Offer Urgent Care Appointments

Establish a mechanism for offering an urgent care appointment within 24 hours of a patient calling your clinic.

Best practices:

1. Create an effective intake and phone triage system for urgent issues

To ensure urgent calls get addressed in an appropriate timeframe, it is important to create a defined intake and phone triage workflow for your clinic.

  • Tip 1: Ensure each step along the intake and triage pathway is mapped out. An effective workflow will adequately address:
    • How urgent calls/messages are received. For example, what phone number should patients be using for urgent issues? Who is answering the phone? Who should be answering the phone (i.e., should it be someone with clinical expertise or knowledge of inflammatory bowel disease)?
    • How urgent calls/messages are responded to. For example, does your clinic have a standard operating procedure to ensure that all urgent calls/messages are reviewed and responded to within a specified timeframe. Most clinics sought to respond to all urgent messages within 1 to 4 hours.
    • What information needs to be collected from the patient to accurately determine how urgent their needs are. Some clinics used a standardized intake questionnaire to help them make this determination. This is especially important if the team member answering the phone is not responsible (or clinically trained) for deciding whether a patient is experiencing an urgent or emergent issue and is simply responsible for collecting the information and passing it onto a different team member who can make that determination.
    • Which team member collects the information from the patient. Most clinics felt it was important to have a team member with clinical training to collect information from the patient.
    • Which team member(s) can make the decision as to whether the patient should go to the emergency room or be scheduled for an urgent care appointment. Most clinics felt that an IBD provider should make this decision.
    • Which team member schedules urgent appointments.
  • Tip 2: Train your schedulers on IBD and how to handle urgent IBD calls. Some clinics found it helpful to hold IBD-specific trainings for staff who are responsible for answering phones and/or scheduling office visits (especially if they are not clinically trained) to ensure understanding of the inflammatory bowel disease population and why they may need access to urgent services.

Examples: 

The Oregon Clinic Gastroenterology East - “Our phone tree is set up with two options: 1. If you are symptomatic, press this button and it will take you to the nursing line and 2. All other calls go to the medical assistant line. The nursing line will ring until someone picks up, but there is an option to leave a voicemail. The voicemail gets checked several times throughout the hour. So, the patient should get a call back within one to two hours.”
Penn State Health - “We have a central phone number, and our nurse navigators carry pagers. So, for an urgent call, the nurse navigator can be reached by page at all times during office hours. This is particularly effective when our patients are trying to get through to our central number. Our voicemail states,  ‘If this is very urgent and you would need a call by the end of the day, please page the nurse navigator.’ The patients have given us great feedback on knowing they can always reach someone. Surprisingly, though, we have found that the pagers are not used much and not abused.”
Regional Gastroenterology - “We have a templated phone interaction for all triage nurses to use across the practice. The template allows us to get a more systematic and qualitative assessment over the phone of how sick someone is and whether they need to go to the emergency room or not. A lot of these decisions are made by a nurse because the medical doctors aren’t immediately available.”
Gastroenterology Associates, Inc. - “We implemented a red-flag for support staff to alert providers that an IBD patient has called with an urgent issue. The criteria for an urgent issue = 1. New, severe abdominal pain, 2. New, severe anal pain, 3. Fever greater than 101 degrees F, and 4. Unremitting emesis = vomiting that does not stop. Patient calls that met any of these criteria were highlighted by support staff with a 'red jellybean,' an oval cue at the top-right corner of eClinicalWorks’ interface. Whereupon clicking the red jellybean, additional details of the phone call is made available for clinical review in a text box labeled 'IBD Urgent.' A gastroenterologist at the office is expected to respond within four hours and provide medical advice directly to the patient or a nurse (who will in turn contact the patient). The red jellybean is inserted by the secretary when they talk to the patient on the phone. The secretary will of course transfer them to an appropriate staff person if they know that person is available, but otherwise they use the jellybean. The red jellybean simply flags the messages as “urgent.” For example, you may be looking through all of your messages, but when you see that red jellybean, you know to check those messages first.”
The Oregon Clinic Gastroenterology South - “We have a general number that patients can call. However, there is an option on the phone to get through to a nurse. Our phone triage nurses start the process.  They get a good assessment of what the issues/problems are and then route that information to the treating physician or another physician.”
Regional Gastroenterology - “We hold an IBD-specific presentation for staff who are responsible for scheduling office visits to ensure understanding of the care/scheduling the IBD population needs and to answer any questions. Most staff found it helpful and gained a better understanding of why these patients are fit into the schedule differently. Most of the people who initially answer the phone, are not nurses. We train them about why the scheduling and phone system is unique for our inflammatory bowel disease patients.”
2. Offer urgent care services to your patients

To prevent unnecessary visits to the emergency room, it is important to have a mechanism in place so that inflammatory bowel disease (IBD) patients with urgent issues can be scheduled to see and/or speak with a provider quickly (within 24  to 48 hours). Most clinics chose to reserve urgent care slots. Although the number of urgent care slots offered varied (depending on preference as well as the number of IBD providers and volume of IBD patients), most clinics chose to reserve at least one urgent care slot in one IBD provider’s schedule per week.

  • Tip 1: So long as you can see a patient with urgent issues within 24 to 48 hours, use whatever urgent care mechanism that works for your clinic – whether it is reserving urgent care slots or simply overbooking a provider’s schedule. Every clinic is different – so work with what you have.
  • Tip 2: Test different days and times to find the time slot(s) that works best for your clinic and your patients. Most clinics found greatest success holding urgent care slots in the middle of the week and in the late morning or early afternoon.  Holding urgent care slots later in the day gives your team time to return urgent phone calls/messages and schedule urgent appointments.  
  • Tip 3: It doesn’t have to be a medical doctor who sees patients with urgent issues. Make sure that you are utilizing each team member and that everyone on your team is working up to their license.  Several clinics had their advanced practice providers (i.e., Nurse Practitioners or Physician Assistants) be responsible for holding urgent care slots or seeing patients with urgent issues. 
  • Tip 4: Try using telehealth. Many clinics found great success in using telehealth as a means of providing urgent care services rather than strictly using in-person urgent care slots.  
  • Tip 5: If possible, try to get labs done before having someone come in for an urgent care slot.  By doing so, you may prevent the patient from having to come in at all.
  • ​​​​​​​Tip 6: Develop a policy for when you can convert an urgent care slot to a regular clinic slot/appointment. There may be times when the urgent care slot(s) go unused, therefore, some clinics found it helpful to adopt a policy whereby if the urgent care slot was not being used the day before (or a few days before), the scheduler was allowed to convert it into a regular clinic slot/appointment.
  • ​​​​​​​Tip 7: Train staff responsible for scheduling urgent care appointments on why it is important for keeping urgent care slots open and when an urgent care slot can be converted into a regular clinic slot/appointment.
  • ​​​​​​​Tip 8: Do your best to convince administration on the importance of holding urgent care slots open for IBD patients experiencing urgent issues. Many clinics found it extremely challenging to keep urgent care slots open – especially if they go unused (i.e., do not generate revenue). Some clinics had success convincing administration by presenting: the reasons why it is important to have this urgent care mechanism for the IBD population, how you intend on measuring usage of the urgent care slots over time, and a plan for releasing urgent care slots before they go unused.

Examples: 

The Oregon Clinic Gastroenterology East - “We trialed 2 slots per day for six months. The first slot was being used 100% of the time, and the second slot was used only 30-40% of the time so we transitioned back to one urgent care slot. The practice has always pushed back on the IBD team saying, ‘Well we want to fill that slot with a non-urgent IBD patient if possible.’ We had two, and they weren’t being used 100% of the time, so we compromised and went back down to one. It is a trade-off you do with your managing partner.”
Penn State Health - ​​​​​​​“When it comes to urgent care, we do have a nurse practitioner. We have intentionally kept her schedule with open spaces on Tuesdays and Thursdays so that she can see urgent patients. We were finding that on Mondays, slots were not being filled. Thursdays allow us to schedule a necessary procedure (ex. colorectal surgery, imaging, etc.) the next day (i.e., Friday).”
Spectrum Health - “Initially, we had the urgent care slot earlier in the day, and that did not work well because you often needed that morning to contact/get-in-touch-with that person. Therefore, later in the afternoon worked better; and sometimes after 1:00 pm works even better. If the patient is trying to avoid the emergency room over the weekend, they will likely call at some point on Monday. Therefore, having the appointment on Tuesday works well because you can just schedule them for the next day.”
Cedars-Sinai Medical Center - “We started with a half-day on Monday. We picked Monday intentionally because if we happened to handle a semi-urgent call over the weekend, we could potentially avoid a hospital admission. However, we realized that if someone called on a Tuesday, they would have to wait a whole week. Therefore, we added another one on Thursday. Then we realized that the rapid access clinic was not being fully used. So, we evolved our system. Since our nurse practitioner has availability in her schedule to see patients nearly every day, it does not require us to have a dedicated urgent care slot available. I think urgent care slots are the better solution if you are very resource-constrained.”
MedStar Health - “I don’t know if there is a magic number of urgent care slots necessarily, it is something that is rather fluid. I think it is reasonable to start off with a handful of slots per provider per week, and then go from there. I have 6 to 9 urgent care slots available over my Tuesday/Wednesday clinic.”
Penn State Health - “Since COVID happened, we have been able to use telemedicine. As a result, I have added what I call a telemedicine noon slot. It is amazing how it reassures the patient and allows us to do triaging as well. Telemedicine can be billed now. If I only have a morning clinic scheduled, and I add a 1:00 pm appointment, within the system it looks like I opened an afternoon clinic with one spot and the rest are empty. So, scheduling the telehealth visit at noon prevents it from looking like I opened an afternoon clinic. This has worked particularly well. There are disadvantages to telemedicine – no physical exam, we can miss things, there are some things that could be lost in translation. But it has been a game-changer. It is pretty much filled every single week. I have some patients who come from 2.5 hours away…so they are loving this. Noon slots work well because patients can have an appointment with us during lunch and disrupt their workday less.”

Resources:

 

This project is supported by a grant from The Leona M. and Harry B. Helmsley Charitable Trust.

 

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