PEDIATRICS Vol. 110 No. 6 December 2002, pp. 1117-1124
Regional After-Hours Urgent Care Provided by a Tertiary Children’s Hospital
Children’s Hospital Pediatric Urgent Care Network
* Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPROGRAM DESCRIPTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Background. Ambulatory presentation to a tertiary pediatric emergency department (ED) is not convenient for many families. Yet many primary care pediatricians (PCPs) desire after-hours urgent care for their patients as an alternative to extended office hours or care by general emergency medicine providers at community hospitals.
Objective. To describe a regional, community-based pediatric urgent care network (PUCN).
Methods. The PUCN consists of 4 models: 1) pediatric emergency medicine faculty in a community hospital ED; 2) general pediatricians in a community hospital ED; 3) general pediatricians in a freestanding urgent care center; and 4) general pediatricians in a community hospital-based urgent care center. Physician staffing at all 4 sites is managed by our tertiary children’s hospital. Billing records were reviewed and a questionnaire was mailed to 55 PCP practices in our metro area.
Results. Year 2001 visits totaled 37 143. Minor trauma, ear complaints, and viral illnesses accounted for 70% of visits. Current Procedural Terminology codes for visits, reflecting complexity levels 1, 2, 3, 4, and 5 were billed at the following frequency: 1%, 35%, 44%, 17% and 3%, respectively. A total of 2.2% of visits required admission or transfer. Mean collection rates ranged from 37% to 68% across the 4 sites. Break-even average hourly patient volumes ranged from 1.1 (site 4) to 1.9 (sites 1 and 3).
A total of 110 PCPs, representing all 55 practices, responded to the questionnaire: 81% reported their patients used the PUCN often, 85% felt that communication between the PUCN and their practice was good, and 99% reported overall satisfaction with the network.
Conclusions. The PUCN effectively addresses the needs of regional PCPs; however, the cost-effectiveness of such a program depends on billing practices, local collection rates, and site-specific staffing patterns.
Key Words: urgent care • regional network • after-hours
Abbreviations: PCP, primary care provider • TCH, The Children’s Hospital • PUCN, pediatric urgent care network • ED, emergency department • PEM, pediatric emergency medicine • EMS, emergency medical services • GEM, general emergency medicine • EMTALA, Emergency Medical Treatment and Active Labor Act
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Over the past decade, nationwide changes in the health care environment have forced academic pediatric centers to develop competitive, market-based strategies to maintain their positions as providers of care to the community. Many institutions seek to promote clinical programs to both primary care providers (PCPs) and the public.
In 1986, we conducted surveys and focus groups with Colorado general pediatricians regarding ways in which The Children’s Hospital (TCH) might assist them. Three priorities emerged: after-hours telephone triage and advice for parents; locum tenens coverage; and after-hours urgent and emergency care in convenient locations. We previously reported on our telephone triage and advice service1 as well as our locum tenens program.2 We now report our experience with a metropolitan-wide pediatric urgent care network (PUCN).
TCH is in the center of a growing metropolitan area, and most children live in surrounding communities at increasing distances from TCH. In the absence of a PUCN, options for after-hours care are limited: expanded office hours for unscheduled sick visits, care in community hospital general emergency departments (EDs), or travel to the TCH ED. The first option may not be cost-effective for the patient’s provider. The second involves care by nonpediatric trained individuals, and delays are frequent as children compete with adults with more acute complaints.3 The third option is difficult for young families living in distant suburbs. We sought to develop in the Denver area a network to provide after-hours urgent care in convenient, child-friendly settings.
We also sought to enhance our relationships with PCPs and promote recognition and visibility in the community. Although our PUCN focuses on general acute care, we anticipated that this strategy would increase the number of contacts with acutely ill children and, indirectly, utilization of TCH inpatient and subspecialty programs.
This report describes our institution’s experience with a regional after-hours urgent care network. Because little medical literature has been published on this topic, we are hopeful that our descriptions, data, and insights will be useful to clinicians and administrators at institutions facing similar competitive pressures.
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PROGRAM DESCRIPTION |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Although the goal of providing accessible urgent care to the community is the same throughout the program, we have used 4 models to achieve this. Some variation has been attributable to local PCP preferences, regional utilization patterns, and demographics. Additional variation has been attributable to the strategic decisions of our partner hospitals and competitors, as well as our interactions with local emergency physician groups.
All sites are integrated with our after-hours telephone triage and advice program. Nearly every (98%) local practice uses this service.1 Working from carefully developed triage and advice protocols, specially trained nurses manage calls from parents. For 75% to 80% of calls, parents receive recommendations for home management or temporizing advice until the next available office visit. In 20% to 25% of cases, urgent care is recommended, and the caller is instructed to present their child to 1 of the 4 PUCN sites or to the TCH ED. The call center faxes to the referral site a description of the parent’s concern and reason for referral.
Administration is centralized through TCH. Medical staff is recruited, trained, managed, and salaried by TCH. Physicians in the PUCN are board-certified or board-eligible pediatricians. Physicians in the TCH ED are pediatric emergency medicine (PEM) faculty from the University of Colorado School of Medicine. Some of these PEM faculty also serve in the PUCN. Billing and collection of physician fees are centralized through a contract between TCH and an independent health care billing service. With the exception of the freestanding site, nursing, ancillary staff, laboratory services, supplies, and other overhead expenses are the responsibility of the community hospital partner. Collection of co-payments and facility charges are managed by these host institutions.
Model 1: PEM Faculty in a Community Hospital ED
The north quadrant of the metro area consists primarily of working-class populations served mostly by family practitioners and several pediatricians. We began a partnership with a local hospital in 1986, when moonlighting TCH physicians were provided to see pediatric ED patients during peak after-hours. This evolved into coverage by full-time, salaried TCH general pediatricians and, for a time (1987–1990), included inpatient coverage. Inpatient coverage was abandoned when it became evident that revenues could not meet expenses because of a low census in the inpatient pediatric unit. However, we continued to provide after-hours care in the ED. In 1994 a competing program was established at a nearby hospital, and our volumes began to decline. In 1996, we began staffing the site with PEM faculty from the TCH ED.
Because this clinic is located within an ED, and staffed by PEM specialists, there is no limit to the acuity appropriate for this unit. During hours of operation, all pediatric ED patients are managed by our staff. Emergency medical services (EMS) teams present patients directly to this unit. The acuity of trauma patients is limited only by the host hospital’s state-regulated trauma center designation.
Currently, the hospital allots 8 beds for the care of pediatric patients, as well as access to a pediatric resuscitation bay. Modest signage and logos identify this unit as "The Children’s Hospital After-Hours Program." The unit operates from 5 
to 1 
weeknights, noon to 1 Saturdays, and 9 to 1 Sundays. Triage of pediatric patients takes place at the main ED triage station. Staffing consists of a single PEM physician and 2 nurses. The site serves as a clinical rotation for family practice residents, medical, and nurse practitioner students.
Model 2: General Pediatricians in a Community Hospital ED
The west quadrant consists of well-established primary care pediatricians and family physicians serving a middle-class population with a slowly growing pediatric component. As in model 1, our original arrangement (1988) consisted of a partnership with a local hospital to provide moonlighting pediatricians to see patients in the ED. These pediatricians initially provided overnight inpatient and ED coverage. Although revenues from overnight coverage failed to cover expenses, coverage was maintained for 10 years through a subsidy from the community hospital (at the request of local PCPs). Once the hospital discontinued this subsidy, the PUCN reduced its role to providing full-time general pediatricians to manage acute pediatric medical visits in the ED during peak after-hours.
Because the PUCN space is located within the ED, EMS crews present critically ill patients directly to the unit, and those children are managed by our physicians. Thus, there is no limit to the medical acuity. However, the arrangement negotiated with the local general emergency medicine (GEM) physician group precludes our pediatricians from managing major or minor trauma (with exceptions at the discretion of the GEM group). This decision was supported by the community hospital, and was intended to minimize the financial impact on the GEM group.
Our site has 9 beds, including 2 dedicated pediatric resuscitation bays. Although this space is identified as "Pediatric After-Hours," the host hospital has resisted signage identifying this as a Children’s Hospital program. The unit operates 5 to 1 weeknights, noon to 1 (summer) or 9 to 1 (winter) Saturdays, and 9 to 1 on Sundays. Triage takes place at the main ED triage desk. Staffing consists of 1 or 2 pediatricians, 2 registered nurses, and 1 technician. This site is also a clinical rotation for medical students.
Model 3: General Pediatricians in a Freestanding Center
The east quadrant includes a growing and diverse population, served by an inadequate supply of pediatricians and family physicians. In 1989 we began ED and inpatient coverage in 1 of 2 local hospitals. However, between 1995 and 1997, both local hospitals were purchased by a for-profit competitor, leaving TCH without a partner in this quadrant.
These circumstances prompted the development of a freestanding urgent care center. Unencumbered by the physical plant of a preexisting hospital, we chose a strategic location with convenient interstate highway access and visibility. In a partnership with another hospital system (also without a facility in this quadrant), we established a shared adult and pediatric urgent care center for ambulatory medical illness and minor trauma. During weekdays from 8 to 5 , our space serves rotating pediatric subspecialty clinics from TCH. After-hours, the clinic is staffed by salaried, full-time general pediatricians employed by TCH.
The clinic’s freestanding nature distinguishes it from the rest of the network. The unit does not have the status of an ED. Thus, ambulances are not dispatched to it, limiting both medical and trauma acuity. Patients requiring hospitalization or overnight observation are transported to TCH. In addition, the management and expense of nursing and ancillary staff, imaging, and laboratory services are borne by TCH.
Signage and logos identifying the site as a TCH program are large and prominent. The clinic consists of 7 examination rooms, a minor trauma room, and a pediatric resuscitation bay. All rooms provide centralized supplemental oxygen. Equipment for plain radiographs is on-site and shared with the adult clinic. Laboratory studies such as complete blood counts, routine chemistry panel, urinalysis, pregnancy tests, and streptococcal screens are performed on the premises. Cultures, spinal fluid studies, and other specialized tests are sent to TCH by courier. Staffing consists of 1 or 2 pediatricians, 3 to 4 registered nurses, 1 x-ray technician, and 2 unit clerks. The hours of operation are 5 to 1 weeknights and 9 to 1 weekends. The adult urgent care facility is open 9 to 9 daily. Children who present during the day on weekdays are managed by the adult urgent care physicians.
Model 4: General Pediatricians in an Urgent Care Center on a Community Hospital Campus
The south metro region of Denver has been one of the fastest-growing areas in the nation. This quadrant now contains a large, affluent population of recently relocated professionals. Busy pediatric practices struggle to serve the growing number of children in this area. The PUCN presence began in 1991 by providing pediatricians to see acute visits and cover inpatients at a local hospital. Similar to our east quadrant experience, our local hospital partner was purchased by the same competitor in 1995.
However, in this instance, another hospital was available with which to form a partnership in a more accessible part of the quadrant. Original negotiations with our new partner resulted in our unit being defined as a "referral only" clinic, with the majority of patients referred by their PCPs or the TCH telephone triage service. Eventually, as our presence was marketed to the community and PCPs gained familiarity with the program, we, de facto, became a general walk-in clinic.
We share our space with a day surgi-center near the main ED. We have an entrance separate from the ED with prominent signage identifying the "Children’s After-Hours Program." We perform triage assessments and registration in our location. Pediatric patients presenting to the main ED are briefly screened there, then directed to our clinic. We have no receiving facilities for ambulances, so EMS arrivals are managed by the ED. In accordance with the hospital’s trauma level designation, major trauma patients presenting to our clinic by private vehicle are redirected to the ED. However, minor trauma, fractures, and lacerations compose a large proportion of our volume.
The dual purpose site (ie, day surgery and urgent care) consists of a waiting area, 4 examination rooms (preoperative bays), a minor procedure room with operating table, and a large area for observation and/or resuscitations (postanesthesia recovery area). Staffing consists of 1 or 2 pediatricians, 2 to 3 registered nurses, an emergency medical technician, a unit clerk and a registration clerk. Hours of operation are from 5 to 1 weeknights, noon to 1 Saturdays and 9 to 1 Sundays. The site serves as a clinical rotation for both nurse practitioner and medical students.
Communication With PCPs
All of our salaried medical staff are exclusively urgent care, emergency medicine, or locum tenens pediatricians. None are regularly employed in primary care. Thus, the program stresses a collaborative relationship with local PCPs. All subspecialty follow-up is arranged in consultation with the patient’s primary physician. Telephone contact with on-call physicians is routine for complicated or worrisome patients. All patients requiring admission are discussed with the PCP, even if the PCP elects to defer inpatient management to a hospitalist group. At the north, west, and east sites, records of patient encounters are dictated and mailed/faxed to the PCP office. At the east site, a brief handwritten note is also faxed to the PCP’s office overnight. At the south site, complete handwritten records for each visit are faxed to the offices nightly.
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METHODS |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Records of patient volumes, admissions, and transfers have been maintained since the inception of the program. Detailed data for 2000 and 2001 were obtained through a review of centralized billing records, providing information regarding total patient volumes, ages, diagnostic and procedure codes, billing, and collection rates.
A survey was faxed to all pediatric practices in the Denver area during the summer of 2001. This survey asked pediatricians how frequently their patients used any of the PUCN sites. They were also asked what alternative care would be provided if the PUCN were not available to them. On a 4-point scale, they were asked to rate the degree to which the program made their practice more efficient, the quality of communication between their practice and the program, and their overall satisfaction, as well as their perception of their patient’s families’ satisfaction. Space was provided for general comments.
Groups failing to respond to the original fax were mailed a second copy. Nonresponders to the mail survey were contacted by telephone. A response from any member of a group was sufficient to categorize the practice as a responder; although >1 member from each group was allowed to record their responses. Data were anonymously coded and entered into an Excel spreadsheet (Microsoft Corp, Redmond, WA).
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RESULTS |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Recent growth of the PUCN is illustrated in Fig. 1. During this period, the pediatric population of the Denver metropolitan area increased by 40%.4 The period from 1995–1996 was notable for the introduction of several large managed care plans in our market. Figure 2 shows the average patient volumes during peak after-hours. There were no significant differences across the sites. Low Saturday morning volumes reflect the fact that many PCP practices keep office hours until noon.
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Figure 3 details the diagnostic categories for visits during 2000. These diagnoses comprised 92% of all visits, and the pattern of medical illness was similar across the 4 sites. However, model 2 managed far fewer minor trauma patients than the other 3 sites.
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Table 1 provides an account of the billing and reimbursement patterns at each site. Complexity levels refer to federally regulated Current Procedural Terminologycodes for ED visits. Physician fees exclude facility charges. Physician salary costs reflect the average hourly costs for each site based on typical staffing patterns during the year, and the "break-even" calculation is a similar average based on total collections and physician costs.
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One hundred ten PCPs, representing all 55 area pediatric practices, responded to our questionnaire. Satisfaction with most aspects of the program was high: 87/108 (81%) reported that their patients used the network "somewhat" or "very" frequently, 100/106 (94%) believed the program helped make their practice more efficient, 100/107 (93%) felt that patients’ families were "somewhat" or "very" satisfied, and 107/108 (99%) expressed overall satisfaction. However, only 92/108 (85%) felt that communication between the PUCN and their practices was "good" or "very good," a proportion significantly lower than their overall satisfaction (P < .01).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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The PUCN has allowed TCH to expand its service to the community. In 2001, our pediatricians managed >37 000 acutely ill children. Were it not for this network, most of these patients would have been managed in community hospital EDs by GEM practitioners. When combined with the TCH ED, the number of pediatric emergent/urgent care visits to TCH-affiliated programs has effectively doubled.
Referring physicians have been satisfied. Given the demands placed on practices by rapid population growth, many PCPs expressed genuine gratitude for the network: "It gives me a life." "If it weren’t for the program, I wouldn’t still be in practice." "Don’t even think of stopping [the program]." These pediatricians have indicated that the most important elements of this program are availability to families and timely communication between the PUCN provider and the PCP.
When surveyed, parents have been similarly supportive. "I was so glad that we were able to see a Children’s [Hospital] doctor, instead of waiting in the ER." Despite the consistently positive feedback we have received from families, we have limited our analysis to PCP perceptions. This is because our response rate among PCPs (100%) was much higher than could have been achieved through family satisfaction surveys. In addition, we suspected that referring PCP’s would be more candid in helping us identify weaknesses in our programs.
The conditions cared for in the PUCN resemble those reported in previous studies of children cared for in community EDs.5 With the resources of the PUCN, the overwhelming majority of diagnoses can be managed by general pediatricians with skills obtained in a pediatric residency,6,7 and for some acute conditions, there is evidence that pediatricians practice more cost-effectively than GEM physicians.8–10 The ongoing continuing medical education that we offer our physicians focuses on those problems for which they may not feel well-prepared.
The majority of the expense associated with having a pediatrician in the ED of a community hospital is compensation for the pediatrician. Review of the daily census of our community hospital partners revealed that 85% of all pediatric ED visits occur during 65 peak after-hours (5 to midnight, Monday through Friday and 9 to midnight, weekends). An average patient volume of 1 to 2 patients per hour, in our health care reimbursement environment, sustains the program. This translates into annual volumes of 4000 to 7000 pediatric visits during peak hours (depending on the model used). Because only 15% of the total pediatric visits to a community ED occur during the other 103 hours of the week, revenues from those visits do not cover the expense of having a pediatrician available.
PEM Faculty in a Community Hospital ED
The strength of this model is that the level of subspecialty training of our PEM faculty enables them to manage the entire spectrum of acutely ill patients.11,12 Their expertise results in a cordial and unambiguous relationship with the host hospital GEM group. An obvious weakness is that clinical PEM providers are in demand nationwide,13 and individual physician costs for this site are the highest in the network (although, because double physician coverage is not needed, overall costs are similar). This fact, combined with an unfavorable payer-mix, contributes to the relatively high break-even point of nearly 2 patients per hour for this site.
A less apparent weakness is the contrast between the resources available at the community hospital with those available in the TCH ED. Some PEM faculty have expressed frustration that a lack of dedicated pediatric nursing, laboratory, and radiology staff limits the added value of their PEM capabilities.
General Pediatricians in a Community Hospital ED
The location of our unit within the host hospital ED provides our pediatricians with access to GEM providers whose resuscitation and airway skills may exceed their own.14 The fixed direct and indirect costs of maintaining the ability to care for these critically ill patients is borne by the community hospital. Nevertheless, our presence in the ED allows us to manage high-acuity medical patients who present by ambulance. This combination of acuity and physician costs resulted in a fairly low break-even volume (1.2 patients per hour).
However, the side-by-side juxtaposition of general pediatricians and GEM providers has introduced several problems. Reliance on the main ED triage system results in pediatric patients initially being assessed by general ED nursing staff, who lack extensive experience with ill children. Among the physicians, competition for patients may be viewed as a "zero-sum" proposition, as evidenced by the insistence of the GEM group that it manage minor trauma patients, because these cases are known to provide attractive reimbursement. These tensions may undermine a more collaborative approach to all pediatric patients.
From a logistic perspective, the small number of minor trauma patients seen by our physicians at this site results in extreme seasonal variation in volumes. Winter monthly volumes are often double the summer volumes, creating manpower and staffing challenges.
General Pediatricians in a Freestanding Center
A freestanding center managed by TCH has numerous advantages. There is no need to identify, or negotiate with, a community hospital partner. This allows autonomy in location, design, and marketing. Nursing and ancillary staff are TCH employees (unlike the 3 other sites) and administrative and clinical policies are standardized. Of course, in exchange for this flexibility and autonomy, TCH must bear all the fixed overhead costs of operating the site.
At the other 3 sites, physicians must obtain community hospital privileges (for which TCH is charged). At the freestanding site, credentialing takes place through TCH, so a much larger number of TCH physicians are available. The ability to draw on a pool of sub-specialty pediatric fellows as moonlighters provides the site with a large, flexible physician work-force.
The freestanding nature of the site distinguishes it from a true ED in positive and negative ways.15 Because EMS crews do not present patients directly, the acuity is limited, and well-matched to the skill-set of general pediatricians. Although the site is equipped with a resuscitation room, patients in need of such interventions are rare. However, unlike our hospital-based sites, there are no personnel with advanced airway skills and experience to "back-up" our staff. In addition, the extent and ways in which the federal Emergency Medical Treatment and Active Labor Act (EMTALA) may apply to such a clinic are not yet well-defined.16,17
The clinic has no inpatient or observation capacity. Thus, all patients requiring hospitalization are transferred to another facility, typically via ambulance. Although the majority of these patients are transferred to TCH, parents may find this inconvenient when compared with a local ED. Perhaps cost-effective from a societal perspective, for individual patients requiring admission, transport by ambulance clearly adds to the charges for their families.
General Pediatricians in an Urgent Care Center on a Community Hospital Campus
This model combines some of the strengths of the other models. Although we share our clinical space with a day surgery unit, the environment is quiet, child-friendly, and separate from the ED. Nursing and other clinic staff are employees of our hospital partner, but are administratively separate from the ED, and have developed a pediatric orientation. Because ambulances and major trauma patients are not received at the clinic, acuity is comfortably within the scope of our pediatricians’ experience. The nearby main ED serves as a resource for critical patients.
The distance between the clinic and the ED entrances allows most children to be triaged by pediatric nurses. This separation also reduces the sense of competition for patients between the 2 staffs. However, occasional disagreements arise over the definition of "major" trauma cases to be transferred to the ED.
There is an important limitation to this model, however. Some patients are directly referred to our "urgent care clinic" by their PCPs or by the TCH telephone triage and advice service. Many families, some PCPs, and a few health plans expect that charges for such visits should be lower than standard ED charges. However, after extensive discussions with our hospital partner, we have determined that our arrangement of triaging and treating patients is subject to the same EMTALA standards as the ED. Under this interpretation, discrimination of acute care charges based solely on location on the hospital campus would not be advisable.
Physician Recruitment and Retention
A position as a full-time urgent care pediatrician is an attractive option for many young physicians who have recently completed residency training. However, we have found that the heavy burden of evening and weekend hours needs to be well-suited to an individual’s personal and family circumstances. Although we are able to recruit very well-qualified young physicians, a high yearly turnover rate presents a challenge. We are currently exploring group practice arrangements and options for professional development that will provide our pediatricians with a greater financial stake in the program, and, we hope, encourage their consideration of this work as a viable, long-term career choice.
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CONCLUSION |
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An overall comparison of the various models is provided in Table 2. We have shown that a network of pediatric urgent care sites administrated by an academic children’s hospital can meet the needs of PCPs and children within our metro area. This system has doubled the number of acute general pediatric patients managed by programs affiliated with TCH. In this respect, we consider the program an unqualified success. Clearly, the general concept of an integrated urgent care network is clinically and financially viable.
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However, it is impossible to identify 1 "best" model for all circumstances. All sites are integrated with our telephone triage service, but each demonstrates unique solutions to local market conditions. Although our institution has 15 years experience with an integrated network of urgent care, this report is simply a snapshot in an evolutionary process. Through such diversity and experimentation, we expect to further refine these models. We believe that a tertiary children’s hospital is most successful when it reaches into the community it wishes to serve. By sharing our experiences and observations, we hope to assist and encourage other institutions as they consider similar programs in their own health care markets.
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ACKNOWLEDGMENTS |
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We thank the entire PUCN administrative and clinical staff (past and present), and particularly Joanie Muzzulin for her role in data-gathering and management since the inception of the program.
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FOOTNOTES |
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Received for publication Jan 8, 2002; Accepted May 3, 2002.
Address for correspondence to Lou Hampers, MD, Section of Pediatric Emergency Medicine, B251, Children’s Hospital, 1056 E 19th Ave, Denver, CO 80218. Email: hampers.lou{at}tchden.org
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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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