Putting patients first

Improving wait times and healthcare access for the Medicaid population

By Wade Mitzel

Features_Wade MitzelYou can call it denial, a focus on other concerns or even just being unaware, but eight months ago I would have denied we had a problem getting Medicaid patients into our physician offices. However, our patients thought otherwise. Clark Physician Group (CPG) is the employed physician group of Clark Memorial Hospital. It was shocking for us to consider we were not meeting our community’s needs or expectations.

In 2013, Clark Memorial Hospital completed a community needs assessment. The focus groups that gave input into the needs assessment stated multiple times that it was very hard to get into our system of care. This was especially the case for people who had Medicaid coverage. We looked at our medical practices to investigate if any barriers existed for our patients. Unfortunately, we found the focus group results were correct – it was very difficult to get into our system.

Our primary care physicians carried very small Medicaid patient panels allowing only a limited number of patients access to appointments. Some providers accepted no Medicaid patients. In addition, our wait times and patient survey scores among this population of patients were not strong.

With Medicaid web sites difficult to navigate and very little educational support on how to access healthcare systems, many patients were left using the emergency room for their healthcare needs. This pattern resulted in backlogs in the emergency
department. The upcoming expansion of Medicaid eligibility in Indiana necessitates a solution to this problem.

Changing the Model
Leaders made access for the Medicaid population a strategic priority. This involved pulling key people, including physicians, practice managers, patients and front line staff, into developing a new model. Using Lean tools, solutions were developed. Through this development, four key points brought us success.

1. Use all team members at the top of their licensure
Following the national trend, our primary care physicians were at capacity and only getting busier. Opening up access to them is very difficult. We leveraged our team-based care approach and used nurse practitioners and physician assistants to help increase capacity in our offices. Developing this team approach and strong collaboration between physicians and advanced practitioners allowed us to double our capacity for accepting new Medicaid patients. We also looked at nursing, medical assistants and other office staff roles to see how each role could be used to make a difference and provide the best care.

2. Understand the adaptive change challenge
Improvement work typically involves adaptive change and this project was no exception. Adaptive change involves transforming behaviors and preferences within the people providing care. The Medicaid population is often seen as noncompliant with a high no-show rate in the offices. When we understood some of their difficulties like transportation, language barriers, and education on when to access different services, the adaptive change was not as difficult.

3. Encourage patient involvement
We reviewed our patient surveys for this population to see if we could see common concerns and areas for improvement. We also did personal surveys in the offices and group discussions to hear how we could improve access and decrease wait times. A few suggestions included giving more appointments in the afternoon when transportation is easier, offering the ability to book consecutive appointments for family members to avoid multiple trips, having transportation options available and giving education in the medical office regarding the most appropriate time is to use the emergency department, the urgent care or the medical office.

4. Develop strong partnerships
We developed partnerships with local organizations that also work with the Medicaid population to see how we can meet their needs together. These partnerships included shelters, churches, civic organizations, state and loca l government and insurance companies. Pooling resources and abilities allowed each group to play a role in providing care but did not overwhelm any one individual group. We also developed a community outreach coordinator position to educate and assist in bringing these groups together.

The 2013 Community Health Needs Assessment and the 2013 Implementation Plan can be found at clarkmemorial.org/community.


Lean Principals in Healthcare

Lean is an operating philosophy that originally derived from the Toyota Production System. It focuses on shortening the time that elapses between a customer’s order and the shipment of the product or the provision of the service that fills the order. Lean accomplishes this by eliminating waste from processes, with waste being defined as anything that is not necessary to produce the product or service. Lean helps organizations reduce both costs and cycle time, resulting in a more agile and market-responsive company.

Clark Memorial used the following tools:

In lean programs, kaizen teams make specific changes to address bottlenecks or constraint areas. By using the lessons learned
from these experiences, lean implementation can then spread to other areas of the operation.

This technique details the specific actions required to bring a product family to the state of being finished goods, based on customer demand.

The mistake proofing process can be modified to make it nearly impossible for mistakes, spills, leaks and other process upsets to occur.

This technique is named after five words that begin with the letter “S” in Japanese. It aims to bring orderliness, tidiness and
cleanliness to operations — along with the discipline needed to keep processes standardized.

Lean in Kentucky
There is a Lean Systems Program at the University of Kentucky. Working with Toyota, the UK College of Engineering established the Lean Systems Program to provide training in the Toyota Production System. The program offers certification in Lean Systems, featuring former Toyota employees as instructors. Leadership training was also first offered that same year, with the creation of the Lean Executive Leadership Institute.

The Lean Executive Leadership Institute is scheduled November 11-13 in Lexington, Ky. Activities are led by faculty and Toyota executives. For information and registration contact Sandra Dunn at sdunn@engr.uky.edu or (859) 257-4886.

Wade Mitzel is CEO at Clark Physician Group in Jeffersonville, Ind.