Skip to main content

Advertisement

Log in

After-Hours Care and its Coordination with Primary Care in the U.S.

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

BACKGROUND

Despite expectations that medical homes provide “24 × 7 coverage” there is little to guide primary care practices in developing sustainable models for accessible and coordinated after–hours care.

OBJECTIVE

To identify and describe models of after-hours care in the U.S. that are delivered in primary care sites or coordinated with a patient’s usual primary care provider.

DESIGN

Qualitative analysis of data from in-depth telephone interviews.

SETTING

Primary care practices in 16 states and the organizations they partner with to provide after-hours coverage.

PARTICIPANTS

Forty-four primary care physicians, practice managers, nurses and health plan representatives from 28 organizations.

APPROACH

Analyses examined after-hours care models, facilitators, barriers and lessons learned.

RESULTS

Based on 28 organizations interviewed, five broad models of after-hours care were identified, ranging in the extent to which they provide continuity and patient access. Key themes included: 1) The feasibility of a model varies for many reasons, including patient preferences and needs, the local health care market supply, and financial compensation; 2) A shared electronic health record and systematic notification procedures were extremely helpful in maintaining information continuity between providers; and 3) after-hours care is best implemented as part of a larger practice approach to access and continuity.

CONCLUSION

After-hours care coordinated with a patient’s usual primary care provider is facilitated by consideration of patient demand, provider capacity, a shared electronic health record, systematic notification procedures and a broader practice approach to improving primary care access and continuity. Payer support is important to increasing patients’ access to after-hours care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1.

Similar content being viewed by others

References

  1. Schoen C, Osborn R, Doty MD, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in 11 Countries, 2009: perspectives on care, costs, and experiences. Health Aff Web Exclusive. 2009;5:w1171–83.

    Article  Google Scholar 

  2. Schoen C, Osborn R, Doty MM, Bishop M, Peugh J. Toward higher-performance health systems: adults’ health care experiences in seven countries, 2007. Health Aff Web Exclusive. 2007;31:w717–34.

    Article  Google Scholar 

  3. Lowe RA, Localio AR, Schwarz DF, Williams S, Tuton LW, Maroney S, Nicklin D, Goldfarb N, Vojta DD, Feldman HI. Association between primary care practice characteristics and emergency department use in a Medicaid managed care organization. Med Care. 2005;43(8):792–800.

    Article  PubMed  Google Scholar 

  4. O'Connell JM, Johnson DA, Stallmeyer J, Cokingtin D. A satisfaction and return-on-investment study of a nurse triage service. Am J Manag Care. 2001;7(2):159–69.

    PubMed  Google Scholar 

  5. Margolius D, Bodenheimer T. Redesigning after-hours care. Ann Intern Med. 2011;155:131–2.

    PubMed  Google Scholar 

  6. Bogdan GM, Green JL, Swanson D, Gabow P, Dart RC. Evaluating patient compliance with nurse advice line recommendations and the impact on healthcare costs. Am J Manag Care. 2004;10(8):534–42. PubMed PMID: 15352529.

    PubMed  Google Scholar 

  7. Piehl MD, Clemens CJ, Joines JD. "Narrowing the Gap": decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care. Arch Pediatr Adolesc Med. 2000;154(8):791–5. PubMed PMID: 10922275.

    PubMed  CAS  Google Scholar 

  8. Starfield B. Primary care: balancing health needs, services and technology. New York: Oxford University Press; 1998.

    Google Scholar 

  9. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits. Health Aff (Millwood). 2008;27(5):1272–82.

    Article  Google Scholar 

  10. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary. Natl Health Stat Report. 2010;26:1–32.

    PubMed  Google Scholar 

  11. Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it’s not at their Doctor’s Office. Heal Aff. 2010;29(9):1620–9.

    Article  Google Scholar 

  12. Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer GE. Practical barriers to timely primary care access: impact on adult use of emergency Department services. Arch Intern Med. 2008;168(15):1705–10.

    Article  PubMed  Google Scholar 

  13. Comprehensive Primary Care Initiative under the ACA, description available at http://www.hhs.gov/news/press/2011pres/09/20110928a.html. (Accessed April 4, 2012)

  14. National Committee for Quality Assurance (NCQA), Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH),Version 2008, available at http://www.ncqa.org/tabid/631/default.aspx (Accessed April 9, 2012).

  15. Lee TJ, Guzy J, Johnson D, Woo H, Baraff LJ. Caller satisfaction with after-hours telephone advice: nurse advice service versus on-call pediatricians. Pediatrics. 2002;110(5):865–72.

    Article  PubMed  Google Scholar 

  16. Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western countries: assessment of different organizational models. BMC Heal Serv Res. 2009;9:105.

    Article  Google Scholar 

  17. Felton JS. Burnout as a clinical entity–its importance in health care workers. Occup Med (Lond). 1998;48(4):237–50.

    Article  CAS  Google Scholar 

  18. Leibowitz R, Day S, Dunt D. A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction. Fam Pract. 2003;20(3):311–7.

    Article  PubMed  Google Scholar 

  19. Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835–43.

    Article  Google Scholar 

  20. Miles MB, Huberman MA. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks: SAGE Publications Inc; 1994.

    Google Scholar 

  21. Atlas.ti, Version: 5.7.1, Qualitative Data Analysis Scientific Software. ©1993-2012 by ATLAS.ti GmbH, Berlin.

  22. Quackenbush J, Shenkel R, Schatzel V. Creating a successful after-hours Clinic. Family Practice Management, 2004:39–42.

  23. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8):1035–40.

    Article  PubMed  Google Scholar 

  24. van Uden CJ, Ament AJ, Voss GB, Wesseling G, Winkens RA, van Schayck OC, Crebolder HF. Out-of-hours primary care. Implications of organisation on costs. BMC Fam Pract. 2006;7:29.

    Article  PubMed  Google Scholar 

  25. Giesen P, Smits M, Huibers L, Grol R, Wensing M. Quality of after-hours primary care in the Netherlands: a narrative review. Ann Intern Med. 2011;155(2):108–13.

    PubMed  Google Scholar 

  26. Grol R, et al. After-hours care in the United Kingdom, Denmark and the Netherlands: New Models. Heal Aff. 2006;25:1733–7.

    Article  Google Scholar 

  27. Willekens M, Giesen P, Plat E, Mokkink H, Burgers J, Grol R. Quality of after-hours primary care in the Netherlands: adherence to national guidelines. BMJ Qual Saf. 2011;20(3):223–7.

    Article  PubMed  Google Scholar 

  28. Abrams M, Schor EL, Schoenbaum S. How physician practices could share personnel and resources to support medical homes. Health Aff (Millwood). 2010;29(6):1194–9.

    Article  Google Scholar 

  29. Fryer AK, Doty MM, Audet AJ. Sharing Resources: Opportunities for Smaller Primary Care Practices to Increase Their Capacity for Patient Care. Findings from the 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. March 2011 CMWF Issue Brief. Available at: www.cmwf.org. (Accessed April 4, 2012).

  30. Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010 Nov 3;(27):1–32. Available at, http://www.cdc.gov/nchs/data/nhsr/nhsr027.pdf. (Accessed April 4, 2012).

  31. Baker R et al. The access/relationship tradeoff: How important is continuity of care to patients and their carers? Sept 2006, Briefing Paper. Available at: http://www.sdo.nihr.ac.uk/files/adhoc/13b-13-briefing-paper.pdf (Accessed April 4, 2012).

Download references

Acknowledgment

This study was funded by The Commonwealth Fund (Grant #20100295).

The authors would also like to thank Dr. Robert Berenson, Dr. Ed Wagner and Dr. Stephen Schoenbaum for serving as external advisors to this project.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ann S. O’Malley MD, MPH.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOC 48 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

O’Malley, A.S., Samuel, D., Bond, A.M. et al. After-Hours Care and its Coordination with Primary Care in the U.S.. J GEN INTERN MED 27, 1406–1415 (2012). https://doi.org/10.1007/s11606-012-2087-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-012-2087-4

KEY WORDS

Navigation