinic model compared with the traditional model: access, quality, clinical outcomes, and financial factors.

Access was measured as the amount of time it would take for a patient to have a first appointment from the initial call to scheduled visit. Lead time (the amount of time it took for an ambulatory neurology patient to be scheduled and seen by a neurologist) was recorded and compared with lead time before the onset of the pilot program. Referral rate, access clinic fill rate, and numbers of both new and return patients seen were also analyzed and collected for the time periods before the access clinic was created and after implementation. Lead times of both traditional clinic visits and access clinic visits were compared. Shorter time duration was considered an indication of improved access.

Quality and clinical outcomes were measured indirectly based on the number of inpatient visits followed by an outpatient visit, time between outpatient visit and inpatient visit, and emergency department readmission rate following both access clinic and traditional clinic visit. Press Ganey surveys were used from years 2016–2019 for this comparison. Financial outcome was conceptualized through 3 variables: cost of running the clinic, professional revenues generated during this time period, and profit margin for both access and traditional clinics. Both types of clinic had the same fixed direct costs as no additional faculty were hired during this time; however, the operating costs varied.

In addition, referral areas were reviewed. The return visits were further examined to gain information on number of inpatient and emergency department visits that were routed to the access clinic, the interval (time in days) by which the referrals were received, referral area by location (cities and states), number of slots for new and return patients, and most common clinical reason for follow-up visit.

Data Sources

Institutional data were obtained through BusinessObjects (SAP, BI Platform 4.2, Version 14.2.7.3116). This platform is standardly used by all clinical departments at the University of Florida's College of Medicine. Clinic visits from 2014 to 2019 were extracted to assess the clinical and demographic characteristics of patients seen in both the traditional and access clinics. Administrative data were provided from the Department of Neurology administrative staff for information on access clinic infrastructure (e.g., new slots, referral slots, time of operation, and staffing). Financial data were acquired through the College of Medicine's and Department of Neurology's monthly, quarterly, and fiscal year budget reports. Press Ganey surveys for the time period January 2016–December 2019 were abstracted for data on patient satisfaction, clinic performance, and provider performance. Before any analysis, all patient identifiers were removed to maintain confidentiality.

Standard Protocol Approvals, Registrations, and Patient Consents

This study was approved by the local institutional review board (IRB# QIPR 1306).

Statistical Analysis

Descriptive analysis was completed to characterize the demographic and clinical characteristics of the patient population. Paired student t tests and 2 sample t tests helped to compare the access clinic and traditional clinic in regard to financial, clinical, patient satisfaction, provider, and clinic performance variables. All analysis was completed using SAS 9.4 and Microsoft Excel version 16.43.

Data Availability

Anonymized data not published within this article will be made available by request from any qualified investigator.

Results

There were a total of 156 weeks during which the access clinic was staffed by an assigned neurology faculty staff attending during a 1-week rotation during the pilot period, and a total of 5,917 unique patients were seen during this period. Per month, there were 143 new referrals on average (range 136–173). Peak referrals occurred on Tuesdays and Wednesdays (29% and 25%, respectively) during the month of July 2018.

The details of clinical and demographic characteristics of patients seen during the entire study are provided in Table 1. At full capacity, the access clinic faculty members were able to see 32 new encounters per week and maintain 8 follow-up visits per week. Lead time changed from an average of 142 days (i.e., approximately 4.5 months) for new patients and 64 days for return patients to 18 days (i.e., approximately 2.5 weeks) for new patients and 0 days for return patients (Table 1).

Table 1.

Traditional Clinic vs Access Clinic Patient Population Demographic and Clinical Characteristics

Fill rate of the access clinic was 93% compared with 89% of the traditional, nonaccess clinic. No-show rates for both access clinic and nonaccess clinics leveled at a constant rate of 8%, and this was similar also when compared with the time period before introduction of the access clinic (p = 0.3074).

The proportion of in-state to out-of-state patients was higher for patients seen through the access clinic (4.35%) compared with the traditional clinic (2.92%). Of note, 5.82% of patients (349) were admitted for an inpatient visit after a traditional clinic visit compared with 3.89% of patients (230) admitted for an inpatient visit after the first access clinic visit. The most common neurologic diagnosis for in-state patients prompting an inpatient visit was epilepsy (19.8%) during the traditional clinic time compared with stroke (21.3%) during the access clinic time. The most common neurologic diagnosis for out-of-state patients prompting an inpatient visit was a diagnosis of benign (18.7%) and malignant (14.1%) tumors during the traditional clinic time vs general dementia (19.1%) and Alzheimer disease (15.6%) during the access clinic time. The traditional clinic's geographical reach spanned 25 states and 103 counties, whereas the access clinic extended over 6 states and 39 counties.

An average inpatient admission followed within 18 days of the traditional clinic visit (range: 0–30 days) during the traditional clinic time and within 19 days (range: 5–37 days) of the access clinic visit (p = 0.12). The average length of stay during the first inpatient visit was significantly shorter during the access clinic duration at 3.4 days (0–26 days), whereas the average length of stay during the traditional clinic was 4.7 days (range: 0–32 days) (p = 0.04). Total readmission rates through avenues other than the emergency department after the first inpatient admission were similar among both durations (p = 0.067). However, there were significantly lower readmission rates occurring through the emergency department for patients seen through access clinic vs traditional clinic (p = 0.016; see Table 1).

In comparative financial analysis to compare the cost-efficiency of both clinics, we found that the clinic staffing and direct costs were significantly higher at a value of $212,015.00 for the access clinic duration compared with $169,362.00 during the traditional clinic (p = 0.043). Clinic revenues, however, were also significantly higher during the access clinic duration at a total of $318,323.00 compared traditional clinic revenue of $232, 587.00 (p = 0.0017). Overall, the access clinic had a significantly higher profit margin by a total of $85,735.00 (p = 0.024).

Clinic ratings are presented in Table 2. During the traditional clinic comparative period, clinic ratings on all dimensions of the Press Ganey survey were not performing as well as University HealthSystem Consortium (UHC) ratings with the exception of the following subdomains: 1d. courtesy of registration staff, 2b. wait time at clinic, 3a. friendliness and courtesy of care provider, 3g. provider use of clear language, 3h. provider time spent with patient, 3j. likelihood of recommending practice, 4c. concern for patient privacy, and 4d cleanliness of practice. During the access clinic pilot duration, all domains and subdomains were found to be better performing than the average UHC standard for that duration. There was significant improvement noted in overall rating, and the domains of “moving through visit,” “convenience of office hours,” “wait time at the clinic,” “use of clear language,” “likelihood of recommending provider,” “sensitivity to patient needs,” and “likelihood of recommending practice” were significantly higher scored than scores of UHC standard which is also shown in Table 2.

Table 2.

Satisfaction Survey Results: Traditional Clinic vs Access Clinic

Discussion

In this novel academic neurology clinic model, we were able to significantly improve access to neurology care in a tertiary care center. We found that by creation of a dedicated access clinic staffed by academic faculty in lieu of traditional inpatient service rotations, lead time decreased, and patient satisfaction increased. Although clinic staffing and direct costs were higher for the access clinic compared with the traditional clinic, the access clinic was overall not uneconomic and hence promises financial sustainability. No differences exist in payer mix between the patients seen in either the traditional clinic or the access clinic. Accepted insurances for both clinics are standard and aligned with managed care contracts negotiated by UF Health. Reasons for increases in cost in addition to inflation and elimination of some codes include increasing nursing and clerical staff as well as varying state funds received by UF College of Medicine (COM). Conversely, state funds received by UF COM may also positively affect the overall budget of a clinic while the launching of new codes and ability to see more patients through the access clinic allows for more revenue to be generated.

Health systems are exploring a number of novel models to try to address inadequate access to outpatient care. Open scheduling and extended practice hours have shown success in increasing access, satisfaction, and outcomes including reduction of emergency department visits.^5,8,11-15

Most of the published models apply to primary care or family medicine, and the literature on subspecialty care is less available. Examples addressing subspecialty care include embedding a general practitioner within a subspecialty practice to assist with access for low to moderate complexity referrals⁹ and shared multidisciplinary appointments.¹⁶ For neurology specifically, one successful model of a physician-nonphysician clinician (nurse practitioners and physician assistants) team model allowed the health system to extend available physician resources in an effort to improve timeliness of outpatient care.¹⁰ Although we did not introduce open scheduling in this iteration of our access improvement, the convenience of the extended office hours was rated higher by patients. Although the concepts of scheduling technology and office hour extension may be more readily generalizable between medical specialties and practice systems, our model carries several additional characteristics that are more applicable to academic medical departments. A particular focus on subspecialty care may also be indicated by the difference in geographic reach that we discovered between the traditional and access clinic, with substantially less radius for the access clinic—this is likely explained by the nature of patients referred to either clinic, with predominance of more urgent and/or general neurologic questions to the access clinic vs subspecialty neurologic conditions requiring expert care with willingness and/or need to travel further. Overall, we found increased patient satisfaction in the new clinic model—and ongoing quality assessments will delve into further identifying the reasons for such.

From an organizational perspective, our model specifically attempted to address access while also taking into consideration the composition and organization of an academic neurology department where traditionally, faculty has variable half-days of clinic and additionally scheduled inpatient service rotation time. Our model provided the advantage of engaging faculty and providing service time, allowing for an additional option in the composition of clinical duties for neurologists in an academic setting. With increasing subspecialization in neurology, many neurologists may feel more comfortable in either the outpatient or inpatient setting but may not have the same comfort level in both settings. Given that neurologists are reporting high burnout rates and low professional satisfaction,^17-19 focusing on a role that is most fulfilling is of importance. One advantage of the access clinic rotation attractive to faculty was that it required duty Monday through Friday but did not include weekend coverage or staffing of overnight calls. With these characteristics, the access clinic rotation was (and is) well accepted by eligible faculty. Whether a choice of inpatient vs outpatient neurology might play a role in career satisfaction and quantification of such exceeded the scope of this study and should be a future item to explore. In addition, our model also addressed another critical factor: financial pressure for academic neurology departments, where in 2019, only 31% of academic departments reported profitable outpatient operations, whereas 69% reported to either break even or operate at a loss.²⁰

The concept of our model is largely focused on academic neurology departments. Our single-center experience may limit generalizability, for example, when considering variability in financial and reimbursement models. Although informal feedback was obtained from faculty, we did not formally quantify faculty satisfaction yet. Given the different time periods for the access vs traditional clinic, inflation of costs over time and change in demographics may be contributing factors that we are unable to quantify. Specifically, the increased proportion of in- vs out-of-state referrals during the access clinic period may have introduced bias. However, this would mostly affect satisfaction ratings and less likely affect the actual improvement in access and faster provision of neurologic care. Furthermore, we did not investigate the proportion of patients seen in the access clinic and requiring subsequent neurology care; this will be a future analysis. Finally, during the time of this analysis, which predated the pandemic, no televisits or e-consults played a role in access clinic visits. However, there are accumulating data on telehealth for neurologic conditions with promising findings with regard to feasibility, outreach, and patient satisfaction.^21-26 Such models should be explored in future iterations.

Our access clinic model successfully improves outpatient access to general neurology by both reduction of lead time and further referral or ongoing treatment with a neurologist. Our department has maintained the access clinic since its iteration, and we plan to adjust the model as needed with the considerations discussed. This model serves as one potential model for addressing inadequate outpatient access to neurology care in an academic referral center while meeting service needs.

Appendix. Authors

Study Funding

No targeted funding reported.

Disclosure

The authors have no disclosures relevant to the manuscript. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.