Leaders from two prominent healthcare organizations present how their distinctive models improve patient care and organizational health.

at Cleveland Clinic and SSM Health

NOVEMBER/DECEMBER 2017 AMGA.ORG x GROUP PRACTICE JOURNAL 9

Retail clinics first emerged in the United States in 2000. Typically staffed by nurse practitioners (NPs) or physician assistants (PAs), these convenient care clinics (sometimes referred to as urgent care clinics or walk-in clinics) have only increased in popularity over the years for their ability to offer extended weekend and evening hours, better walk-in availability, shorter wait times, and most importantly, cheaper cost to the patient.

Walk-in clinics provide low-cost access

points for patients with acute, same-

day needs and improve access for

those with chronic diseases.

By 2018, there will be more than 2,800 alternative care facilities located in some of the nation’s most prev-alent “big box” stores, supermarkets, and pharmacy outlets, such as Target, Walmart, and CVS. Although they present a significant competitor for many medical groups and health systems, some healthcare organiza-tions look at them as an opportunity. Some have partnered with retailers to provide these services, while others have developed their own clinics to meet demands for access and convenience.

Medical groups and health systems have created many convenience clinic models in response to these demands. In this article, Cleveland Clinic and SSM Health present how their distinctive models improve patient care and organizational health.

No Appointment, No Problem: The Evolution of a Walk-In Clinic

Featuring J. Stephen Jones, M.D., President, Regional Hospitals and Family Health Centers, and Renee Kolonick, M.H.A., Chief Operating Officer, Cleveland Clinic Marymount Hospital

In an ideal world, receiving medical care wouldn’t be a reactive experience. We’d be able to predict when our next bout of flu or an incidental injury would occur. We could schedule the appropriate appointment time to see a doctor weeks or even months in advance.

Unfortunately, that day seems unlikely, so physi-cians will diagnose and treat medical problems as they occur, making patient access often complicated and unpredictable.

During the AMGA 2017 Annual Conference in Dallas, Texas, two Cleveland Clinic leaders discussed how the organization uses walk-in clinics as an extension of primary care. It provides relief to the unpredictability by offering low-cost access points for

patients with acute, same-day needs, and also opens primary care physicians’ schedules to improve access for patients with chronic diseases.

“In 2014, I became the vice president of regional operations for Cleveland Clinic,” says J. Stephen Jones, M.D., now president of regional hospitals and family health centers. “I was told that I’d be responsible for coordinating the hospitals’ operations. I’m a urologic oncologist who has spent half my life in the operating room, so I thought sure, I can handle that. My role then expanded to include the family health centers. I had that covered, too, because I had spent a big part of my career in clinics and ambulatory surgery centers.”

Renee Kolonick, M.H.A., was the senior direc-tor for the family health centers at that time. “I first met with Renee, who is now chief operating officer of Cleveland Clinic Marymount Hospital. Moving beyond responsibilities in hospitals and family health centers, she asked me about a program she cared deeply about—urgent and express cares. I didn’t really know the difference, but learned that we shared responsibility for them all. As you might imagine, I still had a few things to learn!”

At that time, Cleveland Clinic already had estab-lished same-day appointments with its primary care providers and many specialists. If you called in for an appointment, you were able to see a provider that same day. While it served as a good alternative to the emer-gency department and was new in the market, it didn’t provide consistency in convenience.

“A same-day appointment would be offered, but it might not at your preferred location,” says Kolonick. “I live on the west side of Cleveland, but my same-day appointment was 40 miles away on the east side of town.” Additionally, Cleveland Clinic’s number of providers didn’t increase. Kolonick says, “In our busiest practices, we basically took slots on an already existing template and put same day on them. We held those slots, which did not actually increase access.”

Cleveland Clinic had a no-appointment strategy for express care, but there were access challenges to over-come. Its five original facilities only treated adults for just five diagnoses (cold, cough, flu, sore throats, and earaches) and had limited hours of operation (usually from 5:00 to 8:00 p.m.). They were typically located in out-of-the way spaces that mostly served existing patients and employees for walk-in care for the simplest of conditions.

In the first phase of improvement, Kolonick had expanded the hours from 1:00 to 9:00 p.m. at most locations, opened three additional locations, expanded the diagnoses to 10 (adding conjunctivitis, skin rashes,

at Cleveland Clinic and SSM Health

10 GROUP PRACTICE JOURNAL x AMGA.ORG NOVEMBER/DECEMBER 2017

minor back or shoulder pain, and urinary tract infec-tions), and moved the access age to 14.

They also staffed the facilities with nurse prac-titioners and physician assistants with supervisory responsibility to physicians. Instead of nurses, they had medical assistants. Patient service representatives registered patients at the front desk. All of it was under a shared leadership approach. One physician was responsible for all facilities and physician supervisory agreements. With these early changes, Kolonick says, “The growth was still amazing. From 2009 to 2012, we had seen a 263% increase in volume through express cares.” (See Figure 1.) Nevertheless, Jones and Kolonick saw significant opportunity to advance further as soon as they started working together.

More Sites, More Hours, More Care Despite early growth, the value of express care to

other clinical institutes, specifically primary care and emergency medicine, was still not obvious. “We needed to show the value of the strategy and the impact that express cares had on emergency services,” Kolonick says. “How did it impact medicine institute practices? How did it impact the patient? And finally, we needed to eliminate the perception among physicians that express care offered sub-par primary care.”

They realized that express cares could contribute more to Cleveland Clinic’s mission by expanding the diagnoses being treated and by offering extended and standardized hours of operation. Express cares began seeing every walk-in primary care diagnosis. While this felt to some like an encroachment on primary care and the emergency department, Kolonick says it was a strat-egy meant to build internal relationships and take down walls between institutes. “We saw this as a way to get patients into the system to help establish a primary care relationship,” Jones recalls. “A generation ago, new physicians built their practices by hanging around the doctors’ lounge in the hospital. That is long gone, so we can fill young primary care physicians’ practices from new patients flowing through the express cares.”

“We started by analyzing the impact of express care on primary care,” Kolonick says. “In the first few meetings, the institute and I were going in completely different directions. The institute thought all express care patients should be seen in primary care, while I thought the patients should be seen at the most conve-nient location for them. We also needed to collaborate with the emergency department. With all parties wanting what was best for the patient, we did well by sharing data with them during the strategy phase and making sure we worked together.”

FIGURE 2

New Patient Volume

FIGURE 1

Volume Growth

FIGURE 3

Express and Urgent Care Visits

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After they succeeded in getting buy-in from the other institutes, Jones and Kolonick moved to the next phase of improvement. The plan included unlimited diagnoses, expansion to 17 locations, longer office hours consistent at every location (from 6:00 a.m. to 9:00 p.m. Monday through Friday, and 8:00 a.m. to 4:00 p.m. on weekends), and seeing anyone over the age of five. They also made sure all express cares were standardized. “You couldn’t have a patient walk into one express care and be sutured, while another express care across town didn’t offer suturing,” Kolonick says. As a result of these changes, new patient volume increased 202% from 2011 to 2016 (see Figure 2).

To get the word out, Cleveland Clinic also invested in a comprehensive marketing campaign that engaged the consumer. A bright fuchsia logo was designed that could be placed anywhere—floors, walls, elevators, etc. Cards, pharmacy bags, and pens got the word out. They also advertised on TV and radio, as well as digi-tally through mobile alerts, e-blasts, and social media, eventually tying this endeavor into marketing for their rapidly expanding Express Care Online.

Ultimately, they demonstrated that walk-in care is a valuable asset to Cleveland Clinic (see Figure 3). “When you take a look at the volume from 2008 to 2016, you see remarkable growth,” says Kolonick. “We had 192,000 express care visits last year. That definitely helps with access. We brought on additional providers, so it’s not just putting same-day appointments on a time slot that already exists. We have locations where people live, where they play, and where they work. It’s a low-cost model and we have additional off-hour care for the convenience of our patients.” Critically, they found that approximately 48% of patients established primary care after initial visits in express care. Their hypothesis was validated when the data showed that, instead of siphon-ing patients from primary care practices, primary care growth in sites with express care far exceeded growth in sites that had no express care. They also found that sites with emergency departments on the same campus had no negative impact from express care.

Walk-In WorksCleveland Clinic continues to work on more

enhancements. They are teaming up with pediatrics to see patients as young as 2, and working with specialties such as neurology to ease the influx of patients with self-referred headaches and lower back pain. Walk-in mammography was initiated in multiple locations, allowing appropriate screening requiring neither an appointment nor a physician’s order (a process was put in place to assure consistent follow-up of results). They

also are now using a mobile app to let patients know the closest sites and the wait times at each, offering alternative locations nearby with less waiting when applicable.

Jones and Kolonick ended their presentation by relating a patient success. After playing golf on a hot summer day, the golfer did not feel well on his drive home, so he stopped at a nearby express care.

“We had a PA with many years of experience in emergency settings who was working that day and quickly recognized that the patient was having a heart attack,” says Kolonick. “The PA started taking care of the patient while another provider called 911.Within four minutes, EMS was transporting the patient to the closest hospital. It was 14 minutes door-to-balloon time, from our express care door to the hospital’s car-diac cath lab.

“The patient called the next day and said the express care providers saved his life,” Kolonick con-tinues. “He said he chose express care instead of going to the hospital because he wouldn’t have to deal with waiting in an emergency department.” The presenters emphasize that they don’t want patients in express care who have emergencies more appropriate to the emer-gency department. “But we assure that any door you walk in, we will get you to the right care quickly and safely,” Jones says.

Kolonick says stories like that make her proud of the services they offer. “It’s about doing the right thing for the patient and providing the care they need. It’s not only about taking care of patients who should be seen in express care, it’s about getting patients to the right place to receive the care they need.”

The Evolution from Retail Clinics to Medical Neighborhoods

Featuring James Bleicher, M.D., M.H.C.M., Regional President, SSM Health St. Louis Physician Organization & Ambulatory Services; and Margaret Head, R.N., M.S.N., M.B.A., Former Vice President, Operations, SSM Health St. Louis Medical Group

“It’s not like a regular medical office.

Retail is completely different.”

Earlier this year at AMGA’s Annual Conference in Dallas, Texas, James Bleicher, M.D., M.H.C.M., regional president, and Margaret Head, R.N., M.S.N., M.B.A., vice president, operations, at SSM Health St. Louis, discussed their own organization’s unique ven-ture into retail clinic implementation with their featured

NOVEMBER/DECEMBER 2017 AMGA.ORG x GROUP PRACTICE JOURNAL 13

presentation “The Evolution from Retail Clinics to Medical Neighborhoods.”

Bleicher recalled, “I remember in 2007 when this was first starting to be talked about, and of course, as health care tends to, we resisted it. ‘No, no. No one wants to go to retail. They want to see the doctor in the office.’ But looking at price, the demand, the tailored service, and what people are looking for from a con-venience standpoint, there’s no way we could match it with our current offices.” (See Figure 4.)

SSM began looking for a partner known for its quality that had a strong customer service focus, a big presence in the market, geographic accessibility, and expertise in the area, all with minimal capital invest-ment, and ultimately aligned itself with Walgreens. Says Bleicher, “It was interesting because we were con-templating this retail strategy, and it was Walgreens that came to us saying, ‘Hey, do you guys want to look at this?’ And I thought, ‘Are you kidding? Yes!’”

Beginning in 2013, SSM began its affiliation with Walgreens, initially providing collaborative physi-cian support for Walgreens’ existent NPs, pediatric advisory services, and its enhanced referral network for patients seeking primary care physicians. While this introductory phase showed that a much stronger relationship could be nurtured between the two organizations, it also provided reassurance to SSM’s

primary care physicians—pediatricians especially—who believed that retail clinics would steal their patients. Eventually SSM took full acquisition of all 26 retail clinics in the St. Louis market, folding them into the medical group as official practice sites (see Figure 5).

At the Corner of Happy and HealthyThe actual handing-over of the keys was of course

a labor-intensive process. Discussions between the two parties took almost a year. Hammering out the details and deals of 26 leases, “It did feel like a real estate transaction,” says Bleicher.

Signing a contract in February of 2016 with a plan to go live at the end of August, SSM had just a short time to complete its operational and transition plan-ning. An operations team focused on human resource issues, how SSM was going to onboard and credential the existing NPs, as well as handled the purchasing arrangements for the clinics and their operational workflows. A marketing team was also diligently working on a co-branding campaign, raising awareness around the community about the clinic’s new offering.

The biggest hurdle for SSM, however, was perhaps the digital transition. More than simply flipping a switch, Head says, “We had to really look at how we were going to use our online scheduling and appoint-ment-making tools. Also, while we don’t use them in

FIGURE 4

Retail Health Care Update

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FIGURE 6

Total Completed Appointments, All Clinics

FIGURE 5

Locations

our main clinics, we wanted to use the Epic self-check-in kiosk. Walgreens had their own kiosk and their own EMR, and so we had to implement that brand-new technology (for us) at 26 locations. The other thing that was important and different was that one of the things consumers told Walgreens was that they really liked to see who checked in first and who was coming up next, so we had to develop a technology around that and had to streamline its ability to process credit card payments via the kiosk and other things. We even had to streamline our Epic documentation so that it would work better in a fast-paced retail environment. Even now, we’re still working on our mobile functionality.”

Despite the quick transition, Bleicher and Head

report that their implementation largely went off with-out a hitch. While it proved difficult to transition over 100 employees, train them on a new EMR, and open 26 clinics in a matter of days, SSM’s efforts to retain employees during the transition paid off with limited turnover in key NP positions. Additionally, while more data at the clinic and market level (i.e., number of customer services calls) would have been helpful earlier on in the process, SSM did manage to quickly develop a strong relationship with its new local market managers.

“It’s not like a regular medical office,” says Bleicher. “Retail is completely different, which is why in the past when we’ve tried to convert our own regular medical sites to retail, it doesn’t work. It’s just not set up for that.”

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Establishing a Medical NeighborhoodMore than just an experimental play into the realm

of retail, SSM’s partnership with Walgreens is designed to serve a much larger purpose in the former’s improve-ment in population health—specifically, reducing inappropriate utilization of high-cost venues of care, opening opportunities for new, more chronically ill patients, and increasing general satisfaction in regards to access.

“We were looking at our attributed lives and looking at how to go about growing good volumes and reducing bad volumes, and how retail could fit into that,” says Bleicher. “If you have somebody who waits overnight to see a physician, it could be worse than what they think and could have been seen at the retail clinic and sent to the emergency department sooner. Also, if your office is clogged up with routine retail visits, you don’t have time to see the chronic patients, people who have chronic heart failure and coronary disease, and then they call at 10:30 in the morning and say, ‘I’m not feeling good.’ The doc then looks at his schedule and says, ‘Oh it’s full. Go to the emergency department.’ We were clearly looking at this as a way to offload our physician offices going forward and attract new patients. We were looking at this as a way of unclogging the offices, of pushing things down toward the lower levels so that our physicians would likely see more chronic patients.”

Thus far, SSM’s mission in entering the space of retail clinics has leveraged positive results. By its fifth month in operation, SSM’s retail clinics were accruing up to 14,000 visits per week (see Figure 6). With their goal for the first year to achieve 19 visits a day at each location, they are already averaging 16.9. As a result of the retail clinic, in the last 18 months, SSM has also managed to slot in more than 40,000 unique patients who have never been seen before in its system.

As SSM Health continues to nurture and develop their burgeoning path into retail clinics, Bleicher says the group hopes to begin taking the lessons they’ve learned and applying them to their existing physician offices.

“As part of this change management, we’re con-stantly talking to physicians about patients who don’t want to come to their offices for low-priority things, the type of issues that can be managed in the retail side,” he commented. “We’ve begun asking what you can do at home with virtual visits and tele-visits. These appoint-ments that they filled their offices with over the years are going to dissipate over time, and we need to have ways to fill it in with chronic care and new patients.”

The AMGA 2018 Annual Conference will take place March 7-10, 2018, at the Phoenix Convention Center in Phoenix, Arizona, with a host of healthcare leaders sharing their strategies and insights. For details, visit amga.org/ac18.

Annual ConferenceMarch 7-10, 2018Phoenix, Arizona

2018

amga.org/ac18#AMGA2018 |