Modify patient care model to reflect changing needs

Audits, direct reports key to success

[Editor’s note: This is the first of several articles Hospital Access Management will publish over the next several months looking at how various facilities are handling the centralization vs. decentralization dilemma, as well as related issues concerning patient-focused care.]

Will the debate over whether to centralize or decentralize access functions ever be resolved? That’s what access managers across the country ask themselves as they help their organizations swing in one direction and then pick up the pieces when the decision is made to go back the other way.

Can "patient-focused care" — whatever your definition of that is — be compatible with cost- effectiveness and high accuracy rates?

Kari Cornicelli, FHFMA, CPA, director of financial planning and support services for Palomar Pomerado Health System in San Diego, has had experience on both sides and with "changing the model midstream," she says.

That experience, Cornicelli notes, has taught her that two elements are essential to a successful patient-focused care model:

• registrars who maintain a direct reporting relationship to the access department;

• a strong audit function.

Her health system’s smaller acute-care facility, the 109-bed Pomerado Hospital, blended the two models so that admitting was decentralized to the patient floors, but the centralized reporting structure stayed in place. Registrars work on the patient units but report directly to the admitting manager as well as indirectly to the nurse manager on the floor.

"This model works very well," she says, "because we’re able to make sure training is kept up to date, and we do an audit process on all the accounts so we know everything going to the billing office is good."

The doubling of the hospital’s census in the past 12 to 18 months added another challenge, Cornicelli says. "We didn’t really have enough staff for growth."

At its other acute care facility — the 332-bed Palomar Medical Center — the health system took another approach. In addition to decentralizing the entire admitting department, it also decentralized the reporting structure and did not maintain an audit function, she explains.

"It was harder, because there was not one person who was responsible [overall] for the registration process," Cornicelli adds. "The staff did become part of the unit, but didn’t have a formal tieback to admitting."

The health system recently changed the model, she says, by taking just enough staff — nine FTEs — to provide a roving admitting team. Previously, at least twice that many employees were deployed on the patient floors and performed both admitting and unit secretary duties.

"The roving admitting team members still go to the patient and do bedside registrations but won’t stay on the unit and answer phones and be the unit secretary," she says. "They go back to admitting and report and process the data. Now they report to a centralized admitting manager, where before they reported solely to a nurse manager."

Under the new plan, outpatient admitting remains completely decentralized, but the emergency department, like inpatient admitting, operates under the new hybrid arrangement, she explains.

The key to success, Cornicelli emphasizes, is the audit function, someone doing a quality review of the work, and doing ongoing training. "That needs to happen no matter what," she says.

The admitting audits work like this: Before the registration document goes to billing, it is reviewed to make sure the demographic and insurance information is correct, that there are copies of the insurance card, and that the right forms, such as advance directives, are signed.

The employee doing the auditing varies at the two facilities. At Pomerado, it’s the person doing insurance verification, and at Palomar, it hasn’t yet been decided who will handle the audits, Cornicelli says. But she adds that it won’t necessarily be a supervisor.

"It’s really important that you monitor the [overall] program on an ongoing basis and make changes accordingly," she points out. "Don’t implement it for a year and let it go. You need to always be evaluating and be willing to change according to the needs of the hospital."

Having enough staff is crucial when you’re dealing with both the admitting and indirect patient care functions that are part of any patient-focused care model, Cornicelli stresses. "You must have enough staff to match a fluctuating census."

Meanwhile, she says she strongly believes that admitting is a financial function and that admitters need to report to a financial manager, rather than to nursing. "Financial issues just aren’t [nurses’] first concern, and I don’t think they should be."