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To identify and describe models of after-hours care in the U. Qualitative analysis of data from in-depth telephone interviews. Primary care practices in 16 states and the organizations they partner with to provide after-hours coverage. Forty-four primary care physicians, practice managers, nurses and health plan representatives from 28 organizations.

Analyses examined after-hours care models, facilitators, barriers and lessons learned. Based on 28 organizations interviewed, five broad models of after-hours care were identified, ranging in the extent to which they provide continuity and patient access. The online version of this article doi: Yet, continuity of primary care, including care received outside usual business hours, is associated with Office encounter after hours patient outcomes and lower ED use for non-urgent problems.

Offering after-hours access to select primary care services, including telephone access and expanded clinic hours, could potentially eliminate many costly ED visits while improving continuity. The published literature on after-hours care suggests that it includes the following characteristics: The objectives of this study were to identify promising after-hours care models in the U.

Through in-depth interviews of practices and organizations providing Office encounter after hours care, we present a typology of models and selected examples. We then identify challenges, facilitators, lessons learned and implications for the design of sustainable after-hours-care.

We included numerous safeguards against researcher bias Office encounter after hours site bias 20 in our design and participant identification. Next, we engaged from the beginning of the study, a steering committee of neutral experts in the U.

These experts listed in our acknowledgement section also reviewed both our study design and the interview protocols.

We identified respondent organizations through Internet searches, references from health plans and PCMH managers, and recommendations from U. Participants completed an emailed questionnaire describing their size, staffing, payer mix and operating hours. In some cases we did a second interview with a practice manager or nurse practitioner if the initial respondent felt that they could add further insights or fill in missing information.

Using semi-structured interview protocols, available in online appendix we asked participants to describe their: The two senior researchers conducted the telephone interviews between January and July of Interviews lasted on average one hour. Two research assistants trained in transcription and coding for qualitative data took verbatim notes during every interview. We continued conducting interviews with new practices until we had reached saturation of themes and repetition of descriptions of after-hours care models.

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Content analysis of the verbatim transcripts initially was based on inductive coding 20 by the senior researchers. They then met as a team with the research assistants periodically to review codes and identify key themes and models. The research assistants applied codes to the units of text based on both our protocol questions and themes. We completed a total of 44 interviews in 28 different organizations across 16 different states.

Five models of after-hours care coordinated with primary care were identified: Three of the respondents worked in federally qualified community Office encounter after hours centers and their CHCs were most like Model 3 in two cases and Model 5 in one case.

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While not a separate model unto itself, an important facilitator of after-hours care across models, in particular for pediatrics, was telephone nurse triage. While any on-call coverage arrangements may be supplemented by nurse triage lines that refer to the covering physician per protocol, some organizations used this more than others.

For example, in Plattsburgh, Office encounter after hours. The practices share on-call responsibilities and use a third-party nurse call center in Cleveland to triage after-hours calls. The cost is covered through the medical home pilot payments.

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If needed, the nurse then pages the on-call physician for the practices. Challenges to sustainable after-hours care models in the U. We code for them regularly and never get compensated. Some practices initially overstaffed and did not have enough patients presenting after hours to justify their investment. Obtaining buy in from community PCPs to collaborate on after-hours care was an initial challenge. Providers reported challenges in encouraging some patients to use after-hours services rather than the ED for non-urgent care.

Complicating these challenges is competition from some EDs that aggressively market non-emergency services to attract Office encounter after hours. Several factors affect the design and feasibility of after-hours models, including gaining primary care clinician buy-in, assessing patient needs and preferences to ensure scheduling and staffing meet demand, consideration of location and practice size and financial sustainability.

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For example, Office encounter after hours Medicare patients may not value late evening office-hours, while working adults do; families may not value access that conflicts with other activities dinner, etc. Similarly, more complex patients value continuity more than others. Respondents felt that older patients with chronic conditions and pediatric patients with special needs placed greater value on after-hours continuity than did young healthy working professionals.

Likewise, the use of after-hours nurse triage phone-lines varied by age. Respondents noted the general pediatric population is more amenable to nurse triage of night-time calls because they are often about routine issues and, in the rare cases when they were truly urgent, required triage to an ED.

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On the other hand, adults with multiple chronic conditions often require the attention of a clinician who knows them well. Rather than making all pediatrics sites open early, the community health center hired an additional nurse Office encounter after hours to do walk-in appointments at one site from 7—8: This simple staffing adjustment led to a drop in non-urgent ED visits.

In rural areas, where Models 1 and 2 were common, populations and provider bases were relatively fixed. Rural providers needed to consider whether the local population and provider workforce could support after-hours access not just to providers but also to other services, such as pharmacy and laboratory services.

In rural Oklahoma for Office encounter after hours, the lack of pharmacies open at night forced some PCPs with extended hours to send patients to the nearest ED solely to obtain medications. In areas where small, independent practices are the norm, on-call arrangements can be challenging because physicians in smaller groups must either take call more often to ensure continuous coverage or develop relationships with other practices. Our guidelines are the product of two years of collaboration with physician contacts and leaders… a flexible approach is key.

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While small independent primary care practices have fewer resources, Office encounter after hours shifts can help meet staff needs for scheduling flexibility and allow them to provide extended hours without paying overtime. Staggered shifts also help maximize use of limited office space. The financial sustainability of after-hours models varies by practice size, ability to obtain higher payment for after-hours care, payer mix and type, population socioeconomic status and whether the practice is part of a system bearing the costs for ED and hospital utilization.

Offering extended hours was not considered a profitable endeavor for small independent primary care practices but is pursued to improve patient access Office encounter after hours continuity. Providers felt that extended hours reduced ED visits and hospitalizations but most lacked the resources to track this empirically. As the main provider serving a defined geographic area, Docs on Call has negotiating leverage with insurers who want to include their practice in their regional networks.

From the perspective of after-hours and urgent care providers employed by integrated delivery systems e.

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GroupHealth that bear risk or that have their own health plans, after-hours services led to lower downstream costs for the system as a whole and limited ED use Office encounter after hours patients with potentially serious medical problems.

On the other hand, for hospitals still responding to fee-for-service incentives, system-owned urgent care centers also generate downstream referrals for the hospital and its employed specialists. A respondent from a hospital-owned urgent care center in Greenville, S.

We are doing our job; the downstream revenue has made up the losses from us. A shared EHR greatly facilitated informational continuity between after-hours and usual daytime providers. When electronic data exchange was not available, after-hours providers faxed a note to the usual PCP if they had a formal arrangement unless after-hours and usual providers were part of the same practice, in which case a note or oral communication was standard.

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In no cases, with the exception of the shared EHRs described previously, were feedback loops set up to confirm information receipt by the PCP. Respondents believed that such a double check would be impractical because most non-urgent, after-hours issues did not require that level of monitoring.

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If the after-hours issue was clinically urgent or needed follow up, respondents believed their communication system was sufficient. So you need clear expectations, and you need to measure it. After-hours efforts that were being successfully implemented as Office encounter after hours of PCMH initiatives involved ongoing collaboration with physician practice leaders, practice staff and, in some cases, the health plan e.

Many practice respondents, including those not in PCMHs, noted the strong relationship between same-day access or open-access scheduling 23 and ability to manage after-hours care. The presence of an after-hours clinic linked with the PC office had the additional benefit of making overnight telephone coverage more manageable for physicians.

Health plan efforts to organize practices to share call may or may not resonate with on-the-ground call-sharing arrangements that practices had established prior to becoming part of a PCMH initiative. In NY, getting several small pediatric practices together to share an outside nurse triage phone line for after-hours care worked well but took extensive effort by the plan manager.

Extended primary care office hours, physician Office encounter after hours, health information technology and nurse triage phone lines are tools to support these models. While it may be challenging for formerly autonomous small practices to work together to share call or telephone triage, when practices share resources 28 they are more likely to routinely track and manage patient information and to provide after-hours care.

With persistence and ongoing input from on-the-ground providers, some health plans have effectively supported such activities.

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The GroupHealth experience further supports this: Supporting after-hours care by small independent practices that are not participating in PCMH initiatives may pose the greatest challenge for payers and policymakers. Some predict that after-hours care in most countries will continue to move toward larger organizations or virtual practice networks. Web-based secure data repositories open to on-call and after-hours care providers could help fill the gap prior to greater adoption of interoperable EHRs.

Future research could include understanding how to make such tools more clinically accessible and Office encounter after hours to health care providers and patients. Future research could also include comparisons of the various models of care with respect to quantifiable outcomes such as ED attendance for minor complaints, overall resource use, and patient satisfaction.

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Enhanced payment for after-hours care, whatever form it takes, also requires additional attention. Given the sample size, our findings do not represent all after-hours care arrangements.

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Another limitation is that we did not assess patient experiences with each of these models. Still, lessons from real-world models can help inform practices struggling to provide after-hours care.

Ultimately, identifying sustainable models to accommodate both provider Office encounter after hours of life and patient access and continuity to after-hours care may require a larger and better distributed primary care workforce, and payment reforms to reward providers for after-hours care. Improved Office encounter after hours and support for daytime primary care will likely help decrease the after-hours-care burden.

The authors would also like to thank Dr. Ed Wagner and Dr. Stephen Schoenbaum for serving as external advisors to this project.

The authors declare that they do not have a conflict of interest. National Center for Biotechnology InformationU. J Gen Intern Med. Services provided outside of normal business hours are reported in addition to the basic service using special service CPT codes. for more than one special services code to be reported per encounter (eg, and ) Services provided in the office at times other than regularly scheduled office hours, or days Example: A physician is called after hours.

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