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Background Primary care telephone access has been associated with patient satisfaction and emergency department utilization even after accounting for objective appointment wait times. However, relatively little is known about how to best structure and manage telephone access in primary care. Objective Assess how primary care telephone access is structured and managed and explore how variation in telephone management may affect primary care teams and patients. Design We used 2016 administrative and patient survey data to select six Veterans Administration medical centers (VAMCs) with above-average primary care access (time to third next available appointment) but variable patient-reported access, geographic region, and urbanicity. Semi-structured interviews were conducted August –October 2017. Participants Forty-three key stakeholders knowledgeable about primary care, telephone management, and operational priorities nationally and/or within each VAMC. Key Results Telephone access was organized and managed differently across sites. Regional call centers were perceived as more efficient but less flexible in tailoring processes to meet local needs. Patient preferences for speaking with their own care teams were cited as a reason to manage telephone access locally rather than regionally, particularly in rural sites. Sites with high patient-rated access described call center functions as well-integrated with primary care team workflow, while those with low patient-rated access perceived telephone management practices as negatively affecting primary care team workload. Call center understaffing was a major barrier to optimal telephone access in all six sites, though rural sites reported greater challenges with provider recruitment and retention. Conclusions In VA, efforts to improve telephone access have focused on centralizing call center operations but current call center performance metrics do not account for the extent to which call center functions are integrated with primary care workflows or may impact patient experience. Efforts to improve primary care access should carefully consider impact of telephone management practices on providers and patients.

Telephone Access Management in Primary Care: Cross-Case Analysis of High-Performing Primary Care Access Sites