Convenient Care Clinics: Quality, Convenience, and Choice

Published Online: Monday, June 16, 2014

Convenient care clinics are filling a niche and offering high-quality, cost-effective, and timely care.
Health care driven by the needs of consumers is the bedrock of the convenient care industry (CCI). Retail and pharmacy-based convenient care clinics (CCCs) are known for providing affordable, accessible, quality health care to consumers who usually would have to wait hours, days, or even weeks for basic primary health care. As a result, the alternative for most people has been to seek costly, time-consuming emergency department (ED) care for illnesses that could have been prevented if health care services had been as readily accessible as they are now in retail locations.

CCCs have been called a “disruptive innovation” by Harvard University professor and New York Times best-selling author Clayton Christensen, because they are consumer driven and serve as an accessible, affordable, quality health care response to millions of consumers who “are frustrated with the conventional health care delivery system,” which is known for providing inadequate access to basic health care services when people need them the most.1

Much of the success of the CCI to date can be credited to the individual clinic operators and the association that focuses specifically on this sector of health care—the Convenient Care Association (CCA). Established in 2006 by industry operators, the CCA is the national trade association for the industry.

The Triple Aim
CCCs have provided basic primary health care to more than 30 million people to date, and they are known for the “triple aim”—providing accessible, affordable, quality care.

Access: CCCs are usually located in retail locations, such as pharmacies and drugstores, supermarkets, big box retailers, and other high-traffic retail settings with pharmacies. Given their location in retail, they provide easy accessibility and are convenient for patients, who can get their necessary prescriptions filled on-site. Today, one-third of the American population lives within 10 miles of a clinic.2 The clinics can range in size from an exam room to multiple exam rooms, complete with sinks and exam tables. The clinics generally occupy 200 to 500 sq ft and are outfitted with all the necessities of an outpatient health care office.

Nationally certified nurse practitioners (NPs) and physician assistants (PAs), who staff the CCCs, have collegial relationships with the pharmacy staff in the retail setting. Many of these clinics have flexible hours of operation, with most of them open 7 days a week—up to 12 hours a day during the workweek and up to 8 hours on Saturday and Sunday, including most holidays. The clinics tend to be busier on the weekends, in the morning and evening, and at lunchtime, reflecting their convenience and consumer focus. Most of the clinics see patients 18 months and older, encompassing pediatric, adult, and geriatric care, with visits generally taking 15 to 25 minutes for diagnosis and treatment.

Clinic providers diagnose, treat, and may write prescriptions for common illnesses such as strep throat, bladder infections, pink eye, and infections of the ears, nose, and throat. They provide vaccinations for influenza, pneumonia, tetanus, pertussis, and hepatitis, among others. Furthermore, they treat minor wounds, abrasions, joint sprains, and skin conditions such as poison ivy, ringworm, and acne. In addition, these clinic providers perform routine lab tests and a wide range of wellness services, including sports and camp physicals, smoking cessation programs, tuberculosis testing, and chronic disease monitoring, as well as services for those with diabetes, high cholesterol, high blood pressure, or asthma.

Initially, only a very limited number of illnesses were treated in CCCs, such as strep throat, mononucleosis, influenza, and bladder, ear, and sinus infections, along with pregnancy testing. The clinics were offered as a cost-effective alternative to basic, episodic care and to keep children and adults with low-acuity (nonemergency) illnesses out of expensive EDs. These clinics also only accepted cash for services. Their scope of services has significantly increased based on consumer needs and feedback, and while upper respiratory services are still popular, today the scope of services has broadened to include some chronic disease care, usually done in partnership with physicians. Additionally, all clinic operators now accept health insurance, and some insurers even provide incentives for their health plan customers to use the clinics for nonemergent care. To date, CCCs have seen more than 20 million people nationwide.3

Affordability: As the CCI has grown and evolved, one of the most striking changes has been the vastly increased involvement of health systems and hospitals. Today, all the major retail clinic operators, including MinuteClinic, Healthcare Clinic in select Walgreens, The Little Clinic, RediClinic, and Target Clinic, have strategic partnerships with hospitals to enhance clinical quality and access, as well as service expansion opportunities for chronic disease management and maintenance. As many of them are gearing up for accountable care organizations, the clinics are seen as strategic partners.

Although several health systems were very early adopters of retail-based health care and were among the founding members of the CCA (eg, Aurora, Geisinger, Sutter), the majority of the first CCC operators were private corporations. In recent years, however, a large number of health systems have entered into the retail-based health care space in 1 of 2 main capacities: (1) direct operator of CCCs in partnership with a retail host store; or (2) a partner to another CCC operator, providing collaborative physicians and allowing for more streamlined transition of patient care from episodic to ongoing.

The CCI believes strongly in the transparency of medical costs, and this sets the clinics apart from traditional medical delivery systems. Consumers are the first to point out that they like the fact that clinics visibly post their health care services, treatment costs, and information about their providers, whether at the clinic or on the clinic’s website. The basic cash cost for a visit to a CCC averages $75. Up to 40% to 50% of the people using these clinics don’t have an existing medical home. This makes the CCCs the lowest cost unsubsidized provider of care.4

In addition to the transparency, consumers appreciate the low costs. The costs are low because the NPs and/or PAs provide all the health services while also handling some administrative functions. Some CCCs also have medical assistants who aid the provider and help with patient flow. Moreover, electronic health records (EHRs) and technology are used to enhance the patient experience with patient consent to assure there is coordination and continuity of care with their medical home and primary care providers. Most clinics have written guidelines and established protocols that the providers use to assist with their decision-making process and to ensure the highest level of patient care and satisfaction.

High-Quality Care: From the outset, the CCI, with the leadership of the CCA, made a strong commitment to quality of care. One of the first steps taken by the CCA was to establish a set of quality and safety standards. All members would be required to adhere to ensure delivery of the highest-quality care. Specifically, industry leaders and operators support the following industrywide, consumer-driven patient care performance standards3:
  1. All providers will be thoroughly credentialed for license, training, and experience, with rigorous background checks.
  2. Commitment to monitoring quality on an ongoing basis and applying the data derived from quality review to implement operational and clinical improvements. Mechanisms of review may include but are not limited to:
    • a. Peer review
    • b. Collaborative physician review
    • c. Use of evidence-based guidelines
    • d. Collecting aggregate data on selected quality and safety outcomes
    • e. Collecting data on patients’ perceptions of care and engagement with the model
  3. Establish collegial relationships with the traditional health care system and its providers, share patient information as appropriate, and ensure continuity of care. All patients are given the option of sharing their health care record with other providers.
  4. Use of EHRs to ensure high-quality, efficient care.
  5. Commitment to encouraging patients to establish an ongoing relationship with a primary care provider and to making appropriate and careful referrals for follow-on care and/or for conditions that are outside the scope of the clinic’s services.
  6. Provide health promotion and disease prevention education to patients to maximize the impact of the patient encounter.
  7. Provide a copy of the visit record, written discharge instructions, and educational materials to patients upon leaving the clinic to ensure that patients understand any diagnosis made, recommended treatment, and care plans.
  8. Compliance with applicable Occupational Safety and Health Administration, Clinical Laboratory Improvement Amendments, Health Insurance Portability and Accountability Act, and Americans with Disabilities Act standards. All CCA members follow Centers for Disease Control and Prevention guidelines.
  9. Provide an environment conducive to high-quality patient care and meet standards for infection control and safety.
  10. Establish emergency response procedures and develop relationships with local emergency response providers to ensure that patients in need of emergency care can be transported to an appropriate setting as quickly as possible.
  11. Empower patients to make informed choices about their health care. Prices for services provided at CCCs are readily available to patients at the clinic. Providers discuss what impact, if any, the provision of additional services will have on the ultimate cost to the patient.
  12. Agreement to pursue a third-party certification or accreditation of their choice, by an organization such as The Joint Commission, Accreditation Association for Ambulatory Health Care, or Accreditation Commission for Health Care, to demonstrate their adherence to these standards, or otherwise be able to document that their clinics’ practices are subject to third-party review and accord with these standards.

The demonstrated ability to consistently deliver high-quality care has been key to the success of the CCI. At most CCCs, standardized protocols assist NPs in clinical decision making. These protocols are used as a tool or guideline and are not intended to replace the critical thinking or the clinical judgment of the provider, but rather to enhance and assist in the decision-making process. 

For example, the leading CCCs’ guidelines are grounded in evidence-based medicine and guidelines published by major medical bodies such as the American Academy of Pediatrics and American Academy of Family Physicians. Most CCCs have incorporated rigorous quality assessments into their evaluative structures. Both internal and external reviews are being built into these new entities; for example, formal chart review by collaborating physicians and peer review by providers with additional standard coding auditing.

Credentialing of providers and thorough work history is one process for ensuring adequate experience level to work in this new independent role. CCCs strive to establish a referral base with physicians and other health care providers in the best interests of their patients, their providers, and for continuity of health care within the medical community. The CCI adheres to all state regulations regarding practice issues for advanced practice nurses and for PAs.

Final Thoughts
The focus of the CCI is quality, convenience, and consumer choice. Established standards, employment of competent professional primary care providers, and the use of ongoing quality improvement mechanisms—including the incorporation of evidence-based practices in the care of the patient—allow the clinics to meet these goals.

The scope of services offered in CCCs has steadily expanded, while staying within a range of treatments that can be carried out in 15 to 25 minutes and do not require substantial or invasive diagnostic testing.

Health care delivery systems are changing in multifaceted ways and are constantly in flux. CCCs have identified the need for change and are filling a niche by moving to bridge the chasm between a challenged health care system and a rising new model of care that offers high-quality, cost-effective, and timely care. With the implementation of the Affordable Care Act, they will continue to play an important role in the health care delivery system, providing accessible, affordable, quality care to millions of people across the United States.

About the Convenient Care Association
For more information about the industry, please visit www.ccaclinics.org or contact Tine Hansen-Turton, executive director, at tine@ccaclinics.org.



References
  1. Christensen CM. The Innovator’s Prescription: A Disruptive Solution for Health Care. 2009.
  2. Rudavsky R, Pollock CE, Mehrotra A. The geographic distribution, ownership, prices, and scope of practice at retail clinics. Ann Intern Med. 2009:151(5):321-328.
  3. Convenient Care Association website. www.ccaclinics.org. Accessed May 30, 2013.
  4. Thygeson M, Van Vorst KA, Maciosek MV, Solberg L. Use and costs of care in retail clinics versus traditional care sites. [published correction appears in Health Aff (Millwood). 2008;27(6):1751]. Health Aff (Millwood). 2008;27(5):1283-1292.


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