Tag Archives: urgent care

Vs Retail Clinics-Are We Going to Whine or Win?

26 Feb

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http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/44450

I noticed the headlines rolling in Monday about the AAP updated policy statement regarding retail based clinics.  The one above particularly caught my eye.  Something about the tacking on of “Again” caught my attention.  It came across to me like we (pediatricians) were perceived to be saying something that was unnecessary, maybe even that we were just complaining. 

Throughout the day, I monitored my Twitter feed and read some articles discussing the issue.  Fortunately, I didn’t see a whole lot to confirm my (perhaps defensive) concern that we would be perceived as whining about the emergence of urgent and retail clinics.

But, the guideline and the response from the retail clinics got me thinking.  Currently we seem to be doing OK in the public perception but how much longer does that hold up?  Are our statements going to forever be met with an understanding or is there eventually going to be backlash about our perceived inflexibility.

There are many things that parents want in medical care for their children but I believe this debate boils down to 2 main issues:

Quality

Convenience

Quality

Pediatricians claim, in the policy, that retail based clinics create a decrease in quality of care for the following reasons:

  • Fragmentation of care
  • Provision of episodic care to children with special health care needs and chronic disease
  • Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information
  • The use of tests for the purposes of diagnosis without proper follow-up
  • Possible public health issues that could occur when patients with contagious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles, strep throat, etc)

I do believe these are concerns that do need to be addressed by the urgent care and retail people.  I have written about many of these previously: My Questions for Urgent Care Clinics

The AAP policy statement goes on to make recommendations for principles with retail clinics (my thoughts italicized):

  • Supporting the medical home model: RBCs should support the medical home model by referring the patient back to the pediatrician or other primary care physician for all future care.  (Is this realistic?  They might even say that they will but will we eventually tell our patients that they should have just used the retail clinic for this complaint because it was simple?  This won’t happen and I don’t know why we’d expect them to refer back to us either.)
  • Communication: The AAP recommends that RBCs promptly communicate with the patient’s pediatrician or other primary care physician within 24 hours of the visit.   (This seems logical and important.)
  • Using evidence-based medicine: The AAP recommends that all those providing care to children follow all AAP clinical guidelines as well as those guidelines developed by other medical organizations that have the support and endorsement of the AAP.  (Again, a reasonable and critical expectation.)
  • Contagious diseases: By providing medical care to individuals in a retail-based setting, RBCs must take the necessary precautions to prevent the spread of contagious diseases.  (While many pediatricians do this, it is not universal and we need to do a better job of providing well and sick waiting rooms.)

Many of these concerns are addressed in the quote from the article:

The Convenient Care Association, a Philadelphia-based retail clinic association, took exception to the AAP’s claims about its members’ work.

“Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care,” Tine Hansen-Turton, JD, the association’s executive director, said in a statement. “Additionally, the industry is very focused on quality care, and EHRs are also used in clinics to monitor evidence-based practice performance.”

Whether or not you agree with the assessment, they do provide an answer to many of the concerns that the AAP has raised.

Convenience

The second major issue I see arising as a result of the conversation is about convenience.

Let’s imagine that the retail clinics drafted a policy statement that addressed their concerns regarding care at pediatrician’s offices.  Some of their concerns might go something like this:

  • Lack of same day illness appointments creates unnecessary overnight suffering for parents and children.
  • Small waiting rooms create difficult environments for parents managing active kids.
  • Minor complaints should be seen by mid-level providers and escalated as necessary to the physician.
  • Parents’ schedules are malleable and need the flexibility of walk-in appointments.
  • Parents need the ability to have their children seen outside of their typical working hours to avoid lost income.

These are some of the benefits of convenience that a retail clinic provides that many of us currently do not or we meet it in some trivial way that does not provide a real solution for families. 

Don’t get me wrong, we have come a long way.  Improving the patient/parent experience has always been a focus of pediatrics and will continue to be for years to come.  But, there is some reason that our patients are using these clinics (and why we have to issue statements about them) and I would guess that for the most part it’s a convenience issue. 

So, we’re still missing the boat (and an opportunity) somewhere.

The Race Is On

The way I see it, the race is on.  One of two things are going to happen.

  1. Retail clinics are going to figure out solution to our perception of their decreased quality of care and the public will know about it.  The quote from Tine Hansen-Turton, JD tells me that they are already far along in their thinking and ready to make strides to improve their quality of care.  They can’t afford to stop trying because it means their future success or failure.
  2. Pediatric offices are going to figure out a way to meet the demand for patient convenience that is currently being met by the retail based and urgent care clinics.  We need to make ourselves agile enough to meet the demands of convenience as they arise in the future.  We can’t afford to stop trying because it means our future success or failure.

Which is it going to be?  Are we going to whine or win?

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My Questions for Urgent Care Clinics

27 Jan

I see a strong trend towards my families moving towards using walk-in/urgent/retail care clinics for their ill care.  We do our best to keep ill visits open for the same day although this time of year it does get a little more difficult given the overwhelming demand.  

So, I can’t say that I completely blame our patients when they do use the urgent care facilities but it still eats at me, especially when they use them during our normal business hours assuming they’ll get in and out “faster.”  We don’t have evening hours at this point so I can’t really blame my patients for using the clinics in the evenings.  I really feel that most of these visits could wait till the next day but I also understand that this isn’t necessarily keeping up with what the market desires at this point.

However, I do have a few questions that I think need to be answered by the walk-in care clinics so that patients still get good care.  We have a few practitioners in our town who do a great job and I feel our patients receive good care but issues still present themselves:

What do we do about continuity/communication?

I commonly have this conversation in my office…

Me: Well, he’s got an ear infection and since he hasn’t been on antibiotics for a year (judging by his medical record), I would recommend that we use amoxicillin.

Mom: Yeah, except he was on amoxicillin last month for an upper respiratory infection and then they changed him to some other antibiotic cause he wasn’t getting better, I think it started with a C or maybe it was a K.  I think it was either once or twice a day.  I’m not really sure.

Me: That’s ok…I have 30 minutes for you to wait in my room while I try to get those records faxed over to see what the heck is going on (sarcasm of course, and not really said)

I’ve thought about the ways I would like for this to go down better.  The only way I can figure it out is to have notes faxed to the PCPs for everyone that is in the walk-in clinic the morning after.  I think if I were designing a clinic that is how I would do it.  In the age of EMRs I don’t think that would be too difficult.  If you are a walk-in clinic that does this or somehow communicates with PCPs I commend you because when I need the records and they aren’t there it is difficulty.

What do you do about your incentives?

The incentives for providing care in a walk-in clinic are very different than what I see as my incentives.  I have a relationship with my patients such that I don’t feel pressure to do what they are asking of me.  I’ve never worked in one before but I would imagine there is a huge motivation to do what the patient is asking because you need to motivate them to come back to you.  I would hope that good doctors/NP/PAs would be staffing these clinics such that this would not be a big issue but I do commonly see things that make me wonder: antibiotics for UTIs with normal U/As, antibiotics for “strep throat” with a negative screen and a cbc, u/a, rsv, flu screen done on a 12 year old with fever to 103, body aches and an exposure history for flu in the past week…

Again for those of you out there doing this right….ignore me.  But I can’ imagine what it’s like to be trying to please people who are walking in and end up not needing any specific treatment.  I would love to hear from some who have worked in an urgent care clinic for their thoughts on this.

What do you do when you can’t provide definitive care?

 I got a phone call this week on about a child who was in a walk-in care clinic with strep throat and severe dehydration.  Fortunately, I knew the NP well who was calling me and we were able to work it out so that they patient could swing by my office on their way up to the pediatric floor for admission.  Also fortunately, the family was very nice and understanding.  But, can you imagine if they hadn’t been?  Here they have waited 3 hours (per the mom) at the urgent care clinic to then be told that they could provide the care that they needed and they were going to have to go wait again in the pediatrician’s office to be seen prior to getting any definitive treatment…My understanding is that commonly in the evenings, our local walk-in clinics send patients to the ER when they cannot provide the care that is needed.  Maybe this isn’t true, I hope it isn’t.  I would propose that it would be better for the walk-in clinics to have some arrangement whereby they can arrange for admissions with providers etc when they feel it is necessary rather than have the family start over again.  Or, if the patient has a PCP that they would call them to discuss the case with them.

Again, these are just some thoughts I had about urgent care and the issues I see beginning to present themselves.  I don’t see this as a trend that is going to come and go so i’m hoping that I can find a better way to interact with our urgent care clinics in a way that benefits my patients in the end.  Any thoughts would be appreciated?

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