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Outpatient Practice Reactivation in an Integrated Community Practice During the COVID-19 Pandemic

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Introduction

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected countries throughout the world unlike any other illness since the 1918 flu pandemic. Because of the newness of the disease, health care practitioners were tasked with learning how best to care for patients with COVID-19 in ambulatory and inpatient settings. This included developing testing capabilities for accurately diagnosing COVID-19, properly isolating patients with COVID-19, dealing with a lack of scientifically proven treatment modalities, and providing adequate safety measures for patients and medical staff members. The precautions required for COVID-19 also negatively affected all other patients needing medical care at health care institutions. These disruptions have led to declining vaccination rates,1 delayed treatments of patients with serious health conditions,2 and worsening of the psychosocial wellbeing of our communities.3 Adults and children have had increased mental health issues4,5 attributable to societal restrictions, including school closures for children and remote work expectations for adults.

The primary value of Mayo Clinic has always been, “The needs of the patient come first,” which guided the Mayo Clinic response to the pandemic, including that of the Mayo Clinic Health System.6 Mayo Clinic Health System in Southwest Minnesota (MCHS—SWMN) Region is a regional community health care provider with 5 hospitals and 22 clinic locations serving a community of 250,000 people in Southwestern Minnesota. In early February 2020, necessary organizational structures were formed to coordinate, communicate, and strategically execute critical priorities in this health system’s integrated clinical practice. In March 2020, following federal and state regulations, Mayo Clinic and Mayo Clinic Health System abruptly deferred the medical practices and patient access to care, especially for patients with elective needs in both medical and surgical specialties.

This article is an effort to review and to share experiences during the pandemic that are specific to regional community care at Mayo Clinic Health System, which can be easily applied to similar scenarios in the same health system as well as other health systems serving patients especially in a community-based setting. After initially deferring in-person appointments, MCHS—SWMN Region was able to continue care for our patients by substantially expanding virtual care, then carefully reactivating in-person care in the outpatient practice. Although continuous enhancement and optimization of processes is still in progress, this article aims to reflect on how a community-based outpatient practice was able to successfully manage the clinical practice during the pandemic and with hope that appropriately sequencing and combining these solutions may be of use to others during this or other future public health crises.

Method

As restrictions were lifted in the outpatient clinics to allow for return of in-person appointments, the practice reactivation team used a systematic approach by creating an Outpatient Clinic Reactivation Framework (Fig. 1) that represented five key areas to resume normal clinic operations. The team created a dashboard and a decision-making algorithm (decision matrix) to determine which practice areas and at what capacity to reopen each week. The team landed on this framework through ongoing daily meetings, group consensus, and brainstorming sessions with the key stakeholder groups.

Fig. 1.

Fig. 1. Five-layered Outpatient Clinic Reactivation Framework.

During the temporary deferral of clinic appointments due to COVID-19 crisis, the Outpatient Clinic Reactivation Framework always centered around patient’s safety, which directly aligns with Mayo Clinic’s primary value, mission, and vision of keeping needs of the patient on the forefront. Next layer of the framework was the rapid increase in virtual care and the management of resource needs driven by increased virtual care needs. For example, Office of Access Management leadership had to come up with a just-in-time solution on how to support check-in process for increased virtual visits. In MCHS—SWMN region, personnel resource need for the virtual visit check-in process was managed by shifting resources from in-person check-in desks to virtual check-in process. This shifting of resources from physical and fixed location to digital platform, in a way, disrupted health care in the year 2020 for not only Mayo Clinic and its health systems but for most health care organizations.

Even before COVID-19 pandemic, video visits and technology associated with virtual care was already popular in connecting patients with doctors in rural locations, but it grew exponentially in 2020 due to the pandemic crisis.7 This directly links the shift of outpatient practice to virtual care to access management needs, which was the next layer of the Outpatient Clinic Reactivation Framework. Assessment and establishment of appropriate technology platform, appropriate alignment of resources to support growing virtual care needs, and management of resources based on patient demand was all part of Access Management. Each specialty has a target fill rate for available capacity but due to various reasons mentioned above all due to pandemic crisis, there was a sudden decline in appointment fill rate for all specialties. However, as the restrictions were lifted at local, state, and federal levels, clinics had to carefully (appropriate social distancing, appropriate use of Personal Protective Equipment by both patients and staff etc.) increase the appointment fill rate without negatively contributing to COVID-19 cases. To do so, a simple yet data-driven algorithm was needed, which was finalized through the team’s effort and was called decision matrix with specific criteria. Last but an important layer of Outpatient Clinic Reactivation Framework was the Outpatient Appointment Clinic Dashboard. Regional leadership and the practice reactivation team was clear from the beginning that all the decisions being made and cascaded down to each practice group was factual and data driven. Outpatient Clinic Appointment Dashboard just did so by providing just-in-time data and charts that helped leadership make data-driven decisions in real time. The use of the data and analysis used in this article does not involve human subjects and hence meets the waiver for HHS protection of human subjects regulations and Institutional Review Board (IRB).

OUTPATIENT CLINIC APPOINTMENT DASHBOARD

In the days and weeks after restrictions were eliminated in the outpatient practice, patient demand for appointments varied by clinical department. Timely and accurate data were required to reactivate outpatient care safely and effectively. It did not take long for the team to realize that centralized approach on data reporting through analytical dashboard powered by a reliable data source is key to effective telemedicine functions. As a first step of the practice reactivation efforts, a dashboard was created for the outpatient clinical practice to help make data-driven decision making for clinical and operational leadership. It was evident from the literature that creation of a real-time dashboard with critical metrics both in inpatient and outpatient setting was key to a successful management of COVID-19 patients and to analyze impact of COVID-19 surge in real time.8 Dashboard included multiple data points that were extracted from the electronic health record (EHR) for each outpatient department, including total capacity available (provider clinic schedules), appointment fill rates, the number of scheduled appointments for the coming weeks, the percentage of appointments compared with the department’s pre-COVID weekly average, and the number of appointment orders in the EHR work queues. The leadership team also monitored capacity by in-person and virtual visits, appointment fill rates for in-person and virtual visits, daily capacity for advanced practice providers and physicians, appointment fill rates for provider type, and the number of appointments by the day of the week. A snapshot of the first page of Outpatient Clinic Appointment Dashboard is provided below (Fig. 2).

Fig. 2.

Fig. 2. Snapshot of a portion of Outpatient Clinic Appointment Dashboard utilized by the practice reactivation team. F2F, face to face.

DECISION MATRIX

The use of decision tree and decision matrix in health care sector is not new. Decision matrix are also embedded in many web-based applications and modern EHR systems to help clinicians and other stakeholders to help make fact-based decisions. Simple to complex decision matrix tools are seen widely used in health care sector not just to help make clinical decisions but to also manage other components of health care.9 A simple decision matrix was created to guide weekly clinic reactivation decisions using the dashboard data. The purpose of creating this algorithm was to incrementally add outpatient capacity for in-person and virtual visits based on patient demand. Capacity was phased in at intervals of 30%, 60%, 90%, and 100% of pre-COVID-19 capacity, with a mix of in-person and virtual appointments. Decisions to increase clinical capacity were driven by our ability to ensure social distancing for patients and staff in the clinic setting. This required assessing patient waiting areas and examination rooms to ensure that we could achieve adequate social distancing (Fig. 3). Staffing levels were then adjusted according to capacity decisions, and only staff members with direct patient care responsibilities and essential functions were scheduled to be physically present in our clinics.

Fig. 3.

Fig. 3. Decision flowchart to manage in-person clinic capacity based on demand.

ACCESS MANAGEMENT

Millions of people in the United States are already deprived from receiving the care they need just in time in an outpatient setting due to many reasons, including but not limited to shortage of providers, communication gaps between providers and patients or between care providers, cost etc.10 COVID-19 pandemic restrictions contributed to deferral of thousands of appointments to future weeks, months, and even potential cancelations. From patient’s access perspective, patients whose appointments were canceled during the practice deactivation were triaged into one of three categories: urgent, semiurgent, and nonurgent. Patients with urgent needs were prioritized for in-person appointments. Patients with semiurgent needs were triaged for in-person or virtual appointments, as applicable. Patients with elective or nonurgent needs were prioritized for virtual appointments, and reasons for appointment changes were explained through numerous channels, including by direct phone calls, text messaging, the patient online portal, and social media messages, as well as by local media outlets. We also provided educational materials about how patients could avoid acquiring COVID-19 and about safety protocols that were implemented for in-person appointments. Physicians, other practitioners, nurses, and access colleagues within each department worked together to triage hundreds of patients.

The demand for in-person appointments for each department was monitored daily for the upcoming week, and clinical calendars were adjusted weekly to match demand. Staffing of practitioners and allied health staff for in-person appointments was also adjusted weekly to match demand, which allowed for effective staffing to workload in the physical space. Demand data and patient acuity data based on patient triage guided the percentage allocation of resources toward in-person appointments and virtual appointments within each department. Frontline staff exercised dynamic decision making supported by data analytics and flexibility.

This approach was unique to existing processes and system in MCHS—SWMN Region, that is, access and all staffing being adjusted weekly by department to match the demand and needs of the community. There were not a lot of literature found on similar approaches from other health care institutions.

The model allowed not only for effective utilization of resources but also had a major role in the safe reactivation of all clinical practices. Table 1 provides example from the week of June 2, 2020 that includes top 10 contributors on highest number of appointments renounced since the appointments were deferred in the March and April time frame.

Table 1. Top 10 Specialties with the Highest Appointment Requests in the Work Queue as of June 2nd, 2020
SPECIALTY TOTAL APPOINTMENT REQUESTS AS OF JUNE 2, 2020
Family Medicine 4,491
Community Internal Medicine 645
Medical Oncology 631
Cardiovascular 599
Pulmonary Medicine 466
Gastroenterology and Hepatology 462
Endocrinology 393
Community Pediatrics and Adolescent Medicine 334
Physical Medicine and Rehabilitation 329
Psychiatry and Psychology 327

VIRTUAL CARE

After the Centers for Medicare & Medicaid services relaxed regulations around telemedicine, virtual care became an important part of our patient care response during COVID-19 pandemic.11–13 Virtual care includes care delivered using telephones, secure messaging through patient portals, and video technology. Training modules were quickly developed for staff to learn how best to use the technology. Staff in each department used triage to determine in-person versus virtual visits based on patient acuity and preference. Because clinic capacity and practitioner staffing were adjusted each week to align with patient demand and current fill rates, additional practitioners within the departments were asked to continue with virtual appointments. Scheduling templates were divided into in-person blocks and virtual blocks. Figure 4 provides a graphical synopsis of fill rates by block type for face to face and virtual appointments scheduled between April 23, 2020 and July 22, 2020. One important thing to note from this graph is that the breakeven point (when virtual visit fill rates take a lead over face-to-face visit fill rates) was on the late June to early July 2020. This was when COVID-19 cases were still fluctuating at a higher-than-expected rates in the state of Minnesota and MCHS—SWMN Region.

Fig. 4.

Fig. 4. Overlay of F2F and VIRT fill rates by block type. VIRT, Virtual.

PATIENT SAFETY

Each patient scheduled for an in-person appointment was contacted by scheduling department within 2 days of their appointment and screened by telephone for COVID-19 symptoms. This screening provided a point of contact with family to address safety concerns and to reinforce safety protocols, including expectations of masking, social distancing, and limits of one visitor per patient. On the day of an appointment, patients were screened at facility entrances by questionnaire and temperature checks, and we established a workflow for patients with questionable conditions to be further assessed by clinical teams for in-person visits at the appointment-day screening.

Staffing all the clinics and hospitals to match the workload was key to ensuring compliance with social distancing within the hospital and clinic settings. The staffing model also allowed the region to have alternate staff available in case primary staff had to be quarantined because of exposures and allowed for conservation of personal protective equipment.

Results

The practice reactivation team began meeting in April 2020 to reactivate the outpatient practice and used the aforementioned tactics and tools for increasing clinical capacity. The practice reactivation team initially met daily, transitioning to twice weekly, then biweekly meetings once the outpatient practice reached pre-COVID-19 appointment volumes. Once the patient volume remained steady, the team met monthly.

Capacity and fill rate for the outpatient practice were monitored weekly during practice reactivation. Although capacity returned to pre-COVID-19 levels, the practice was different in that virtual care constituted a much larger portion of clinical appointments, based on patient demand. For example, the psychology and psychiatry services have been very successful in providing at least as many virtual as in-person visits. Increased appointment volumes were observed within the first week of reactivation, resulting in more than double the number of completed appointments from the previous week. Gradual increase in appointment volumes was observed in each subsequent week. From week 1 to 5 (Table 2 and Fig. 5), volumes increased by 36%, and additional 36% increase in volume was observed from week 5 to 9, returning the outpatient practice to pre-COVID-19 volumes. Figure 6 shows data for practice recoveries from family medicine, one of region’s highest-volume clinics. Over the course of 9 weeks, clinic visit volumes and clinic utilization rates came back to pre-COVID levels (pre-COVID fill rate range: 87% to 94%, post-COVID fill rate range: 86% to 89%). This exceeded target fill rate of 80%. This was achieved through established initiative as a shared priority, care team’s commitment to a robust schedule and decisive actions, well-defined structure, extensive communication, use of available data to make decisions, agreed-upon guiding principles, and appropriate training and education plan for care teams.

Fig. 5.

Fig. 5. Regional appointment volumes showing reactivation progress.

Fig. 6.

Fig. 6. Appointment fill rates in Family Medicine. With practice deactivation, the rate decreased to 35% but rebounded to pre-COVID-19 levels within 9 weeks. The bars represent 2020 appointment capacity. The dotted line represents a target fill rate of 80%, and the line chart represents actual fill rate. COVID-19, coronavirus disease 2019.

Table 2. Appointment Volumes in the Region Between March and June 2020
WEEK OF TOTAL APPOINTMENT VOLUMES IN THE REGION
March 29, 2020 1,674
April 5, 2020 3,362
April 12, 2020 3,683
April 19, 2020 3,930
April 26, 2020 4,576
May 3, 2020 4,890
May 10, 2020 5,043
May 17, 2020 5,422
May 24, 2020 4,291
May 31, 2020 6,229
June 7, 2020 5,947
June 14, 2020 6,131

Discussion

As we reflected on what we have learned thus far from managing the crisis of COVID-19, we identified 7 important actions that led to our success, which may be useful now and in the future for our health system as well as other organizations especially in the community-based outpatient practice.

1.

Establish initiative as a shared priority. In a large medical practice with numerous specialties and ancillary staff members, teamwork and shared responsibilities allowed us to ensure a high level of support and participation at every level of the organization. This dedicated focus was a catalyst that drove our progress and decision making.
2.

Commit to a robust schedule and decisive action. Daily meetings that transitioned to less frequent meetings with set agendas and expectations for decision making allowed us to be nimble, act decisively, and make timely decisions. This robust schedule not only created traction for practice priorities but also maintained it.
3.

Create and maintain a well-defined structure. In the very early stages of the pandemic, we established a decision-making body with well-defined membership and a virtual meeting structure, which supported team members’ active participation and ownership of the work. This situation also revealed how effectively we could work remotely and with increased productivity.
4.

Take an inclusive approach. The decision-making body consisted of a multidisciplinary team with representation from clinical, operational, and support areas of the practice. This structure helped us understand the full scope of work that was needed for patient care from all areas of the organization. This same team developed the objective assessment tools that enabled execution in a data-driven and objective approach.
5.

Overcommunicate and ensure easy access to data and support materials. We depended on multiple touch points within the practice, including virtual town halls, phone huddles, email communication, and the internal website. Regularly updated practice data and support materials were shared through electronic forms of communication to ensure transparency and ease of access, which allowed for a common understanding of terminology and metrics early on to minimize staff confusion while aligning all of our expectations.
6.

Establish guiding principles for decision making. Our guiding principles were rooted in two key elements: (1) access to patients with ongoing medical needs; (2) safety of our patients and staff.
7.

Focus on education and training of staff as well as on patients and communities. To leverage virtual care, especially in cases of natural emergencies, our ability to engage with our care teams, even during a lockdown, was immensely valuable not only to our patients but also to our staff. This engagement was important in preventing mental health issues among staff.

Conclusions

Several key findings were identified that made MCHS—SWMN Region’s outpatient practice reactivation successful, as defined by speed and rate of serving the medical needs of our patients’ medical needs, during the COVID-19 pandemic: establishing initiative as a shared priority, committing to a robust schedule and pace, creating and maintaining a well-defined structure, taking an inclusive approach, overcommunicating and providing sufficient data for transparency, and training and educating staff. These factors allowed clinic appointment volumes and fill rates to recover safely and quickly to pre-COVID-19 levels over 9 weeks. Our guiding principles allowed us to facilitate decision making and create a well-defined and dynamic multidisciplinary structure that could change rapidly as supported by data analytics. Our experience also suggests that an effective communication plan is a key element in managing challenging, unpredictable, and extraordinary events within a community care setting. We recommend community-based health care organizations to consider utilizing our collective learnings in preparing for the future health care emergencies.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

REFERENCES





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