IHP 505 Module 5 Milestone Two Example

Milestone Two: What the Evidence Says About Advanced Access and Team-Based Care

[Student Name]

Southern New Hampshire University

IHP 505: Leadership in Clinical Microsystems

Module Five Milestone Two

[Instructor Name]

[Date]

Milestone Two: What the Evidence Says About Advanced Access and Team-Based Care

Milestone One defined Northgate Family Medicine's access problem: a 28-day wait to the third next available appointment, a 19% no-show rate and clinicians charting two hours after clinic, with daily demand exceeding supply and a large backlog. This review examines evidence on two approaches that address those causes, advanced access scheduling and team-based care, and draws implications for the clinic's design. Sources were identified in PubMed and CINAHL, focusing on reviews and foundational descriptions.

The Principles of Advanced Access

As explained by Murray and Berwick (2003), advanced access is a way of scheduling in which patients can see their own clinician on the day they choose, often the same day. Its principles include measuring and matching daily supply and demand, working down the backlog of future appointments through temporary extra effort, reducing the number of appointment types so the schedule is flexible, developing contingency plans for predictable surges such as Mondays and flu season and reducing demand that does not require a visit, for example by handling some issues by phone. They argued that practices adopting these principles in the United Kingdom and United States had reduced waits dramatically without adding clinicians, and they recommended third next available appointment as the core measure.

What a Systematic Review Found

Rose et al. (2011) systematically reviewed studies of advanced access implementation in primary care. Most studies reported reductions in time to the third next available appointment, and about half of those measuring no-show rates found decreases. Effects on patient satisfaction were mixed, and results for continuity with a patient's own clinician varied. Few studies examined clinical outcomes. The authors noted that most studies simply compared a period before the change with one after, with no control practices, and that implementation varied widely, with some practices adopting only parts of the model. They concluded that advanced access can improve waiting times but that evidence on other outcomes was limited.

Why Implementation Matters

Reading the two sources together suggests that advanced access is not a single intervention but a set of practices that must be adopted together. Practices that opened same-day slots without working down the backlog saw waits return, and those that kept many appointment types found it hard to match supply and demand. The variable results in the review may reflect partial implementation as much as limits of the model. For Northgate, this means planning for all core principles rather than simply reserving some same-day slots.

Team-Based Care

Bodenheimer and Sinsky (2014) argued that improving care for patients requires improving work life for clinicians and staff, the fourth aim. Among the practice changes they described are sharing work across the team, such as having medical assistants handle pre-visit planning, standing orders and some documentation, and nurses managing chronic disease follow-up under protocols. These changes free clinician time for visits and reduce after-hours work, which both expands supply for access and addresses burnout. They cited practices where such redistribution had improved clinicians' work life.

Lessons from Practices That Tried It

Reports from practices that adopted advanced access, summarized in the sources, point to several practical lessons. Backlog reduction usually required several weeks of extra sessions, and practices that skipped it found same-day slots filled by patients who could not get routine appointments. Reducing appointment types met resistance from clinicians who preferred long physicals, but most adapted once the schedule became more flexible. Planning for predictable peaks, such as Mondays and the days after holidays, prevented waits from creeping back. And measuring third next available appointment every week kept the team focused. For Northgate, these lessons translate into a realistic timeline and a weekly measurement routine from the start.

Synthesis

The evidence supports advanced access for reducing waits, with more modest and uncertain effects on no-shows, satisfaction and continuity, and it shows how much depends on implementing the model fully. Team-based care complements advanced access by increasing effective supply and reducing burnout, addressing Northgate's balancing measures directly. Neither approach requires new clinicians, fitting the project's scope.

Table 1. Summary of Evidence

Note. Evidence types are described as reported.

Gaps

The literature leaves questions important to Northgate. Few studies examine advanced access in practices serving many Medicaid patients or patients with limited English, whose no-show rates and needs may differ. Evidence on sustaining gains beyond a year is thin. And studies rarely report staff experience during the backlog reduction phase, which is when burnout risk is highest.

Reducing Demand That Does Not Need a Visit

Advanced access also works by lowering demand for visits that are not needed. At Northgate, a review of one week's appointments found that about 12% were for medication refills, test result discussions or form completion that could be handled by phone, secure message or the care manager. Blood pressure checks for stable patients could be done by medical assistants under standing orders. Moving this work off the schedule would free roughly twenty slots a day, more than closing the daily gap between demand and supply. This approach fits both the advanced access model and team-based care, because it shifts tasks to the team members best suited to them.

Design Implications

The evidence suggests five design choices. First, adopt the full set of advanced access principles, including backlog reduction, rather than same-day slots alone. Second, cut appointment types from seven to two, short and long. Third, protect continuity by booking patients with their own clinician whenever possible and tracking continuity as a balancing measure. Fourth, expand team roles, with medical assistants doing pre-visit planning and standing orders and the care manager handling routine diabetes and blood pressure follow-up by phone. Fifth, spread the temporary backlog effort across volunteer sessions to avoid adding to burnout.

Conclusion

Advanced access and team-based care together address Northgate's backlog, supply-demand mismatch and staff overload. The evidence is encouraging for waits and more uncertain elsewhere, which argues for careful measurement. The next milestone turns these choices into an implementation plan.

References

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. https://doi.org/10.1370/afm.1713

Murray, M., & Berwick, D. M. (2003). Advanced access: Reducing waiting and delays in primary care. JAMA, 289(8), 1035-1040. https://doi.org/10.1001/jama.289.8.1035

Rose, K. D., Ross, J. S., & Horwitz, L. I. (2011). Advanced access scheduling outcomes: A systematic review. Archives of Internal Medicine, 171(13), 1150-1159. https://doi.org/10.1001/archinternmed.2011.168