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Revising the advanced access model pillars: a multimethod study

Author/s: 
Breton, M., Gaboury, I., Beaulieu, C., Sasseville, M., Hudon, C., Malham, S. A., Duhoux, A., Rodrigues, I., Haggerty, J.

Background: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

Methods: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

Results: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model (“Appointment system” and “Interprofessional practice”), 1 was merged with a revised pillar (“Develop contingency plans” with “Planning of needs and supply”) and 1 underwent major transformations (“Backlog reduction” to “Continuous adjustment”). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

Interpretation: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Timely access is a cornerstone of strong primary health care and a key component of a patient-centred medical home for ensuring population health.1 Numerous innovations have been implemented to improve timely access,2 with one of the most recommended around the world being the advanced access model, also called open access.2,3 Based on greater accessibility linked with patients’ relational and informational continuity with a primary health care professional or team, the advanced access model aims to ensure that patients obtain access to health care services at a time and date convenient for them when needed, regardless of the urgency of the demand.4 Originally developed in the United States in the early 2000s, advanced access is defined by Murray and Berwick as having 5 pillars: balance supply and demand, reduce the backlog of previously scheduled appointments, review the appointment system, integrate interprofessional practice and develop contingency plans.5,6 Several scientific papers on the foundations of advanced access have been published over the past 20 years, and its benefits have been reported in many countries, including the US, the United Kingdom and Canada.6–9

Over the last 2 decades, primary health care practice has evolved to increase interdisciplinarity in clinical teams. Thus, the need for a model that incorporates new practices and professionals has necessitated development of an updated advanced access model. Furthermore, advanced access was originally developed in a context that prioritized implementing a new way of doing, with less emphasis on the ongoing practice and sustainability of the model.10,11 However, changes in primary health care practice require revisions to the advanced access model to adapt it to the contemporary context.

In this study, we redefine the pillars and subpillars of the advanced access model by integrating an interdisciplinary team–based focus, while considering the integration of primary health care professionals, such as nurse practitioners, registered nurses, social workers and other allied professionals, in primary health care practices. The objective of this study was to revise and operationalize the pillars and subpillars of the advanced access model.

Keywords 
Family Physicians social workers referral and consultation nurse practitioners scheduling models

Revising the advanced access model pillars: a multimethod study

Author/s: 
Breton, M., Gaboury, I., Beaulieu, C., Sasseville, M., Hudon, C., Malham, S. A., Duhoux, A., Rodrigues, I., Haggerty, J.

Background: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

Methods: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

Results: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model (“Appointment system” and “Interprofessional practice”), 1 was merged with a revised pillar (“Develop contingency plans” with “Planning of needs and supply”) and 1 underwent major transformations (“Backlog reduction” to “Continuous adjustment”). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

Interpretation: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Timely access is a cornerstone of strong primary health care and a key component of a patient-centred medical home for ensuring population health.1 Numerous innovations have been implemented to improve timely access,2 with one of the most recommended around the world being the advanced access model, also called open access.2,3 Based on greater accessibility linked with patients’ relational and informational continuity with a primary health care professional or team, the advanced access model aims to ensure that patients obtain access to health care services at a time and date convenient for them when needed, regardless of the urgency of the demand.4 Originally developed in the United States in the early 2000s, advanced access is defined by Murray and Berwick as having 5 pillars: balance supply and demand, reduce the backlog of previously scheduled appointments, review the appointment system, integrate interprofessional practice and develop contingency plans.5,6 Several scientific papers on the foundations of advanced access have been published over the past 20 years, and its benefits have been reported in many countries, including the US, the United Kingdom and Canada.6–9

Over the last 2 decades, primary health care practice has evolved to increase interdisciplinarity in clinical teams. Thus, the need for a model that incorporates new practices and professionals has necessitated development of an updated advanced access model. Furthermore, advanced access was originally developed in a context that prioritized implementing a new way of doing, with less emphasis on the ongoing practice and sustainability of the model.10,11 However, changes in primary health care practice require revisions to the advanced access model to adapt it to the contemporary context.

In this study, we redefine the pillars and subpillars of the advanced access model by integrating an interdisciplinary team–based focus, while considering the integration of primary health care professionals, such as nurse practitioners, registered nurses, social workers and other allied professionals, in primary health care practices. The objective of this study was to revise and operationalize the pillars and subpillars of the advanced access model.

Keywords 
Family Physicians social workers referral and consultation nurse practitioners scheduling models

Mobile Telemedicine for Buprenorphine Treatment in Rural Populations With Opioid Use Disorder

Author/s: 
Weintraub, E., Seneviratne, C., Anane, J.

Importance
The demand for medications for opioid use disorder (MOUD) in rural US counties far outweighs their availability. Novel approaches to extend treatment capacity include telemedicine (TM) and mobile treatment on demand; however, their combined use has not been reported or evaluated.

Objective
To evaluate the use of a TM mobile treatment unit (TM-MTU) to improve access to MOUD for individuals living in an underserved rural area.

Design, Setting, and Participants
This quality improvement study evaluated data collected from adult outpatients with a diagnosis of OUD enrolled in the TM-MTU initiative from February 2019 (program inception) to June 2020. Program staff traveled to rural areas in a modified recreational vehicle equipped with medical, videoconferencing, and data collection devices. Patients were virtually connected with physicians based more than 70 miles (112 km) away. Data analysis was performed from June to October 2020.

Intervention
Patients received buprenorphine prescriptions after initial teleconsultation and follow-up visits from a study physician specialized in addiction psychiatry and medicine.

Main Outcomes and Measures
The primary outcome was 3-month treatment retention, and the secondary outcome was opioid-positive urine screens. Exploratory outcomes included use of other drugs and patients’ travel distance to treatment.

Results
A total of 118 patients were enrolled in treatment, of whom 94 were seen for follow-up treatment predominantly (at least 2 of 3 visits [>50%]) on the TM-MTU; only those 94 patients’ data are considered in all analyses. The mean (SD) age of patients was 36.53 (9.78) years, 59 (62.77%) were men, 71 (75.53%) identified as White, and 90 (95.74%) were of non-Hispanic ethnicity. Fifty-five patients (58.51%) were retained in treatment by 3 months (90 days) after baseline. Opioid use was reduced by 32.84% at 3 months, compared with baseline, and was negatively associated with treatment duration (F = 12.69; P = .001). In addition, compared with the nearest brick-and-mortar treatment location, TM-MTU treatment was a mean of 6.52 miles (range, 0.10-58.70 miles) (10.43 km; range, 0.16-93.92 km) and a mean of 10 minutes (range, 1-49 minutes) closer for patients.

Conclusions and Relevance
These data demonstrate the feasibility of combining TM with mobile treatment, with outcomes (retention and opioid use) similar to those obtained from office-based TM MOUD programs. By implementing a traveling virtual platform, this clinical paradigm not only helps fill the void of rural MOUD practitioners but also facilitates access to underserved populations who are less likely to reach traditional medical settings, with critical relevance in the context of the COVID-19 pandemic.

How to Excel at Access — and Why It Matters

Author/s: 
Mils, Terry

Health care spending in the United States totaled $3.3 trillion in 2016, more than double the amount spent in 2000. Twenty percent of the cost went toward physician services, with primary care accounting for approximately 7 percent.

These rising costs have real consequences for patients. A Kaiser Family Foundation survey found that, because of cost, 67 percent of the uninsured and 21 percent of the insured had forgone needed medical care. To address costs, payers are increasingly adopting reimbursement models that reward or penalize physicians based on their ability to keep costs down.

Now here’s the good news: When it comes to rising health care costs, we in primary care are not the main problem, but we are a key part of the solution. This article will explain how improving access to primary care can reduce costs and the steps practices should begin taking now.

Keywords 
primary health care access
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