The clock starts ticking as soon as a new patient requests an appointment within the Duke Department of Medicine.

From that moment on, a metric called "time to arrive" tracks the span between that first phone call and the actual date of the appointment. Department-wide, the time-to-arrive goal limit is 25 days.

Three years ago in Duke's outpatient endocrinology service (Clinic 2F/2G), the combination of high disease incidence and dearth of local care alternatives amounted to overwhelming demand and appointments booked six months out.

"There is a high prevalence of diabetes in this region, and Duke is one of a few providers in the area for tertiary diabetes care," says Lindsay MacDiarmada, associate director for access and performance improvement. "And it's not just diabetes patients in the clinic; the endocrinologists also see patients for lipid management and complex thyroid conditions."

Staff Changes Increase Patient Access

Early in 2009, Duke leadership declared addressing wait times to be a priority, and in February that year, MacDiarmada began an evaluation of the clinic's capacity, access issues, and solutions in response. Implementation followed in 2010, and the new processes have now been in effect for a full year.

Among them, the responsibilities of advanced practice providers -- nurse practitioners and physician assistants -- have been restructured so that everyone works "at the top of their license," according to MacDiarmada.

Returning patients have the new option of scheduling appointments with highly skilled advanced practice providers, thereby decreasing new patients' wait for initial physician evaluations and diagnoses.

Two full-time endocrinologists were added to the clinic staff to open up the backlog of patients, while a dedicated nursing staff took the lead in telehealth/triage.

Patient Education Improves Care

"We have also placed a strong emphasis on patient education. Floor nurses work with patients one-on-one to guide patients through their treatment plan and answer questions the same day as their appointment," says MacDiarmada. “That way, patients can leave feeling more in control of their condition.”

Diabetes patients also see a nutritionist and a certified diabetes educator, as necessary, to stay on top of chronic disease-related issues and avoid painful and costly complications.

While additional tweaks continue to be made, the initiative to open up access has received positive feedback from those involved, and the consensus is borne out in traffic data.

Model of Care

Clinic 2F/2G is now serving as a model for the whole of the Department of Medicine, as each division in the department is undergoing a structured process to increase patient access.

Seven divisions are currently under way and five more are in the kickoff process, with full impact to be felt in 2012 -- for the benefit of Duke patients as well as Duke staff.