Integrating an Urgent Care Clinic Into an Academic Family Medicine Practice

Long wait times, inflexible hours, and scheduling difficulties in primary care practices lead many patients to seek nonemergency care in emergency departments (EDs).1 An estimated 13%-27% of ED visits could be handled by other facilities, saving $4.4 billion per year.1 This demand for convenient, cost-effective care has led to the rise of urgent care centers (UCCs) as evidenced by 1,725% growth in UCC visits from 2007-2016.2,3 In November 2018, the number of UCCs reached 8,774, an increase of 8% from 2017,4 comprising a nearly $18 billion industry.5

Despite the convenience of UCCs, they lack the continuity and comprehensiveness provided by primary care practices.6 This report describes the development and 1-year outcomes of a UCC at the Family Medicine Center (FMC) of the University of North Carolina at Chapel Hill (UNC)–a Patient-Centered Medical Home (PCMH) site. Our goals were to provide after-hours care to patients and to introduce new patients to our continuity practice, while decreasing ED utilization. We hoped to manage both acute issues and chronic diseases.

The UNC FMC is a large, resident-training clinic located approximately one mile from UNC Hospitals. The clinic serves approximately 19,000 patients. Before opening the UCC in February 2018, the clinic operated from 7 am to 7 pm on Monday, Tuesday, and Thursday, 9:30 am to 7 pm on Wednesday, 8 am to 5 pm on Friday, and 8 am to 12 pm on Saturday. By adding a UCC to the practice, the hours expanded to 7 am to 9 pm on Monday-Friday, 8 am to 5 pm on Saturday, and 12 pm to 5 pm on Sunday. We collaborated with our partners in the health care system to increase our inventory of supplies and medications accordingly (See Appendix 1).

Our weekday UCC staffing included one physician, one medical assistant (MA), and one licensed practical nurse (LPN) or registered nurse (RN) from 7 am to 8 am and 5 pm to 9 pm. From 8 am to 5 pm on weekdays, two providers, two MAs, and one LPN/RN staffed the UCC. Weekends were staffed with two providers, two MAs, and one LPN/RN. We also worked with our laboratory and radiology partners to ensure access to their services (including on-site access for lab draws and plain film radiology). This staffing was in addition to our required staffing for the continuity clinic.

We defined measurements that reflected quality, access to care, prevention of unnecessary ED utilization, and enrollment of new patients who did not have a primary care physician (PCP). We added questions into an electronic medical record (EMR) note template that required a manual response from the provider via a selection menu. We asked providers to document responses to these questions at the end of each encounter (Table 3). In addition, patient volumes, continuity data in the FMC, and financial data were extracted from existing systems. The UNC Institutional Review Board exempted this process.

Patient growth was gradual at first and continued to rise, with volume stabilizing around 900 patients/month (Table 1). The growth in the UCC did not negatively impact patient volumes and continuity rates in our clinical practice, with 2018-2019 showing the highest rate of continuity over the last 4 years (Table 2).

Cumulative data from provider notes indicated that over 33% of UCC patient encounters may have prevented an ED visit. This response was based on the provider’s judgement and/or the patient voicing they would have gone to the ED when asked. Of all visits, fewer than 3% resulted in a direct admission to a hospital or transfer to the ED. Furthermore, 25% of patients seen (regardless of PCP) had preventive or chronic disease management needs addressed, and an average of 115 new patients (largely patients who were not considering our practice prior to coming to the UCC for primary care) per quarter established care after coming to the UCC (Table 3).

Financially, we tracked revenue and costs on a quarterly basis. Including all initial staffing and supply costs, we project a break-even point after 3 years. If quarterly balances are computed without carryover of upfront costs, our UCC was profitable by the fifth quarter of operations.

By opening a UCC, we saw more people enter primary care, provided a comprehensive approach to UCCs, reduced unnecessary ED visits, and provided our practice with a new revenue stream. Reducing ED burden was a primary motivation for our initial institutional financial support, and our data on prevented ED visits is testimony to the program’s success. Prior studies have shown that UCC visits cost around $200 to $400 less than the same care at an ED.7,8 We project that our UCC saved the health care system between $568,000 and $1,136,000 based on the estimated savings of $200 to $400 saved per ED visit avoided.

Our UCC provided improved access to the comprehensive care provided at a PCMH. Through a provider questionnaire that was integrated into each visit note, we were able to track quality and utilization metrics. Furthermore, access to the entire EMR and a comprehensive, primary care approach toward the UCC process allowed us to close preventive care or chronic disease quality gaps on a quarter of patient visits.

Initiating the UCC posed both financial and personnel challenges. Since the health care system was a partner, we worked on developing an extended hour schedule that would allow us to be open during the peak hours of ED demand to help offload our emergency room. Extended hours posed scheduling challenges due to an increase in staffing demand that we overcame through moonlighting pay and overtime. The financial support of our health care system allowed us to achieve profitability in less than 18 months; however, the lack of such support would likely lead to more time needed to achieve profitability for others trying to replicate our design.

Another potential challenge that we were well poised for was limitations in space. Fortunately, we recently remodeled our clinic for efficient space utilization, increasing our exam rooms by a third on the same footprint. This allowed us to open the UCC without new construction.

We acknowledge some limitations to our data. Provider response rates to our questions waned on busy days, leaving our data incomplete and constituting a potential source of error. We also did not track patients after their UCC visit to see if they presented to an ED. At times, we were unable to staff an LPN/RN and required providers to start IVs and administer medications. Lab and imaging staffing were absent on limited occasions. Likewise, we did not collect any patient satisfaction data.

In summary, we have seen a large increase in patient visits in our practice through the incorporation of a UCC. While acute problems are the focus of urgent care, we found that a significant amount of visits could also address chronic or preventative care. In addition to providing expanded service, we added value to the health care system by decreasing unnecessary ED visits and attracting new patients into primary care.