Practice Management Building Urgent Care Referral Relationships: and Retail Host Clinics

Urgent message: Viewing other community healthcare providers (e.g., pharmacists) or even possible competitors (e.g., retail clinics) as referral sources can increase revenues and bolster the urgent care center’s place in the healthcare system. The first of two parts.

Alan A. Ayers, MBA, MAcc

rgent care has evolved to scope of services, identify Uthe point that it is a vital mutually beneficial referral part of a community’s relationships, and develop healthcare infrastructure, processes to coordinate best offering access when pri- patient care. mary care appointments are unavailable and relief Urgent Care is Not a when emergency rooms are Threat at capacity. Before an urgent care center As a first point of triage can build any referral rela- for many patients, urgent tionship, it must overcome care also serves as a hub the perception that urgent from which patients are di- care is a competitor. Some rected to diagnostic facili- primary care fear ties, medical specialists, and that urgent care’s focus on services. The episodic treatment leads pa- greater ties urgent care has tients to neglect preventive to the tertiary healthcare care and chronic system, the more effec- management. Likewise, tively it works to assure af- © corbis.com some emergency room ad- fordable, accessible care in a community. ministrators fear urgent care siphons away privately in- Before the benefits of urgent care can be realized, how- sured patients, increasing the financial burden of ever, community providers must understand how urgent Medicare, Medicaid, and charity care on the ED. care complements their practices and adds value for their Ideally, a well-organized healthcare delivery system patients. This requires urgent care operators to educate matches a patient’s needs to the most appropriate the healthcare community on its delivery model and provider skill set and facility capabilities. For example,

www.jucm.com JUCM The Journal of Urgent Care | January 2010 29 BUILDING URGENT CARE REFERRAL RELATIONSHIPS: PHARMACIES AND RETAIL HOST CLINICS

Table 1: Urgent Care Referral Sources and Downstream sources is the retail . According to Providers the National Association of Chain Drug Stores (2009), there are more than 56,000 Referral sources Downstream providers pharmacies in the United States, including •Primarycarephysicianoffices •Diagnosticimaging 39,000 operated by food, drug, and mass-re- •Medicalspecialistoffices •Laboratory tail chains and 17,000 independents. •Retailhealthclinics •Primarycareoffices Most patients who visit a doctor will go •Hospitalemergencydepartments –Familypractice to a pharmacy immediately after, making •Employeron-sitemedicalclinics –Internalmedicine the pharmacist the first person to hear •Studenthealthservices – about the patient’s experience. Pharmacists •Ambulance/emergencymedical •Medicalspecialists: gain unique insight as to providers’ reputa- services –OB/GYN tions, practice methods, and patient base. •Publichealthdepartments – And by managing all of a patient’s prescrip- •Pharmacies – tions, a pharmacist can see a patient’s entire –Physiatry health history. Pharmacists not only iden- •Generalandspecializedsurgery tify potential treatment interactions, but •Hospitalemergencydepartments understand the complexities of chronic dis- •Physicaltherapy/rehabilitation ease states like diabetes and hypertension. •Pharmacies Because pharmacists are tied in to pa- •Durablemedicalequipment tients and their providers, are trained in patient counseling, and are generally trusted advisors, consumers who have ques- emergency rooms are designed for trauma, resuscitation, tions about their health will often ask their pharmacist and admissions. Although an ED with excess what steps to take. Pharmacists routinely assist patients capacity can profitably treat a patient with a minor in selecting over-the-counter remedies, but when a sprain, urinary tract infection, or seasonal , the more serious illness is suspected—such as a cough that ED’s capabilities (and by extension, operating costs) could be pneumonia or swelling that could be a frac- are far beyond what’s required for low-acuity cases. ture—the pharmacist can recommend that the patient When an ED becomes congested due to staffing short- go to urgent care. Likewise, pharmacists may refer pa- ages, hospital patients boarding in ED beds, a surge in tients who need refills on expired prescriptions and do ambulance traffic, etc., shifting non-emergent cases to not have a local doctor. urgent care improves flow and reduces wait times in the Building a referral relationship starts with introducing ED. And because an urgent care visit costs approxi- the pharmacist to the urgent care center’s range of serv- mately one-sixth of an ED visit, the availability of urgent ices, operating hours, insurance participation, and pric- care can reduce hospital write-offs, as many patients ing for cash pay patients. Providing the pharmacist with who cannot afford a $600 to $800 ED visit can easily pay marketing collateral—magnets and maps to the cen- $100 to $200 for urgent care. ter—will facilitate referrals when opportunities occur. Urgent care is not intended to replace established Pharmacy customers are healthcare consumers, so if providers, but, rather, to support them in assuring pa- the pharmacist is willing, display urgent care collateral tients get care in the most efficient and effective man- at the pharmacy counter to raise awareness among all ner possible. Integrating urgent care starts with identi- customers. Whenever collateral is placed, be sure to set fying what sources of care are available, understanding afollow-upscheduletoassesscontinuedinterestandre- how patients access and navigate medical providers, and plenish those materials. by creating win-win scenarios in which referral providers Because the pharmacist is interested in building his build up urgent care and in turn, urgent care builds up own business, he may ask for your support in directing referral providers. Table 1 lists common referral sources prescriptions to the pharmacy in return for promoting and downstream providers for urgent care patients. the urgent care center. Urgent care centers sometimes re- ceive promotional benefits from pharmacies, such as Pharmacy Referrals free magazines for the waiting room placed in phar- One of the most visible (yet often overlooked) referral macy-branded vinyl covers. Or, a pharmacy may pro-

30 JUCM The Journal of Urgent Care Medicine | January 2010 www.jucm.com BUILDING URGENT CARE REFERRAL RELATIONSHIPS: PHARMACIES AND RETAIL HOST CLINICS

vide coupons for the urgent care to display Table 2: Conditions for Referring a Pharmacy or give to patients at discharge. These perquisites add value to a patient’s urgent Generally, an urgent care center may recommend a particular pharmacy to care visit. patients when the: In addition, co-promotions such as •patientmakestheultimatedecisionwhethertousethepharmacy health fairs or immunization clinics held at •recommendationisincompliancewithallregulationsandcontractual the pharmacy and staffed by urgent care agreements personnel can also drive traffic into the •pharmacyisconvenienttopatients pharmacy (while increasing awareness of •pharmacyacceptscommoninsuranceplans urgent care), especially if the event is adver- •pharmacyisreputable,chargescompetitiveprices,andprovidesgood tised. service. There is nothing inherently wrong with an urgent care center recommending a par- ticular pharmacy, provided the conditions Table 3: Conditions Subject to Referral From Retail Host in Table 2 are met. Having data on hand— Model Clinics to Urgent Care Centers: such as the number of patients seen at the •Automobileaccidentsandon-the-jobinjuriesrequiringaphysician urgent care or number of scripts written— examination. can strengthen an urgent care center’s pres- •Proceduresrequiringspeciallights,tableandsuppliessuchas: entation to the pharmacist. –incisionanddrainage –removingforeignobjects Retail Health Clinics –suturingcuts An increasing number of pharmacies also –castingfractures operate in-store medical clinics. According •Conditionsrequiringanx-rayfordiagnosis—frompneumoniato to MerchantMedicine.com, as of November sprains/strains. 2009 there were 1,165 retail host model •Otherconditionsrequiringequipmentbeyondtheretailhealthclinic’s clinics in 40 states, about three-quarters of capabilities—such as a pulmonary function test or nebulizer treatment which are operated by the two largest phar- for asthma. macy chains—Walgreens’ Take Care Health •Otherconditionsbeyondthescopeofpracticeofthemidlevelprovider and CVS’ MinuteClinic. (often dictated by state laws). Retail health clinics range from 100 to 300 square feet and are staffed by solo nurse practitioners or assistants whose scope of prac- when making referrals. tice is limited by state regulations and the off-site super- Building a referral relationship with a retail health vising physician. Retail health clinics lack much of the clinic starts with introducing the midlevel provider to basic equipment of an urgent care center, such as x-ray, urgent care and positioning urgent care as the solution slit lamps, and gynecology stirrups (many don’t even to the retail clinic’s limited practice scope. Meet with the have an exam table or a restroom), which further limits retail clinic’s practitioners one-on-one to review the the scope of services to conditions like sore throat, ath- services and hours of the urgent care center, explain lete’s foot, and pink eye. cash pricing and insurance plans accepted, provide Recognizing the provider and facility limitations of re- maps and other marketing collateral, and offer assurance tail clinics, American Academy of Family Practice (AAFP) that referrals will be treated on a priority basis. Also con- guidelines state, “Retail health clinics must have a refer- sider inviting retail practitioners to visit the urgent care ral system to physician practices or to other entities ap- center to see firsthand the good experience his or her pa- propriate to the patient’s symptoms beyond the clinic’s tients will encounter. scope of work.” Table 3 outlines common conditions Like pharmacists, retail clinic operators are interested aretailhealthclinicmightrefertourgentcare. in expanding their businesses; where there are services Although the retail clinic’s corporate owner may be provided by the retail clinic that urgent care does not of- interested in steering referrals to affiliated or fer, agree to promote those services in the urgent care supervising physicians, midlevel practitioners take pride center. For example, many retail health clinics utilize a in their autonomy and rely on their own experience national distribution network to carry a broad range of

www.jucm.com JUCM The Journal of Urgent Care Medicine | January 2010 31 Call for Articles BUILDING URGENT CARE REFERRAL RELATIONSHIPS “Reciprocal referral JUCM,theOfficialPublicationofthe Urgent Care Association of America, is relationships strengthen looking for a few good authors. the urgent care center’s Physicians, physician assistants, and nurse practitioners, whether practicing standing in the in an urgent care, primary care, hospi- tal, or office environment, are invited to medical community submit a review article or original re- search for publication in a forthcoming and improve coordination issue. Submissions on clinical or practice of patient care.” management topics, ranging in length from 2,500 to 3,500 words are wel- come. The key requirement is that the vaccinations that an individual urgent care center article address a topic relevant to the may find unprofitable to stock due to short shelf life, real-world practice of medicine in the high inventory costs, and/or low insurance reim- bursement. urgent care setting. Awell-positionedretailhealthclinicmayalso Please e-mail your idea to function as overflow for a busy urgent care center. JUCM Editor-in-Chief After the initial meeting with the practitioner, set a Lee Resnick, MD at follow-up meeting to review data on number of pa- [email protected]. tients referred, replenish marketing collateral, and seek feedback on how to improve the referral He will be happy to discuss it with you. process.

Strategic Value of Referrals Referrals should be viewed as a strategic asset of an urgent care center—they tie the urgent care center into other healthcare providers and solidify urgent care’s position in consumer minds as a “front door” to the healthcare system. Every time a patient is referred to an urgent care center, the urgent care provider has the opportunity to capture that patient’s repeat business and spur word of mouth among the patient’s friends and family. Reciprocal referral relationships strengthen the urgent care center’s standing in the medical community, improve coordination of patient care, and build urgent care revenue and volume—a win- win solution. I

Note: This article is part 1 in a two-part series on build- ing referral relationships for urgent care. Part 2 will detail referral relationships with primary care, emergency rooms, and specialists, as well as describe the processes necessary to facilitate referrals and coordinate patient care.

32 The Journal of Urgent Care Medicine | January 2010