Ambulatory Services (6850P)

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1 1-132 Program Locator County Healthy Community Administration and Financial Services Patient Care Services Psychiatry Services Ancillary and Support Services Long-Term Care Services Ambulatory Services Headline Measures Cycle Time in Primary Care Clinics (in minutes) Estimate Percent of Clinic Visits by Payor Source 100% 75% 50% 25% 0% County 26% 34% 33% 34% 34% Medi-Cal/ Medicare Estimate % Other Pay ors 25% Program Outcome Statement Ambulatory Services provides high quality, patient focused, outpatient care services through a system of community-based clinics throughout the County. The Division provides primary care and chronic disease management services for adults and children as well as a full spectrum of medical and surgical specialty care that is (1) patient centered, (2) culturally competent, (3) outcomes based, and (4) chronic disease-focused while continually striving to open doors to health care for those who have traditionally encountered access barriers. Services and Accomplishments Ambulatory Services Program (ASP) contributes to the Shared Vision of a Healthy Community by 2025 by operating 11 clinics throughout the County that provide primary healthcare, preventive services, and limited public health services. Geographically, this includes three North County Clinics (Daly City Clinic, South San Francisco Clinic, and Daly City Youth Health Center); the Mid- County clinics (Main Campus Clinics, Ron Robinson Senior Care Center, and Coastside Clinic), and five South County clinics (Willow Clinic, Fair Oaks Clinic, Fair Oaks Children s Clinic, Sequoia Teen Wellness Center, and the Methadone Clinic). At the Main Campus Clinics, a full range of medical and surgical sub-specialty services are provided. Ambulatory Services also works with the Health System s Edison Clinic located at s Main Campus to provide HIV, STD, and general infectious disease services. The following are major accomplishments in the current year: Implemented an electronic medical record system at all primary care clinics Opened an Urgent Care Clinic to decompress the Emergency Department Received a Sequoia Hospital District donation of $4 million dollars for provision of care to patients in the District Applied for and received a $400,000 grant for a Mobile Dental Van from American Recovery and Reinvestment Act (ARRA) funds Received $1.7 million dollars in federal stimulus funding to expand services to low income patients in the Coastside area. Existing Coastside Clinic moved to larger, renovated space on the second floor of its building Story Behind Performance The Ambulatory Services Program (ASP) is the major provider of outpatient medical care to indigent persons residing in San Mateo County with approximately 235,000 visits. It serves as the safety-net provider for the medically underserved, uninsured and underinsured members of a culturally diverse population. ASP patients consist largely of the working poor and their families who are often non- English speaking persons. Services are provided by a culturally diverse and multilingual staff of physicians, nurses, and clerical support personnel. In the absence of national or state level solutions to the problem of the rising number of uninsured individuals, ASP addresses the increased need for care through a combination of productivity improvement, cost reduction, aggressive linking of patients to available payor sources, and seeking of external grant

2 1-133 funding to be able to continue to meet the needs of the community in a high quality manner. More than 90% of patients rate overall service quality as good or better. The identification of payor sources is an important component for the Ambulatory Services Program. This information is critical to maintaining the financial health of the Medical Center. Through the expanded use of Community Health Advocates and partnerships with the Human Services Agency, more and more patients are screened for eligibility and, if appropriate, are linked to state and federal funding sources to reduce the reliance on the County General Fund. The data indicate that an increasing percentage of outpatient visits are being attributed as a County payor source. This result must be further qualified wherein many of these outpatient visits are actually registered under the Access and Care for Everyone (ACE) Program which is a County payor source funded through federal grants and only minimally impacts the County General Fund. Increasing the number of pediatric visits was an important part of a plan to increase Medical Center revenue. In contrast to adults, all children in the are covered by insurance through Healthy Kids, Healthy Families, or Medi-Cal. Pediatric visits would therefore have a higher income margin than adult visits. Given its importance, it was added as a performance measure in FY The number of pediatric visits per year is projected to be approximately 60,570 which is very close to stated targets, and represents more than 25% of total outpatient visits program wide. Access into the clinics remains a challenge. As a way to measure access, a new measurement, time to third next available appointment has been added. These are non-urgent, follow-up visits for established patients. This is considered a more accurate assessment of appointment availability rather than simply looking at the next appointment. A next available appointment can be created by a cancellation or other occurrence. The third next available appointment essentially eliminates those unforeseen events from the measurement and more closely reflects availability of follow-up appointments. Cycle Times, a Headline Measure started in FY , is defined as the amount of time in minutes that a patient spends at the clinic, beginning at the time of arrival and ending when the patient leaves the clinic. Patient wait times have been patient satisfaction issues in the past. One project to improve patient satisfaction by decreasing patient wait times has been Cycle Time management. The target was set at an overall average of 60 minutes for each patient s visit. Efficient and timely strategies that reduce delays in a patient receiving care are required to shorten cycle times. These strategies include improved registration, scheduling, and discharge procedures, patient care teams, efficient clinic design, and patient visit planning. In addition to improving cycle times, staff update patients regarding anticipated wait times once in the clinics and alert those to unforeseen problems that could lengthen their visit time. Timely updates regarding events that may impact the patient s cycle time are thought to improve overall satisfaction. Unfortunately, the recent economic recession has caused significant unemployment in the community, consequently causing an increase in the number of uninsured and underinsured patients. This increase in the number of patients using the County Health System, coupled with implementation of the Ambulatory Electronic Medical Record (AEMR) system, has caused Cycle Times to spike in the first half of FY Previous experience has shown that any increases in Cycle Time due to AEMR implementation are only temporary and should improve in FY as staff and providers become more comfortable with the system. The Ambulatory Services Program is able to pursue its goals amidst a culture of innovation and engagement. There is a range of active medical leaders on staff, newer and updated facilities located throughout the County, an integrated system of care, and strong relationships established between the Health Plan of San Mateo and the newly created San Mateo County Health System. In addition, the new Ambulatory Electronic Medical Record will help to more effectively serve patients and meet performance measures. Major challenges over the next two years will to be: To meet the growing demand for medical care amidst resource constraints. The wait list for patients seeking to establish care with the County Health System has grown substantially throughout 2009 To return productivity to pre-aemr implementation levels To manage the cost of indigent health care by increasing non- County payor sources and improving operational efficiencies Program Objectives Ambulatory and Medical Services will meet performance targets by doing the following: Increase the Total Number of Pediatric Visits to 65,000 per Year Implement Evening and Weekend Clinics Develop a recruitment and hiring plan for providers Return Primary Clinic Productivity Levels to Pre-AEMR Implementation Complete AEMR implementation in the Medical and Specialty Clinics Train Clinic Staff in use of new system Monitor for improved management of chronic diseases

3 1-134 Performance Measures Summary Table Performance Measures FY FY FY Estimate FY FY What / How Much We Do (Effort) Number of clinic outpatient visits 218, , , , ,814 Number of senior center visits 9,893 11,319 9,950 12,000 12,000 Number of pediatric visits 55,698 59,254 60,572 65,000 65,000 How Well We Do It (Quality / Efficiency) Cycle time (in minutes) Percent of clinic visits by payor: - County - Medi-Cal / Medicare - Other Payor Sources 26% 49% 25% 34% 33% 34% 34% Is Anyone Better Off? (Outcome / Effect) Percent of customer survey respondents rating services good or better Average length of time (days) between a non-urgent appointment request and the 3 rd next available appointment (1) 98% 95% 93% 90% 90% (1) New performance measure beginning FY Resource Allocation Summary Revised Recommended Change Recommended Salary Resolution (2.0) Funded FTE (3.2) Total Requirements 37,847,879 44,045,991 51,946,332 54,309,222 2,362,890 54,934,432 Total Sources 61,086,417 80,635,451 79,373,809 86,441,200 7,067,391 86,441,200 Net County Cost (23,238,538) (36,589,460) (27,427,477) (32,131,978) (4,704,501) (31,506,768) Discretionary Net County Cost The County s General Fund contributions to the are centrally budgeted as revenue sources in the Medical Center s Administrative and Quality Management Services budget. Ambulatory and Medical Staff Services is funded by patient charges and intergovernmental revenue sources. Gross patient charges are budgeted in this unit and contractual allowances (for Medi-Cal and other payors that provide reimbursement at capitated rates that are below charges) are budgeted centrally in Administrative and Quality Management Services.

4 1-135 FY Program Funding Adjustments The following are significant changes from the FY Revised to the FY Recommended Budget: 1. Adjustments to Provide Current Level of Services Budget adjustments have been made to reflect current costs for existing levels of service and performance: inclusion of merit increases, and increases in retirement contributions and health benefit costs; and inflation for Extra Help, purchased services, supplies and other non-labor expenditures. These appropriation increases will provide needed support for the ambulatory service programs of the Medical Center. 200,240 3,667, ,467, Adjustments to Reflect Operational Requirements Revenues have been increased to align gross patient revenues with prior years performance and projected volumes. Grant funding from the Sequoia Health Care District has been included in this budget unit to align the revenues with expenses. Appropriations have been adjusted to reflect additional needs in Extra Help and overtime. These increases have been offset by reductions to several non-critical patient care expenditures in an effort to meet the budget reduction target. The third-party agreement fee for the Access Care for Everyone (ACE) and has been reduced as a portion of the expense has been budgeted in the Administrative Services unit. 6,301,755 (811,274) 0 0 (7,113,029) 0 3. Comprehensive Perinatal Services Program The Medical Center will begin a Comprehensive Perinatal Services Program (CPSP) that will be reimbursed at Federally Qualified Health Care (FQHC) rates. An existing vacant position will be filled to support this program. 365, (365,298) 0 4. Methadone Clinic Efficiency Increase Revenue has been increased due to an increase in patient volume served at the Methadone Clinic. Additionally, one vacant Community Worker II position has been deleted and one vacant Staff Physician s hours have been reduced as a result of ongoing efficiency efforts in the operation of the clinic. 113,698 (132,744) 0 0 (246,442) (1) 5. Women s Health Exams The Medical Center will offer a Women s Health Exam service, as part of the Pay for Performance agreement with the Health Plan of San Mateo, providing more proactive attention and care to the patient s health. Services will be provided with existing resources. 86, (86,400) 0

5 Workforce Reduction to Meet Budget A vacant Staff Physician position in Pediatrics has been deleted to meet the budget reduction target. A thorough review of the Medical Center s staffing requirement determined that the elimination of this Staff Physician position would have minimal impact on service delivery. 0 (221,427) 0 0 (221,427) (1) 7. Vacant Position Freeze A vacant Staff Physician position has been frozen to reduce labor expenditures. There will be minimal impact to performance. 0 (221,427) 0 0 (221,427) 0 8. Long Term Care - Hours of Care Reduction A vacant Medical Services Assistant II has been deleted with the reduction of hours of care provided in the Long-Term Care unit at the main campus. 0 (36,807) 0 0 (36,807) (1) 9. Staffing Adjustments - Specialty Clinic Realignment A vacant full-time Office Assistant I position has been deleted, and a half-time Patient Services Assistant II position has been added to improve service and prepare for a greater volume of patients in the Speciality Clinic. 0 (25,080) 0 0 (25,080) Administrative Services Manager An Administrative Services Manager has been added to support patient service delivery. A vacant Clinical Services Manager position in the Patient Care Services Program (6610P) has been deleted to offset this addition , ,919 1 TOTAL FY PROGRAM FUNDING ADJUSTMENTS 7,067,391 2,362, (4,704,501) (2)

6 FY Program Funding Adjustments The following are significant changes from the FY to the FY Recommended Budget: 11. Adjustments to Provide Current Level of Services Budget adjustments have been made to meet performance targets: inclusion of merit and health benefit cost increases. The Medical Center expects to make up this gap with net revenue increases , ,

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