Creating a Care Home for the Homeless

“We think sometimes that poverty is only being hungry, naked and homeless. The poverty of being unwanted, unloved and uncared for is the greatest poverty.”
– Mother Teresa (1910-1997)

Brief History

Like many clinics with high demand, Albuquerque Health Care for the Homeless (AHCH) was bursting at the seams. Early each morning, a long line of patients would gather at the front door before the clinic opened. It would often take more than an hour to check-in and register these patients.

Protracted waits to see providers were routine, with patients spending, on average, over 2.5 hours in the clinic to complete their visits.

Before redesign training, the average patient visit was 2.5 hours.

Patient visits that should have been quick, such as TB skin test readings or pediatric immunizations, sometimes took all day. Patients were routinely triaged, and often those patients with less urgent needs would be turned away at day’s end and asked to return the following day. The next day it would be as Yogi Berra once said: “It’s deja vu all over again.”

Enter Patient Visit Redesign™

In June 2001, Albuquerque Health Care for the Homeless brought in Coleman Associates to lead the clinic through a Patient Visit Redesign™ Program. AHCH staff, with guidance from a Coleman Associates trainer, selected a five-member redesign team. Over the course of the next several months, this small group, with the active support of managers and staff, radically transformed how AHCH saw patients. “We came up with a hell of a model,” said team member, Jeff Olivet. And, they sure did.

The redesign team, Equipo Innovación (Team Innovation), was quick to look at all of the clinic’s work processes with fresh eyes, examining everything they did with the goal of making each step in the patient visit more patient-friendly. “I don’t think we ever lost focus, or lost ambition, in terms of creating the model. We approached our task with a sense of discovery every day, with fresh creativity, and with a real patient-centered mentality,” said Olivet.

• AHCH’s Patient Care Teams [A Patient Care Team is a cross-trained, cross-functional team where providers, nursing staff and clerical support staff work closely together to make sure the patient gets everything he/she needs.] were particularly successful at eliminating traditional clinical hierarchies. Instead of staff members doing no more than what was stipulated in their job descriptions, they understood that being on a real team meant doing everything that needed doing, regardless of one’s official position. “A nurse or a patient advocate or a provider would come get the patient,” said Olivet. “We were very fluid that way; it could really be anybody who was free to get the patient, all day long.”
• Equipo Innovación understood the importance of starting each clinic day on time, and implemented a clinic-wide countdown. Over the clinic intercom system they would count down the minutes until 8:00, at which time they would open the doors. Once the clinic was in session “all hands were on deck”: Providers, nurses, medical assistants, and case managers were all right out front in the waiting room, ready to greet patients and bring them back to the exam rooms. This created excitement and a sense of urgency to begin each day on time, every day.
• It is commonly believed that the homeless population is unable to keep appointments, so AHCH was largely a walk-in clinic. As part of their redesigned patient visit, Equipo Innovación experimented with giving patients appointments. Remarkably, they found that their patient population was no different from any other patient population and had the same no-show rate as any other clinic, provided the appointments weren’t made much longer than two weeks in advance. Equipo Innovación challenged one of their biases and got great results: That long line of patients waiting to get in the clinic every morning disappeared.
• One of the greatest innovations at AHCH was side-by-side visits—when a provider and a nursing support person (RN, LVN, or MA) worked closely and seamlessly together during the patient visit. The provider and the nursing support person would be in the exam room together for the entire visit.
• This meant that the provider could focus entirely on the patient while the nursing support person would take care of all the odds and ends that would inevitably come up. “In certain visits there were specific tasks for the nursing support person to do, such as in a GYN exam,” said Olivet. “In other kinds of visits she might be taking vitals while the provider was beginning to take a history.

“The nursing support person was part runner and part strategic consultant, anticipating what would be needed next. She could leave the exam room to get necessary supplies. She could prepare or administer immunizations, fill out forms, draw blood—whatever was necessary, eliminating unnecessary waiting for the patient.

This arrangement greatly increased provider efficiency. Since the provider was able to focus entirely on the patient, and not the plethora of other distractions, the patient received better care.

• Many redesign teams have a Front Flowmaster, or a patient visit choreographer, whose principal job is to greet patients and direct them to the appropriate Patient Care Team. Equipo Innovación’s Flowmaster wasn’t just a greeter, but in fact utilized his clinical experience to make sure every patient was appropriately attended to by the appropriate person. Sometimes this meant taking care of the patient’s needs without the patient even needing to be seen by a provider. And very importantly, since Equipo Innovación realized the tremendous value of a Front Flowmaster, he wasn’t expected to divide his attention with other duties. He was able to stay tactical and strategic, and this served the patients very well.

 Conclusion

After redesign, the cycle time average had plummeted to 74 minutes—less than half of what it was pre-redesign, and for many patient visits this included additional social services that patients were not getting before.

More services in much less time. That was the genius of this Patient Visit Redesign model. AHCH increased on-site social work visits by 78% after redesign was implemented. Same day social work referrals increased by 156%.

Equipo Innovación was a tremendously enthusiastic and innovative team, and was able to implement radical changes. “It’s a mission-driven organization,” said Olivet, “so it was natural to think about how we could improve the lives and experiences of our patients. That was our approach every day.” By reducing cycle times, increasing the level of service, and focusing intensely on their patients, they were able to reinforce the deep commitment they felt about providing care to the homeless.