—Stephen R. Covey
By Karen O’Hara
Todd Baker distills his approach to clinic management down to a few critical, interrelated concepts: philosophy, entrees of scale, and communication.
Mr. Baker, executive director of ambulatory care services at Proctor Hospital, Peoria, Ill., is a proponent of the mixed-use model. He believes occupational medicine complements immediate personal care, and vice versa.
Under his direction, Proctor First Care operates a network of five geographically dispersed clinics offering primary, urgent, and episodic care and occupational medicine services on a walk-in basis and by appointment. (Episodic care is defined as care provided when a patient’s own doctor is not available or when a patient does not have a primary provider.)
While the patient mix varies by location, about 8 percent of Proctor First Care’s business is true urgent care and 30 percent is occupational medicine. The remainder is primary or episodic care, Mr. Baker said during a presentation at RYAN Associates’ recent seminar on Integrating Urgent Care and Occupational Health Services.
“I submit to you that blending urgent care and occupational medicine is a philosophy that requires a certain type of leadership,” Mr. Baker told the assembly of occupational health professionals at the seminar.
The following is a “Baker’s dozen” of recommendations for the successful operation of a blended clinic network:
Challenge 1:
Competing Agendas
In any community health system, it is not unusual to find an urgent care manager with one agenda reporting to a hospital executive, an occupational health program director with another agenda reporting to the same or a different executive, and clinics that “go into the never-never land where doctor’s offices owned by hospitals seem to go all the time,” Mr. Baker said. In such cases, multiple entities vie for resources within the same organization, potentially creating an “us-against-us” scenario.
Baker’s Solution:
“Top management should make one person responsible for all those businesses. When that is the case, all of a sudden the politics start to crumble and we can get to economies of scale.”
Challenge 2:
Provider Coverage
Physicians working in emergency departments often have sporadic, unpredictable schedules. When they transition to urgent care settings (as is often the case), they may bring along the expectation of working without a stable schedule, not realizing the customer values a greater degree of provider consistency.
Baker’s Solution:
“Create a fixed schedule for providers. It’s a matter of not putting the physicians into a blender, pouring them out into the ice cube tray and whoever lands in the tray works the shift that day. Instead, Dr. X knows what days of the week he or she will be working in the clinic.
“We are talking about the same docs, in the same box, on the same day, all working a full shift. We have very few one-day-a-week docs in those boxes.”
Challenge 3:
Managing the Mix
In a busy blended clinic, providers must learn how to adjust to the variety of patients who walk in the door on any given day. “That is going to be hard for your physicians,” Mr. Baker said. “They are not necessarily going to be able to shift hats on the fly, because your sales and marketing team will be doing such a great job filling up the waiting room.”
In addition, a treating clinician may wonder: What exactly is the difference between treating a woman who sprained her ankle while mowing her lawn and treating the same woman who sprained her ankle while pushing a cart at work? Regardless of the source of the injury, the patient is always the customer, but as occupational health professionals are well aware, there are numerous additional clients when managing a workers’ compensation case.
Baker’s Solution:
“Allow your physicians to focus on the patient and provide the best possible care. Give them tools to help them work through each patient’s specific concerns. Rather than say, ‘Write the patient’s limitation on this blank piece of paper,’ give them a template with restrictions so they can check, ‘Do this, don’t do that,’ whether it is at work or at home. The template provides the foundation for excellent follow-up care.”
Challenge 4:
Centralization
Human resource managers and other employer representatives frequently say they prefer a “one-stop shop.” With five clinics, they may be confused about which site to contact.
Baker’s Solution:
“You need a couple of key people who are the primary contacts for occupational medicine. We have a service line director for occupational medicine and centralized staff dedicated to managing all employer relationships, so the employer doesn’t have to figure out which clinic to call. They serve as our liaison with companies, and they can offer employers a customized package of services in response to their specific circumstances. To appear seamless and reduce the number of follow-up calls that we need to make, we give the customer one number to call.”
Challenge 5:
Establishing Relationships
While employers appreciate a centralized point of contact, they also want an established relationship with clinic staff.
“With five clinics, we have observed that employers will evolve toward one clinic and use it all the time,” Mr. Baker said. “We go out and talk about extended hours, 24/7 service for drug screening, picking the location nearest you, etc., and we will still have a business on the north side of town that uses a clinic 15 minutes away instead of the one that is a three-minute drive. Why? Because they like it and the relationship they have established there.”
Baker’s Solution:
“We don’t care which clinic they use, as long as they are using one of ours. Established clinic relationships give our dedicated occupational health staff more time for marketing and sales. So, you could say we have five independent clinics with a program in each clinic, supported by a central office, run by an individual, and some support staff. That is great because we can meet our customers’ expectations by getting people in and out right now.
Challenge 6:
Being Responsive
In a mixed-use clinic, front office staff often complain about being too busy to respond in a timely fashion to occupational medicine patients’ and employers’ questions or concerns, while providers typically are with patients and not immediately available. The challenge is how to make both the patient and the client company feel special at the time of treatment.
Baker’s Solution:
“First, I always challenge the statement: ‘I am too busy,’ but I understand where that comes from. In our clinics, every receptionist has access to employer profiles that include all the information we need to convey back to the employer. When an occupational health patient comes in, they pull up the profile and it follows that patient all the way through the process. We have one receptionist per provider on the phone, entering charges, creating bills, and collecting information. They are not just processing patients. It is an important position. You need exceptional staff in each clinic to figure that out.”
Challenge 7:
Improving Profitability
Mr. Baker said he generally finds that professionals who are accustomed to running occupational health programs as a business entity tend to be more entrepreneurial in nature than personnel who transition into clinic management from other hospital departments.
“When you work in a hospital you deal with politics all day long just trying to figure out which way is up,” he said. “They move slowly in hospitals, and they are used to doing things a certain way. You have to be entrepreneurial to put this together. If you don’t have that spirit, you are going to struggle, because you are doing something different from the norm.”
When a health system operates urgent care and occupational health clinics as distinct facilities, it becomes harder to sustain profitability, especially in rural to mid-sized markets with a finite number of prospective clients. Many hospital-based occupational health programs also are encumbered by overhead. The result is an occupational health program that has to repeatedly justify its contribution to the health system to get the support and resources it needs to be successful.
Baker’s Solution:
“Combine services. If you have a building with exam rooms and dedicated staff, there is no reason not to cross-train the staff to handle both urgent care and occupational health. Again, there has to be a leader to act as the driving force. Years ago, we added occupational medicine to increase volumes and produce additional revenue.”
Two other suggestions:
- “When a non-client company recommends our clinic to an injured worker, our sales representative follows up with that company to upsell our services.”
- Base physician compensation partly on production: “I say, doctor, here is where the money is. During the times when you are not seeing four or five patients an hour, I can give you an hour to perform work-related physical exams…it pays, it is gravy.”
Challenge 8:
Documentation & Billing
Group health documentation and billing differs from employer-paid and workers’ compensation documentation and billing.
Baker’s Solution:
“We push the information out electronically. In essence, the patient is the payer for urgent care. The occupational medicine patient is not the payer, so we have separate financial classes set up in our system: employer-paid/billed and workers’ compensation billing to the employer or carrier. Same staff, same window. It’s a training and implementation issue. We are introducing an electronic medical record system this summer that will allow us to use templates.”
Challenge 9:
Wait Times
Patient and employer surveys suggest an expectation of no more than 15 minutes of wait time and a total time of 45 minutes in the clinic for a routine visit. What if you know the clinic will be busy with walk-in patients at 8 a.m. and a client company wants an 8 a.m. appointment? What do you do when your clinic gets overrun with patients? How do you handle urgent care patients who complain when an injured worker appears to be given priority?
Baker’s Solution:
“If the company wants an 8 a.m. appointment, give it to them, because that is good money. If your clinic gets overrun, communicate with the patients who are waiting. During flu season, ramp up providers; bring in a retired physician. We ‘park’ anyone who needs an X-ray in a treatment room (they are not going to be out of there in an hour anyway) and then process the other patients who are waiting.
“Some physicians prefer a ‘first-in, first-out’ system. That doesn’t work in a blended clinic. Sometimes a staff person has to help the doctor understand the flow: ‘This one is going to be here a bit longer, this is a school physical, this is a sore throat,’ and queue things up in the right way. We have to remember we are pushing our doctors and they have to change hats. We match every physician with a nurse because it helps keep the flow going. Hospital executives want to know why we need a nurse for every doctor. I tell them it is because otherwise, the doctors would end up performing nursing duties for which we cannot bill. You have got to make that point.” Also, pay attention to site-specific utilization and staff accordingly.
Challenge 10:
Physician Expertise
Board-certified occupational medicine physicians are difficult to find and there is a risk of under-utilizing their expertise in a mixed-use setting.
Baker’s Solution
“We have one board-certified occupational medicine physician who works at a single location. The rest of our physicians are family practitioners.”
This was not the original model: “Early on we made a huge mistake: we thought we needed a centralized occupational medicine clinic that would serve as the hub and the urgent care clinics would be the spokes. It turned out the doctors on the spokes thought, ‘Why would I send my revenue to occupational medicine when I get paid to see that patient? What does this person know that I don’t know?’ We ended up dissolving the spoke-and-hub concept. Now the other physicians use our occupational medicine physician as a resource and we market his credentials.”
Challenge 11:
Competitive Threats
Many blended clinic operators find themselves competing with a new crop of start-up operations and/or retail-based walk-in clinics. Some are getting into the quick-clinic business themselves in order to remain competitive, which presents its own set of challenges. “You can’t swing a dead cat without hitting a new urgent care center, but when there is that kind of growth, there is going to be a shakeout,” Mr. Baker predicted.
Baker’s Solution:
“I respect the ‘Minute Clinics.’ I am even a little afraid of them, although in our town Walgreens has downsized their clinics and released a number of nurse practitioners. I don’t know if you can sit in Walgreens sick while everybody else is buying newspapers and gum. We had a plan to operate our own cash-only, quick clinic, but we put it on the shelf because we didn’t want to confuse our brand. I am glad we did that now.”
Regarding the WalMart model in which a local provider organization enters into a contract to operate an in-store clinic, Mr. Baker says: “For those who are operating a clinic in the WalMart in your area, good for you. I thought their expectations were oppressive, so we backed away and the goliath hospital in our community is now in there.”
Challenge 12:
Adapting to Trends
Occupational health professionals who are experienced with integrated delivery models are trying to determine where they fit within an Accountable Care Organization or medical home model in their organization.
Baker’s Solution:
“I see urgent care as the front door to the ACO. Our operation is positioned that way and that is the direction we are going. I have no idea how it is all going to turn out, but I don’t want to be behind the curve.”
