Health Care for the Future: Growing the Family Practice Clinic Report to the Community From the Wahkiakum Family Practice Clinic Advisory Board October 2008



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Identifying Efficiencies

From October 2007, the Family Practice Clinic has had two Clinicians attempting to perform all the services the Clinic has offered since it came under County control in 2005. This includes the admission of patients to the hospital and conducting rounds with those who are hospitalized. In addition, the Clinic provides medical direction to the Emergency Medical Services, supports the Columbia View Care Center, and sees patients at the Hotel Cathlamet, Hospice and in-home Adult and Child Care facilities.


During this period, the Family Practice Clinic decided to add a Nurse Triage Phone Service, to provide phone support to patients who called after hours and on the weekends. This service is used when the Clinicians are overloaded. Discussions began regarding the costs and benefits of maintaining management of patients in the hospital. The Clinic Advisory Board determined that the Family Practice Clinic loses more than $49,000 a year in lost office hours and travel time. This amount of revenue would support approximate half of an ARNP position or a third of a doctor position. If mileage to and from PeaceHealth is added, the true cost exceeds $5,000 per year or a total of $54,000.
Maintaining this level of service has required that the remaining two Clinicians with hospital privileges share the responsibilities for taking call from the hospital during regular and off-hours as well as conducting rounds. There have been many occasions when one of the Clinicians is alone in the Clinic all day and then must see patients in the hospital and take calls during the night. This workload is not sustainable.
In addition, new state rules require that the Admitting Clinician see a patient within 12 hours of their admission to the hospital. This has resulted in the on-call Clinician making two trips to the Hospital each day. Beginning March 1, 2008, the Advisory Board and Clinicians agreed to stop providing this service to newly admitted patients. Negotiations are underway with PeaceHealth to develop a working relationship with Hospitalists at this institution. However, in the meantime, patients going to the hospital will be admitted through the Emergency Department and seen by the physicians on call that day. Every effort to coordinate their care will be taken and when they are discharged, the Clinic will continue with their follow up care. Patient records from the Wahkiakum Family Practice Clinic are available electronically to the doctors at St. Johns.
In addition, the two Clinicians have continued to provide Medical Control for the Wahkiakum Emergency Medical Services responders. This means that the Clinicians receive calls from the EMTs around the clock, seven days a week. Again, both the Clinic Advisory Board and the Clinicians have agreed that maintaining this level of service is beyond the capability of two Clinicians. Therefore, negotiations are underway to have medical control for the Emergency Medical Services provided through PeaceHealth and a locally based, PeaceHealth Emergency Department physician.
With the arrival of our new physician, the Clinic will perform an internal review of policies, practices and protocols in an effort to identify unprofitable areas of the practice. Areas identified will then be evaluated first by the Clinicians and then by the Advisory Board in an effort to balance the scope of the service with the cost effectiveness of providing said services.

Marketing

The Family Practice Clinic’s revenues have been 20% under expenditures for the last several years. The Board of County Commissioners has subsidized the Clinic through 2008, but will no longer provide support for the Clinic after this year. Growing Clinic revenues is critical to securing its long-term future. Further, moving the Clinic toward a wellness model will also require growing the patient panel, as well as addressing current space limitations.


The growth in revenue will come from three distinct sources; population growth within the county, organic growth within the current patient roster and attracting new patients from outside the county.
Population Growth
Wahkiakum County is one of the fastest growing counties in the State of Washington. Current population is estimated at 4,400. The growth rate for last year, as calculated by the state, was 10.7%. Assuming a more modest growth rate of 5%, the county can expect 220 new citizens each year. The clinic served 3,390 patients in 2006, 87% of them reside in the county for a patient capture rate of 63%. Maintaining the capture rate for the new citizens would net the clinic 139 new patients each year.
Average revenue from each patient in 2007 was $312.50. If revenue per patient remains the same, the 139 new patients would generate an additional $43,437.
Organic Growth
Organic growth is growth that is generated by existing patients. The clinic has not been as judicious as it could be in scheduling and following patients with chronic conditions. A program of proactive solicitation of patients for Pro-Time testing, diabetes, hypertension and other chronic conditions, could generate two additional office visits each year per patient. Currently the clinic serves 506 such patients. The current patient response rate for annual physicals is 30 % and it is believed that a more aggressive contact program could increase this rate to 50%. This would result in an additional 640 visits per year. The average revenue per office visit was $70 in 2007 and assuming the same rate, a follow up program would generate an additional $115,000.
Neighboring Counties
Patients from neighboring counties make up 13% of the current clinic patient base. A review of the patient zip codes indicates that these patients reside primarily in western Cowlitz and eastern Pacific counties. The clinic is attractive to these patients due to the quality of care they receive, the ease of access, exemplary customer service and transportation convenience. To date there has been no marketing activity by the clinic to encourage greater participation by residents of our neighboring counties. A program of direct mail, point of service promotional materials and an internet presence will stimulate growth in this patient sector. It is expected that this promotional activity will generate 300 new patients in the first 18 months. At the average patient revenue of $312.50 per annum, an addition of $93,750 in revenue is anticipated.



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