The pre-appointment intake (PAI) process is a scheduled appointment to conduct a medical intake phone call one to three business days prior to the patient’s arrival on campus. Before scheduled PAI appointments, calls were made in the hopes we would reach patients, resulting in our ability to connect with only 40% to 50% of patients. Implementing this change has resulted in reaching about 87%, which was a more productive use of the patient and staff’s time.
The patient’s appointment type drives the determining factor if they are due for an intake appointment. The appointment types that currently include a PAI appointment are new, consult, and established appointments. Practice standards require that the PAI be completed every 14 days (about two weeks) to ensure compliance with medication reconciliation in the patient chart. To provide a consistent experience for patients, the following elements are confirmed/collected by allied health staff during every PAI appointment:
- Identity
- Date of birth
- Current medications
- Allergies
- Medical devices/implants
- Prescription benefits
- Preferred pharmacy
- External primary care provider (PCP)
- Advance directive opportunities
- Benefit of patient portal enrollment
- Reminder to complete questionnaires
- Tobacco use.
This appointment also serves as an appointment reminder for the patient and allows the patient to ask any questions they may have before they arrive on campus (e.g., where to park, accessibility concerns).
The efficiencies gained by scheduling the appointments created opportunities to conduct virtual training and hire remotely for this position.
Another unique aspect of this project was creating “pods” of team members in different medical departments to work together in small groups to accomplish this work. Pod determination was based on practice metric volumes in each department. Using Teams technology and pod chats for communication, we have been able to support multiple departments and complete a standardized intake. This effort has been FTE neutral pre- and post-go-live. We have transitioned some of the resources from clinical trained nurses to non-licensed delegates, which has allowed our nursing team to work at the top of their licensure.
Background
Healthcare has seen a rapid acceleration of virtual care offerings to patients that previously were done in person, a pivot expedited by the COVID-19 pandemic and patient demand. A task force of Desk Operation and Practice Optimization & Acceleration (POA) leaders gathered in late 2019 to understand and improve the workflows of the desk and allied healthcare teams prior to a patient’s visit to Mayo Clinic Rochester.
Pandemic workflows were quickly implemented to reduce in-person exposure during the intake process and to set expectations prior to the patient’s appointment, which resulted in a scheduled phone appointment (the PAI). This appointment occurs one to three business days before the patient’s provider appointment. In addition to reducing the exposure time, efficiencies were gained by having vital patient information available for the care teams before meeting with the patient.
Streamlining the tasks done prior to arrival helped providers prepare for visits and increased the share of patients who were ready to start their appointment on time. This work, now performed by non-licensed staff, allows nursing greater flexibility and the ability to function at the top of their licensure while caring for patients.
The PAI not only improved how we are prepared to care for patients but also bridged a gap in quality and became the standard across the Rochester Mayo Clinic campus.
Analysis
The need to change our quality reporting was identified as part of the PAI appointment implementation. Prior to PAI appointments, medication reconciliation was only measured on the providers completing this task, and completion rates were often under 10%. Since allied health staff were also now completing the task consistently, a new report was created that measured medication reconciliation as a joint effort by providers and allied health staff.
This new report showed a dramatic increase in medication reconciliation completion and was used to solidify the effectiveness of the PAI process. In comparing the 2019 data to 2022 for orthopedics, with allied health staff included in the measurement, the medication reconciliation completion rate increased from 79.63% in 2019 to 93.84% in 2022. The new report validated allied health’s previous work that hadn’t been measured and improved our medication reconciliation metric.
One of the measures taken during the pilot was rooming duration (the time it takes from when a patient arrives in the lobby to when they are ready in a room). We found a significant decrease in rooming time when a patient arrived for their medical appointment. The impact is the ability of our physician and NP/PA to start the appointment on time and allow nursing and allied health staff to focus on tasks to support the patient’s direct, in-person care.
The team also measured the ability to connect with the patient on the first attempt.
We theorized that the no-show rate for appointments would decrease due to connecting with the patient prior to the appointment. However, this did not show an impact and was variable in our pilot group (see Table 4). We realized that the last-minute cancellation rate might be the better metric for future analysis.
The final measurement for the team was to look at overall efficiency to analyze the PAI phone call’s duration, with the average being eight minutes and 45 seconds. When combining the average call duration with the time it takes for rooming, we found that the overall efficiencies did not decline with the two patient touches.
The data, while mixed, did show enough evidence that the pilot could be expanded to impact the overall rooming times for the outpatient clinic and expand remote work opportunities for on-site clinical support team members in a competitive market.
Assessment
PAI has provided an opportunity to gain efficiency, resulting in positive patient, allied health staff, and provider feedback.
Patient comments
- “Mayo Clinic is always at the cutting edge in the future of medical care. The phone intake is a great example.”
- “I really appreciate this information in my chart prior to the date of my appointment.”
- “Knowing all this information is done before I arrive, really helps with my anxiety. Now I do not have to worry about remembering to bring all my medications to my visit. “
Allied health staff comments
- “We are one of the first steps or introduction to our patient-orientated practices on their medical journey. We provide a confident and reassuring sounding board for their beginning questions and can help them understand what to expect when they arrive.”
- “Pre-visit calls also help remind patients of their upcoming appointments, we can go over their itinerary and remind them of any prep instructions. The call can also prompt the patients as a reminder to reschedule or cancel if needed.”
- “We help to confirm our patient’s trust in choosing Mayo Clinic for their health care needs.”
Provider comments
- “It has been fabulous. It saves time rooming, and patients are now roomed promptly. It is very helpful to quickly review the medication list before I see the patient, so I am more prepared for my appointment.”
Lessons learned
As with any initiative, it is important to learn what works well and what opportunities still exist. Throughout the pilot, key lessons learned were compiled to help with future implementation.
Creating an effective communication plan to ensure that support staff and stakeholders at every level are fully aware of upcoming changes is crucial for the success of any project. Communicating early and often and employing various communication methods reduces the chance of missing critical information.
It is easy to assume that staff know how to use technology associated with their roles. However, it proved beneficial to provide additional training on the effective use of Epic. We specifically focused on resolving information received through Care Everywhere and properly reviewing and updating the medication list to help reduce physician burden. Eliminating manual solutions as much as possible, as well as making the correct option the easiest to complete and the incorrect option the hardest to complete helped staff adhere to process changes.
Initially, it can be beneficial to have “boots on the ground” resources available on-site for staff and stakeholders to ask questions and get clarification as needed. This also allows for quicker problem-solving and modifications as needed. As staff become more experienced with the new processes an easy-to-access, central repository for workflows, frequently asked questions (FAQ), and training resources reinforces learning and encourages staff to be self-sufficient.
All these items will support staff in successful implementation and long-term sustainability.
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