Provider scheduling for game of thrones

Operations/Work Flows
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Winter is coming.

I sent a message to our employees last week asking if anyone had seen my crystal ball that I left at the nursing station. No questions asked if it was returned to my desk. Don’t even care what it was used for.

So, currently I do not have the crystal ball. Leaving me to make the best educated guesses I can and plan for the winter and staffing. I find it best to ask other providers what their educated guesses are and double check to see if I am on the right page.

Goal this winter is flexibility with the schedule. Since our local governors have lifted the order on non elective office visits, and folks are learning to live with COVID so to say, my prediction is that Well Visit numbers should stay roughly the same as previous years in our area. We caught up this summer with missed Well visits from March-May. Currently we are on track with 2019 for Well Care and we consider ourselves lucky because I know this is not the case for other parts of the country. In March, I would have never imagined this possible. June, July, August was our busiest summer ever, and again I acknowledge this was not possible in many parts of the country.

Goal will be to double down on Well care, all hands on deck, this is the life line now more than ever.
For our office, roughly 30% of revenue comes from ill visit related events and 70% from well visit related events. Granted this excludes supply related cost (35% of gross revenue is related to vaccines). However, scheduling related 40% of scheduled time on ill visits and 60% on well visits.

So my current train of thought is that Well child care will roughly stay the same (hopefully). Hopefully increased effort to recall will offset decreased demand, and optimistically increased effort would result in increased demand beyond 2019 numbers.

For ill visits, it is the tale of two cities. We will have decreased demand due to social distancing, mask wearing, stay at home. However we will have increased demand due to need for return to school note to ensure it is not COVID (AKA socially responsible parent or CYA school lawyer)

For us, this summer our ill visits on average are down to 70% of average.

I do not know which force will be stronger. Decreased illness or need for a test and a note. If families appropriately social distance and wear mask, illness overall will be down no doubt. Just not sure what the demand for testing and notes will be.

From a budgeting standpoint, I like to work off worse case scenarios and then hope to be pleasantly surprised like we were at last P&L.

So there is the background and happy to elaborate on any aspects. So now the planning and questions.

When planning for provider schedules, I am thinking Well visits will be similar to 2019 and ill visits will be down 70%. From a budgeting standpoint this would be 30% visit revenue (from ill visits) times (70% of typical ill visit volume) = 10% roughly total decrease in revenue over next few months (darkest winter ever).

Remember my crystal ball is missing, so just an educated guess. If this is true, please nobody worry about how to account for your CARES or PPP money. It’s covered with COVID related losses.

So real question for planning for winter schedule. How to schedule providers and thoughts. Again understand very regional.

For this summer we have had 10 providers doing solely Well visits at our “clean offices” and 3-4 providers each day working at ill office (one of the providers is doing telehealth only). We have 3 offices. 2 are designated well only and one is ill only. For ill office, 80% has been in person, and 20% has been telehealth.

My gut is to see increased demand for telehealth provider ordering COVID testing, so expect to see increase in this utilization. However overall demand for ill visits to stay around 70% of typical.

So ask to other forum members is what do you expect your ill visit volume compared to 2019 to be this winter.

My gut is to plan to schedule 60% well visit time slots for the winter and 40% ill visit time slots (with 25-40% of ill slots planned for telehealth, flexibly can switch to seeing in person ill visits). This is opposite of our typical winter when 60% is geared toward ill and 40% to well.

So end to stream of conscious. Please produce my crystal ball and I will be ever so thankful.
If you do not have my crystal ball, I would gladly accept ideas and thoughts.
Bill

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Thank you, I enjoyed your witty post.
My crystal ball agrees with yours.
I predict dramatic decrease in sick visits this winter in areas where children are at home doing distance learning and not participating in sports. We will still see lots of rashes, skin infections and acne. We will still see lots of allergy related issues. We may see more ingestions of foreign bodies and toxic materials. We will see more mental health visits, and we will need to learn how to treat some psych conditions ourselves because the mental health providers are/will be overwhelmed. We should consider visits for counseling in life and coping skills. Our patients needs may change, but they will still need our support.
I predict a baby boom with increase in well baby visits.
I hope telehealth continues to be reimbursed by insurance, because it is here to stay.

Hope this is helpful to you!
Best of luck to everybody, I believe we will be OK if we adapt to the needs of our patients.

Lilia

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My gut feelings generally line up with yours, but it has to be a broad brushstroke because of how variant the COVID impact has been.

Two points:

One adjustment I’d make here which is implied, but not fully formed, is the application of a THIRD type of visit: chronic visits. These are different from well visits and acute/sick visits though often grouped in the latter category. Chronic visits are things like ADHD med reviews, asthma management visits, everything under mental health, etc.

IMO, those issues will - and should - become a growing part of what a pediatric practice delivers. From a practice management perspective, they will help regulate your business. From a clinical perspective, however, they more closely tie your special expertise to the service you provide your clients. The fact is, of the 30% of your business represented by sick visits, how many of those visits could be picked up by an UCC? Or even managed with a telemed visit? Too many. But is Wal*Mart going to help a kid manage asthma or Dr. Google really going to manage those behavioral issues? No.
My gut tells me that those visits could and should replace as much as 1/2 the missing sick volume you’re likely to lose this winter.

Point Two:

Louis Pasteur said, “Chance favors the prepared mind.” Like you point out, we still don’t know what the impact of COVID and testing will be in your offices. And there’s still also flu, strep, etc. You will want your office to be ready for the hose to get fully turned on - and then shut off again - at a moment’s notice.

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Thank you @Bill for this great post. I hope that crystal ball gets returned real soon!

We are preparing similarly in scope although we are smaller in scale.

We have always said we have two locations, but we have shifted our “phraseology” to start referencing our 3 locations- two physical and one virtual office for telemedicine.

In the Well Only Office, we are running one provider column that is preplanned Well that is 100% booked with on site visits. The second column in that office is a hybrid column with a few onsite visits but the rest blocked for same day sick telemedicine and spillover (for new babies who have to be seen that day).

In the split office (physically separated Well Side and Sick Side with their own entrances and staffed separately), we have the capacity for 2 provider columns that are booked with on site Well Visits. The Sick side provider can either see telemedicine in the morning or start on the Well Side and see Well Visits in the morning.

We are adding an offsite column for preplanned telemedicine (med reviews, etc) and same day telemedicine sick.

We are projecting near-summer levels for Well Visits, lots of planned visits for med reviews, mental and behavioral health, asthma, etc (through robust recall efforts) and telemedicine as a triage tool with the mantra that every sick visit starts as a telemedicine visit.

For COVID-related, we are starting with telemedicine to get history and provide counseling. We are in the process of transitioning the specimen collection from the Sick Provider column to an RN column.

Lots of planning, lots of reconfiguring, would sure love to borrow that crystal ball when you are done with it!!!

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We started mental health team in our office this past winter and pushed right through COVID growing it. Started from zero and now have mental health NP, and three LPCC. Looking to add more LPCC.
Completely agree that our business is Well visits and chronic care. Although I do love an ear infection or strep throat thrown in:) For those thinking about adding counselors, go for it. Already breaking even and only up and running for 8 months

Normal year we have well visits, chronic care visits, and acute visits on all of our schedules any given day.

Not normal year and now we have an acute sick office and 2 clean well offices/chronic care offices.
The tricky part when building the schedule is deciding how many to schedule at the acute sick office, of course wanting the minimum at the acute office in case it does not fill, and maximizing full schedules at the clean office.

Currently that is what we have done, and for a few providers each day have blocked half their schedule at clean offices in case we need to pull them to acute office. We unblock their schedules on a rolling 2wks if it seems we will not need to shift them to the acute office. If we need more at acute office we reschedule the the unblocked half of the day and pull the provider to the acute office.

Imagine for single office practices it is similar trying to determine when the acute sick in afternoon schedule starts.

We also shift folks with openings at well office to seeing telemedicine, and have ill providers able to do telemedicine or see patients in office.

Chip, look forward to seeing the data nerd in action. Going to be very helpful to get views from around the country when it comes to ill visits and where that area is when it comes to COVID spikes and level of quarantine. AS our individual areas experience waves of disease, this will help in planning for staffing. Nothing perfect and have to remain totally flexible. Ready to fill the schedule with what is demanded and create visits with what we can.
Thanks for the input on this everyone.
Bill

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@Bill can you say more about how you are scheduling and billing for the mental health team!

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Our counselors have 60 minutes for follow up and 90 minutes for initial. In the schedule it looks like 45 minutes for follow up with 15 minute block and 60 minutes for initial with 30 minute block. This helps them pace themselves. The blocks acknowledge they need time for charting, etc. We started without the blocks and they were having difficulty finishing their charting to get into the billing department. Total mind games with the mind game specialist. Truly they enjoy the blocks and easier to keep up. We are billing counseling codes. Follow ups are 45 minute counseling and initial are 60 minute diagnostic codes.

We are in process of credentialing them with all insurance companies. When not credentialed with specific payers then they bill incident to an MD. All patients we are sending to our counselors come with a diagnosis to start the process from the MD. Currently 70% of visits the counselor is credentialed with insurance company, and 30% are billed incident to. Gradually changes over time.

We set the charges low in case no coverage and family needs to pay full cash price. Yes with some insurance companies we could be leaving money on the table, but goal is to get program paid for and get patients into counseling that for whatever reason did not do it before.

The main insurance carrier in our area pays between $50-60 per 45 minute visit, and our charge is $100. Most families are happy to pay $100 per visit because cash pay counselors in the area charge more. Have to build in benefits, vacation, payroll tax, office space, billing, front desk time, and MD cosign time into the equation. In our area LPCC and LISW make around $30/hr plus benefits depending on experience. We average this out to create salary number depending on part time vs full time. It is our job to keep the schedules full and adjust new patients with follow ups to ensure smooth full schedule and fill holes and cancelations.

We have more demand than counselors, so no problem keeping schedules full. Always give out patients backup referrals with number in case our providers cannot accommodate them into schedule in timely manner. Likely could use 1FTE counselor per 3 FTE Provider. Currently we have 2.5 FTE counselor per 16FTE provider. Thus we could easily double the number of counselors with current demand.

Goal is breakeven in our office and we have exceeded that in short order. The burn out meter for our providers, the lost lunch breaks, the no time to pee or poop returning calls from our complicated patients has far exceeded our wildest expectations. Honestly was willing to lose a little money to be able to not feel guilty using the restroom during the day or wanting to see my family after work.

Our mental health NP currently has 30 minutes with follow up(scheduled as 20 minute, with 10 minute catch up block) and 60 minutes with new (40 minute scheduled and 20 minute charting block). Bills incident to MD seeing our patients that are more complicated and time consuming that already have a diagnosis. Uses 99213, 4, and 5 codes. This has been amazing during COVID well check season. Personally I am booked out for Well care and ADHD/psych follow ups until December do to crazy scheduling. So many of my patients will see our mental health NP for the 3-6month follow up for anxiety/ADHD/Depression. My patients have loved the increased availability and knowing that the NP and I talk to each other and are on the same page. Of course I am always available to the patients and the NP anytime if any issues arise, also to just say high and agree with plan.

Many ADHD patients will now see me for Well visit/ADHD follow up visit and see the mental health NP inbetween yearly visits. Of course the best part, is it opens up my schedule for more acute mental health visits when the patient needs to see me specifically because now I have more potential openings from the patients that are stable and getting their rubber stamp follow up stay the course visits with the NP.

So NP is great from the stable patient perspective, but also great from the patient that may need to come in weekly/monthly for a period of time and is calling the office every other day. Our NP has more openings in current schedule (likely to change quickly because she is awesome)

Bottom line, my lunch breaks are better. I get to see my family more. I use the bathroom more regularly during the day. The NP and counselors are fantastic. The patients love it. My personal mental health is better. And of course the key as managing partner for our practice, it is better than break even. Win, Win , Win. Go get mental health for all involved.
Bill

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Thank you @Bill for taking the time to answer this so thoroughly- much appreciated! We have had a Care Management program in place for awhile now (initiated through a state-sponsored pilot and then supported through a VBP from our state’s BCBS). We echo what you are saying that the program carries so many benefits to the providers in making your day better.

We use a lot of the Care Management codes (G9001, G9002, G9007 and G9008) as well as the non-provider telephone codes. It’s really helpful to see how you are using the E/M codes.

Thank you!

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Hi Bill,
About how many hours per week does each counselor spend on direct patient care? Are you finding that the 15 - 30 minute blocks give them sufficient time to keep up with their notes? Finally, are they responsible for their own authorizations and admin tasks or does other staff help with that?

Thanks!
Tracy

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Their schedules are varied with patient hours. One works 36 hours, another 32 hours and the third is 18hrs per week. So in a given 8hr day for example they may have 2 new (3hrs) and 5 follow up (5hrs). Another day may have 8 follow ups (8hrs). They have charting time built in since for example follow up is 45minute time slot and 15 minutes for charting.

The reality is everyone charts differently. Some of my partners, you see the template and very little other information except what the RN entered in HPI. Other partners tend to write novels and end up staying late to chart or charting at home. Some partners spend 30 minutes with patient when pt was scheduled for 10 minutes and others spend 10 minutes when visit was scheduled 30 minutes. Imagine this is universal across all practices.

I have encouraged the counselors to include relevant information such as very brief bullet point of topics discussed, plan for what to work on, and time frame for follow up. Do not need proper english or paragraph format like they would have done in a consult note to a referring physician. This is the beauty of having counseling in the office, charting needs to cover the basics for coding and communication, beyond that taking away from family time.

The counselors are only responsible for seeing patients. We have schedulers and billing and front desk do everything else such as authorization. We emphasize this is the biggest perk of working in our office instead of their own private practice. Also they get paid vacation, 401k, health insurance, etc.
Hope that helped
Bill

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What type of rooms do you have for them to see patients?

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Thanks! Very helpful info!

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We did some rearranging in our office and used existing space. We have four administrative rooms that we turned into counseling rooms. We had a complete office reshuffle of space utilization, realizing MD/NP do not need an entire office just for their backpack and papers they do not want to deal with.
They range in size from 8ft by 12ft to 12 by 15ft. We have the rooms complete with 3 comfy chairs for the patients/family. The counselor or NP has a rolling desk chair to use at desk or when chatting with families. Laptop and phone in each room. At one of our satelite offices we used an existing exam room that wasn’t getting much utilization. Left the sink with surrounding cabinets. Added area rug comfy chairs, mood lamp, and book case. Must say that all of the rooms are works in progress. We add and subtract from the rooms every other month based on what the counselors are finding works or does not work in the room. Been mostly telehealth anyway for past 6 months. As patients are coming back into office likely will be making some more tweeks.

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