Virtual waiting room helps fill no-show spots

Where: Baystate High Street Health Center, an academic health center in Springfield, Mass.

The issue: Improving appointment workflow and boosting care access.

Background

Baystate High Street Health Center had high no-show and appointment cancellation rates for understandable reasons. The clinic serves close to 9,000 patients in a diverse urban community, with more than half of its payer mix from Medicaid accountable care organizations (ACOs) and over a third from Medicare ACOs. Many of the center's patients face socioeconomic barriers to care, including limited transportation, child care needs, work obligations, and housing instability.

The result was less-than-optimal schedule utilization, a crucial performance metric for ambulatory care, explained Mayu Sekiguchi Runge, MD, MPH. Meanwhile, patients who needed same-day appointments and couldn't get them often had to be directed to urgent care or the ED.

Dr. Runge saw a way to address both of these problems at once: a virtual waiting room for same-day telehealth appointments, which would fill some of those empty time slots and improve patients' access to care.

How it works

In the virtual waiting room program, nurses triage patients' calls about acute concerns and put those considered appropriate for telehealth into a standby pool, letting them know to keep their phones nearby as they might receive a call at any point during the day. When a primary care clinician has a no-show or a cancellation, they can access the standby pool to fill the slot. Clinicians can choose to use a first-come-first-serve method or prioritize their own patients, those with acute issues, or those who have been waiting the longest. All patients placed in the virtual waiting room are advised to go to urgent care or the ED if their condition worsens while they wait, and those who are placed in the virtual waiting room late in the day or on a Friday afternoon are informed that a clinician will contact them the next day or the following Monday.

In April 2023, the program began as a pilot with one physician and one nurse practitioner taking a max of 10 virtual waiting room patients per day, then expanded in June 2023 to include all 14 of Baystate High Street's primary care clinicians, with a 20-patient-per-day cap.

Results

Dr. Runge and her colleagues compared clinic utilization rates between July and September in 2022 and 2023 and found that they improved from 75.2% before the intervention to 81.2% afterward. Weekly appointment utilization after implementation of the virtual waiting room also improved, from 76% to a peak of 94%. Chart review of the first 100 triaged patients found that 76% got telehealth visits on the same day they called, with a mean wait time of 1.9 hours. The results of the program evaluation were published in the September 2024 Journal of General Internal Medicine.

“Patients were expressing gratitude for being accommodated so quickly. … Although telehealth visits may lack that comprehensive element … the clinicians can still address many of the concerns, initiate the workup, and then schedule in-person follow-ups if necessary,” said Dr. Runge, who is an assistant professor of medicine at UMass Chan Medical School–Baystate. “The ability to connect with the clinician so quickly is the part that they really appreciate, because they otherwise would have had to wait days for an appointment.”

Clinician feedback was also uniformly positive, Dr. Runge said. Being able to offer the option of a virtual waiting room helped the triage nurses save time and decrease patient frustration, for example.

“The other big thing, for me at least, is the [primary care clinicians], all of them, had positive feedback in that not only did [the program] improve utilization, it allowed them to receive credit for the work they've always been doing,” Dr. Runge said. “Clinicians often address a lot of the acute issues in the inbox messages that they get from the triage nurses, and that's done between patient sessions, outside of dedicated clinical time. Now these interactions are becoming telehealth visits and official visits that are counted. ... I'd say that's a win-win.”

Challenges

The main challenge Dr. Runge outlined is a common one: buy-in. The clinic hadn't routinely offered telehealth before for acute same-day visits, so both patients and clinicians needed to be reassured that this method could provide quality care.

“I remember when I started telehealth during the pandemic, I was worried about missing something. The patients also felt that way,” Dr. Runge explained. “Clinicians in the same way were concerned about the limitations …but we just had to convince them that if we want to improve our utilization, improve access for our patients, telehealth could really help, because it allows us to fill in gaps in a timely fashion.”

For staff, committing to the new workflow was key, since they needed to maintain the virtual waiting room list and coordinate with clinicians to transfer patients from the virtual waiting room to telehealth appointments when spots became available, Dr. Runge said.

Next steps

The virtual waiting room is ongoing at Baystate High Street Health Center, but Dr. Runge envisions it expanding beyond primary care to other specialties that use telehealth more often, such as behavioral health.

“The other thing we're doing is we're exploring ways to be more proactive, rather than reactive,” she said. “We started the virtual waiting room to use for urgent visits when patients request them, but we're also considering ways to apply it for proactive outreach, by calling patients with uncontrolled diabetes or hypertension to adjust their medications. This hopefully would prevent issues before they become urgent, and then provide even more timely care for our patients.”

Words of wisdom

The critical piece of the puzzle for this intervention is improving access, Dr. Runge noted. “The big thing I always tell people is, if we don't know about it, we can't help the patient,” she said. “I really think that telehealth is here to stay and that it should continue to be used to improve access for patients who may otherwise have difficulty getting care.”

She also encouraged other practices to consider working together to implement virtual waiting rooms in their own health systems. “This was an innovation that I came up with, and I thought it might work, but actually tweaking it constantly and having my colleagues being OK with change was the biggest reason for its success,” she said. “Give it a try.”