Appointment planning and scheduling in primary care

The Affordable Care Act (ACA) puts greater emphasis on disease prevention and better quality of care; as a result, primary care is becoming a vital component in the health care system. However, long waits for the next available appointments and delays in doctors offices combined with no-shows and late cancellations have resulted in low efficiency and high costs. This dissertation develops an innovative stochastic model for patient planning and scheduling in order to reduce patients’ waiting time and optimize primary care providers’ utility. In order to facilitate access to patients who request a same-day appointment, a new appointment system is presented in which a proportion of capacity is reserved for urgent patients while the rest of the capacity is allocated to routine patients in advance. After the examination of the impact of no-shows on scheduling, a practical double-booking strategy is proposed to mitigate negative impacts of the no-show. Furthermore, proposed model demonstrates the specific circumstances under which each type of scheduling should be adopted by providers to reach higher utilization. Moreover, this dissertation extends the single physician’s model to a joint panel scheduling and investigates the efficiency of such systems on the urgent patients’ accessibility, the physicians’ utilization, and the patients’ waiting time. Incorporating the newsvendor approach and stochastic optimization, these models are robust and practical for planning and scheduling in primary care settings. All the analytical results are supported with numerical examples in order to provide better managerial insights for primary care providers

Acuity-based Performance Evaluation and Tactical Capacity Planning in Primary Care

Effective primary care requires timely and equitable access to care for patients as well as efficient and balanced utilization of physician time. Motivated by a family health clinic in Ontario, Canada, this research proposes ways to improve both of these aspects of primary care through tactical capacity planning based on acuity-based performance targets. First, we propose a new metric based on acuity levels to evaluate timely access to primary care. In Canada, as well as other participant countries in the Organization for Economic Co-operation and Development (OECD), the main metric currently used to evaluate access is the proportion of patients who are able to obtain a same- or next-day appointment. However, not all patients in primary care are urgent and require a same- or next-day appointment. Therefore, accurate evaluation of timely access to primary care should consider the urgency of the patient request. To address this need, we define multiple acuity levels and relative access targets in primary care, akin to the CTAS system in emergency care. Furthermore, current access time evaluation in the province is mostly survey-based, while our evaluation is based on appointment data and hence more objective. Thus, we propose a novel, acuity-based, data-driven approach for evaluation of timely access to primary care. Second, we develop a deterministic tactical capacity planning (TCP) model to balance workload between weeks for each family physician in the specific primary care clinic in this study. Unbalanced workload among weeks may lead to provider overtime for the weeks with high workload and provider idle time for weeks with low workload. In the proposed TCP model, we incorporate the results from access time evaluation in the first study as constraints for access time. The proposed TCP model considers 11 appointment types with multiple access targets for each appointment type. The TCP model takes as input a forecast of demand coming from an ARIMA model. We compare the results of the TCP model based on current access time targets as well as targets resulting from our acuity-based metrics. The use of our proposed acuity-based targets leads to allocation of time slots which is more equitable for patients and also improves physician workload balance. Third, we also propose a robust TCP model based on the cardinality-constrained method to minimize the highest potential physician peak load between weeks. Therefore, the developed robust TCP model enables protection against uncertainty through providing a feasible allocation of capacity for all realizations of demand. The proposed robust TCP model considers two interdependent appointment types (e.g., new patients and follow ups), multiple access time targets for each appointment type and uncertainty in demand for appointments. We conduct a set of experiments to determine how to set the level of robustness based on extra cost and infeasibility probability of a robust solution. In summary, this dissertation advocates for the definition and subsequent use of acuity-based access time targets for both performance evaluation and capacity allocation in primary care. The resulting performance metrics provide a more detailed view of primary care and lead to not only more equitable access policies but also have the potential to improve physician workload balance when used as input to capacity planning models

Single versus hybrid time horizons for open access scheduling

Difficulty in scheduling short-notice appointments due to schedules booked with routine check-ups are prevalent in outpatient clinics, especially in primary care clinics, which lead to more patient no-shows, lower patient satisfaction, and higher healthcare costs. Open access scheduling was introduced to overcome these problems by reserving enough appointment slots for short-notice scheduling. The appointments scheduled in the slots reserved for short-notice are called open appointments. Typically, the current open access scheduling policy has a single time horizon for open appointments. In this paper, we propose a hybrid open access policy adopting two time horizons for open appointments, and we investigate when more than one time horizon for open appointments is justified. Our analytical results show that the optimized hybrid open access policy is never worse than the optimized current single time horizon open access policy in terms of the expectation and the variance of the number of patients consulted. In nearly 75% of the representative scenarios motivated by primary care clinics, the hybrid open access policy slightly improves the performance of open access scheduling. Moreover, for a clinic with strong positive correlation between demands for fixed and open appointments, the proposed hybrid open access policy can considerably reduce the variance of the number of patients consulted.Journal Articl