Educate staff on talking to confused patients

Good communication is key

A patient comes in with a mass of misinformation about coverage and benefits, completely unaware of hospital procedures and federal requirements. In situations like this, information is the patient access employee's best friend.

To be truly comfortable responding to a patient's misperceptions, though, the staff person has to fully comprehend them.

"We openly discuss patient concerns in staff meetings to better understand what the issue is and how to resolve it," says Aaron McDaniel, director of patient access at Palomar Pomerado Health in San Diego. "Sometimes it's as simple as looking up information on the web, doing a short inservice, or providing scripting that will help them calmly resolve a difficult situation."

All of these strategies involve communication. "The leadership team needs to be coaching their staff regularly," says McDaniel. "The staff need to feel safe to bring up concerns one-on-one or in group meetings. And lastly, they need the knowledge to be able to communicate back with patients in a customer-focused way." The department uses these six approaches:

1. Scenario-based education is used.

This is a similar approach to role-playing, but it involves a facilitator. "All of our scenarios are developed from the personal experience of leaders down to frontline staff," says McDaniel. "We talk in real-world scenarios because they are easy to relate to. These can often be applied in the future exactly as we discussed in our meetings."

McDaniel says that he has had better success with the scenario-based approach than with the role-playing that previously was done.

"In my mind, role-playing is part acting and part training," he explains. "Many people are uncomfortable playing the acting role. I have gotten both resistance and reluctance when trying to role-play, because it calls on a skill set many people do not have or have not developed."

Scenario-based education, on the other hand, puts people in a mock work environment where they are already comfortable. They are dealing with scenarios they have probably seen and experienced many times.

The facilitator of the training is the one who creates the scenario. Then, the staff are invited to participate in reviewing the learning elements. "The scenarios normally come from the staff and sometimes the supervisors," says McDaniel. "These are hands-on incidents with a customer that warrants an education session."

2. Wrong assumptions are corrected.

McDaniel says the most difficult customer service situations are usually the ones in which patients assume something incorrectly, based on their limited knowledge of health care or hospital procedures.

For instance, with the rise in health care savings and reimbursement accounts, many patients claim they do not have to pay their copays because they have a spending account.

"But much like any other spending account they often have from their employer, like one that covers day care for children or prescriptions, these plans require the patient to pay the copay and seek reimbursement from their spending account," says McDaniel. "These scenarios require us to explain to the patient their own benefits."

Other patients make assumptions about what their insurance covers. "Rarely do they read the benefits information they receive from their employer," says McDaniel. "When my staff have to explain why their coinsurance or deductible amounts are so high or why a service is not covered, it puts the staff in a delicate situation again of having to explain the patient their own coverage."

Emergency department patients sometimes assume they will be evaluated and treated immediately simply because they are in the ED. "They do not understand that, for most hospitals, the emergency room is the largest source of inpatient admissions for the hospital," says McDaniel. "Long wait times can result in long waits to get them in a bed in the hospital."

For all of these situations, patient access staff are put in a position of correcting the patient's misinformation. "It's difficult to have a conversation when one party has all the knowledge and the other has limited or no knowledge," says McDaniel. "We need to build that trust with the patient that will help us to empathize, and then explain the issue."

3. Clarifying questions are asked.

This helps patient access staff understand the underlying issue. When a patient in the emergency department refused to give his real name, an experienced patient service representative went in to complete the registration. She advised the patient that she was concerned that the name he was using was not accurate and asked him if that was his legal name.

The man told her that he didn't want to give his real name, saying that the hospital had to treat him anyway. The representative asked him why he did not want to give his name. Was he concerned about his privacy? Did he not want someone to know he was in the hospital? Did he not want to involve his insurance, or was he unable to pay for services? Was he aware that the hospital offered financial assistance?

By asking these questions, the representative discovered that the man was worried about being able to pay for his visit. She was able to get to the underlying cause of the patient's concern and work with him on a resolution.

"The patient was uninsured on a limited income. By gently probing and clarifying, she was able to convince the patient to give his real name and fill out an application for financial assistance," says McDaniel. "This skill can be applied in just about every customer service scenario to help get you to the root cause."

4. Staff restate the issue to be sure the patient understands.

This assures the patient that his or her problem is understood and will be resolved. Recently, an uninsured patient became irate about the cost of care during a conversation with the financial counselor.

"The uninsured patient was upset when a summary of charges incurred part of the way through their stay was discussed," says McDaniel. "The patient went on to complain about the cost of care, how were they going to pay for it, and the government's failure to help the uninsured."

The financial counselor was able to "reel in" the patient by restating what she understood the issue to be. She stated, "I understand that health care is expensive. You are clearly very concerned and would like to take care of this. Did I understand you correctly? I would like to make you aware of your options. You may be eligible for one of many government programs, such as County Medical Services or Medicaid, or even our own financial assistance program that can reduce the cost of your care substantially. I would like to first start you off with assisting you on completing the applications for the government programs I mentioned. The forms should take you less than 30 minutes to complete and require some documentation on your part to complete the approval process. Once you complete the application, I can get it to the county worker and expect a pending approval within days. This is the best option for someone who may need follow-up care, so you are not worried about how you are going to pay for your care every time you need to see a doctor or come to the hospital."

In this particular case, the financial counselor was able to calm the patient by reiterating to him what she understood his concerns to be. "She got confirmation on her statement. Then, she helped to set expectations by going through the steps and detailing timelines for him," says McDaniel. "She ended by giving him the ideal outcome, which gives him his "what's in it for me?"

What the patient really wanted was to get his health issues resolved. "By getting coverage through a government program, he can do that. He's able to focus on getting better rather than on figuring out how to pay for it," says McDaniel.

5. The role of financial counselors is explained.

When an inpatient receives a visit from the hospital's financial counselor, this sometimes results in a misunderstanding. The patient may become upset and ask to speak to a supervisor or manager.

"The first reaction to someone asking questions about their finances is often met with resistance," says McDaniel. "Health care has not always done a good job in explaining the costs to the patients, so our financial counselors help to fill that need. The resistance will need to be overcome."

On one occasion, an uninsured patient flatly refused to speak with a financial counselor. The onsite manager made a visit to the patient to explain that the financial counselor is an advocate.

The patient began to understand that the counselor really was on his side and would try to help the patient find funding, get eligibility from one of many government programs, or get him a payment plan or discount.

"The manager then met with the financial counselor, reviewed the issue, and then successfully met with the patient," says McDaniel. "The financial counselor was then able to resolve an identical situation the following week on her own without the manager."

6. Scripting is used.

"This is an important part of our department and is often documented in department procedures," says McDaniel. "Just recently, we began a new program to improve courtesy issues with patients and the multiple staff who enter their rooms."

Staff were given a sample script of what to say to the patient, in order to determine whether this was an appropriate time to complete the registration, and to have a financial discussion. "After presenting the staff with a model script, I asked them what they currently say. Several people offered their own personal scripts, which were not too different from what I had drafted," says McDaniel.

This brought home the point that the message, not the exact words used, is the important thing. "I encouraged the staff to try and say the same thing my script said, but using different words," says McDaniel. "If the staff are allowed to say it in their own way, they are more likely to really 'own' it and make their words effective."

Once staff get comfortable, they are then able to "flex" their conversations with patients and families. Since this sounds more natural, it's more effective than repeating words of a script verbatim. "At our staff meetings I ask for volunteers to offer their own version of the scripts," says McDaniel. "Sometimes they are far better than what I came up with."