Results Summary
What was the research about?
Community health centers, or CHCs, often want to improve access to care so that patients can get health care easily. Improved access includes patients getting appointments when needed, without a long wait.
In this study, the research team looked at appointment scheduling at seven CHCs in Indiana. The team learned from community members that the biggest problems patients had in getting access to care were
- Not being able to get appointments when needed
- Long wait times between calling the CHC and getting an appointment
The team used computer simulations to create new ways of scheduling appointments. They custom-made solutions to test at three of the CHCs.
What were the results?
Two of the three CHCs that used new ways of scheduling had positive changes in patient appointments. The first CHC had shorter appointment wait times and fewer patient cancellations. The second CHC had more same-day appointments and shorter appointment wait times. However, this clinic also saw slightly fewer patients per hour.
Among the four clinics that did not test new scheduling practices, three also saw changes. The first CHC had slightly more same-day appointments and slightly fewer patient no-shows. However, the second CHC had fewer same-day appointments and more patient cancellations. The third CHC had longer appointment wait times.
Who was in the study?
The research team worked with seven CHCs in Indiana. The CHCs served patients from different racial and ethnic backgrounds with and without health insurance.
What did the research team do?
To find out what made it hard for patients to get appointments, the research team worked with patients and CHC staff and clinicians. The team used appointment-scheduling data from electronic health records and computer simulations to suggest new strategies for each CHC. With these data, the team created new ways of scheduling appointments.
The team picked three of the seven CHCs to start scheduling appointments using the new strategies. The other four kept scheduling appointments the same way they did before. After six months, the team looked at each of the seven clinics to see if there were changes.
Patients, clinicians, and a group that represents clinics in Indiana helped design and conduct the study.
What were the limits of the study?
Each CHC used a different way to schedule appointments. As a result, it is hard to know which scheduling methods helped people get better access to care. Future research could look at different ways to improve access to care.
How can people use the results?
CHCs could use computer simulations to identify problems and help tailor solutions when considering ways to improve access to care.
Professional Abstract
Objective
To modify appointment-scheduling practices in community health centers (CHCs) to reduce barriers and enhance access to care
Study Design
Design Elements | Description |
---|---|
Design | Pre- and postintervention comparison |
Population | 7 CHCs in Indiana |
Interventions/ Comparators |
|
Outcomes | Access to care: percentage of same-day appointments, appointments with lead time equal to or greater than 28 days, patient no-show rates, patient cancellations, provider productivity (number of patients seen per scheduled provider hour) |
Timeframe | 36-month follow-up for study outcome |
This pre- and postintervention comparison study examined how implementing new appointment-scheduling practices affected access to care. The research team recruited seven CHCs in Indiana that serve racially and ethnically diverse patients with and without insurance.
First, the research team worked with patients, clinic staff, clinicians, and CHC administrators to understand the challenges in providing and receiving needed care. They identified appointment availability and wait times as the highest priority problems. Next, the team used computer simulations of various appointment-scheduling scenarios to identify the critical access factors and to evaluate the effects of potential new appointment-scheduling practices.
The research team selected three of seven CHCs as intervention clinics. The remaining four clinics continued with their usual appointment-scheduling practices. Each intervention CHC selected a set of scheduling practices to improve access to care, customized for the specific CHC.
Before implementation and six to eight months after adoption of the strategies, the research team used administrative and electronic health record data to assess outcomes, including same-day appointments, appointments with a 28-day or longer lead time, patient no-show rates, patient cancellations, and provider productivity (patients seen per scheduled provider hour).
The Indiana Primary Health Care Association, patients, and clinicians provided input during the study.
Results
Intervention CHCs: Two of the three intervention CHCs had significant changes. One clinic showed increased same-day appointments (22% to 41%, p=0.004) and decreased appointments with a lead time of 28 days or more (15% to 6%, p=0.019). The second clinic had decreases in appointments with a lead time of 28 days or more (50% to 34%, p=0.004) and patient cancellations (17% to 15%, p=0.004). However, this clinic also had a slight decrease in productivity (2.5 patients seen per provider hour to 2.1 patients per hour, p=0.004).
Control CHCs: Three of the four control CHCs had significant changes. The first clinic had improvements in same-day appointments (23% to 24%, p=0.02) and patient no-show rates (13% to 12%, p=0.025), although of low magnitude. The second clinic had decreased same-day appointments (41% to 38%, p=0.018), increased patient cancellations (14% to 18%, p=0.016), and reduced productivity (2.02 to 1.79 patients per hour, p=0.015). The third clinic showed an increase in appointments with a lead time of 28 days or more (9% to 11%, p=0.026).
Limitations
The CHCs had competing initiatives, and each intervention clinic implemented its own strategy to improve access to care. The research team did not compare results between the intervention and control clinics.
Conclusions and Relevance
In this study, patient-centered redesign methods and simulation modeling helped clinics identify areas for improvement and develop alternative interventions. Findings suggest that use of these interventions may help CHCs improve access to care.
Future Research Needs
Future research could build on the techniques used in the study to evaluate different approaches to facilitating access to care in CHCs.
Final Research Report
View this project's final research report.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers observed that the study did not focus on addressing which strategies are effective for enhancing access but instead on finding strategies that patients and other stakeholders identify as important or promising. The researchers agreed that their focus was to find patient-centered strategies to improve access to care. Rather than find the most effective strategies, the researchers wished to identify a collection of useful strategies. They removed the word, effective, from the research question.
- Reviewers also noted that the second research question, which regards the Delphi panel approach and modeling to identify the best strategies and policies, did not involve any evaluation that could actually test whether the best strategies were identified. The researchers acknowledged that the work on this research question did not involve a test of healthcare strategies but rather used an iterative process to derive the best strategies based on expert opinion.
- Reviewers noted that the study did not completely implement the culture-change intervention although it seemed to hold promise as a feasible and impactful strategy. The researchers explained that completing the culture-change intervention would take years, but even so, they felt the study was of value in providing a structured approach that helped clinics start the process.
Conflict of Interest Disclosures
Project Information
Key Dates
Study Registration Information
^ Bradley Doebbeling, BS, MD, MS was the original principal investigator for this project.