We all have stories of the ridiculous challenges in accessing sufficient allied health (and other) workers to meet the burgeoning demand in the disability, aged care, community, hospital sectors – and in fact any space that employs health workers right now. These challenges are exacerbated further by the deployment of allied health professionals to help manage surge demand as a result of COVID.
The first (and often the only) solution that most people think of when they have workforce shortages is to increase supply – in other words, train more workers. However, as we highlight in this article, training a new workforce is not a realistic, quick fix to address workforce shortages. Training requires planning – there is normally at least a four year lag before new allied health professionals qualify to practice. Even then, new graduates may lack the experience and expertise needed in your particular organisation.
There are other more responsive approaches to increasing workforce capacity, such as the introduction of allied health assistants, role substitution, increasing workforce participation and introducing strategies to increase workforce retention, but most require some strategic implementation and coordination.
So how do you cope if you have a waiting list of several hundreds of prospective clients – right now – all needing essential prevention, early intervention or support?
Another way that services can optimise workforce capacity is to manage service demand. That doesn’t mean bumping people off waiting lists (unless they really shouldn’t be there). Indeed, in an ideal world, all clients / patients will be seen in a timely manner, triaged according to their level of urgency or need, and managed in the most appropriate way to meet their needs.
The purpose of this article is to help services identify ways to optimise their allied health service capacity by managing service demand instead of worker supply.
We see a lot of examples of this in allied health. In fact, when clinicians and managers do our Easy PEASI program logic workshops, most come to us because of health workforce shortages, but many leave with a solution that more effectively optimises their health service capacity by managing service demand instead.
The principles underpinning this article are that once clients enter your referral system, you have an opportunity to start some kind of intervention. Even the first phone contact can be a part of a therapeutic interaction if it is managed appropriately. Clients need to be managed fairly, have their expectations managed, prioritised according to risk and need.
Managing patient flow is a big deal in hospitals, but several of the principles are relevant to allied health services and practices as well.
Let’s look at better ways to optimise service effectiveness by managing service demand more efficiently:
- Be clear about what your service offers (service scope)
- Provide accurate information to your referrers
- Know your service capacity
- Keep good quality data on your clients and service capacity
- Establish clear protocols for service delivery
- Triage clients into your service
- Have a clear system for managing referrals who are not your clients
- Protect bookings for high priority clients
- Use appointment reminders
- Communicate clearly with all clients on your referral pathway
- Identify alternative pathways for ineligible / low risk clients
- If possible, start the therapeutic relationship from the time of referral
- Use group therapeutic approaches / interventions where possible
- Set clear limits around therapeutic interventions
- Actively discharge clients when their episode of care is complete
1. Be clear about what your service offers (service scope)
The starting point for optimising your service capacity by managing service demand is to be clear about where your service has the greatest potential to benefit patients or the community. Allied health services tend to be very nimble and responsive to a range of patient needs. This means they are often very good at stepping-in where other services cannot meet demand – but very bad at saying “no” to inappropriate referrals. Apart from creating unrealistic expectations, burgeoning service capacity, this also leads to staff burnout and overwhelm.
An important starting point for managing your workload is to be clear about who your clients “are” and who your clients “are not”.
Clarity of service scope determines the parameters around what services you offer, at what price, and at what quality. When you deviate on service scope without a concurrent increase in service supply, your quality will inevitably suffer.
2. Provide accurate information to your referrers
Ensure that your referrers are clear about your service scope so they don’t direct inappropriate people to your service. Have clear referral and entry pathways into your service to reduce confusion and ensure that the most appropriate clients are directed to you.
3. Know your service capacity
If you are clear about your service scope and understand your ability to meet that scope with the resources (generally staffing) you have available, then you can calculate your service capacity. In other words, how many clients can you manage with the resources you have? When you are over capacity, let clients and referrers know.
Service capacity can also be managed within existing resources by reducing the quality of the service (generally time, or providing an alternative intervention / provider) or increasing the price of the service. Squeezing your services beyond capacity risks service quality and the health of your workforce.
An excellent study of a structured approach to managing patient demand in community outpatient settings, the “STAT” (Specific Timely Appointments for Triage) showed that using a structured demand management system could reduce patient waiting times by 29%. The intervention involved (1) protecting new appointments to meet demand in clinician schedules; (2) introducing a short-term, targeted intervention to reduce the backlog of patients on the wait list; and (3) redesigning the workflow to that patients could have rapid access to a first appointment. Clinicians were then able to make the decisions about how to prioritise the ongoing service needs of clients within the context of the service demands.
4. Keep good quality data on your clients and service capacity
Keep good quality data on your service capacity, throughput and service volumes to help with future planning to manage service demand. This includes data that will let you plan the service requirements for specific types of clients and particular needs.
Use the data to understand the impact that changes to price and quality have on your client throughput – and ideally, on their outcomes.
5. Establish clear protocols for service delivery
Establish clear service protocols for managing specific types of clients / patients. Use research evidence where it exists – use your own audit data where it does not. This will help you understand your own service capacity. Be as specific as possible. How much time is required, how many occasions of service, what works, what does not. When is the intervention finished? When should you change track? How will you know? How will you communicate that to your client?
This probably sounds like a very clinical and reductionist approach which will only apply to certain types of services or interventions. In reality, whether you are a physiotherapist, a social worker or a spiritual counsellor, you have a certain repertoire of skills that people purchase from you (directly or indirectly) to make a difference to their personal circumstances. Understanding and defining what you do is essential to being able to manage your work and your workload and refine your offering to your clients.
6. Triage clients into your service
Have a triaged intake system, so that those with the greatest service needs are managed first / or with the highest resource provision, and those who are lower need can be managed appropriately using other models. This both gives people a plan of action, and may start to deliver a solution. The STAT model mentioned above has produced this excellent online guide help manage workflow within a wider triage system.
7. Have a clear system for managing referrals who are not your clients
Despite the allied health ‘saviour’ mentality, we cannot be all things to all people. Know your boundaries. Know who your clients are… and clearly communicate to your referrers who your clients are not.
Have an explicit eligibility ‘cut-off’ so that those clients who are highest need and eligible will be prioritised, those who are lower need / ineligible / will be appropriately managed. This also helps to manage expectations for you and your clients.
8. Protect bookings for high priority clients
Where appropriate, manage your waiting lists and booking systems so you can see high priority clients quickly. This might involve keeping one appointment free every day at a set time. If the appointment isn’t taken by a certain time, then fill it.
9. Use appointment reminders
Typically, without a reminder, not attendance rates in outpatient services range from 15 – 30%. Reminders not only reduce non-attendance, and therefore risk wasting precious intervention time, they can be used effectively to provide supportive health messaging which can support clients who might have to wait for their appointment.
10. Communicate clearly with all clients on your referral pathway
Communicate clearly with your clients (and prospective clients) – ensure their expectations are clear, both in the pathways to accessing your services, and in their likelihood of receiving services within a timely way.
11. Identify alternative pathways for ineligible / low risk clients
Have a list of referral services for those clients who are lower risk / priority and for whom you do not have capacity to manage. This might include options such as social prescribing (links to groups, other kinds of support).
12. If possible, start the therapeutic relationship from the time of referral
If clients are on a waiting list, try to provide some support / intervention that will start the therapeutic process from the first point of contact where possible. This might include regular emails or links to online resources to start to provide help and support for those clients. Perhaps you can create resource kits that will help your clients manage their condition themselves. You will create strong goodwill and social capacity – and you are actually increasing your service capacity and provision by doing this. You could build an online community where clients can support each other – or direct them to others you are aware of.
13. Use group therapeutic approaches / interventions where possible
Use group therapeutic approaches where and when possible. This is obviously not appropriate for all service types, but there is good evidence in the chronic disease literature that group consultations can achieve effective outcomes for some client groups. Can you manage this from a business perspective? It will depend on your funding sources and rules, probably require some innovative and entrepreneurial thinking. For example, a number of private physiotherapy practices run online, group falls prevention programs.
14. Set clear limits around therapeutic interventions
Where possible, set clear time limits and expectations (goals) around therapeutic interventions. Not all service needs and funding models support this (indeed, some funding models encourage dependency, which further reduces service capacity), however if you can clearly aim to achieve a therapeutic goal within a set time frame, then review that outcome, you may be able to discharge the client, or refer them to an alternative model of care/ service that will help them achieve their next or a sequential clinical goal.
15. Actively discharge clients when their episode of care is complete
Discharge clients who have finished with your service. Make it clear to the client and the clinician that the episode of care is complete and that the goals have been achieved, or the extent to which those goals have been achieved. Have a clear pathway or process for re-entry to your service if the client needs it. Try to avoid a revolving door if possible.
Know that what is best for your client is best for you. If you work in a fee-for-service setting, you may think that having a long waiting list equates to a long, guaranteed income. You can only increase your income by increasing your service volume. Providing a high quality, high value intervention for your clients can only benefit your service and protect the health of you and your workforce.
If you have an example of good practice that you have effectively used to optimise health service capacity by managing service demand, please share it as a comment below so others can learn from your experiences.