Nurses are the difference in Vanderbilt POS success
Nurses are the difference in Vanderbilt POS success
Administration commitment strong
Nursing accountability and a strong financial commitment from hospital administration are fueling a successful point-of-service (POS) collections program in the pediatric and adult emergency departments (EDs) at Vanderbilt University Medical Center.
The EDs went from having no POS collections effort at all to taking in just under $20,000 in March 2004, the first month of the program, says Tina Williams, CPC, manager of admitting and emergency registration for Vanderbilt Children's Hospital.
By March 2006, she adds, POS collections for both EDs totaled almost $87,000. (See graphs.)
Underlining the initiative is "a new spin" on automating the old grease board-style ED board and integrating it into the hospital-wide electronic bed board, Williams notes.
"The system automatically lets the nurse know if a patient needs to come to the discharge station," she says. "Then the database can run reports telling us which nurse that patient 'belongs to,' so we can go directly to the source if someone is not doing her part in bringing patients out."
When registrars click on the white board, indicating that a patient needs to come by the discharge station, Williams explains, the database is prompted to issue a report to that effect. A report from the discharge station database shows whether or not the person did, in fact, come by the station, she adds.
The system is color-coded "just like a stoplight," Williams says, with the colors red, yellow, and green indicating the status of an account.
Beginning at the point the patient presents at the ED, she explains, the process works as follows:
"When our registration greeter does a quick registration, the system pops the patient's name on the white board, which can be viewed at every computer in the ED," Williams says. The triage nurse sees the name and chief complaint, she notes, and can decide, for example, "Am I going to take the person with chest pain or the one with abdominal pain?"
Staff in front or back, including ED physicians, can, with a touch, check the board to see the number of people in the waiting room and their chief complaint, Williams says.
Meanwhile, physicians in the ED's fast-track area can see what's going on, she adds, and may direct staff to pull a particular patient for care in that less acute setting.
Another click moves the person into the treatment area, Williams says. Once the "update registrar" there takes ownership of the patient, that employee goes into the white board and changes the color of that field to yellow, which indicates that someone is working with the patient.
"When the registrar verifies the insurance and knows what the copay is, that person changes the color to red and puts the amount due in the comment field," she says.
At that point, anybody in registration can move the keyboard mouse over to the column, see the status of the account, she adds, and say, "You have a $100 co-pay due. How would you like to handle that?"
If the person doesn't have a copay due, the registrar changes the field to green, which tells the nurse the patient doesn't need to come to the discharge station at all.
"Part of the discharge station function is to review the registration in real-time," Williams points out. "If there are any questions — say, the update registrar didn't get an emergency contact outside the home — the registrar at the discharge station will click the field to yellow, and put in a comment saying to get the contact.
"Anybody in registration knows to 'mouse over' and see what is needed, so whoever is there will get that information and text it in."
Electronic white board speeds process
The speed and ease with which the electronic white board operates facilitates the entire process, Williams notes. "The last thing we want to do is hold up the patient any longer than we have to."
Nurses escort patients who are in "red" or "yellow" status to the discharge station, she says, and place a label on a clipboard indicating they have done so. If the station happens to be unmanned, Williams adds, the label serves as documentation.
"We don't have [staffing] depth on the discharge station — just enough staff to cover it during most of the peak hours," she notes. While all registrars are trained to handle that function as needed, Williams says, "we may miss one. The labels ensure that nurses still get credit for bringing the patient out."
Discharge staff manually note in the database if a collection opportunity was missed due to the station being unmanned, she says.
Monthly reports are sent to nursing administration giving the overall percentage of patients from each ED who are brought by the discharge station, she adds, "so they know to keep talking to the charge nurse about how important it is."
"We're still not at 100%," Williams says. "We were at 40% when we started measuring this, and now we are over 80% on most days; it depends on who is working. Some nurses are great and understand the need for buy-in, and others don't really think it's their job."
The only time these efforts didn't seem to make a difference was in November and December, when holiday demands had "people hanging on to every dime," Williams says.
"If patients are not able to pay, we give them a payment coupon card with a number to call, and we enter into the system whatever arrangements they've made," she says. "We put a note that, for example, the patient said [he or she] will pay on Dec. 12, and the person doesn't need to wait on a statement."
This step also ensures that, if the patient does follow through with the arranged payment, ED registrars get credit for the collection, Williams points out. "The business office knows to post the code [on the coupon] to give us credit, even though we didn't collect at the time of service."
Before instituting its program in 2004, Vanderbilt in Nashville was the only hospital in the area not collecting in the ED, she says. "We got a lot of people who wouldn't go to [a facility in] their network because there they would have to have a copay."
"It was a well-known fact that you could go to Vanderbilt without an out-of-pocket [payment] at the time of service," Williams recalls.
In preparation for the new policy, the hospital put out news releases "to prepare people for the culture shock," she says. "We tried to be conscious of the fact that it was a big change."
Based on visits that hospital staff made two years ago to other facilities in the area, Vanderbilt has been "much more successful as far as dollars collected" than its counterparts with similar patient volumes, Williams says.
"I've had people from other states call me because they were not able to collect the dollars that we are collecting," she says. "From what I can tell, it's mostly the nurses' buy-in — because the administration holds them accountable — that makes the difference.
"I want to give the nurses a lot of credit," Williams says. "At other facilities that didn't have [nurse buy-in]; they didn't really have a clear way of getting the patient to the discharge station.
"We can collect if we talk to [customers]," she notes, "but if we don't talk to them, we can't get anything."
Pediatric collections higher
In the business plan they put together for Vanderbilt Medical Center administration, hospital department heads and outside consultants predicted that the adult ED would collect more than its pediatric counterpart, Williams says.
The rationale, she adds, was that most children are either insured through their parents or covered by TennCare, the state's Medicaid program, which does not require a copay.
However, on the adult side, there are quite a few TennCare patients who do have copays, Williams says.
Surprisingly, though, "for the most part, we're collecting more at the children's ED," she notes. "We've never really figured out the reasons behind that, but it was a nice surprise to be that successful in the children's ED."
The collections effort required extra employees, Williams notes. "At the beginning, we added a total of seven people for both EDs, which was 6.3 full-time equivalents [FTEs] since our staff work 36-hour shifts.
"Originally we just manned the discharge station during peak hours, but now we're up to 10 FTEs," she says. "We have expanded our hours over the two years, but we still don't man it 24/7, although we're close to that."
While the intent of the program is to collect the amount due at the time of service, it also is to provide assistance when needed, Williams says. "Our discharge stations are set up so [the function is] more like a patient advocate."
If a person comes to the ED for treatment and needs follow-up orthopedic care, but is out of network, she adds, "We tell the patient to please contact his primary care physician and [ask for a referral] to an orthopedic specialist in that network. Why send them back within our system if they'll have to spend twice as much?"
If the patient is self-pay, Williams says, "we have handouts listing clinics within the area that offer preventive care and see people on a sliding [fee] scale. We also initiate a Tennessee Medicaid application for state residents who are uninsured, and give them an instruction sheet on how to complete the process."
The hospital's case managers assist with patients who need follow-up care within the Vanderbilt system, she says.
While she thought patient satisfaction surveys would suffer with the advent of ED collections, the latest scores are in the 99th percentile, she says. "They're better than they've ever been. It's not as big of a shock anymore."
The possibility exists for more dramatic increases in collections, Williams suggests. "We have gone from collecting $20,000 a month to upwards of $80,000, and we still have days when only 50% of patients who owe co-pays are brought to the discharge station."
Although there are many days when that figure is 80% or even 90%, these outliers bring the average down to "about 60% or 65%," she says.
"As we tighten our process," Williams adds, "there's the potential to get much more of this low-hanging fruit."
[Editor's note: Tina Williams can be reached at [email protected].]
Nursing accountability and a strong financial commitment from hospital administration are fueling a successful point-of-service (POS) collections program in the pediatric and adult emergency departments (EDs) at Vanderbilt University Medical Center.Subscribe Now for Access
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