Access to Continuity—Strategies for Symbiotic Improvement of Access and Continuity of Care

Proposition

Family Medicine commits to improving access to continuity of care and enhancing patient experience.

Introduction

Family medicine and primary care face ongoing pressures for access, with demand for care overwhelming current and projected capacity to deliver it. Healthcare systems have attempted various strategies to maximize access, often to the exclusion or detriment of continuity of care. Among quality metrics, those related to access are ubiquitous and frequently prioritized, while continuity of care metrics are often considered secondarily, if at all, despite the fact that continuity has been well-established as important to improving the Quintuple Aim of enhancing patient experience, improving population health, reducing costs, improving care team wellbeing, and advancing health equity.^1–5

During the August 2025 Family Medicine Leadership Consortium meeting, a different perspective was applied to the concepts of access and continuity—rather than presuming a tradeoff between the two as inevitable, the proposition that Family Medicine is committed to improving access to continuity of care was put forth. Improving access and continuity of care do not have to be a zero-sum game—both are essential in family medicine and can be symbiotic with the right systems. Models for improving access that simultaneously preserve or elevate continuity of care were discussed and are summarized here.

Managing Demand

One way to manage demand is to re-balance panel sizes, both at the overall clinic level and between clinicians. Other ways to manage demand are to create more efficient alternatives to 1:1 office visits (such as addressing care needs through patient portals asynchronously, group visits, or use of technology like artificial intelligence to expedite or automate aspects of care),⁸ to do more at each visit and increase the intervals at which patients need to return for follow-up, and improve continuity (eg, reduce extra appointments needed with continuity clinicians after patients see non-continuity clinicians who are unable to address as many of their needs in one visit).

The approach to access at University of North Carolina’s ambulatory clinics exemplifies an advanced understanding of demand, starting with detailed and proactive empanelment processes.⁹ Panel reports with actual, expected, and weighted panel sizes per clinician are tracked monthly, and include the average number of visits per patient and monthly continuity rates. Reports are used to “right-size” or close panels for clinicians with panels exceeding expected panel sizes. Understanding of demand is further drilled down to the day-to-day level to be able to predict daily visit demand, by tracking the number of patient requests for appointments, plus the number of walk-ins, plus the number of follow-up appointments previously generated by clinicians for that day. Historic and projected data on visit demand for a given day or week in a clinic is used to plan accordingly for surges in demand, such as by scheduling more clinicians in clinic on days of higher predicted demand.

Meanwhile, appointment templates at University of North Carolina are designed to prioritize both access and continuity. Types of visit demand are sorted by levels of priority for continuity—follow-up and wellness visits are prioritized for continuity with the empaneled primary care clinician, while acute demands are considered acceptable for visits with any clinician on the empaneled team (still allowing some team-based continuity). Different visit types were created to reflect continuity priority in the appointment template, with continuity visit types reserved for empaneled continuity patients. Most appointments on the template start out as continuity visit types; if not used a week prior to the appointment date, appointment types convert to start allowing non-continuity visit types (acute/symptomatic care) to be scheduled. Clinician and team continuity as well as access rates are closely monitored, and how soon in advance appointment types are opened to non-continuity patients can be adjusted based on how the continuity and access metrics are faring for a clinician. For example, if a clinician has low continuity, appointment types are kept as continuity visit types longer, 3 days, say, before the visit date. A clinician with low access might have appointment slots open up further in advance. Thus, continuity needs and access needs can both be factored in and acted on directly through the appointment template, while managing the upstream demand from panels by frequently adjusting panel statuses.

Increasing Capacity

Increasing capacity can involve increasing the number of visits per day and opening more days per year—typically these options are already exhausted in many healthcare systems. Otherwise, using other team members to add capacity to address patient needs is the main approach. Many examples of team models exist, including using RNs, clinical pharmacists, behavioral health clinicians and staff, or physical therapists to address chronic conditions, mental health, or musculoskeletal needs with minimal time needed from the primary care clinician.^10,11

Models that maximize the roles of other team members help free up clinician capacity while supporting continuity. At Bellin Health¹² and University of Colorado,^13,14 two upskilled medical assistants/care-team coordinators work with one primary care clinician (PCC) by collecting templated history from patients, staying in the visit while the PCC sees the patient to document and pend orders in the chart, and coordinate with the patient after the PCC leaves; because they were present during the whole visit, the medical assistants/care-team coordinators have an advanced understanding of the patient’s healthcare plan. This model allows clinicians to see a few more patients per half-day, with less documentation, order entry, and care coordination demands, which offsets the cost of the additional staff. Clinician continuity is supplemented by the continuity of deeper relationships between patients and the medical assistants/care-team coordinators.

In another example, Baylor Scott & White Health has piloted a model of team-based care with one physician and 3 or 4 advanced practice practitioners (APPs) per panel of patients (approximately 5800 patients), to maximize capacity for seeing patients in a timely manner while keeping continuity preserved among a small number of clinicians. In this model, physicians focus on seeing high-risk/high-complexity patients, while APPs see patients with stable chronic disease and for wellness visits with physician supervision. Physicians have 30%–40% fewer scheduled visits per day compared to a typical physician schedule, allowing time to supervise or have co-visits with APPs and spend more time with the higher complexity patients. RN-care managers are also used to provide support for chronic disease patients. For the teams using this model, TNAA is currently 0–1 day, with new patient TNAA less than 7 days. Team-based continuity (defined as the percentage of visits a patient has with the physician or an APP on their own team, including acute visits) is currently >96%, compared to <60% for traditional team models in the health system (individual physicians or 1:1 physician to APP teams).

Demand-Capacity Mismatch and Advanced Access

Besides directly increasing capacity or managing demand, the question of how to use capacity most efficiently when scheduling appointments should also be considered. Often, on a day-to-day basis, the problems lie in efficiently matching capacity for appointments with demand for them, more so than an absolute lack of capacity. For example, in scheduling models that reserve some appointment slots for same-day care, these slots are unavailable for general appointment requests, which adds to future appointment demand in the following weeks or months. The urgent slots themselves may not be used or used appropriately, depending on the triage process. If more urgent slots are reserved than used, those slots are wasted. In the meantime, staff time and resources are spent in triaging and managing intentionally created delays in care considered “non-urgent.”

Advanced access, as described by Murray et al,^6,15 uses queuing theory to optimize how capacity is used. The underlying concept is that the most efficient way to match demand and capacity is to minimize the time between when appointment demand is presented and when it is met, or “doing today’s work today.” The goal is to have at least half of all appointment slots open at the beginning of the day to offer to patients as they call (making TNAA <1 day by design); the other appointments have been made in advance for clinical need or patient preference. This maximizes flexibility by having most appointments still open to address issues as they arise, and minimizes wasted capacity in the form of no-shows (as no-show rates are proportional to the length of time between when an appointment is made and the appointment date).¹⁶ A 2020 systematic review of 18 studies on advanced access scheduling found that the model reduces appointment scheduling wait time and no-show rates, increases patient/visit volume, and decreases emergency/urgent care visits.¹⁷ Advanced access also prioritizes continuity by allowing clinicians to have maximum availability to address their patients’ requests as they arise. In some case studies, advanced access scheduling increased continuity and patient satisfaction while reducing TNAA to 0-3 days.¹⁸

While advanced access models are not new, certain operational barriers have limited their widespread implementation. Implementing an advanced access model requires a detailed understanding of day-to-day demand and capacity, factors that are not often measured or routinely tracked in most systems. Panel sizes need to be balanced, overall and between clinicians. Advanced access uses the concept that for a given panel size, the backlog of unmet demand reaches a steady state. Instead of continuing to allow, for example, a 3 month backlog of appointments, investing upfront in a temporary increase in capacity to address the backlog then allows practices to keep up with appointment requests as they come in. If a practice is over-paneled, however, the steady state is not sustainable, and the backlog will recur.

Some practices may not have the leadership investment to devote resources to the upfront work of reducing the backlog. Unbalanced panels between clinicians undermine continuity, as other clinicians will end up seeing the patients of an over-paneled clinician. This highlights the need to monitor and protect continuity while access interventions are implemented.

During initial implementation of an advanced access model, it is necessary to re-set the expectations of both patients and clinic staff to trust that immediate availability will be provided. Also, scheduling system inefficiencies, such as difficult-to-navigate phone appointment systems, create barriers for patients to communicate efficiently about appointments, undermining attempts to build the advanced access culture.

Future Directions

In summary, there are several approaches to improving access that use a fuller understanding of demand and capacity, and that incorporate continuity as a core feature rather than something to sacrifice in the short-term pursuit of temporary access. Moving forward with more effective improvements for access requires building a strong foundation of empanelment and data-driven improvement to measure and understand the day-to-day level of appointment demand on a granular level. Continuity needs to be tracked and built into access improvement processes. Both care teams and appointment template changes can be built to center continuity and access at the same time. Technology such as artificial intelligence and machine learning can provide new opportunities to use insights from operational data to understand nuances of day-to-day demand and capacity, and facilitate strategic appointment scheduling to maximize access and continuity.¹⁹ By valuing and centering continuity among access interventions, healthcare systems can shift the access/continuity paradigm from an either/or proposition to a symbiotic relationship, one in which access to care entails access to continuity of care and improving the Quintuple Aim.