In sum, five models of after-hours care coordinated with a patient’s regular primary care provider were identified; they ranged from solo practitioners available around-the-clock to contractual relationships between primary care practices and after-hours clinics (or urgent care centers) to provide after-hours care and communicate back to the PCP about that care. Extended primary care office hours, physician call-sharing, health information technology and nurse triage phone lines are tools to support these models.
Three key themes were common to current models that coordinate after-hours care with a patient’s usual PCP: After-hours care systems must incorporate feasible and sustainable designs that meet local population needs; A shared EHR and systematic notification procedures between the after-hours provider and daytime PCP are extremely helpful; and 24
7 access is best implemented as part of a larger practice approach to access and continuity.
For small practices especially, efforts to improve the design of after-hours care and its coordination with one’s usual PCP in the U.S. can be informed by other countries’ experiences.16,24–27
For example, small practices in the Netherlands, U.K. and Denmark, have been particularly active in sharing coverage and identifying how nurse telephone triage may be efficiently and safely deployed and supported by an on-call physician. 25–27
While it may be challenging for formerly autonomous small practices to work together to share call or telephone triage, when practices share resources28
they are more likely to routinely track and manage patient information and to provide after-hours care.29
Efforts to encourage small practices to create “virtual panels” for after-hours care need to take into account providers’ real-world working relationships. With persistence and ongoing input from on-the-ground providers, some health plans have effectively supported such activities.
Respondents who were in a PCMH believed that current initiatives undervalue the resources required for 24
7 coverage. The GroupHealth experience further supports this: having already made significant infrastructure investments, including shared electronic health records, substantial additional resources were required to hire more clinicians and decrease physician patient panel size to support a system that effectively decreases both provider burnout and demands for after-hours care.19
Supporting after-hours care by small independent practices that are not participating in PCMH initiatives may pose the greatest challenge for payers and policymakers. However, given that more than 70 % of office visits are to practices with five or fewer physicians,30
support for small practices to offer after-hours care has the potential to benefit a large proportion of patients. Planning grants from payers or foundations can help support small practices’ efforts to design after-hours programs.
Some predict that after-hours care in most countries will continue to move toward larger organizations or virtual practice networks.16
Electronic health records will be crucial to informational continuity in these arrangements and after-hours care providers need to be part of this loop. Systematic notification processes are also important to ensure that a patient’s usual clinician is prompted to review notes from after-hours care. Web-based secure data repositories open to on-call and after-hours care providers could help fill the gap prior to greater adoption of interoperable EHRs.
Future research could include understanding how to make such tools more clinically accessible and relevant to health care providers and patients. Future research could also include comparisons of the various models of care with respect to quantifiable outcomes such as ED attendance for minor complaints, overall resource use, and patient satisfaction. Enhanced payment for after-hours care, whatever form it takes, also requires additional attention.
Patients’ willingness to trade continuity for immediate access varies by population and urgency of after-hours needs.31
Open-access or same-day care has been identified as a means for improving patient access while also emphasizing interpersonal continuity (assuming patient demand is not in excess of provider supply).23
While qualitative research can uncover details about respondents’ experiences, identify hypotheses for further investigation, and permit triangulation of themes from various perspectives, our study has limitations. Given the sample size, our findings do not represent all after-hours care arrangements. Another limitation is that we did not assess patient experiences with each of these models. Still, lessons from real-world models can help inform practices struggling to provide after-hours care.
Ultimately, identifying sustainable models to accommodate both provider quality of life and patient access and continuity to after-hours care may require a larger and better distributed primary care workforce, and payment reforms to reward providers for after-hours care. Improved efficiency and support for daytime primary care will likely help decrease the after-hours-care burden.