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Advice on how to run a walk in clinic


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Guys and gals -

I need to give some background - sorry for the length.

I have been with the same group for almost 6 years now.  Started out in the walk-in clinic/urgent care and now I'm on the internal medicine side of the house managing my own patient panel.  The walk-in clinic has been a sore spot for us pretty much ever since it opened 12 years ago or so.  Basically, the providers and staff who only do the urgent care get treated like unwanted step-children.  They work 11 hour shifts and see on average 33+ pts/day, much higher during peak season.

Where we're struggling as a group is how to staff this and how to schedule patients.  Staffing is difficult because very few people want to work in the walk-in clinic.  I did it for 4 years and transitioned to IM partly for the complexity of patients, partly for loan repayment, and partly because I wanted a better work/life balance than working until 1930 every evening allowed me.  We are largely a production based practice - 1/2 of my annual income is based on collections. So double staffing the walk-in clinic gets tricky because one person always feels they get the short end.  In some cases, they do get the short end and don't make enough to cover the cost of employing them.  Is there a better way that still incorporates production into the overall pay scheme but protects the clinic from the liability of a clinician who doesn't see enough patients?

How do other clinics schedule patients?  We have 44 patient slots per day per provider.  When we're solo and it gets close to closing time, we watch the number of slots vs. the number of Pts waiting and will close the doors when we have filled our slots.  Sometimes this means we close at 1700, sometimes it means we stay open until 1900 or later (and this depends somewhat on the provider - some providers close early, others stay open and take all comers until the closing time).  The biggest issue is that if we don't cut it off, we sometimes won't get out of here until 2100-2200 at night.  But patients complain about us closing early.

I'd like a sense of how you all run your walk-in clinics/urgent cares.  I don't have enough perspective since this is only 1 of 3 places I've worked (and the last place would assign the patients to slots and once those were full they would not take any more). 

 

Andrew

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That is a tough one for a few reasons. The productivity aspect of pay which, for me, would be problematic in the UC because you have no control over how many people will show up on a given day. The other is trying to have a reasonable limit on the total number of patients the provider sees.

Some time ago we did the same thing where I currently work and, quite simply, it didn't work for the very reasons you describe. After a lot of trial and error they final formally split the 2 functions and the FP clinic had a staff and the UC had a staff and it remains that way today. We are all hourly non-exempt employees so if we get held over we get time-and-a-half which turns into some good money. We manage the patient flow, in the clinics with more than one provider, with a one-for-you-one-for-me system. However if someone gets tied up with something time consuming like a big lac or a chest pain transfer the other provider just picks up the slack. We play nice. If it is a single provider clinic you just plod along and take care of people as fast as you can.

Limiting the number of patients per provider is also really tricky for the reasons you elucidate. Some days you aren't taking any more hours before closing. Before I was here they did that and I don't know how it worked out but we don't have a proscribed limit at this time and, some days, it really sucks. It will create provider churn and eventually be an expensive policy. The flip side of that coin is the unhappy patients when they show up an hour before closing but you aren't taking any more patients. There would only seem to be 2 possible answers... more provider or no limits on patient numbers (assuming you want to change what you are doing).

Consider something dramatic like fully dividing the 2 clinics and the staff. keep me posted on how (or if) things progress. I am always looking for examples of what has and hasn't worked for others to try and improve things here.

 

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40 minutes ago, sas5814 said:

Some time ago we did the same thing where I currently work and, quite simply, it didn't work for the very reasons you describe. After a lot of trial and error they final formally split the 2 functions and the FP clinic had a staff and the UC had a staff and it remains that way today. We are all hourly non-exempt employees so if we get held over we get time-and-a-half which turns into some good money. We manage the patient flow, in the clinics with more than one provider, with a one-for-you-one-for-me system. However if someone gets tied up with something time consuming like a big lac or a chest pain transfer the other provider just picks up the slack. We play nice. If it is a single provider clinic you just plod along and take care of people as fast as you can.

We do the same thing. FP does their thing and is staffed separately from the UC but we're all under the same Physician Group umbrella. UC staff are non-exempt and hourly. My extra shift a week is 1.5X my base rate which is a nice incentive for me to pick up extra shifts. There are some hours where a patient doesn't come in, others where it's non-stop from start to finish. Not sure how helpful the above information is, but it's worked very well for my current gig.

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In our shop, the walk-in is a flat salary are open 7-7.  Family practice has scheduled slots, with 3 or so slots that open the day of.  They are paid on some sort of productivity, I'm not sure how, but they get to leave on time.

As we are a walk-in, anything complex either goes to the ED or scheduled with a PCP the same or next day- basically anything more than a uri or uti.  No I&D's, no suturing, no abdominal pain, no pregnancy tests, no med refills, and absolutely no controlled substances. I did a Robitussin ac once, but if ibuprofen ain't gonna work, or "allergic", you will be seeing one of the pcps.  

Yesterday two of us saw 70 total.  I myself saw 60 a week ago.  If I send someone to the ED, I document my thoughts in the note, but the walk in personell are considered idiots, frankly, because hindsight is 20/20...at 60 patients a day I'm not going to send a 70 yo home with wheezing, cough, weight gain...and I can't spend the time to work up any abdominal pain.

So, the doors close at 7, we'll see you if you there, otherwise your uri has to come in the next day.

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We're a government entity operation for our employees and dependants >2 y/o.  Our two providers are exempt employees on salary.  We're open 10-6 M-Th and 7:30-4 on F.  Walk-ins M-Th from 10-1, F from 7:30-12.  30" lunch break M-Th and 1' break on Fridays.  In afternoons it's 15" slots only and only 7 slots every two hours.  If someone walks in and wants an open time slot then it is theirs.  Last appt. is booked for 30" before close.  Latest I've been is maybe 5" after close and any staying late is extremely rare.  I chart as I go.  Most of the time I'm ready to walk out 15" before close though one provider has to stay until official closure, even though doors are locked (not sure why and it didn't use to be that way).

We're not the PCP, don't do refills, don't do f/u's, no vaccinations or wound care, don't do Gyn, don't see M/S issues except to assess for outside radiology assessment and further care by others (it's been over a year since I've seen one and we don't advertise it), and if an urgent/emergent scenario appears then out the door they go.  Had a suspected early peri-tonsillar abscess yesterday afternoon with early protrusion of the superior tonsillar fossa wall and trismus.  Told pt. it's outside our scope of practice and she needed further care so off to the ED she went, or so we assume.  No answer to f/u call today.

N/V/D, we'll check for hydration status only and check for unlikely bacterial etiology to exclude anti-diarrheal agents.  I will prescribe anti-emetics in adults if a benign hx./PE.  If a belly c/o is voiced then r/o acute abdomen and off they go (unless a clear cut UTI).  I did pick up an early appy two weeks ago with presentation of "fever" and "her stomach was hurting this morning".  Periumbilical tenderness, looked sick, and equivocal early peritoneal sx.  Off to her peds and she ended up with one less appendage on f/u call the next day.

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I'm caught short here - the way you guys are describing your clinics is so much different from ours; Scott's is the closest.

We deal with pretty much all comers.  We are not an ER so anything that requires monitoring goes down, but we do belly pain w/u, we do acute MSK management, lacs, I&Ds, etc.  Basically what I'm gleaning is that we need to change the way we're thinking about what we're doing - either we double staff at all times *or* we start turfing a crap load of our patients to the ED. 

I am very eager to hear more input on this... 

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One addition to our setup.  One of our two SPs is just down the tollway from our clinic (2-3 mi.).  We have a setup in place that if the pt. needs help with an I&D, lac, or something else that may not warrant ED assessment but needs a better workup than we can provide then we provide them a card similar to a Disney FastPass that they present at the front desk for expedited care.  We contact the clinic administrator, make them aware of our concern (I also text the SP so that they know as well), and the administrator walks them through their visit and expedites the care.  I think I've done it 1-2 times in 2 1/2 years that we've been in operation.  There are other clinics in our area part of the SP's network so we have the same option at their other facilities.  They also have walk-in clinics as well during other times.

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In the time it takes for and I&d or suturing, we could easily squeeze in 3-4 level 3's; not to mention not tying up one of the nurses. It's all volume. We don't have any set time slots per se, but I try to limit  to four people scheduled per ten  minute time period to give the people waiting an idea of the wait.  Depending on your volume, you might want to think about having a rotating set scheduled person have a few blocked slots to take the people who don't warrant an Ed visit, who would take up a lot of your time, but should be seen sooner rather than later or if you have concerns about compliance, like elevated bp- not to start clonidine, but you could start the work up then, that's level 3/4 and they could follow up as indicated. 

Now, we are a walk in connected (both literally and figuratively) to a health system, and we only handle cough, cold, sore throat, uti.  Musculoskeletal concerns get a brief history, ibuprofen/Tylenol, and scheduled follow up with a pcp.

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I work at a Big 10 university health service. Every APP has to staff walk-in (they call it "triage") for four 1/2 days per week.

Basically it's a first-come, first-serve clinic, with doors closing at 4:30. So at 4:30 all patients not yet seen get divided evenly across providers.

Wait times can be 3-4 hours on a busy day. They all complain, but it's a walk-in clinic. If you want to come in on a monday with your 1 day sore throat, then you will have to wait.

What happens is the faster providers end up seeing a disproportionate amount of patients, like 16 in a half day, and the slow pokes will see 6. So since we are all salaried, us faster providers have learned not to work so hard, because there is no incentive. We are taking work off other provider's plates for no extra compensation, just more stress. Plus the MAs will never stack more than 2-3 patients behind your current patient. Steady pace keeps the stress down.

 

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10 hours ago, Acebecker said:

I'm caught short here - the way you guys are describing your clinics is so much different from ours; Scott's is the closest.

We deal with pretty much all comers.  We are not an ER so anything that requires monitoring goes down, but we do belly pain w/u, we do acute MSK management, lacs, I&Ds, etc.  Basically what I'm gleaning is that we need to change the way we're thinking about what we're doing - either we double staff at all times *or* we start turfing a crap load of our patients to the ED. 

I am very eager to hear more input on this... 

Our shop does all you outlined. Aside from really emergent stuff, we treat most minor ailments and workup acute belly pain. 1PA, 1 Doc, 1RN, 1MA and 1 Rad tech who functions as an additional MA when there isn't x-rays to do.

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Let me expand a bit on what we do and don't do. We do all the usual cold, flu stuff, UTIs etc. We do I&Ds, suture uncomplicated wounds, deal with uncomplicated fractures and dislocations. We have VERY limited diagnostic capability. All the CLIA waived stuff plus a CBC during the 8-5 clinic hours. No chemistry, no micro for slides like vag swabs. After the attached clinic closes the lab tech goes home and one person does double duty so it is CLIA waived only. Chest pain= ambulance ride. No real ability to evaluate abdominal pain.

No med refills, no monitoring or treatment of long term problems like HTN or diabetes, no pain meds. It is fairly low stress and the system wants complicated problems in the ER.

Currently we are hourly with OT after 40 hours but they simultaneously clamped down on OT and changed the required weekly hours to get full time bennies to 40hrs/week. It is a razors edge walk that drives everyone crazy.

We have been in budget slashing mode for 4-5 months so even clinics with 2 providers often has a single nurse or MA which is stupid but hey... we just deliver the care.

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One issue we've had is that we had previously had command of our own destiny in deciding when to close, what to see.  We would get complaints, though, about the chest pain that was sent to the ED and turned out to be GERD.  So our management has said, "Hey, try to see and work up all of these patients" while simultaneously leaving us with a lone provider in the walk-in clinic.  Physician backup is easy to get, but cumbersome - takes time to present and discuss the case.

They have started double coverage part time, but then the hours that are not double covered are still horrendous and they do not provide double coverage at the end of the shift.  On the weekends we are open for 6.5 hours and it's not unusual to see 30+ patients in that time span.  Weekends are the worst - when you're on, you work Sat and Sun and get hammered; then you're back in clinic Monday for regular hours.

I doubt that there will ever be a solid fix.

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An UC or WIC that is RVU/collections-based sounds rough. On one hand, the provider stands to make a lot of money if the practice is busy, but on the other hand they will likely get burned out quickly, and bringing a second provider in dilutes the compensation. Would it be possible to bring in a second, hourly provider that sees overflow for part of the day/end of the day?

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Definitely something we'll pursue...  Another component that I'm dealing with is that our manager is not particularly pro-change.  She's dragging her feet from my perspective.

She downplays all of the salary data that we have collected from NCCPA and other local clinics.  She cannot get away from the RVU/production based pay scheme because she believes we're all going to just quit trying to see extra patients as soon as our pay is not based on productivity.

Many details to work out.

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In Kentucky, there are laws governing what we can see in a "Limited Services Clinic", i.e. Acute Clinic, i.e. Retail Clinic.   The Urgent treatment centers and clinics are the ones who repair lacerations, order films, do casting, I & D's, etc.   In the Acute Clinics, we can do a Steri-Strip if it's appropriate, but that's as far as wound repair goes.   Lots of URI's, school, work, and DOT physicals, lice (ew), limit of one refill on chronic medications.   I absolutely love it.   After years and years of family practice, this is exactly where I want to be (if I can't work from home).    I get to see lots of kids, I get to make people feel better, and I have thankful patients who don't have to make an appointment and sit in the waiting room at the doctor's office.   For some reason, here in Kentucky, a lot of the Urgent Treatment Clinics will only hire NP's.   I assume this is something to do with the PA's supervising physician necessity.    That's fine with me, other than the Urgent Care pays a little bit more.

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