Ambulatory Care Transformation to Improve the Patient Experience | NYC Health + Hospitals

NYC Health + Hospitals Adopts Five-Point Strategy to Transform Ambulatory Care and Reverse Declining Outpatient Visits

Oct 03, 2018

New York, NY

NYC Health + Hospitals today announced a series of strategic initiatives designed to transform the health system’s vast ambulatory care operation, improve access to in-demand primary and specialty care, and reverse the recent trend of declining outpatient visits. The changes are endorsed by President and CEO Dr. Mitchell Katz as laid out in a five-point strategy: build strong relationships between patients and their primary care physicians, reduce common and costly no-show rates, improve clinic efficiency, reduce long wait times to specialty outpatient services, and increase revenue with new billing and coding practices.

The five-point strategy reflects goals outlined in “One New York: Health Care for Our Neighborhoods,” the transformational plan for NYC Health + Hospitals issued by Mayor Bill de Blasio in April 2016. The strategy will be adopted across the public health system’s more than 70 community-based health centers, including 11 hospital-based outpatient operations, which together provide more than five million outpatient visits to children and adults every year. The specific plans reflecting the five points will be implemented system-wide over the next six months, some completed sooner.

“Fixing primary care is key to our financial turnaround and vital to our promise to be responsive to the health needs of the communities we serve,” said Dr. Katz, who began practicing primary care this summer at NYC Health + Hospitals/Gotham Health, Gouverneur, one of the health system’s largest health centers, located on the Lower East Side. “Through our plan, we will improve patient care, the patient experience, and our public health system’s financial standing.”

“Having met with staff at every ambulatory care site in our health system, I’ve heard the challenges they face, and their input has guided our plan,” said Theodore G. Long, MD, MHS, Vice President for Ambulatory Care. “To establish a solid foundation for our ambulatory care future—and for primary care in particular—we will build stronger relationships with our existing patients, support them through using technology and innovative scheduling for appointments, allow our doctors and nurses to work to the tops of their licenses, and collect every dollar to which we are entitled for the services we provide from both public and private insurance.”

The five major areas of strategic improvements are:

Fix Continuity of Care and Build Fidelity with Assigned Primary Care Clinician

Under the plan, a new scheduling system is being adopted to consistently connect patients to their assigned primary care clinician. Currently, clinicians spend more than a third of their time seeing patients who are assigned to another primary care clinician. The new system will allow for greater continuity of care and stronger relationships between patients and clinicians, which will lead to better care and better outcomes.

The new system began implementation on in July and is expected to be completed in October, using existing resources.

A secondary benefit of solidifying patient-clinician relationships is that patients can more consistently be paired with clinicians who understand their cultural background, including their language, which also leads to improved care. Patients may prefer to have a provider who better understands their priorities, which may touch on ethnicity, religion, and/or sexual orientation.

The plan also includes the hiring of more primary care clinicians to expand capacity. A recruitment campaign, DOCS4NYC, was announced in May. Of the campaign’s 75 targeted new hires, 30 clinicians are expected to be hired by November, tied to today’s announced plan.

Reduce No-Show Rates and Use Technology to Help Patients Come to their Appointments

Under the plan, the new scheduling system will also empower patients to schedule appointments with realistic expectations of less waiting time than they currently experience. This will address the enduring challenge of high no-show rates—between 30 and 40 percent—in outpatient clinics. This is a priority because when patients do not come to their appointments, they miss having continuity with their doctor, and there are lost opportunities for other patients to be seen.

The new system will both allow appointments further out, as some patients prefer, and still reserve 30-40 percent of slots for the following week, to build in capacity for patients to make appointments when they know their schedules. This “open access scheduling” model was launched in July at NYC Health + Hospitals/Bellevue and will be rolled out system-wide this fall.

The system will also use technology for appointment scheduling, using a suite of interventions including text messaging to communicate with patients in their preferred language and be sensitive to different levels of literacy.

Expand eConsult to Reduce Long Wait Times for Specialty Care

The plan also calls for the expansion of the eConsult system that the health system has successfully piloted. Addressing the high demand for specialty care, especially in fields where specialists are in short supply, eConsult makes it easier for primary care providers and specialists to communicate about and co-manage patients when appropriate.

When a primary care provider’s patient has a health concern that would typically be treated by a specialist, the primary care provider can send a message about the patient through eConsult and get a quick response. In some cases, the response is guidance that empowers the primary care provider to treat the patient in the primary care setting. For example, the specialist might instruct the primary care provider to prescribe a medication, as well as present instructions for both the provider and the patient.

The response might also be direction to schedule an appointment with a specialist, with instructions about tests and imaging studies that the patient should undergo before the first appointment. In the past, the first visit with a specialist might be very brief, resulting in direction for the patient to undergo testing; eConsult is eliminating those inefficient visits, which frees up time for maximally effective visits.

Under the pilot, wait times for specialty care appointments decreased—different amounts of time for different specialties—as a result. Wait times for specialty services will be tracked as one metric to assess the impact of eConsult over time.

Improve Clinic Management by Empowering Doctors and Nurses to Practice at the Tops of Their Licenses

Roles and functions for clinicians are being redefined to liberate them from tasks and responsibilities that others can do and empower doctors and nurses to function at the tops of their licenses—doing things for patients that others cannot. New standing orders system-wide will redirect staff so that, for example, physicians and nurse practitioners do not have to place individual orders for routine vaccinations; nurses, who are trained to administer vaccinations, will routinely handle them. Administrative functions will be handled by other staff so that doctors, nurse practitioners, and nurses can all spend more time on direct patient care.

The plan also entails adding nurse practitioners to the health system’s call center operations. These clinicians will have the ability to respond to requests for medication renewals, providing prescriptions by phone when appropriate. Medication renewals are one of the most common reasons that patients go to clinics last minute, so streamlining this process will save patients time and free up clinicians’ schedules to treat patients who truly need to be seen. Having a clinician in the call center to renew medications has been successfully implemented at NYC Health + Hospitals/Bellevue, and new nurse practitioners are being hired—initially, five of them—to assume that responsibility system-wide from the call center.

Increase Revenue by Improving Billing and Coding

A new multipronged strategy will be implemented to improve billing and coding to ensure insurance payment for services provided, in part by teaching clinicians and giving them feedback on billing and coding.

Ensuring reimbursement for services involves multiple components, which may include pre-registration, complete patient registration information, and the submission of appropriately coded billing paperwork to the payer, as well as appropriate documentation from the clinician. All components need to be just right or payment rejection is likely.

To be given on site at every location where ambulatory care is provided, training will teach best practices in coding and answer questions.

The education will also entail review and assessment of clinician-completed documentation, both to correct errors in coding and to provide follow-up training.

Others involved in the billing and coding process are also receiving training on their components of the process, including through the Coder Academy, which was announced in May.

Earlier Work

The new ambulatory care transformation efforts follow other investments to upgrade or create new facilities at a number of locations, many supported by investments under the city’s Caring Neighborhoods initiative, which was created to increase primary care access for thousands of residents in underserved neighborhoods across New York City. Much of the resulting work was announced in October 2017.

One of the goals of the new ambulatory care transformation is to stem the gradual decline in ambulatory care visits. The number of unique patients seen in primary care declined from 446,000 in Fiscal Year 2016 to 417,000 in Fiscal Year 2018.


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