ENSURING TIMELY primary care access is a major focus for health care organizations as they take responsibility for providing care to large patient populations across multiple care settings. Access to primary care is of particular importance because of the assessment, triage, and long-term continuity follow-up function that primary care health care providers serve (Bhat, 2005). While access to health care is often thought of as a measurable concept reflecting the degree to which patients are easily able to obtain a face-to-face visit with a doctor, the reality of access within health care organizations is more complex.
Multiple access-related capabilities, processes, and patient population dynamics within health care organizations affect whether and what kinds of access patients can achieve. These access determinants require ongoing attention; yet, few studies have addressed management strategies required to achieve and sustain access to care in health care delivery organizations. Thus, how “access” and “access management” are defined will affect organizational procedures and resource management and will also determine quality improvement (QI) goals and shape how organizations go about meeting them.
It is critical to discuss patients' access to care in the context of today's health care environment. Fortney et al. (2011) reconceptualized access for the 21st century, given that technology is now available to promote virtual patient-provider interactions (Totten et al., 2016) in contrast to traditional indicators of access that focused on face-to-face clinical interactions. This reconceptualization distinguished 5 dimensions of access: geographical (eg, ease of traveling to providers), temporal (eg, time to receive services), financial (eg, eligibility for services), cultural (eg, acceptability of services), and digital (eg, connectivity enabling digital communication). Maximizing the ability of health care personnel to meet patient demand, such as using nonphysician clinicians, is being increasingly employed and has changed our understanding of health care interactions (Committee on Optimizing Scheduling in Health Care, 2015; Staton et al., 2007; Van Vleet & Paradise, 2015).
Our workgroup convened an access management expert panel informed by research evidence to establish recommendations for improving access management in primary care. We describe here the process and results to understand the conceptual dimensions of access management and to establish relevant definitions for access management and optimal access.
This study was assessed by the RAND human subject protection committee, determined to be minimal risk, and thus exempt (IRB ID2016-0610). All participants signed nondisclosure agreements and agreed to treat information as confidential to enable meaningful discussions.
Panelists were selected using a structured recruitment strategy based on a patient-centered framework (Concannon et al., 2012) and incorporated various pathways of accessing primary care. The 20 panelists represented patients (ie, consumers of health care), providers (primary care emphasis), purchasers (responsible for underwriting health care costs, such as the Centers for Medicare & Medicaid Services [CMS]), payers (eg, insurance companies responsible for reimbursing medical care such as Kaiser Permanente), policy makers (Veterans Health Administration [VHA] personnel), product makers (represented by VHA call centers, the most frequent “point of entry” for primary care), and researchers with access expertise. Additional expertise was sought to represent the needs of rural populations (who face barriers to care), nursing staff (recognizing their key role in coordinating care), group practice managers (a new VHA position established to improve access management), the Veterans CHOICE Act (2015 legislation intended to improve veterans' timely access to care), Veterans Integrated Service Network (VISN)–level staff, non–US health care systems (specifically to learn from unintended consequences of access models), continuity of care (potential competing goal), and measurement (emphasis on QI measures). An additional 20 participants with expertise in access management, including RAND researchers (a nonprofit policy think tank) and VHA practitioners, provided input at an in-person panel meeting.
Prior to the in-person panel meeting, panelists received a systematic review on access management improvement in primary care. The systematic review searched PubMed and CINAHL databases, reference-mined included citations, and consulted technical experts. The concise yet thorough review documented a modest body of evidence about primary care access management strategies but noted that the literature is dominated by evaluations of one strategy (ie, advanced or open access). Details of the systematic review methodology are documented in detail elsewhere (Miake-Lye et al., 2017). Panelists had access to an online article collection on access management literature prior, during, and after the in-person panel meeting.
In preparation of the in-person expert panel meeting, panelists received a written survey that asked about access management strategies from the point of view of primary care (response rate 20/20). It included a working definition of access management: “Access management encompasses the set of goals, evaluations, actions, and resources needed to achieve optimal use of health care services by defined eligible populations of patients. Optimal access incorporates considerations of equity, patient preferences, patient needs, and value.” The working definition had been developed on the basis of the existing access management literature. Panelists were asked to indicate agreement or disagreement on the working definition and to provide further comments or improvements.
In-person panel meeting
At a 2-day in-person panel meeting using an experienced moderator, sessions were dedicated to access management definition and conceptualization and survey results were presented. We established 5 parallel stakeholder subpanels dedicated to defining “access.” We chose the format of concurrent panels to determine recurrent themes. Panels were established ad hoc with up to 6 participants and purposefully designed to include similar proportions of technical experts from the main panel and those joining for the in-person meeting. The total number of panelists was similar across panels, but participants were free to select panel groups they would want to contribute to.
The 5 access subpanels were instructed to establish a definition of access. To facilitate the discussions, participants received a handout outlining the objective of the overall project goal (establish key recommendations for primary care access management), a draft definition of access management developed in the workgroup, and a published definition of health care access. The access definition was developed by VHA staff and based on expert consensus (Fortney et al., 2011):
Access to care represents the potential ease of having virtual or face-to-face interactions with a broad array of health care providers including clinicians, caregivers, peers, and computer applications. Actual access to care represents those directly observable and objectively measurable dimensions of access. Perceived access to care represents those self-reported and subjective dimensions of access.
The 5 subpanels could choose to adopt the published health care access definition unchanged or modify it. A member of the team that developed the working definition was available to facilitate discourse or respond to questions. After the within-panel breakout, each subpanel presented its conclusions to the main group.
Literature review results were abstracted and documented in a comprehensive evidence table that differentiated the publication type (eg, intervention evaluation), perspective (eg, population health approach to access management), and whether continuity of care was referenced in the conceptualization. We abstracted the definition of access, access management, and other relevant definitions (eg, “advanced access”), as well as operationalized access measures.
We collated survey responses from individual panel members and documented suggested changes to the working definition, with emphasis on changes requested by 2 or more panelists. We documented editorial changes, including nomenclature or terminology changes due to semantic drift, as well as conceptual changes.
The presentation and subsequent discussion of the 5 subpanels and the group discussion at the in-person panel meeting were recorded and transcribed. We conducted qualitative content analysis of textual data submitted by each subpanel. Two researchers (content and qualitative analysis methods experts) independently developed lists of emerging themes from subpanel discussions, combined lists, and reconciled discrepancies by consensus. We analyzed word frequencies and visually inspected word clouds to compare results across subpanels. Word clouds excluded common words (eg, “you”), stop words that do not convey meaning (eg, “there”), and words with less than 3 characters (e.g., “on”) using “wordcloud: Word Clouds,” R package version 2.5. The analysis aimed at identifying converging aspects of definitions. Using the same approach, the 2 researchers then analyzed the final revised versions of the definitions produced during the panel meeting. A merged word cloud was used to highlight key themes that emerged across subpanels and group discussions. Using a post–panel meeting survey and a written peer-review process, we monitored additional comments or disagreement regarding the access and access management definitions.
The key findings from the evidence review and expert panel on access definitions, conceptualization of health care “access” in primary care, and definition of “access management” are presented in the following text. Other project results are documented elsewhere (Hempel et al., 2018; Kaboli et al., 2019).
Definitions in the literature
The definitions of access in 19 empirical studies of access improvement interventions from 28 articles and 9 additional publications targeting the definition of access and/or access management are shown in in Supplemental Digital Content Table 1 (available at: https://links.lww.com/JACM/A100). In most cases (22/28 publications), “access” was not defined; however, authors described the improvement intervention evaluated such as advanced access. Publications usually referred to “access” as a primary care provider visit (ie, a narrow definition of access addressing only in-person visits). Definitions varied in whether they included a population-based perspective (access to primary care as a critical goal to ensure population health, 11/28) rather than exclusively focusing on a supply-demand perspective of access (ie, balancing patients' requests and available providers, 17/28). Studies varied in their inclusion of continuity of care; any such reference to patients' health care provider of choice was only present in half (14/28).
Access was most commonly operationalized as the time to third next available appointment (12/28), concentrating on the temporal aspect of access without reference to patient experiences of access. Other information on the access measure was often missing (eg, whether access improvement initiatives explicitly addressed routine care, urgent care, and/or whether established and new patients were included).
Results of subpanels aiming to define access
The discussions across 5 parallel subpanels aiming to define access are summarized as a visual overview in a word cloud (Figure). Most frequent terms were access (n = 41), patient/patients (n = 31), care (n = 18), need (n = 18; verb), needs (n = 15; noun), contact (n = 14), definition (n = 12), management (n = 11), first (n = 9), group (n = 9), actual (n = 8), health care (n = 8), response (n = 8), when (n = 8), defined (n = 7), ease (n = 7), subjective (n = 7), system (n = 7), timely (n = 7), perceived (n = 6), self (n = 6; including hyphenated word combinations), use (n = 6), veterans (n = 6), and clinical (n = 6).
The Table documents the deliberation results from the 5 subpanels: (1) themes that emerged from the discussions; (2) final definitions; and (3) themes in the final definitions within and across subpanels. Recurrent themes identified were the importance of the patient perception of access, timeliness, ease of access, and actual versus perceived needs. A key aspect of the access definitions established by each subpanel was patient preferences, patient needs, and access being defined by the patient. Definitions varied in style and complexity, with one subpanel opting to keep the working definition while 4 subpanels simplified the definition.
Comparisons of Access Definitions Across Subpanels
||Themes Emerged From Panel Discussions
||Themes in Final Definitions
||Actual vs perceived access
Ease vs need
Facilitate self- management
Patient access to materials
VA-community partners hybrid model
Access management encompasses a set of processes designed to achieve optimal delivery of health care services to our veterans and their families and requires continuous improvement.
Health care services for veterans and their families
Health care services for veterans and their families
Timely response to patient requests
Access is defined as a timely response to patient requests and incorporates patient preferences and clinical necessity.
Timely response to patient requests
Defined eligible populations of patients
Ease of getting access to care
Primary care vs first contract
Without ease of access, there cannot be use
Opted to keep original definition: Access to care represents the potential ease of having virtual or face-to-face interactions with a broad array of health care providers including clinicians, caregivers, peers, and computer applications. Actual access to care represents those directly observable and objectively measurable dimensions of access. Perceived access to care represents those self-reported and subjective dimensions of access.
||Actual access is directly observable, objectively measurable
Actual access vs perceived
Array of providers/caregivers/peers/computer applications
Ease of access
Perceived access is self-reported and subjective
Virtual or face-to-face interactions with providers
||Access defined by patients
Actual vs perceived
Comparisons with the European example of access
Confidence in follow-up after first contact
Distinction between first contact and access
Hard time with term “potential”
Resolution of access needs trumps first contact
Timeliness: first contact to resolution of access needs
Access is defined by patients, and it varies from patient to patient.
||Access defined by patients
Access definition varies from patient to patient
||Access is what patient perceives
Actual vs perceived access
Any method (ie, team member or place) of contact
Around the first contact
Communication methods essential
Ease of getting health needs met
Location of connection essential
Timeliness of getting health needs met
Who defines timeliness
Access to health care is the ability of a patient to get their health care needs met with ease and in a timely manner.
||Health care needs met in timely manner
Health care needs met with ease
Access management definition results
Pre–panel meeting survey responses showed that a quarter of the panelists (13/20) had no comments on the working definition of access management; 7 did provide further comments. The comments included general agreement with the definition, agreement but noting a focus on preferences, and whether optimal use of health care services was defined by the patient. Four panelists made suggestions for changes (ie, adding staff needs and capabilities, considering equity and value, incorporating provider and team engagement, and reversing the order to emphasize supply rather than patient behavior or demand).
The definition and suggestions for revisions were discussed in detail at the in-person panel meeting, resulting in a consensus to define access management, optimal access management, and optimal access. The approach enabled participants to address broader concepts without proposing specific measures that may be limited to an organization or site. Anonymous voting and transparent “live editing” resulted in the following agreed definitions:
- Access management encompasses the set of goals, evaluations, actions, and resources needed to achieve patient-centered health care services that maximize access for defined eligible populations of patients.
- Optimal access management engages patients, providers, and teams in continuously improving care design and delivery to achieve optimal access.
- Optimal access balances considerations of equity, patient preferences, patient needs, provider and staff needs, and value.
All panelists independently reviewed the definitions in a post–panel meeting review process, with no changes.
Using an evidence review and expert stakeholder panel process, we conceptualized access to care and established definitions of access management, optimal access management, and optimal access. The literature review showed that existing access research often does not define access and studies do not address access management as a comprehensive organizational management process. When attempts were made to operationalize the concept of access, empirical studies often narrowly focused on face-to-face appointments, failing to represent the bandwidth of currently defined access considerations (Fortney et al., 2011). Many publications used “time to third next available appointment” as a measure of access as a reliable metric because it is not affected by chance cancellations. However, studies varied by whether they counted all appointments or addressed only routine care. A key result of stakeholder discussions was that access and access management need to be conceptually addressed from a broader perspective.
Our study also showed that stakeholders strongly emphasize patient perspectives and highlighted that a patient-centered definition of access is critical. Published research evaluating different access models such as advanced access often shows positive effects on wait time, but these improvements do not always translate into improved patient satisfaction (VanDeusen Lukas et al., 2004) or provider support of the approach. There is also evidence that patients value being seen on a day or a provider of their choice more than they value simply being seen quickly, unless the need is urgent (Mehrotra et al., 2008; Rose et al., 2011). Patients also do not necessarily experience easier scheduling after a practice moves to an advanced access model (Salisbury et al., 2007). An important finding was that reducing access management to objective temporal aspects may lose important facets of the patient experience of access that ultimately may not result in access management improvement.
We used a format of parallel subpanels that allowed us to identify aspects of the definition of access that were replicated across subpanels and kept independent of group-specific dynamics. Identifying components established independently in more than 1 stakeholder panel is a valuable tool to identify robust components of definitions (Khodyakov et al., 2011). Furthermore, we collected structured and independent input from panelists by using written surveys, completed by each panel member without the group present. The resulting output highlighted key aspects of access and access management. Most notably, panel deliberations indicated that definitions of access to care and access management need to be patient-centered, while incorporating an understanding of realistic trade-offs and constraints faced by managers. However, the format of the definitions varied across subpanels, indicating the complexity of access management and need for consensus.
Definitions of access and access management determine the perspectives and goals with which a health care delivery organization approaches access improvement. Our work indicated that it is critical for organizations to first establish shared definitions. Furthermore, it is essential that any conceptual understanding considers today's care environment and is not limited to face-to-face, physician-centered approaches (Fortney et al., 2011; Kilo et al., 2000). The established definitions of access, optimal access management, and optimal access aim to advance our understanding of access, specifically in an era of increasing non–face-to-face visit modalities and newer primary care team models such as patient-centered medical homes (Arend et al., 2012). They emphasize the need for a patient-centered view and the need to simultaneously optimize multiple worthy management approaches.
Conceptual work to understand dimensions of access management is also instrumental in evaluating QI initiatives. The work established the need for patient-centered, current, and comprehensive conceptualization of optimal access management and optimal access. How access is defined within a health care delivery organization determines the selection of measures of access (Prentice et al., 2014) and shapes how access management is evaluated.
Our research not only has several strengths but also has key limitations. While panel composition was purposeful and represented diverse stakeholders with competing and potentially conflicting interests, not all relevant perspectives will have been included. In addition, our work outlines the importance of definitions for research and practice but whether these will result in successful and sustainable improvement needs to be shown in future research. A central limitation is that our work was limited to primary care considerations, acknowledging that access to specialty care may face additional or unique challenges.
The presented work aims to advance primary care access management practice and research relevant to health care delivery organizations. Access to health care is substantially determined by how health care delivery organizations manage it. The developed concepts suggest that access management, improvement, and research require ongoing attention to relevant health care organization processes and multiple relevant perspectives. Health care organizations and researchers can use the definitions as starting points to shape procedures and resource management, inform QI initiatives, and advance research into effective and sustainable access improvement strategies.
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