Location: San Antonio, TX
Practice Type: On-site workplace clinic
Primary Care Physicians: Staffed primarily by nurses and mid-levels with part-time physician supervision
Approximate Annual Patient Visits: 6,108 provider visits/
31,819 total clinic visits
Reimbursement Model: Cost-plus payment to Premise Health, which runs the clinic on behalf of USAA
Located on the campus of the United Services Automobile Association’s (USAA) headquarters, USAA Health Services has served the company’s 14,000-plus employees for more than 10 years. The main clinic is staffed by one part-time physician, six registered nurses (RNs), three medical assistants (MAs), one registered nurse practitioner, one physician assistant, and four administrative assistants. A satellite location is staffed by one nurse practitioner, one MA, two RNs, and one administrative assistant.
As a workplace clinic, USAA Health Services strives to keep employees healthy by offering convenient, efficient and cost-effective primary care. The clinic offers extraordinary accessibility—with extended hours during the work week for both scheduled visits and walk-ins, and wait times averaging less than six minutes. Patients are also offered rapid access to select specialists. For example, USAA Health Services runs a nurse-staffed allergy clinic supervised by a local allergist to improve compliance with allergen desensitization injection regimens. The allergist also works with the nurses to provide serums and dictate regimen. In addition, the clinic also contracts with a cardiologist who offers rapid preferential access to patients referred from the clinic.
USAA Health Services also uses a unique risk-stratification tool to assess patients. The tool looks at both clinical risk factors, as well as occupational measures, such as days of work missed and workers compensation cost. High-risk patients are referred to a care management team provided by another contractor, while moderate- and low-risk patients are managed within the clinic.
USAA Health Services relies on more than 90 evidence-based protocols and guidelines, developed by an advisory group comprised of physicians and nurses using national guidelines and clinical evidence. These protocols and guidelines are embedded in the clinic’s electronic medical record—allowing nurses to manage patient care for a wide range of issues, including low back pain, sore throats and urinary tract infections.
The clinic uses an assessment tool to gauge prospective new hires for their ability to listen and communicate well, and assigns these skills high-priority when making hiring decisions. The clinic also encourages clinicians to practice near the top of their licenses, giving RNs and MAs more responsibility than they might receive in other work environments.
Donna Garcia, NP, and Gregory Gamboa, account manager, answer questions about the model for providing high-quality care and keeping costs low.
Q: What was the clinic’s purpose before becoming a primary care medical home, and why did it evolve?
A: “In the beginning, our clinic was focused on addressing occupational health issues, like work-site injuries and helping to accommodate employee work restrictions due to health. When the employers noticed an increase in time lost from people leaving work to go see their own primary care physicians in town—especially during cold/flu and allergy season—they realized that it made much more sense for us to offer on-site primary care. Since then, we have seen a steady increase in utilization of the clinic. Employee surveys indicate that people are very grateful to have primary care at the work-site and appreciate the clinic’s ease of access and efficient care.” —Gregory Gamboa, account manager
Q: How does your risk-stratification tool improve patient care at your clinic?
A: “We use this risk-stratification tool to help us more fully engage with our patients while being mindful of cost risks for the employer. A patient’s risk score—on a scale of one to five—gives us perspective on whether we’re getting all of the necessary information from a patient during a visit, and helps us ask the right questions to fill in any gaps. For example, they may not give us all of their health history or tell us about medications they are taking, so when we see a higher score in the risk tool, we can address unarticulated needs. For cost control, we know that the average cost to the employer for a patient with a score of one is about $10,000, while a score of five will be closer to $80,000 or $90,000.”
—Donna Gracia, NP
Q: How does your system for utilizing standing orders improve efficiency?
A: “Standing orders allow us to effectively treat our patients’ symptoms and get them back to work quickly. For example, if a patient comes in to triage with sinus symptoms, they could have allergies, but the symptoms may also meet the criteria for strep throat. There is a standing order in place to run a rapid strep test. If the test is positive, we can then get them in with a provider almost immediately. If the test is negative, our RNs will educate them on how to manage their symptoms and encourage them to come back if they don’t improve. Most of the time patients just want reassurance that they won’t get family or co-workers sick, and we can quickly accommodate that need.”
—Donna Gracia, NP
Q: Why does being a work-site wellness clinic make USAA Health Services unique?
A: “I think what makes our clinic so special is the time we have to spend with patients. Because we are not serving upwards of 50 patients per day, we don’t need to focus on getting patients in and out quickly. They don’t have to wait long to see someone, and we have more than adequate time to answer questions, address concerns, conduct tests and perform thorough evaluations. The ability we have to coordinate specialty care, like physical therapy or health coaching, with our patients’ employer is also unique and saves time for our patients. Our providers are given the chance to treat the whole person.”
—Gregory Gamboa, account manager