Achieving a New Standard in Primary Care for Low-Income Populations: Case Studies of Redesign and Change Through a Learning Collaborative

The full case studies of the four hospitals discussed in this overview report are available at:

• Case Study 1: Redesigning the Patient Visit Program at the Jerome Belson Health Center
• Case Study 2: Advanced Access Learning Collaborative at Union Health Center
• Case Study 3: Revenue Maximization Program at the Brownsville Multi-Service Family Health Center
• Case Study 4: Marketing and Customer Service: Attracting and Retaining patients at the Urban Health Plan

Executive Summary

Community health centers deliver primary health care to much of New York City's low-income population. But the design and delivery of health care services at these centers can be made more patient friendly. There often are delays in access to care, making it difficult to get an appointment. Inefficiencies in patient flow also are common, resulting in office visits that are needlessly long.

This paper describes four case studies that focus on improving patient care delivery systems through "learning collaboratives." The nonprofit Primary Care Development Corporation (PCDC) implemented its learning collaborative model at four community health centers in New York City. Using PCDC's methods, each center made dramatic improvements in key operations: getting patients in and out of the center quickly; offering appointments with the patient's primary care provider on demand; enhancing revenue collections; and attracting and retaining patients.

Founded in 1994, PCDC works closely with city, state, and federal governments and with private funding sources to provide construction loans and technical assistance to health care providers. These funds are used to modernize, expand, or build medical facilities in communities that lack critical primary care services. This program aims to build a sustainable, permanent, community-based infrastructure capable of delivering affordable primary care services in underserved communities.

To lend additional support, PCDC set out to provide operational technical assistance to health centers. It advises providers on "change concepts" that can radically improve their delivery systems. Working with experts from around the country, PCDC developed a comprehensive strategy for improving efficiencies and building operational and programmatic capacity. This effort resulted in the creation of several technical assistance programs (Operations Success Programs) that focus on performance improvements. By revamping their operational processes, ambulatory care centers can accommodate higher volumes of patient visits and offer a better level of care.

Over the past six years, PCDC has worked with 100 teams from 22 New York City health care organizations to create patient-focused health care centers. When care is patient focused, a visit to the doctor should last no more than an hour, and patients should be able to get an appointment with their own primary care provider within 24 hours.

PCDC created learning collaboratives modeled after the Institute for Healthcare Improvement's Breakthrough Series Model. A learning collaborative is an initiative that provides clinical, technical, and social support to health care organizations. The goal is to make dramatic improvements in specific clinical and operational areas. To participate in a learning collaborative, an organization appoints several staff members to a team. Over the course of six to eight months, teams from various organizations that share common goals meet in learning sessions. There, they learn from expert faculty how to improve their performance, and share progress reports. The period between learning sessions is called the "action period"; during this time, teams work intensely to implement what they have learned at the learning sessions.

PCDC created a set of four unique learning collaboratives. Two of them (Redesigning the Patient Visit and Advanced Access) address delays in access to care and long cycle times. The other two collaboratives (Revenue Maximization and Marketing and Customer Service) focus on key operational areas.

In its consulting capacity, PCDC developed broad expertise on the challenges of adapting transformational change at primary care health centers. Change is extraordinarily difficult to implement and sustain—even when leadership and staff both endorse it.

A successful implementation model is based on clear, simple, and effective principles. There are five strategic principles that apply to all collaboratives.

Five Strategic Collaborative principles:

• Build a high-functioning team
• Cultivate leadership support and involvement
• Track data and map the process from the patient's perspective
• Open lines of communication
• Utilize the expertise of PCDC coaches and program leaders

Each PCDC learning collaborative has these five principles at its core, but also has its own unique set of principles targeted to a specific process.

Patient-centered care requires a significant expenditure of energy. PCDC has been fortunate to work with experts from around the country to develop comprehensive strategies for building the capacity of freestanding health centers. The following four case studies illustrate the success of PCDC's collaborative model. Each of these studies follows the framework of a learning collaborative model but was implemented in very different settings.

Case Study 1: Redesigning the Patient Visit Program at the Jerome Belson Health Center
This case study documents the rigorous six-month redesign of the patient visit process at the Jerome Belson Health Center in the Bronx. The health center is one of four full-time and three part-time centers in New York City operated by the Cerebral Palsy Association (CPA) of New York State. The center serves a developmentally disabled population, which makes the task of reducing patient cycle times even more challenging than usual.

Even so, the principles of redesign successfully transformed an overcrowded waiting room that was far from user-friendly into an environment where the patient comes first, and providers and staff are highly productive.

The Jerome Belson Health Center followed a rigorous PCDC training program as it implemented the learning collaborative model. The center benefited dramatically from these changes. It decreased its average patient cycle time (total clinic visit time) from 68 minutes to 41 minutes, a reduction of 40 percent. As clinic visits became more efficient, provider productivity rose 58 percent. Providers had been treating 2.85 patients per hour, but were able to treat 4.5 patients per hour after the redesign.

The Jerome Belson Health Center followed the five strategic collaborative principles outlined above. In addition, it followed 12 principles that were specific to its Redesign Collaborative:

Twelve Redesign principles:

• Don't move the patient
• Eliminate needless work
• Increase clinician support
• Communicate directly
• Exploit technology
• Monitor capacity in real time
• Get all the tools and supplies you need
• Create broad work roles
• Organize patient care teams
• Start all visits on time
• Prepare for the expected
• Do today's work today

Case Study 2: Advanced Access Learning Collaborative at Union Health Center
This case study examines how a health center dramatically redesigned its patient visit process. Union Health Center, which has provided health care services to garment industry workers in New York City since 1914, turned to PCDC to implement its Advanced Access program. The redesign was led by experts Mark Murray, M.D. and Catherine Tantau, R.N.

Union overhauled its patient scheduling system to meet its goal: offering patient appointments on demand. The key to reducing backlog and meeting demand is to measure the third-next-available appointment time. Union patients commonly had to wait as long as 15 days before they could schedule an appointment. After the seven-monthlong redesign, patients received an appointment within one day or less, which represents a 93 percent decrease in appointment scheduling time. In addition, the patient no-show rate fell, and both staff and patient satisfaction levels increased.

Union's efforts to decrease cycle times and increase productivity through the Redesign Collaborative laid the groundwork for the next program it undertook, called an Advanced Access Collaborative. This process enabled Union to implement a scheduling system that offers patients appointments on demand.

In summary, Union implemented the five strategic principles adopted by all collaborative participants. In addition, it implemented the Advanced Access core program principle (Doing Today's Work Today), and embraced six Advanced Access principles (also known as "high-leverage changes").

Advanced Access principles:

• Do today's work today
• Work down the backlog
• Reduce appointment types and times
• Develop contingency plans
• Reduce demand for visits
• Balance supply (provider time) and demand (patient visits) daily

Case Study 3: Revenue Maximization Program at the Brownsville Multi-Service Family Health Center
This case study chronicles the Brownsville Multi-Service Family Healthy Center's (BMS's) effort to collect revenues efficiently throughout the entire collection process. BMS serves a low-income community living predominantly in public housing. BMS's challenge was how to sustain revenue while meeting the overwhelming needs of its clients.

BMS was acutely aware of its pressing need to increase revenue, but its numerous attempts to fix the problem internally had failed. BMS turned to PCDC for help, and implemented PCDC's Revenue Maximization (RevMax) Learning Collaborative.

BMS used the learning collaborative model over a six-month period to streamline its entire collection process, which produced dramatic results in several financial indicators. As a result of the changes, average weekly cash receipts increased by 46 percent. Reimbursement per visit rose 55 percent, from $78 to $121.

This case study also documents how the work of the collaborative improved employee morale and encouraged high performance throughout the organization. These changes delivered another significant result: the adult medical care unit increased patient visit volume by 5 percent after several years of decline.

BMS improved its bottom revenue line by following the five strategic collaborative principles and, in addition, 10 RevMax specific change principles.

Ten RevMax principles:

• Do it right the first time
• Collect money due at the point of service
• Eliminate lag times between service and billing
• Manage claim rejections
• Redesign bad processes
• Encourage teamwork
• Leverage technology
• Share the data
• Establish good internal control systems
• Maintain appropriate staffing

Case Study 4: Marketing and Customer Service at the Urban Health Plan
This case study provides insight into how a South Bronx health center adapted highly targeted marketing practices and by doing so was able to increase and sustain patient volume in a very competitive environment.

Urban Health Plan (UHP) had conducted an extensive and expensive media campaign for its new facility, which had generated much interest. But UHP soon realized it needed help in understanding the process of marketing without relying on expensive consultants. UHP enrolled in PCDC's Marketing and Customer Service Learning Collaborative.

PCDC helped UHP understand the importance of a two-pronged approach to community outreach. The first step was to create an in-house marketing division that was able to customize outreach efforts to narrowly defined populations. The second step was to create and maintain employee and customer satisfaction.

The case study examines how UHP created an in-house marketing division. Its goal was to increase and sustain patient volume through outreach to a specific population base. By achieving this goal, it significantly improved both employee and customer satisfaction.

Patient satisfaction survey results:

Over the six-month course of the collaborative, the team clearly identified the unique needs of targeted market segments. It established a method of tracking new patients who came to UHP from those market segments. It also secured support from providers, board members, and other staff members, which is crucial to sustaining gains.

Urban Health Plan followed a Marketing Road Map, which is an outline for following new customer service principles that places strong emphasis on the patient. The health center used the five basic marketing principles as well as an additional eight customer service principles.

Five Marketing principles:

• Situational analysis
• Marketing objectives
• Marketing strategies
• Marketing tactics
• Evaluation

Eight Customer Service principles:

• Leadership commitment
• Service defined from a patient perspective
• Service standards
• Continuous improvement
• Internal communication
• Ongoing communication
• Reward and recognition
• Patient satisfaction measures

In conclusion, the data from these four collaboratives support the effectiveness of the learning collaborative model for implementing change. The groups used the model to achieve such goals as appointment access within 24 hours; visit cycle times of less than one hour; increase in reimbursement; and improved patient and staff satisfaction.

PCDC believes it can reproduce its success in diverse settings with future collaboratives. Its experience in working with a variety of groups over the past six years has enabled it to identify common issues that can hamper the process.

One challenge, for example, is helping organizations sustain the processes that were changed so that benefits continue to accrue. Frequently, PCDC has encountered what it labels the "myth of the self-maintaining innovation": the belief that gains achieved during a collaborative can be sustained without further effort. PCDC has learned that the improvement process is not a finite project; it is a never-ending commitment that requires continued organizational focus, resources, and course corrections.