D. Squires, Ensuring Access to After-Hours Care, The Commonwealth Fund, April 2012.
Urgent care needs are not confined to weekdays and work hours. Nonetheless, patients often have difficulty accessing care after hours without going to the emergency department, which in many circumstances can be an inappropriate and inefficient use of health care resources. Ensuring that patients have timely access to the appropriate level of care on nights and weekends has the potential to reduce unnecessary emergency department use; it can also ensure that patients receive patient-centered, efficient care.
According to past Commonwealth Fund International Surveys, after-hours care is particularly difficult to obtain in the U.S. without going to the emergency department. In recent years, several countries, including the Netherlands, Denmark, and Germany, have sought to expand access to after-hours care—often by transitioning from the traditional approach, in which practices designate someone to be “on-call,” to group-based or regional approaches. As the U.S. seeks to strengthen primary care, particularly through the development of patient-centered medical homes, it has a great deal to learn from these international models.
Between 2000 and 2003, Dutch general practitioners (GPs) transitioned from offering after-hour services through small rotation groups to providing them in large primary care cooperatives. These cooperatives include from 40 to 250 GPs and cover between 100,000 and 500,000 patients, all living within roughly 20 miles of the cooperative. When patients call the cooperatives, they are triaged by nurses (usually with a physician at hand). Triage nurses can choose to provide self-care advice over the phone, advise the patient to visit their GP the next day, invite the patient to visit a GP at the cooperative, order a GP house call, or refer the patient to an emergency department or ambulance service. For house calls, cooperatives have chauffeured vehicles outfitted with communication equipment, oxygen, infusion drips, and automatic defibrillators.
The new system appears to work well for patients and physicians. Patients reported high levels of satisfaction with the after-hour services, though those who received only self-care advice tended to be less satisfied. Physicians, whose average after-hours workload dropped from 19 hours to four hours per week, also reported being satisfied with the system. Some patient safety issues have been raised, for example related to the use of nurses for triage and the lack of information exchange between GP practices and the cooperatives. Further efforts are being made to integrate the primary care cooperatives with hospital emergency departments, which can still be accessed through self-referral, and to improve the electronic flow of patient information.
Since 1992, after-hours primary care in Denmark has been organized on a regional level. General practitioners participate on a voluntary basis, and receive higher fees for providing after-hours care. After-hours clinics are often located at hospital emergency departments. When patients call the clinics, a GP performs triage—giving advice, suggesting they come in to the clinic or emergency department for care, or recommending a home visit. In general, patients cannot not self-refer to an emergency department, except in emergency situations.
Following the introduction of the after-hours care arrangements, the number of telephone consultations doubled and home visits fell dramatically. Physicians also reported working less outside of office hours, and patients reported being broadly satisfied.
All German ambulatory primary care physicians are required to participate in their regions' after-hours care systems, which differ by region. Nurses are not used for triage or to provide counseling; rather, after-hours care is usually delivered by a physician either in person or, less often, through a home visit. In cities, after-hours care may be provided in central clinics or in hospitals, whereas in rural areas it is often provided by physicians in their own practices. Physicians receive higher reimbursement for services provided after hours, and patients are charged a copayment of €10 (US$14). Physicians providing after-hours care cannot usually access patients’ electronic medical records, as those are generally stored at the patients' primary care physician's office.