Caring Wisely FY 2023 Project Contest

Incentivizing Increased Patient Access in Ambulatory Clinics

Proposal Status: 
  • PROPOSAL TITLE: Incentivizing Increased Patient Access in Ambulatory Clinics
  • PROJECT LEAD(S): Roseanne Krauter FNP, Director of APP Informatics and Clinical Systems
  • EXECUTIVE SPONSOR(S): Ivette Becerra-Ortiz, DNP, Chief of Advanced Practice Providers
  • ABSTRACT – Patient access remains an issue in the ambulatory setting for UCSF Health. Patients requesting a new consult are especially impacted. UCSF Health employs a workforce of 850 Advanced Practice Providers (APP) that are underutilized as frontline providers in some ambulatory areas.  Financial incentives are widely used to promote provider productivity, and this is an opportunity to leverage this approach to increase ambulatory patient volumes with the APP workforce. While we cannot provide cash incentives to these represented employees, we can award stipends to address gaps in work satisfaction using this grant funding.
  • TEAM – 
    • Roseanne Krauter FNP, Director of APP Informatics and Clinical Systems
    • Brandon Sessler, PA, Director of APP Professional Practice
    • Alisa Yee, NP, Director of APP Operations
    • Kurstan Del Rosario, Administrative Officer
    • APP Educational Committee Stipends Workgroup
  • PROBLEM – Fiscal year to date 2023 UCSF Health did not schedule 40.5% of incoming referrals1 resulting in an estimated leak of 29m in charges per month2.  39% of our new patients wait more than 14 days until they can see a provider3. In contrast, APPs are an underutilized resource at UCSF Health with APP overall ambulatory slot utilization at 78%and averaging only 70 patient visits per month1. In FY22 UCSF Health APPs had a 122m gap in return on investment4.  There is an opportunity to increase ambulatory patient volumes by utilizing the current work force.
    • Data sourced from 1. Practice Metrics Dashboard – Tableau, 2. Enterprise Referral Metrics- Epic, 3.Ambulatory Recovery Dashboard – Tableau, 4. Internal Faculty Practice Offices Finance Report completed by Ibrahim Fahmy
  • TARGET -  Increase independent new patient visits by 15% for fifty APPs in ambulatory practices.  APPs completed 40,463 new patient visits in the first and second quarters of FY231 . They averaged 72 new visits per provider in the first half of the year with 12 new visits (15% of total visit volume) per APP per month. The target is to increase APP visit volume to 144 patient visits per month2 with at least 30% new patient visits. If fifty APPs increased their new patients visits to 30%, this would result in a net additional 18,600 new patient visits per year.
    • Data Sourced from 1. Clarity Report 0776676, 2. Office of Advanced Practice Criteria developed in collaboration with the Faculty Practice Offices and included in the attached “UCSF APP Utilization” pdf.
  • GAPS – This problem exists due to misguided operational decisions. In some areas  APPs are being utilized as care coordinators in a support role as opposed to frontline providers. At the systems level, productivity expectations were communicated to APPs and their managers only recently. A third gap exists where in some instances APPs are lacking the clinical and administrative support to run their clinics at increased capacity.
  • INTERVENTION - Incentivize outpatient APPs to increase their new patient visits. Those APPs averaging 144 patient encounters per month with new patients accounting for 30% of those visits for FY24 are eligible to apply for $1,000 stipends towards educational funding or a 3-month parking permit.  The rationale for the incentive is based on FY22 Net Promotor Score Work Experience data. Two common requests from APPs were reimbursement for continued medical education and parking passes. If we receive more qualified applicants than what is available for funding, then patient experience scores will be used to prioritize candidates. If we receive fewer qualified applicants, then additional monies will be distributed to those candidates. Under the APP Education Committee there is a workgroup made up of frontline APPs to review applications for evidence-based practice education and the costs associated with presenting at a conference. I plan to leverage these current workflows for review and approval of the incentive stipends. The largest barriers are effective communication of the incentive program across the institution and sustained engagement from the APPs.  There are no concerns for adverse outcomes impacting quality and safety of patient care.
  • PROPOSED EHR MODIFICATIONS: None,  use existing APeX functionality. We can recommend enrollment in OAPP Ongoing Apex Training utilizing Physician Power User course to increase efficiency with increased patient volumes.
  • COST – There will be no additional baseline costs to the institution with this proposal. UCSF Health’s current investment is $173,606 per 1.0 FTE of APP. 50 APPs increasing to 30% new patients would result in a net additional 18,600 new patient visits per year, assuming an average level 4 of service (1.92 wRVU) at the 2023 Medicare amount per relative value unit of $33.06 this would equate to an additional $1.18m in charges in FY24.
  • SUSTAINABILITY – If this program is successful in financially incentivizing APPs to increase productivity, then this could be parlayed into the annual Incentive Awards Program under financial governance. The UC Office of the President would retain process ownership with Office of Advanced Practice Providers acting as UCSF-specific leadership.
  • BUDGET – I am requesting $50,000 in funding to maximize the number of APPs incentive to increase new patient access. The full funding of this project would be dedicated to fifty $1000 stipends distributed by the Educational Committee under the direction of the Office of Advanced Practice Providers.