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Fall 2010 - Vol.5, No.3 Lancaster General Health Urgent Care and Express Care   Susan Wynne Senior Vice President of Planning and Business Development Kent Carr, M.D. Senior VP of Physician Services

THE PROBLEM

Demand for primary care will continue to escalate as more baby boomers begin enrolling in the Medicare program, and over 30 million more Americans are covered by health insurance as a result of the Patient Protection and Affordable Care Act. Access to primary care is becoming even more strained due to the growing shortage of primary care physicians in rural, urban, and suburban communities. Emergency departments (EDs) have become surrogates for family physicians as the number of non-emergent patients swells, maxing out ED capacity. Concurrent with this crisis, expectations of patients have changed. Patients, as consumers, want the same service and convenience they receive from their banks, grocers, and retail stores. When a problem arises, they prefer not to schedule an appointment but to be seen immediately, if not sooner. Patients are now less willing to wait a couple of hours or even to wait for the nurse to call them back for an appointment. If they must schedule an appointment, they prefer the convenience of online scheduling. Lastly, they resent long delays in the waiting room to see a physician.

THE SOLUTIONS

As the gap widened between physician availability and consumer demand, alternative options were developed. In the early 1980s, recognizing the need for other models of delivering primary care, providers, including entrepreneurial physicians, opened urgent care centers. The number of urgi-centers proliferated over the next 30 years, and today stands at around 20,000. The first MinuteClinics opened in Minneapolis in 2000, and as of July 2009 approximately 1,100 retail clinics were in operation in retail pharmacies, grocery stores and big box retailers.

Lancaster County is fortunate to have an ample number of family practitioners, due in large part to the outstanding family practice residency program at Lancaster General Hospital. Nevertheless, recent studies point to current and future primary care physician shortages throughout the region. More telling in terms of service shortages, the number of Lancaster General Hospital ED patients continues to increase alarmingly. The number of patients treated in the ED’s “Fast Care” section grew 8.8% in fiscal year 2010 to nearly 50,000 visits, roughly half of the approximately 100,000 ED patients treated. Aside from the unnecessarily high cost of treating non-emergency patients in an ED, the facility was built to accommodate 90,000 patients. In addition to the lack of contiguous space to expand the facility, the cost per square foot for additional ED space would be $450/sq. ft., compared with $110/sq. ft. for retail clinics and urgent care centers.

Area primary care physicians have done an excellent job of responding to patients’ demands by extending evening and weekend appointment hours. However, though in most cases patients prefer to see their family doctor, quantitative consumer research in the LGH service area indicates that when the doctor is not available, patients are very likely to use an alternative option such as an urgent care center or a retail clinic, rather than an ED.

THE NEW MODELS

In 2008 Lancaster General Health made the decision to create new delivery models under the direction of its physician group practice, Lancaster General Medical Group (LGMG). An urgent care clinic was opened in June 2010, and three retail clinics (LG Express Care) opened in Parkesburg, Lancaster City, and Lititz in May, June and July 2010 respectively. Although Urgent Care and Retail Clinics both offer “walk in” care, their models and scope of care are very different. At present, in the LG Health model, Urgent Care is staffed primarily with physicians trained in family practice, emergency medicine, or occupational medicine. They see most of the same conditions seen in family practice offices or in the “Fast Care” section of the ED. They also offer plain film radiography that is linked to the same picture archive and radiologist readings as available in the ED. It is expected that board certified physicians will always be on duty, though it is anticipated that as the center grows, midlevel providers will also be available during a portion of the operating hours.

Retail Clinics offer a more limited scope of care, and are staffed only by family nurse practitioners (NPs). Although physicians are not on site, each retail location is partnered with one of the LGMG family practices, whose partner physicians are available to the certified nurse practitioners for telephone consultations while patients are present at the retail sites. Even if physicians are not needed at that time, they review the records daily. These partnerships and the accompanying oversight are felt to be critical success factors for the LG Health Retail Clinic sites. In order to foster the partnerships, all full-time nurse practitioners rotate to the home family practice site for approximately one half day per week. This routine not only strengthens the partnerships, but allows further training of the NPs and offers them the ability to broaden the scope of services when they are working in the home practice.

THE SERVICES

A menu of the services that are provided and the conditions that can be treated is posted at all Retail Clinic sites. When patients present to the retail clinic sites with problems that are not on the defined list of services, or if their problems require more advanced care, they are referred to their primary care physician or to other appropriate sites based on their symptoms or conditions.

INTEGRATION OF CARE

Although LG Health is responding to the increase in patient consumerism and the need for improved access, it recognizes that patients - especially those with chronic illnesses - need a primary care physician and a medical home. The providers at both the Retail Clinic and Urgent Care sites support the patient’s primary care physician and can serve as extensions of those practices. They are careful to refer the patient’s back to their primary care physicians for follow up of acute problems or chronic conditions. They also can recommend preventive care visits when appropriate. They expand access to needed healthcare and to the LG Health system, and for those with no established physician, they can serve as entry points into the system. When referrals are needed, the providers follow the preferences of the patients and their primary care providers for advanced care. All encounters are documented in the LG Health electronic health record and those notes are available to all who have access to the system. Primary care providers who are not in the electronic record system receive faxed copies of records so they are informed of their patients’ care.

The Urgent Care Center, and to a more limited extent, the Retail Clinics, are closely tied to the LG Health Occupational Medicine Department. Urgent Care offers employers an alternative site for referral of injured workers or workers who require drug testing or alcohol breath testing during hours when the Occupational Medicine Department is not open. The Occupational Medicine documentation and information systems have also been incorporated into the Urgent Care setting.

THE FUTURE

Although the models for Retail and Urgent Care are currently distinct, walk-in services will continue to evolve. Also, it can be anticipated that as patients’ expectations grow, and walk-in care becomes more widespread, primary care physicians will also enhance access to their office practices by using advanced open access scheduling and other innovative methods. All these developments will assist the LG Health system to provide an extraordinary experience to everyone we serve.