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Population Health

Building Better Schedules and Beating Burnout

A Spotlight on Quality Community Health Care’s Success

The stress of fitting seven-day follow-ups into your demanding schedule can push you and your staff toward burnout. What if you could implement changes and maximize your patient access for post hospital discharge follow-ups while avoiding burnout?

Quality Community Health Care (QCHC) did just that. QCHC was the only Tier 1 practice to achieve the highest preliminary performance improvement compared to previous baseline Contract Year (CY) 2017 in the Quality Measure: Care Coordination— 7-Day Follow-Up Visit with PCP Post Hospital Discharge.

Dedicated to Improving Measures

QCHC’s previous baseline measure during CY 2017 was 11.6%. Their performance during Contract Year 1-Period of April 2018 through March 2019 increased to 20.2%. This represents a 74.1% preliminary improvement—an astounding turnaround. Annually, the practice sees 17,000 patients and bills 35,000 encounters. However, QCHC’s infrastructure is not as robust as other members of the Tier 1 Group.

Achieving Better Practices

The QCHC team is dedicated to improving quality measures that will improve patient health outcomes and reduce costs. The team improved its performance by rebuilding and refining the provider schedules to increase patient access, providing daily transition-of-care (TOC) appointments, and accommodating same-day open access and walk-in appointments while decreasing patient wait times. In addition to refining the providers’ daily schedules, the team also refined the front-office operational procedures to ensure insurance verifications, confirm patient demographics prior to scheduled appointments, complete daily capacity assessments, and monitor providers’ schedules for no-shows throughout the day.

By managing daily workflow operations, the QCHC team identified and eliminated duplicate workflow processes in order to efficiently distribute daily appointments among all practice providers. The team used the participation tools available through the Temple Care Integrated Network to assist with aligning its primary focus of linking patients back to the primary care office post-hospital inpatient discharge and/or ED discharge. By accessing the participation tools and fine-tuning operational workflow processes, the QCHC care management team was successful with completing pre-visit planning, thereby allowing an efficient, organized follow-up appointment.

This incredible improvement in performance could not have been achieved without a strong, very dedicated, and focused care management team, who works together for the best results.

How This Was Accomplished

Practice Infrastructure

  • The practice uses an Electronic Practice Management (EPM) System for their scheduling and billing.
  • Current staffing: 9 providers; clinical administrator, care management team (6 FTEs consist of manager, health care coordinator, community health worker); licensed clinical social worker; medical assistants; patient service representatives and security officers.
  • Services provided include pediatrics, family and internal medicine, geriatric medicine, women's health care (OB/GYN), and behavioral health.
  • Operating hours: Monday – Thursday 7:00 am – 8:00 pm, Friday 7:00 am – 4:30 pm, no weekends or holidays, every 1st Wednesday/month 1:00 pm – 8:00 pm (providers monthly meeting in the morning).
  • Practice sees 17,000 patients annually and bills 35,000 patient encounters annually.


Provider Schedules

  • Created specific color-coded open access/same day appointment slots. These are 14 daily appointment slots for open access appointments divided equally among providers’ schedules and based on each provider’s daily no-show rate. These slots can be 15 or 30 minute appointments.
  • Color-coded daily walk-in appointment slots. There are walk-in appointments available throughout the day, however, these appointments are determined based on daily capacity assessments and the providers' schedule. All walk-ins stop at 7:00 pm daily. The number of walk-in patients that can be seen each day varies according to the operational hours/day of the week, calendar holidays each month, and seasonal inclement weather. (The average is 4–10 daily walk-in patients.)

Care Management Team

  • Developed a team-based care management with specific goals of transition-of-care and care coordination to improve health outcomes of their patients and reduce costs. Due to the extremely high patient no-show and non-adherence rate, the care management teams targeted their focus to linking their patients back to their office post hospital inpatient discharge and/or ED discharge.
  • To avoid duplication of processes and workflows, the care management team designated specific goals to each individual that were effective in the coordination of patient care: specific goals include capturing those patients/members on the panel who have never been to the practice or members lost to care (nonvalid telephone number, address, homeless, etc.), patients with specific chronic illnesses, outreach to those patients with missing gaps in care.
  • Each team member is focused on capturing and linking the patient back to the practice for an appointment within 7-14 days for a follow-up visit.
  • Retrieving daily reports of their patient's ED visits, patient admissions, discharges, diagnostic imaging, etc.
  • Once the team has received notification of a patient's hospital activity, documentation is noted in the chart and a "flag" is assigned to the patient in EPM to alert staff that the patient needs a transition-of-care appointment.
  • Medication review begins with the medical assistant.
  • Team members access the TUHS Epic Portal to retrieve all patient discharge information: diagnostic studies, lab work, medications, etc. The team member compares the patient demographic information in the TUHS Epic Portal with the information in the EPM system to ensure accuracy. Often, patients are located who had been lost to care due to frequent address changes and disconnected telephone numbers. The patient's chart includes all transitional care information and is handed off to the medical assistant, who then reviews the information in its entirety with the provider.
  • This information is used for the pre-visit planning process to ensure a thorough patient medical assessment is completed and the provider is prepared for the patient’s visit prior to the scheduled appointment. This includes medication reconciliation, patient referrals, and scheduling specialist appointments.
  • The medical assistant, patient service representative and provider work as a team to ensure the transition-of-care patient is on the provider’s schedule within 7 days of post-hospital discharge. The medical assistant initiates and manages the pre-visit planning process and the patient service representative manages all the providers’ schedules to ensure scheduling protocols are consistently followed to allow flexibility when scheduling transition-of-care patients for follow-up appointments within 7 days. The provider reviews the pre-visit planning package with the medical assistant to ensure all necessary information/reports are included, if referrals are needed, etc., in preparation for the transition-of-care appointment. If a provider’s schedule does not have the capacity for a 7-day time frame, the patient is scheduled on an alternative provider’s schedule. The patient is called to be informed of the appointment and the need to return for the follow-up visit. The team has been successful in getting approximately 80% of its transition-of-care patients into visits within 7 days.
  • Letters and calls are made to patients at the end of the day if they fail to show for appointment.
  • The care management team calls patients that have been discharged from the ED the next day to try to schedule them in a same-day appointment slot.
  • Has a 50% success rate with getting their patients to come into the office for an ED follow-up visit.
  • The care management team engages in social determinant assessments with their patients to identify those patients who may qualify for specific outreach services to assist with maintaining scheduled appointments, medication assistance, food resources, etc. Based on the overall assessment and evaluation of patient needs, outreach initiatives are provided on a case-by-case assessment.

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