Countless news stories are reporting on what clinicians are facing in overwhelmed emergency departments (ED) and intensive care units during the COVID-19 pandemic. However, few people realize what is going on behind the scenes in patient access.

“We are adjusting to a new normal every day,” says Craig Pergrem, senior director of revenue cycle, onsite access, and financial counseling at Winston-Salem, NC-based Novant Health.

At Memorial Hermann Health System in Houston, fluctuating patient volumes have driven many changes. “This has impacted staffing needs and job responsibilities,” says Shannan Dillard, director of patient business services.

Instead of working at their usual cubicles or registration areas, patient access employees now are stationed at triage tents outside facilities. “We are working elbow to elbow with our ED clinical teams,” Pergrem reports.

The health system’s emergency operation plan for patient access as a whole is in effect. The plan is fine-tuned by each facility’s patient access department, based on its unique needs and scope of services. A large hospital may need five extra ED registrars, for instance, while a smaller hospital needs two.

Patient access has four different levels of staffing planned, depending on the severity of the outbreak. “This includes our own staffing being reduced due to illness,” Pergrem explains.

The department created “pandemic” codes to allow some employees outside of patient access to register patients. These employees (who normally handle preregistration, preservice collections, and scheduling) receive some online training first. They can use critical access sign-ons, allowing them temporary access to register patients. “This allows them to come to a site in need of assistance and immediately have an impact in registration of our patients,” Pergrem says. Once the pandemic abates, the sign-ons can be canceled when appropriate.

Nonurgent surgeries and procedures were rescheduled. Patient access employees who normally would work those accounts have been moved elsewhere. “The big drop-off in volumes frees up additional staff to assist where needed,” Pergrem observes.

Face-to-face encounters always have been an integral part of the job of patient access. The following are three examples of how in-person processes are handled remotely at Novant Health:

Consents and financial counseling for admitted patients are handled by phone. Typically, these are conducted at bedside. “We are now looking at whether we need to send team members to rooms for signatures,” Pergrem says. At press time, the department still was evaluating if state agencies will allow some consents to be handled by phone during the pandemic.

Registrars are explaining required signatures for the Medicare Outpatient Observation Notice (MOON) and Important Message from Medicare; nurses are obtaining signatures. “With agencies still requiring signatures, we are telephonically explaining these to the patient or family,” Pergrem reports.

Nurses obtain the actual signatures from patients at some point during the day. This helps save personal protective equipment, since only one person is going into the patient’s room. Later, registrars notate in the system that the patient’s signature was obtained.

Preregistration and scheduling are no longer handled on site. Hundreds of employees were sent home to work remotely. “Our centralized billing office, which houses them, has gone from 300 to 14 team members working on site,” Pergrem says.

The onsite employees perform any task that cannot be handled in a home setting, such as sorting through incoming mail and printing materials that require mailing. “This allows business to continue to flow normally with a tweak in timing,” Pergrem adds. Keeping up morale during the pandemic has become a top priority for patient access. “Our biggest challenges are meeting with team members to ease their own fears,” Pergrem says. Mainly, patient access leaders are doing this by cautioning employees to obtain information only from reliable sources (e.g., the Centers for Disease Control and Prevention website and the health system’s own intranet site).

Memorial Hermann’s patient access department is no stranger to disasters; the area regularly faces floods and hurricanes. But with COVID-19, “the most difficult challenge we have seen is less about tasks and the ability to staff our areas. It is more about keeping the team morale positive,” Dillard says. “Not only are we balancing multiple changes in volume and needs at the facilities, we are also balancing how we handle our personal lives and needs of our families.”

Leaders are in constant communication with staff to alleviate concerns. New processes for ED registrations of respiratory patients and rescheduling of elective cases were shared immediately. “Every possible change that can be predicted is reviewed throughout the day,” Dillard explains.

There are other ways processes have changed in patient access departments:

Staff re-allocation. At Los Angeles-based Ronald Reagan UCLA Medical Center, patient access is working hard to maintain enough staff in registration areas onsite. “This is a top challenge,” says Drew D. Totten, principal administrative analyst for patient access services.

At the same time, the department is busy configuring equipment and processes to allow other patient access staff to work from home. “We’re working to ensure there’s adequate work for the staff to do remotely,” Totten adds.

Postponing planned “go-lives.” The patient access department at Mt. Graham Regional Medical Center in Safford, AZ, was in the process of a computer conversion, with a go-live date of April 1. Travel restrictions prevented the vendor from working on site. “The decision was made to postpone it,” says Julie Johnson, CHAM, FHAM, director of health information management and patient access.

Putting contingency plans in place to ensure adequate staffing. Since someone takes the temperature of every patient access employee before he or she enters the hospital, there is a chance the department suddenly will find themselves short-staffed.

If anyone is sent home, that means someone has to cover for that person without notice. At Mt. Graham, a designated person is assigned for this. “We have one on-call employee to cover any shift,” Johnson notes.

Directing patients to handle many tasks remotely. “We are emailing, faxing, mailing, and signing patients up over the phone for our patient portal to keep foot traffic to a minimum,” Johnson reports.

Even lunch breaks have changed. Instead of socializing in the cafeteria, staff call in to-go orders to pick up. “We do this on a staggered schedule to avoid congregating in the department,” Johnson adds.

Editor's Note

This is a special issue of Hospital Access Management on how the COVID-19 pandemic has changed patient access. Almost overnight, registration, scheduling, financial counseling, and collections all were upended. We report on how staff are handling different roles, working in different locations, and using different tools to complete their jobs. A future issue will cover long-term changes for the revenue cycle, and how hospitals are staying financially viable.