Access to population health data and a creative approach to team-based care has led to high quality and a dramatic drop in avoidable emergency department visits at the Randy Walker Family Clinic – and not just because there isn’t a local hospital anymore.
In rural communities across America, hospitals are shutting fast. More than 100 rural hospitals have closed their doors since 2010 and nearly 700 more are at risk, leaving close to 12 million people without local access to hospital care, according to the National Rural Health Association.
For many of these areas, primary care providers (PCPs) are filling the gaps left by hospital closures. Independent practices with deep roots in the community are stepping up to the plate to deliver vital relief in service areas that often include whole counties with few other options.
The Randy Walker Family Clinic in De Queen, Arkansas, is one such provider. The clinic offers many of the services that one might expect to see in a fully operational emergency department, but does so within the framework of an accountable care organization (ACO).
This combination of responsibility for the community as a whole and accountability for a defined population of Medicare beneficiaries creates a number of challenges for an independent primary care provider. Yet the Walker Clinic has risen to meet each one.
With access to robust population health management data and a true commitment to team-based care, the Walker Clinic is able to provide a lifeline for local residents while achieving a 94 percent quality rating in the Medicare Shared Savings Program as part of the Aledade Arkansas ACO.
De Queen Medical Center began to falter in December of 2018 as financial troubles led to delayed paychecks and layoffs for staff, report local news sources. The medical center stopped accepting patients in February of 2019 and officially closed in May despite city and county efforts to save the Critical Access Hospital (CAH) for the region.
“We knew it was coming for a while, so we did have some time to prep our practice,” said Angie Walker, the clinic’s office manager and Dr. Randy Walker’s wife. “We knew we had to add a few more services to keep our patients healthy. Now, it’s a different type of care than it used to be with the ED right next door, but it’s actually lower cost and a better experience for patients.”
In addition to routine primary care, the clinic provides allergy care, fracture care and casting, minor dermatology, and IV services. Bone density scans, ultrasounds, hearing tests, and x-rays are also available on site. An upgrade to the lab is in the works, allowing the practice to expand its cardiac triage capabilities and better determine whether a patient needs to be sent directly to the next closest ED.
Patients can see a provider from 7:00 AM to 7:00 PM Monday through Saturday and during the afternoons on Sundays. The clinic accepts walk-ins and urgent appointments in addition to scheduled patients. The office is always busy.
“We didn’t know what was going to happen when we opened for 12 hours on Saturday, but it’s actually our most popular day of the week. That’s why we’re preparing to move to a 12-hour day on Sunday, too. Every day, our early morning and later evening appointments are often double booked, because that’s when patients have free time to come see us,” Walker said.
While this uneven patient flow might take a toll on a less organized practice, the Walker Clinic has architected its staffing schedule to handle peak times without overextending any of its clinicians.
“Dr. Walker is here 8:00 to 5:00 Monday through Friday, and our nurse practitioners are the ones with shifts that cover the full twelve-hour days,” Walker explained. “They are also the ones who manage the walk-ins and urgent appointments most of the time.”
“We have an excellent front desk staff to manage the scheduling and keep everyone on track. It requires a lot of awareness of what every staff member is doing and how much availability they have. It’s very collaborative and everyone stays very flexible, because it isn’t always possible to predict what is going to happen each day.”
The clinic has implemented some low-cost, high-impact strategies to help coordinate and manage this adaptable approach to patient care.
“We added a nurse practitioner who comes in at 7:00 AM, and we took some of our existing staff and changed their schedules so that the clinic is properly staffed at our busy times,” said Walker. “That makes sense as an investment when you think about how many more patients we can see.”
“We also changed the phone system so that we can start getting calls at 7:00 AM, and we make sure that we stagger lunch times so that the clinic stays open throughout the day. Neither of those cost anything up front, but the results of these small, incremental changes are extraordinary.”
Being a member of an Aledade accountable care organization brings extra benefits to the Walker Clinic. By embracing the principles of patient-centered, team-based care, staff members can rely on each other the same way that patients rely on the practice for ongoing support.
“This whole system we’ve created only works because we are fully committed to the idea of team-based care,” stressed Walker. “Once you develop the idea that the entire clinic is responsible for each and every patient, you start building the teamwork that keeps the schedule moving and flowing well.”
Access to data through the Aledade App supports the seamless coordination of patient care, she continued, allowing the practice to stay on top of attributed Medicare beneficiaries and their health concerns.
“We use the Aledade App for the prioritized patient work lists and notifications of ED and hospital events, because it’s not really possible to manage patients well in an ACO if you don’t know who they are, what their needs are, and whether or not those needs are being met,” said Walker.
As a result of this enhanced visibility into population health and patient utilization patterns, the Walker Clinic has seen a significant drop in ED utilization and 30-day ED recurrence.
“We started seeing a reduction in ED visits before the hospital actually closed,” Walker observed. “We see that as a generally positive thing.”
The practice recorded a 13.8 percent decrease in all-cause ED visits between 2017 and 2018. That number jumped to a 21 percent decrease between the first quarter of 2018 and the first three months of 2019, during which De Queen Medical Center stopped accepting new patients.
“Patients are putting a little more consideration into how they’re engaging with the healthcare system, because it’s not just a five-minute ride to the ED anymore,” she said. “Patients in the community are more likely to come to us first – and they know we can provide the care they need – which is actually a good thing for all those non-emergency situations that tend to end up in the ED when it’s right around the corner.”
30-day all-cause ED recurrences are also on the decline. The Walker Clinic saw a 26 percent decrease between 2017 and 2018, and a 14 percent reduction between the first quarter of 2018 and the beginning of 2019.
Overall, the Aledade Arkansas ACO reduced emergency department visits by 12 percent in the Medicare Shared Savings Program performance year 2018.
“A lot of these results are only possible because we’ve been stretching ourselves professionally,” said Walker. “Providers need to do more than work to the top of their license. They need to work the full breadth of their license, too.”
“Primary care doctors learn how to perform a huge range of services. They might not always like doing everything, because they’re only human and they all have their comfort zones and preferences. But they need to be flexible and expand what they offer so that they’re able to tackle situations like this and serve their communities to the best of their abilities with the help of their teammates and staff.”
In October of 2019, county residents approved funding for a completely new 12-bed hospital near De Queen, reports the Texarkana Gazette. The facility intends to partner with another regional health system to support the operation of an emergency department as it finds its feet.
While the project will be extremely welcome in the region, a new hospital won’t stop the Randy Walker Family Clinic from pushing the boundaries of what primary care can do.
“We want to keep our avoidable ED usage low because it’s simply better for patients and better for the healthcare system,” said Walker. “We’re doing that by making sure we are available for everyone who needs us no matter when they need us.”
“Primary care providers need to get rid of the whole mentality of only being open from 9:00 to 5:00 with an hour for lunch,” she added. “That’s simply not the way healthcare works anymore. If you’re going to meet patient expectations and deliver the best possible care to them, you have to expand your hours and your services. We need to make it easy for people to seek care, because we all know what happens when they let things slide.”
Delivering a high-quality experience for patients is only possible when the entire practice is committed to change and aligned around the responsibilities and goals of accountable care.
“I think that if we ever stopped focusing on continuous improvement, it would be much harder to keep up the momentum and collaboration,” Walker said.
“You can’t get stagnant because healthcare is never stagnant. It might not seem possible to achieve change when you’re in the middle of it, but you really will see the results if you have the right tools at your disposal and use them efficiently to improve the way you care for your patients.”