Improving Continuity of Care through Care Team Integration, Empanelment, and Open Access Scheduling at Dena’ina Health Clinic

Josh J. Huhndorf, Project Coordinator, and Tim Scheffel, DO, Medical Director, Dena’ina Health Clinic, Kenai, Alaska

One of the four priorities of the Indian Health Service is to improve the access to and quality of care for Alaska Native and American Indian beneficiaries. Patients with a designated health care provider and care team can build an effective relationship, and that results in higher quality of care; however, access barriers can undermine that relationship. Development of care teams, empanelment of patients and their families to those care teams, and advanced access scheduling can, if implemented properly, improve continuity of care and provide the level of access necessary to deliver higher quality care. This has been the goal of Dena’ina Health Clinic, and this article describes the journey we are taking to create the relationships that are at the heart of high quality health care.

Dena’ina Health Clinic has 2,700 active patients, three FTE providers, and four nurses. In previous years the clinic provided mostly episodic care, but from January to June 2010 we made substantial gains in transitioning to the planned care model by implementing completely empanelled care teams and open access scheduling.

Our process is described in Figure 1. The first step was to organize our clinic practice into three care teams. Next we empanelled patients to these care teams by dividing our patient population into three even quantities, which were distributed alphabetically by last name. Patients were allowed to override the assignment and change to a provider of their choice. The electronic health record was queried to determine the volume of empanelled patient visits per month, and patients were identified by their designated provider panel in the electronic health record. Continuity was determined by calculating the ratio of the total number of patient visits per panel and the number of patients seeing their empanelled provider.

Figure 1. Steps taken to increase continuity of care

We monitored continuity of care and visit volume from January to June 2010, reporting results to the care teams regularly. Continuity of care for the care teams ranged between 18% and 45% in January. In June, continuity of care ranged between 71% and 83%. The overall increase in continuity over the six month period was 121%. During that same period total patient volume fell by 16%. See Table 1 for detailed results.

The rapid increase in continuity demonstrated in Table 1 is attributable to complete care team empanelment and advanced access scheduling. We see this trend beginning with the point of complete empanelment (February) and accelerating with the implementation of advanced access scheduling (May). During this same sixmonth period, utilization of the overflow walkin provider decreased by 40%, suggesting that the improved continuity with the care team did not come at the cost of access to care. We also note an inverse correlation between the continuity trends and the overall patient volume. While we suspect that the decreased visit volume is the result of seasonal variation or improved continuity, we find it remarkable that, regardless of monthly demand fluctuations, the continuity figures indicate that patients are being seen by their appropriate provider at an increasing rate.

Total empanelment alone does not resolve all continuity and access issues. We observed a disparity in provider availability when schedules completely filled days in advance, resulting in a spillover of excess daily panel volume to other providers, thus reducing our continuity rates. The implementation of advanced access scheduling opened up appointments for same day access, significantly diminished our noshow rate, and increased our overall availability of appointments. In order for this to work, we had to limit the amount of appointments scheduled in advance to four per provider, with more permitted for inordinate circumstances.

Overall we are very pleased with the increased continuity and access to care that these changes have brought to Dena’ina Health Clinic and believe that the strengthened relationships that have resulted build a strong foundation for health.

1. Mainous AG, Baker R, Love MM, et al. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Fam Med. 2001 January;33(1):22–27.
2. Continuity of Care, Definition of Policy & Advocacy American Academy of Family Physicians. Home Page American Academy of Family Physicians.
3. Roubideaux Y. Update on Director’s Priorities. Letter to All IHS Employees. 2 Dec. 2009. Indian Health Service. U.S. Department of Health and Human Services.