Welcome to the AETC NCHCMC Webinar January 31, 2012
To join the teleconference call 1-‐877-‐668-‐4493 and enter the event number 668 246 315. If you are prompted for an access code, please press #. This webinar will be recorded and posted in the Virtual Learning Lab. Users must seek permission from the author of these slides if you wish to use them in your own presenta5on.
Improving Access; What’s it All About? Catherine Tantau, BSN, MPA
Welcome! Schedule of Webinars 1. 2. 3.
Jan 17 Pre-‐work Review, Baseline measures Jan 24 Coaching Q and A Jan 31 AA: What’s it all About? IntroducRon to Advanced Access 4. Feb 7 Coaching Q and A 5. Feb 14 AA: How to Make it Work Part 1… Matching Demand and Supply 6. Feb 21 Coaching Q and A, discussion 7. Feb 28 AA: How to Make it Work Part 2… Backlog Reduc5on 8. Mar 6 Coaching Q and A 9. Mar 13 AA: How to Make it Work Part 3… Final High Leverage Changes 10. Mar 20 Closing Remarks and Ac5on Planning
copyright Tantau Associates
3
Objectives • Recognize the Gold Standard for Appointment access. • Learn the characteris5cs, piValls and benefits of three Access models.
The Messenger Challenge‌
Your Resources… • Presenta5ons • Advanced Access Informa5on Series – AA; What’s in it for Me? – What is Advanced Access? • Ar5cle: Accessing Pa:ent Centered Care Using the Advanced Access Model, Catherine Tantau, Journal of Ambulatory Care Management • PCMH
What if….
…you could offer your paRents an appointment with the physician of their choice at a Rme that was convenient for them?
“I had to think about this for awhile before I jumped in. I realized everything in medicine has changed steadily constantly looking for better ways to diagnose and treat patients. But, office flow has stayed the same for 50 years. It is about time we pay attention to it “ Waiting list of 4 months for 26 years. Eliminated in four months— 50% now booked same day, 50% next day “Minor changes in flow can help greatly with a very busy schedule.” 3rd next available 15 days to 5 days in 4 months.
“I have seen that it works in other places so we have adapted the principles in our service.” Achieved access goals in 5 months.
Access
An access problem is‌ Delay problem System property
The longer patients/families wait, The harder we work‌. Established Patient Calls (Most) PCP Receptionist (4) #
New Patient Calls
(1/wk/MD)
Switchboard Admin. - Q & A - Page Pedi MA - Assist patient
Hold Busy
Answer N.A.
recept
Appt. req.
Bounce to others when PCP recept. fall
Note: - No triage on phone - Occas. triage walk in
Check insur. & confirm on 2 systems new patients longer
Q & A Sick?
Not sure +
-
- Book it w/PCP - Overflow MD if walk in when avail
Next avail. w/PCP
Mesg. To MD min. -hours or lost
MD calls patient Q & A
+ Book it
30" hrs.
Advise
Note: Always see pts.
Appt.
Emerg. - ED
Admin. to resolve - non PCP - 1st available
- Add on sooner - Occas. Msg to MD or
Advanced Access AA is… • No delays for an appointment. • CONTINUITY for paRents and providers. • Doing today’s work today
AA is Not… • Holding appts in anRcipaRon of same day urgent demand. • A Walk in Clinic or Urgent Care Clinic. • 100% open schedule each day • Telling pts to all back tomorrow
Advanced Access is the ability of a practice to…
…Offer paRents/families an appointment with the provider of their choice at a Rme that is convenient for them.
Start with an Aim The Gold Standard
Primary Care
Offer an appointment today for any problem (urgent or rou5ne) with the PCP or teammate in the absence of the PCP.
© Tantau & Associates.com
Feeling overwhelmed?
Gold Standard; Why Today ????
• • • •
Constant tension between medical definiRon of Urgent and paRent definiRon. Nice for pts. TransformaRve for the prac5ce Room to grow prac5ce TODAY. Compe55ve advantage
16
Advanced Access
NUMBER OF CALENDAR DAYS UNTIL 3RD APPT
2/28/06
1/31/06
12/31/05
11/30/05
10/31/05
9/30/05
8/31/05
7/31/05
6/30/05
100 80 60 40 20 0
5/31/05
• Innova5ve model • Primary, specialty care x 15 years. • System wide applica5ons
Source: Providence CHC
PEDI OB/GYN I MED
Capitol Hill CHC - Providence, Rhode Island Decrease No Show rate CHHC NO SHOW RATE 2005-2006
AP RIL MA Y JU NE JU AU L Y GU ST OC SEPT T NO OBE R VE DE MBE CE R MB E JA NU R A FE BR RY UA R MA Y RC H AP RIL MA Y JU NE JU LY Au g Se pt Oc t No v De c
35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%
PEDI OB/GYN I MED
Delay
What’s a “3rd Next Available”?
rd 3
next available appt…
• Anchor Measure for Access • Delay for a Rou5ne Appointment • 3rd more reliable indicator of access
3rd NEXT AVAILABLE PHYSICAL Carillion 3rd NEXT AVAILABLE PHYSICAL Medical Group 1 Carillion Medical Group Team Team 1 160
140
120
What’s a “3rd Next Available”?
100
80
HARCUS LEWIS PRINCE STAMBAUGH YOUNG ZIMMER
60
40
9/18/02
9/11/02
9/4/02
8/28/02
8/21/02
8/14/02
8/7/02
7/31/02
7/24/02
7/17/02
7/10/02
7/3/02
6/26/02
6/19/02
6/12/02
6/5/02
5/29/02
5/22/02
5/15/02
5/8/02
4/24/02
4/17/02
0
5/1/02
20
3rd Next Available Appointment (Standard Project Measure) Everett Clinic Team 30.0 25.0
Day s
20.0 15.0 10.0 5.0
1
0.0 12/1/2002 3/1/2003 7/1/2003 9/29/2003 11/11/2003 10/1/2002 1/15/2003 5/1/2003 9/1/2003 10/22/2003 1/1/2004 Month [Family Practice]
[Internal Med]
[Peds] 22 Â
Radiology Mammo 3NXA Appt
30 Days
20 10 0
6/9/03 6/23/03 7/7/03 7/21/03 8/4/03 8/18/03 9/2/03 9/15/03 10/6/03
Critical Access Design Elements 1. Con5nuity / familiarity 2. Appointment capacity 3. Demand and Supply equilibrium
1. Continuity Satisfaction Ratings Comparison of Provider Ratings (Qs 56- 65) by Demographics 1996 90
100 Ethnicity
Gender
80
Age
Educ
Health Status
Care Type
# of Visits
Tenure
Range PCP
90
Familiar Stranger
70
60
50
70
40 60
30
50 20
10
Am Africian Hispani White Indian Am. c
Range
19.8
21
23.3
PCP
78.5
81
79.5
Familiar
71.9
75
69.1
Stranger
58.7
60
56.2
Other Asian
Other
Male
Female
< 18
18-34
35-44
45-64
65+
LT 12
H School
PostSec.
College G.
Grad Sch.
Poor
Fair
Good
V. Good
1
2-3
4-5
6+
LT 1
1-2
3-5
6-10
11+
20.5
22.9
23.3
22.7
22.1
20.6
22.1
27.2
18.4
19.3
16.6
14.5
19.7
22.3
22.1
21.4
20.6
21.6
21.9
22.5
21.9
22.2
19.5
20.7
21.4
20.7
16.6
16.7
20.3
22.1
24.1
21.5
23.6
22.2
21.24
20.14
84
72
75.7
80.8
71.3
80
82.6
81.4
85.7
73.4
79.3
81.5
82.3
78.1
80.7
82.9
81.4
84.4
76.6
74.5
77.5
83.8
88.3
81.4
82.4
83.8
79.6
78.4
78.9
81
82.2
83.2
80.9
80.8
80.1
81.99
82.67
78
64.5
67
70.5
61.4
72.8
76.3
74.8
71.1
70.3
73.2
78.9
82.2
73.8
73
75.6
75.4
78.7
73.4
70
71.8
76.9
79.4
77.1
75.6
79.8
70.3
75.4
73
74.5
75.4
76.3
70.1
69.3
72.8
75.45
77.98
63.4
51.5
52.8
57.5
48.6
57.9
62
59.3
58.5
55
60
64.9
67.8
58.4
58.4
60.8
60
63.8
55
52.6
55
61.9
66.1
61.9
61.7
62.4
58.9
61.8
62.2
60.7
60.1
59.1
59.4
57.2
57.9
60.75
62.53
20.6
Chines Japane Filipino e se
ŠTantau & Associates
Excelle Prevent Contin Emerg Routine Urgent nt ive uing ency
40
%VG/EX
Range (Max_Min)
80
What is Continuity? The rate at which patients see their PCP when coming in for primary care visit. • Con5nuity decreases: • Hospitaliza5ons and LOS • ER visits • UC visits • Referrals • RX’s • Tests • Demand for appts.
• Con5nuity increases: • Pt, provider and staff sa5sfac5on ©Tantau & Associates
2. Capacity (appt supply) % Open Next Four Weeks
45% 40% 35% 30%
Dr. S
25%
Dr. T Dr. V
20% 15% 10% 5% 0% Sep-99
Oct-99
Nov-99
Dec-99
Jan-00
Appointment Availabilityâ&#x20AC;ŚCapacity Family Medicine Clinic Average Percentage of Appointments Open at 8:00 a.m. 60%
51%
48%
50%
56%
49% 46%
40%
33% 30%
35% 29%
28%
20%
42%
40%
37%
18% 10% 7%
7%
Dec-00
Nov-00
Oct-00
Sep-00
Aug-00
Jul-00
Jun-00
May-00
Apr-00
Mar-00
Feb-00
Jan-00
Dec-99
Nov-99
Oct-99
Jul-99
ŠTantau & Associates
Sep-99
4%
0%
Aug-99
10%
Patient / Physician Continuity Family Medicine Patient / Provider Continuity 90%
80%
75%
77%
75%
70%
70%
66%
77% 69%
69% 66%
60%
60%
70%
65%
60%
50%
53%
40%
36% 30%
20%
24%
17% 14%
10%
0% Jul-99
ŠTantau & Associates
Sep-99
Nov-99
Jan-00
Mar-00
May-00
Jul-00
Sep-00
Nov-00
Jan-01
#3 Demand and Supply Equilibrium • No Shows • Triage • Rework • Call backs • Messages • Testing • Rx’s
Demand
DELAY
Evidence of a stable reservoir ???
Supply
Access Continuum • Tradi5onal Model • Carve Out Model • Advanced Access Model
Traditional Model • Saturated schedules • Triage & rework; expensive resources (MD and RN) • Mul5ple appointment types, 5mes • Urgent , Rou5ne juggled • Capacity: Overbook, over there • Con5nuity: sacrificed, delayed
Carve Out Model • Smoller’s formula • Predict demand for Urgent • Reserve space for Urgent demand (carve out) • Rou5nes delayed; no space for intermediate care • Con5nuity: fair to poor • Capacity: Future filled or held
Carve Out Model Flaws • “Call back tomorrow” • Black market • Self – destruct “Do some of today’s work today”
Advanced Access • Paradigm shio: No dis5nc5on between Urgent & Rou5ne • Evidence of stable reservoir • Backlog eliminated (good vs. bad) • Con5nuity: System property • Capacity: Future is open not held • Pull into today vs push in to future
Advanced Access • Fears: – Saturated schedules – Demand is insa5able – Panel size • PiValls: – Panel size – Supply side varia5on “Do today’s work today.”
Traditional and Carve-outs In order to protect today, we push work to tomorrow.
Advanced Access In order to protect tomorrow, we pull work into today.
Results of Advanced Access • Reduced delays for appointments • Decreased Urgent Care and ED visits • Improved con5nuity for pa5ents and providers • Improved clinical outcomes • Enhanced compliance with guidelines • Reduced No Show rates • Growth opportuni5es and financials • Increased pa5ent, physician and staff sa5sfac5on.
ŠTantau & Associates
5/1/00
4/17/00
4/3/00
3/20/00
3/6/00
2/21/00
2/7/00
1/24/00
1/10/00
12/27/99
12/13/99
11/29/99
11/15/99
11/1/99
10/18/99
10/4/99
Days
Delay Reduced
3rd Next Avail. Appt. for PE Appt. with PCP
30.0
25.0
20.0
15.0
10.0
5.0
0.0
IPC2 White Earth source: Lori Sampson
Apr 17-21
Mar 13-17
Feb 14-18
Jan 17-21
Dec 20-24***
Nov 22-26
Oct 25-29
Sept 27-Oct 1
Aug 30-Sept 3
Aug 2-6
10 9 8 7 6 5 4 3 2 1 0 June 28 - Jul 2
May 31-June 4
April 26-Apr 30
Mar 29-Apr 2
Before Advanced Access
Mar 1-5
Feb 1 - 5
Jan 4-8
Dec 7-11
Nov 9-13
Delay for Appointments Wisconsin Group 1 Days to 3rd Next Available Appointment
After Advanced Access
Target Level
Days til 3rd Available Routine Appointment
ŠTantau & Associates
Emergency Department Visits ER Visits per 1000 Patients in Panel 20 18 Group 2
16 14 12 Group 1
10 8
Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Wisconsin Group ŠTantau & Associates 54% 53%
Delay dropsâ&#x20AC;Ś No Show rate drops
Source: Emory
Improved Clinical Outcomes 2000 1Q
120% 110% 100% 90% 80%
97%
97%
94%
88%
99%
98%
96% 88%
1999 Q4
86%
86%
93%
70% 60% 50% 40% 30%
1998 Q4
20% 10%
Lipids Colorectal BP - diag. Tetanus Influenza Pneumovax Breast Ca Cervical Ca Tobacco Use Tobacco users advice % of serv. Complete
©Tantau & Associates
1998 Q 4 59% 50% 88% 50% 52% 65% 69% 76% 70% 93% 60%
1999 Q4 92% 74% 100% 80% 100% 92% 70% 95% 97% 90% 87%
2000 Q1 88% 97% 94% 97% 96% 88% 86% 98% 99% 86% 93%
Complete
% of serv.
advice
Tobacco users
Tobacco Use
Cervical Ca
Breast Ca
Pneumovax
Influenza
Tetanus
BP - diag.
Colorectal
Lipids
0%
Interventions: v Health prompt v Continuity v Advanced Access
Change in Visit Utilization
April 1995-March 1997 Sacramento
250,000
2.250
Visits
194,305 170,746
200,000
2.200
Visit Rate
Visits
2.150
150,000
100,000
Impaneled Members
2.100
83,867
86,896
(-8.3 %)
50,000 End Year 1
Visits / Impaneled Member
2.050
End Year 2 1.950
4/95 to 3/96
4/96 to 3/97 Year
ŠTantau & Associates
Avg. # Impaneled
2.000
Initiated Second Generation
-
Primary Care Visits
“Over and Under” Appointments
©Tantau & Associates
Getting Startedâ&#x20AC;Ś
The Big Picture: High Leverage Changes for Access Improvement • Balance demand and supply daily • Reduce backlog • Decrease appointment types, 5mes • Develop con5ngency plans • Reduce demand for visits • Op5mize the Care Team
Tools for Next Steps
Low Risk, High Impact Tools for Next Steps…. • Set an Aim…start thinking about this! • Measure Delay; 3rd Next Available RouRne appt. • Measure Appt Demand and Supply for each Provider
Tool #1: How to Measure Delay for 3rd next available appt. • • • • • • • • • • •
Anchor Measure for Access Delay for a RouRne Appointment for each Provider Number of calendar days to third next available rou5ne appointment. Pick appt type or length most delayed (physical?) to track Or, measure Long appts and Short appts. If that is more meaningful to you. 3rd Next Available a reliable reflec5on of system’s availability. 1st or 2nd appt likely due to cancella5on or random event. Use your scheduling system; computerized or manual. Count number of days from today to the day when 3rd next appointment is available. Measure for each Provider. Measure same day and 5me each week … 7:30 Monday morning is good. Plot the number of calendar days to the third 3rd next available appointment, each week An example of a Delay run chart …..
3rd NEXT AVAILABLE PHYSICAL Carillion 3rd NEXT AVAILABLE PHYSICAL Medical Group 1 Carillion Medical Group Team Team 1 160
140
120
What’s a “3rd Next Available”?
100
80
HARCUS LEWIS PRINCE STAMBAUGH YOUNG ZIMMER
60
40
9/18/02
9/11/02
9/4/02
8/28/02
8/21/02
8/14/02
8/7/02
7/31/02
7/24/02
7/17/02
7/10/02
7/3/02
6/26/02
6/19/02
6/12/02
6/5/02
5/29/02
5/22/02
5/15/02
5/8/02
4/24/02
4/17/02
0
5/1/02
20
Delay: 3rd Next Available Routine Appt NUMBER OF CALENDAR DAYS UNTIL 3RD APPT
2/28/06
1/31/06
12/31/05
11/30/05
10/31/05
9/30/05
8/31/05
7/31/05
6/30/05
5/31/05
100 80 60 40 20 0
PEDI OB/GYN I MED
Tool #2 How to Measure Appt. Demand and Supply
Demand • Look at historical data? • True Demand Formula: External Appointment requests, called in and appted regardless of day appted. To (today or future)
+ Walk-ins for appts. + Other portals of entry ?(email, fax,”add-ons” etc.) + Deflections (UCC etc, if possible) Internal
+ Returns booked today for the future
Total Demand © Tantau & Associates
56
Appointment Demand Worksheet Appointment Demand Worksheet Date: ____________
Care Unit 3
Patients calling today, requesting appt, regardless of day appted to (External)
Walk-Ins today appted (External)
Deflections, eg UCC, if trackable
Return appts booked today as pts leave today’s appt.
(External)
(Internal)
Total Demand
Provider A Provider B Provider C Total
Note: • Appt booking transactions are counted. • What is on today’s schedule booked prior not counted.
Optional; Pts turned away, not booked. Do not add into Demand
How to Track… How long to track… • Tic Marks vs Electronic tracking • 4-‐6 weeks and then forever • Separa5ng Internal from External 58
Measured demand Monday Tuesday Wednesday Thursday Friday
Calls for visits 44 34 29 30 37
Other external demand 2 5 8 3 1
Internal demand 29 25 35 18 31
# appt per day 75 64 72 51 69
Appointment Capacity versus Demand Provider capacity
Measured demand
100
Provider capacity Monday Tuesday Wednesday Thursday Friday
# appt per day 70.125 61.5 87 58.875 84
90 80 70 60 50 40 30
VISIT RATE Provider A Provider B Provider C Provider D Provider E Provider F HOURS per session Provider A Provider B Provider C
20
Visits per hour 3 3 2.25 3 3 3
10 0 Monday
Mon AM 3.5
Mon PM 4
2.5
4
Total 22.5 0 14.625
Tues AM 2.5
Tues PM 4 3
Total 12 16.5 0
Wed AM 3.5 2.5
Tuesday
Wed PM 2 3 4
Wednesday
Total 16.5 16.5 9
Thursday
Friday
Thu AM
Thu PM 4
3.5
4
Total 12 0 16.875
Fri AM 3.5 2.5
Measured demand Monday Tuesday Wednesday Thursday Friday
Calls for visits
Other external demand
Internal demand
# appt per day 0 0 0 0 0
Appointment Capacity versus Demand Provider capacity
Measured demand
1 Provider capacity Monday Tuesday Wednesday Thursday Friday
VISIT RATE Provider A Provider B Provider C Provider D Provider E Provider F HOURS per session Provider A Provider B Provider C Provider D Provider E Provider F
0.9
# appt per day 0 0 0 0 0
0.8 0.7 0.6 0.5 0.4 0.3
Visits per hour
0.2 0.1 0 Monday
Mon AM
Mon PM
Total 0 0 0 0 0 0
Mon Total
0
Tues AM
Tues PM
Total 0 0 0 0 0 0
Tue Total
0
Wed AM
Tuesday
Wed PM
Total 0 0 0 0 0 0
Wed Total
0
Thu AM
Wednesday
Thursday
Thu PM
Total 0 0 0 0 0 0
Thu Total
0
Fri AM
Friday
Fri PM
Total 0 0 0 0 0 0
Fri Total
0
Supply • Macro Supply dept level …PCP’s and day5me UCC? • Deployment of Supply…bookable, clinical hours • Measures – Measure when schedule is released before booking. – Appts per session for each day of week per provider. – Es5mate % long and shorts based on prior schedules – Hours per session ? – Produc5vity standard? – Office FTE modifica5on • Process of Supply; later – What is the work? – Who does the work? PCP and day5me UCC? – What can we try doing differently?
61
Appointment Supply Worksheet Appointment Supply Worksheet Week of:____________ Provider
Mon
Tues
Wed
Thurs
Fri
Sat
Provider A Provider B Provider C Total
Fill in numbers when schedule released
62 Â
Total Supply
Measured demand Monday Tuesday Wednesday Thursday Friday
Calls for visits 44 34 29 30 37
Provider capacity Monday Tuesday Wednesday Thursday Friday
# appt per day 70.125 61.5 87 58.875 84
Other external demand 2 5 8 3 1
Internal demand 29 25 35 18 31
# appt per day 75 64 72 51 69
Appointment Capacity versus Demand Provider capacity
Measured demand
100 90 80 70 60 50 40 30
VISIT RATE Provider A Provider B Provider C Provider D Provider E Provider F HOURS per session Provider A Provider B Provider C
20
Visits per hour 3 3 2.25 3 3 3
10 0 Monday
Mon AM 3.5
Mon PM 4
2.5
4
Total 22.5 0 14.625
Tues AM 2.5
Tues PM 4 3
Total 12 16.5 0
Wed AM 3.5 2.5
Tuesday
Wed PM 2 3 4
Wednesday
Total 16.5 16.5 9
Thursday
Friday
Thu AM
Thu PM 4
3.5
4
Total 12 0 16.875
Fri AM 3.5 2.5
Tracking Demand and Supply source: YKHC, Bethel Alaska
Supply & Demand 350 300 250 200 150 100 50 0 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Day of the Month Demand
Supply
S&D Average A pr-‐05
Demand Supply
197 171
May-‐05
186 179
J un-‐05
J ul-‐05
174 159 195 179
A ug-‐05 S ep-‐05 Oct-‐05 Nov-‐05
161 159 201 176
Dec-‐05
156 164
J an-‐06 F eb-‐06 Mar-‐06 A pr-‐06 Average
216 211 192 174
168 146 176 150 118 173
Demand Supply
M 261 193
Weekly Averages W TH F 235 208 184 162 195 175
T 240 190
Average Weekly Supply and Demand
Family Medicine Supply & Demand Daily Average by Month 300
250
250 200
200 150
150
100 50
100
0 M
50
T
W Demand
0 Apr-05 May-05 Jun-05
Jul-05
Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average Demand
Supply
TH Supply
F
30
Your Next Steps Exercise…. • Set an Aim… • Measure Delay; 3rd Next Available RouRne appt. • Measure Appt Demand and Supply for each Provider
XXXX
Last Chance?
Whatâ&#x20AC;&#x2122;s next????????
Advanced Access Sequencing Steps
Foundation Steps
Empanel pts
Empanel pts
Set Access Aim…Gold Standard Measure delay…3rd next available routine appt Measure Demand, Supply, Actual Match Demand, Supply, daily and weekly
Action Steps
Reduce Backlog Simplify appt types/times Contingency planning Reduce Demand for visits Optimize the Care Team At every step… Track and display data weekly. Celebrate successes and failures!
© Tantau & Associates
Schedule of Webinars 1. 2. 3.
Jan 17 Pre-‐work Review, Baseline measures Jan 24 Coaching Q and A Jan 31 AA: What’s it all About? Introduc5on to Advanced Access 4. Feb 7 Coaching Q and A 5. Feb 14 AA: How to Make it Work Part 1… Matching Demand and Supply 6. Feb 21 Coaching Q and A, discussion 7. Feb 28 AA: How to Make it Work Part 2… Backlog Reduc5on 8. Mar 6 Coaching Q and A 9. Mar 13 AA: How to Make it Work Part 3… Final High Leverage Changes 10. Mar 20 Closing Remarks and Ac5on Planning
copyright Tantau Associates
68
References… • • • • • • • •
Tantau, Catherine, Accessing Pa:ent Centered Care Using the Advanced Access Model, Journal of Ambulatory Care Management, Winter, 2009 Managing the Unexpected, Karl E. Weick and Kathleen M. Sutcliffe, University of Michigan Business School, 2001 Kilo, C.M., Trifflew, P., Tantau, C., & Murray, M. (2000). Improving access to clinical offices. The Journal of Medical Prac5ce Management, 16(3):126:132. Tantau, Catherine. Same-‐Day Appointments Create Capacity, Increase Access. Execu5ve Solu5ons for Healthcare Management, February 1999. Tantau, Catherine, Murray, M., Sept 2000. Same-‐day appointments: Exploding the access paradigm. Family Prac5ce Management, 7(8):45-‐50. Retrieved January 15, 2004: huxp://www.aafp.org/fpm/ 20000900/45same.html. Raddish M, Horn S, Sharkey P. Con:nuity of Care: Is it Cost Effec:ve? American Journal of Managed Care. 1999:5:727-‐734. Jon O. Neher, MD; Gary Kelsberg, MD; Drew Oliveira, MD, Improving Con@nuity by Increasing Clinic Frequency in a Residency SeEng, Family Medicine Journal, Vol.33, no. 10 p 751, November -‐ December 2001 John W. Saultz, Jennifer Lochner, Interpersonal Con:nuity of Care and Care Outcomes: A Cri:cal Review, Ann Fam Med 2005;3:159-‐166. DOI: 10.1370/afm.285.