The Problem
Residents are significantly less likely than demographically similar peers to have a primary care provider or dentist, or to have participated in routine health maintenance[^1]. GME trainees often have difficulty seeing primary care providers during routine business hours, largely due to rigorous residency schedules[^2].
At Duke, there are several additional factors limiting primary care access. First, population growth in the Triangle area has increased overall demand for primary and urgent care visits making on demand access more challenging. Second, most primary care clinics and providers at Duke are not within walking distance of Duke University, Duke Regional, or Durham VA hospitals where most trainees practice, thus requiring trainees to drive to PCP appointments and be away from work.
Our Solution
Our objectives for this project were to:
- Increase support and awareness of concierge scheduling for GME trainees within Duke Primary Care to increase the number of trainees who are established with a DPC provider;
- Perform an environmental assessment of relevant stakeholders to understand their needs and concerns regarding a video visit platform;
- Develop a video visit platform; and
- Pilot video visits as a method to increase primary care access for trainees.
We developed an innovative GME Trainee Primary Care Video Visit Program within Duke Primary Care for current and future GME trainees. The intervention allows GME trainees access to virtual primary care services for both acute and chronic care conditions. Thus, trainees are able to access primary care services without having to leave the hospital. Furthermore, support of the concierge line allows trainees to access and establish primary care with greater flexibility by increasing the number of appointment slots available to trainees.
We have held seven resident feedback and focus group sessions, built and tested the video visit platform, and presented the service at four GME orientations. Two providers were identified to conduct video visit appointments. Video visits were available to trainees starting July 2018. Since then, 18 video visits have been completed. Out of video visits that were completed in 2018, 100% of patients were satisfied with the telehealth experience, connected easily to the platform, and felt the visit was just as effective as a face to face visit. While the video platform functioned as planned, the demand for video visits was not as high as expected.
On the other hand, we have seen a much larger utilization of the concierge line than the video visits. 147 calls were answered and handled from October 2018 to April 2018. Through a review of recorded concierge line calls, we can see that the concierge line is an effective way to connect trainees to primary care. Out of the 142 available recordings, 111 (78.2%) appointments were scheduled, and the leading reason for an appointment not being scheduled was because the caller requested an appointment with a provider who was not in the Duke Primary Care practice group (N=12). The recordings also revealed low overall demand for video visits. 126 callers (88.7%) requested in-person appointments while only 16 (10.9%) requested a video appointment.
Despite low utilization of the video visits, survey results demonstrate decreased barriers to primary care after implementation of this service. When we compare the results of the annual GME wellness survey before and after implementation of our interventions, we see a significant decrease in barriers to accessing primary care services, from 58.10% to 30.85% (p < 0.0001), and a significant decrease in delays in access to primary care, from 27.00% to 20.92% (p=0.023). Out of residents who did experience delays, there was a statistically significant reduction in scheduling barriers (81.59%, 70.36%, p=0.04) and untimely appointments (59.19%, 40.68%, p=0.0039).
The availability of resources to connect patients to primary care greatly reduces trainee perception of barriers to health care and provides trainees a convenient mechanism to schedule flexible primary care appointments. Well-being and burnout is multifactorial and it is possible that a reduction in perceived barriers to health care will improve overall trainee wellbeing and hopefully contribute to decreasing burnout.
Impact
The analysis demonstrates that the concierge line is effective both in improving trainee perceptions around access and barriers to care, as well as improving trainees’ ability to schedule with primary care providers. The analysis did show that residents frequently request more flexible locations and hours. Duke Primary Care does not have locations at the hospital, and trainees often ask for primary care locations near the hospital. In addition, trainees are often requesting evening or weekend appointments – while some DPC clinics have this availability, this is an opportunity that could be expanded.
In addition to primary care, there were notable requests for similar access to specialty care. Expanding the concierge line to schedule appointments outside of Duke Primary Care to include obstetrics, gynecology, and pediatrics, would address an unmet need among trainees where there is clearly demand.
Finally, low demand for video visits suggests there could be an alternative service that is more useful for trainees. Many callers to the concierge line were scheduling appointments for specific requests such as medication refills, lab orders, or imaging orders. An asynchronous service where trainees are able to communicate with physicians via a more responsive system than Epic MyChart, could be helpful in those cases. This service would allow trainees to fulfill specific medical requests at a convenient time and location and with a 24 hour expected turn-around time (72 hours is the institutional expected turn-around time for Epic MyChart).
References
[^1]: Cedfeldt, A. S., Bower, E. A., Grady-Weliky, T. A., Flores, C., Girard, D. E., & Choi, D. (2012). A comparison between physicians and demographically similar peers in accessing personal health care. Academic Medicine: Journal of the Association of American Medical Colleges, 87(3), 327–331. https://doi.org/10.1097/ACM.0b013e3182448731.
[^2]: Eckelburry-Hunt J, et al. Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs. J Grad Med Educ. 2009 Dec; 1(2): 225–230.
