Tips and Guidelines for Improving Access to Care
Date: 02/29/24
Managed Health Services (MHS) is committed to improving the patient experience for members. Applying the tips and guidelines for improving access to care included in this brochure in your practice may help increase patient satisfaction and provider satisfaction scores.
Improving Access to Care
Key points for improving access
Improving access to care and the patient’s experience with access is about:
- Finding the correct balance between supply and demand.
- Demonstrating flexibility to patients by offering same-day appointments as well as convenient and sufficient hours of operation that take into account the needs of the populations being served, and the appointment scheduling standards for the region and product line.
- Returning patients’ phone calls timely, especially after hours, when urgent or emergent medical advice is needed.
- Keeping patients informed of processes and outcomes when a referral and authorization for a service are needed, and in a format and language the member can understand.
Measuring supply and demand
One of the top challenges to accessing care MHS members cite in patient satisfaction surveys is the inability to schedule an appointment with the provider at a convenient time. It is important to maintain convenient, appropriate, and sufficient office hours to provide timely access to care. Additionally, requesting a convenient date or time from the patient, and offering at least three appointment dates and times that meet the patient’s criteria can help improve patient satisfaction.
The disproportion between supply and demand not only contributes to a delay in meeting patients’ needs and member dissatisfaction but can also result in quality-of-care issues that may be detrimental to the patient’s health. The demand for any kind of service –appointment, advice, requests for laboratory or radiology results, or leaving a message for a provider – can be predicted over time based on the types of populations served, the scope of the provider’s office practice and the style of each provider in the practice. Analysis of supply and demand data can be used by providers to predict periods of high or low demand. For example, by measuring your supply and demand, you may learn that you need to increase your practice’s hours of operation on certain days of the week, as demand may be higher. Conversely, you may identify that demand is low on other days of the week, which provides an opportunity for you to schedule follow-up types of appointments.
Open same-day appointment slots
To improve patient satisfaction, serve the acute and urgent needs of your patients, and meet the regulatory-mandated access standards, MHS encourages a system of appointment scheduling that allows for same-day access for your patients. To migrate from a fully booked schedule to one with several appointment slots reserved for same-day appointments, monitor the daily requests for urgent visits and reserve multiple slots each day, leaving them unfilled until the afternoon. If the practice is unable to conduct the measurements, employ the quick-start method.
Quick-start method
During the first week, leave two to four appointment slots open each day (evenly divided between late morning and afternoon). These slots should only be given out the same day. Record the time of the day that they fill up. After one week, if the appointments have been regularly filled before 2:00 p.m., add two to four more available appointments. Continue weekly adjustments based on demand. Modify the number of open slots based on days of higher (typically Monday) or lower (often Thursday) demand.
Included under the Resources section are appointment scheduling tips, listed by type, and associated access standards that providers and office staff can reference to help ensure members have appropriate access to providers, as required by regulatory and accreditation agencies.
Improve after-hours access
Directing patients to the appropriate level of care using simple and comprehensive instructions can improve member satisfaction and health outcomes and reduce inappropriate use of emergency room (ER) services. Be sure to discuss after-hours and weekend access to care during your first visit with each patient and at least annually thereafter. This includes access to the Nurse Advice Line, which assists members in obtaining primary care 24 hours a day (refer to the Interpreter and Advice Nurse Services section for more information). If possible, offer a brochure reinforcing your office hours, which hospital the patient should use for emergency care and other details about accessing care after hours.
Included under the Resources section are sample after-hours scripts. MHS created these scripts to serve as a guide for providers to address after-hours requirements. Providers may use these scripts to advise members on how to access after-hours care, or as a training tool or guide for live voice or answering machine messaging. Modifications can be made according to the provider’s needs.
Urgent care center use
Educate patients about how to contact you with urgent care questions after hours and your availability for urgent visits. It is particularly important to review the access to care availability during weekends or holidays, as well as urgent care appointment access standards.
Your patients should:
- Seek care from their primary care physicians (PCPs) (if applicable) if they have conditions that require prompt attention but do not pose an immediate, serious threat to health or life.
- Inform you of any urgent care or ER visits they have had so you may provide follow-up care within a few days of the urgent care or ER visit.
- Call their physician’s office to determine whether to go to the emergency room. Another option for members is to contact MHS at 1-877-6474848.
Address multiple medical problems
Try to handle more than one medical problem during the visit to help reduce future visits, especially the demand for physical exams. Go beyond the chief complaint by asking patients to list all conditions and concerns at the start of the visit. Providers should try and gather patients’ medical needs, negotiate priorities, and identify whether additional follow-up appointments are needed to address all the patient’s medical problems, concerns, and questions.
- Review the patient’s medical problems.
- Conduct recommended preventive screenings, and schedule or perform preventive services, as appropriate, even when a patient presents for other reasons.
- Address self-management techniques and coping strategies with patients based on their medical needs.
- Schedule quarterly or monthly follow-up appointments before the patient leaves the office.
Decisions to extend the time frame between visits depend on patients’ abilities to self-manage and seek care if and when their conditions worsen, as well as the availability of urgent appointments.
Keep patients informed of the referral and authorization process
Another top challenge to accessing care MHS members cite in patient satisfaction surveys is that care, tests or treatments were delayed while waiting for approval. This information is substantiated by analysis of member grievances where it is evident members get frustrated in negotiating the referral and authorization process for seeing a specialist or obtaining tests or treatment that require prior authorization. When MHS reached out to these members to follow up on their experiences and reasons for dissatisfaction with the referral and authorization, many members stated that the authorization was either delayed or denied, but they did not know why.
In an effort to improve the patient experience, it is important to evaluate the manner and format in which the referral and authorization procedures are communicated to the member, as well as the appropriateness and timeliness of the referral and authorization processes. Providers may consider the following questions to assist in this evaluation:
- Are your communications informing the patients of processes in plain language and at reading levels they can understand?
- Are your communications in patients’ preferred languages?Are you providing language assistance to limited English proficient (LEP) patients to help them understand the communications?
- Are referrals being processed and submitted for approval the same day the need is identified? If not, and there is a lag, is there anything you can do to improve the turnaround time?
- Do you have a process in place to ensure that all referrals are submitted with all required documentation to prevent delays?
- Are you informing the patient of applicable authorization review and decision-making timelines? Additionally, are you explaining to the patient the difference between a regular routine referral and an expedited referral?
If you are a provider delegated for utilization management processes, it is also important that you evaluate your practice’s authorization review and decision-making processes and timelines, including what processes you have in place to try to prevent unnecessary delays. Addressing any needed areas of improvement in the specialist and ancillary care referral system and authorization process will increase member satisfaction.
Interpreter and Advice Nurse Services
Access no-cost interpreter services
Interpreter services are available to both providers and members at no cost, 24 hours a day, seven days a week, 365 days a year. These services ensure access to qualified interpreters trained in health care terminology and a wide range of interpreting protocols and ethics, as well as support to address common communication challenges across cultures.
Providers are responsible for using interpreter services resources to provide qualified interpreters to members who require or request them. To meet language services’ established requirements, providers must:
- Ensure LEP patients are not subject to unreasonable delays in the delivery of services.
- Not require or encourage patients to use family or friends as interpreters. The use of minors as interpreters is prohibited by state and federal regulations, unless used in an emergency.
- Provide interpreter services at no cost to patients.
- Extend the same participation opportunities in programs and activities to all patients regardless of their language preferences.
- Ensure that services provided to LEP patients are as effective as those provided to others.
- Record the language needs of the patient in the medical record.
- Document the patient’s request for or refusal of interpreter services in his or her medical record, including the patient’s request to use a family member or friend as an interpreter.
Nurse Advice Line
The Nurse Advice Line assists members in obtaining primary care and is available 24 hours a day. The program offers services in conjunction with the PCP’s services and does not replace the PCP’s instruction, assessment, and advice.
According to community access-to-care standards, all PCPs must provide 24-hour telephone service for urgent and emergency instructions, medical condition assessment and advice. The program allows registered nurses (RNs) and other applicable licensed health care professionals to assess a member’s medical condition and, through conversation with the caller, take further action, provide instructions on home-care techniques, and offer general health information.
The Nurse Advice Line services are provided in a timely manner appropriate for the member’s condition, and the triage or screening wait time does not exceed 30 minutes. Physicians may direct members to contact the Nurse Advice Line through the MHS Member Services at 1-877-648-4848 or the number found on the back of the member’s medical card.
Resources
Appointment Scheduling Tips
Help Managed Health Services (MHS) members obtain health care services in accordance with access standards as required by the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA).
PCPs and Specialists
| Appointment Type | Appointment Standard |
|---|---|
| Urgent care appointments with PCPs that do not require prior authorization | Within 48 hours of request |
| Urgent care appointments with specialist that do not require prior authorization | Within 48 hours of request |
| Non-urgent appointments with PCP | Within 10 business days of request |
| Non-urgent appointment with specialist | Within 15 business days of request |
| Physical exams and wellness check appointment | Within 30 calendar days of request |
| First prenatal appointment with PCP | Within 10 business days of request |
| First prenatal appointment with specialist | Within 10 business days of request |
| Well-child visit with PCP | Within 10 business days of request |
Ancillary Services
| Appointment Type | Appointment Standard |
|---|---|
| Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition. | Within 15 business days of request |
Behavioral Health Services
| Appointment Type | Appointment Standard |
|---|---|
| Access to non-urgent appointment with physician (psychiatrist) for routine care | Within 15 business days of request |
| Access to non-urgent appointment with nonphysician behavioral healthcare provider | Within 10 business days of request |
| Access to urgent care (psychiatrist) | Within 48 hours |
| Access to urgent care (non-physician) | Within 48 hours |
After-Hours Access
| Appointment Type | Appointment Standard |
|---|---|
| Emergency care | Call 911 or go to the nearest emergency room |
Clinical: Appointments for members for covered health care services shall be within a time period appropriate for their individual condition. All providers must offer hours of operation that are no less than the hours of operation offered to commercial and fee-for-service patients.
Primary Medical Provider (PMP) After-Hours Access
Members should be able to access PMPs 24-hours-a-day, seven-days-a-week, for urgent and emergent health care needs, regardless of a holiday. Therefore, PMPs must have mechanisms in place to ensure that members are able to make direct contact with their PMP or the PMP’s clinical staff person through a toll-free member services telephone number 24-hours-a-day,
seven-days-a-week.
PMPs are deemed available to provide services if they:
- Answer the phone themselves, or designate an employee
- Hire an answering service, or
- Use a pager system to facilitate members’ contact with an on-call medical professional 24-hours-a-day, seven-days-a-week.
To be considered compliant, PMPs must also provide instruction for life-threatening situations in all above situations. The PMP must provide appropriate direction to the member to contact 911 or the nearest emergency department.
After-Hours Sample
One of the following scripts may be used by physicians and medical groups as a template to ensure MHS members have access to timely medical care after business hours or when your offices are closed.
Important: Effective telephone service after business hours ensures callers can reach a live voice or answering machine within 30 seconds.
I. Calls answered by a live voice (such as an answering service or centralized triage):
If the caller believes that he or she is experiencing a medical emergency, advise the caller to hang up and call 911 immediately or proceed to the nearest emergency room/medical facility.
If the caller believes the situation is urgent or indicates a need to speak with a physician, facilitate contact with the physician by doing one or more of the following:
- Put the caller on hold momentarily and then connect the caller to the on-call physician.
- Get the caller’s number and advise him or her that a physician will return the call within 30 minutes (immediately send a message to physician).
- Give the caller the pager number for the on-call physician and advise the caller that the physician will call the member within 30 minutes or direct the caller to the nearest urgent care center location.
- If a caller indicates a need for interpreter services, facilitate the contact by accessing interpreter services.
Examples:
Hello, you have reached the <answering service/centralized triage> for Dr. <Last Name>. If this is a medical emergency, please hang up and dial 911 immediately or go to the nearest emergency room. If you wish to speak with the on-call physician, please stay on the line and I will connect you.
Hello, you have reached the <answering service/centralized triage> for Dr. <Last Name>. If this is a medical emergency, please hang up and dial 911 immediately or go to the nearest emergency room. If you wish to speak with the on-call physician, Dr. can assist you. Please <page/call> him/her at <telephone number>. You may expect a call back within 30 minutes.
II. Calls answered by an answering machine:
Hello, you have reached <Name of Doctor/Medical Group>. If this is a medical emergency, please hang up and dial 911 immediately or go to the nearest emergency room. If you wish to speak with the on-call physician (select appropriate option):
- Please hold and you will be connected to Dr. <Last Name>.
- You may reach the on-call physician directly by calling <Telephone Number>.
- Press <number> to transfer to our urgent care center. Our urgent care center is located at (appropriate language options should be provided for the location).
- Press <number> to page the on-call physician. You may expect a return call within 30 minutes.
Examples:
Hello, you have reached the <Name of Doctor/Medical Group> for Dr. <Last Name>. If this is a medical emergency, please hang up and dial 911 immediately or go to the nearest emergency room. If you wish to speak with the on-call physician, please leave a message with your name, telephone number and reason for calling, and you may expect a call back within 30 minutes.
Hello, you have reached <Name of Doctor/Medical Group>. If this is a medical emergency, please hang up and dial 911 immediately or go to the nearest emergency room. If you wish to speak with the on-call physician, you may reach him/her directly by calling <telephone number>, or press <number> to page the on-call physician. You may expect a call back within 30 minutes.