Cut costs and improve quality
Admitting patients into hospice care is a significant challenge because of issues related to timing and making the first contact with the patient a pleasant experience.
"It’s also important because if you do it right, you’ll probably get a higher percentage of patients referred to hospice to sign on for hospice services," says Martha Tecca, MBA, president of Perforum in Lyme, NH. Tecca has spoken at national conferences about optimizing the admissions process in hospice care. Perforum provides performance management services through benchmarking and works with individual hospice agencies.
Drawing on her experience with benchmarking hospice performance data and developing best-practice guidelines, Tecca offers these suggestions for improving the admissions process:
• Make the intake effective.
Hospice managers need to ask themselves these questions:
— How do we make sure we’re picking up the telephone without letting it ring too many times?
— How can we ensure our intake staff are polite?
— How do we prevent patients and family members from being transferred to people who will repeat the same questions they were asked by the first person who answered the telephone?
— What is our admitting intake strategy in terms of what kind of staff will first see the patient?
"For example, we’ve had clients who were committed to having a non-critical person, a marketing person, make the first visit to the patient," Tecca says. "The belief was that this person would have a way of speaking openly and really listening well to the patients, helping the hospice put forward the best foot."
Some hospice managers also believe that nurses have a mindset focused on solving problems and are committed to a certain approach, rather than having a flexibility that might improve hospice-patient relations, Tecca adds.
Another intake issue is related to timing: How quickly should a hospice send out someone to visit a patient or family member after the first telephone call comes in? "The two schools of thought are that, one, we send somebody out as quickly as possible without asking very many questions of the person who called us," Tecca says. "The other approach is to talk with the caller to help them get through their current crisis and delay having them act on their need to get somebody into hospice."
The philosophy behind the first approach is that a prospective patient’s questions can be answered in person, and it’s more likely the patient and family would engage in hospice services after an in-home meeting, Tecca explains. The philosophy behind the second approach is that if a patient calls and is not yet ready to switch to hospice, then the hospice is serving the patient’s best needs by giving the patient and family time, Tecca says.
One organization with which Tecca has worked found that switching to the first approach — sending someone out to the home after the first call — immediately worked better, contributing to the hospice agency’s growth from a daily census of about 200 to more than 400 within two years, she says.
Quicker visits mean more admissions
"They found they previously were doing a lot of consulting support over the phone, and that turned people away rather than turn them more quickly to hospice care," Tecca says. "So, if you ask the caller fewer questions, get the basic information, and then say, Gosh, we’ll be right there,’ you have a much higher chance of turning that referral into an earlier admission that is more appropriate and has a longer length of stay."
With the new approach, the hospice changed the staff’s mindset to one of "What can I do for you now, and let me come solve your problem," Tecca says.
• Improve admissions staff productivity.
Expediting the referral-to-admissions process is one side of the coin; the other is monitoring and improving productivity among admissions staff, Tecca says. "In addition to growth, there’s the productivity side," she explains. At one hospice agency, the inpatient admissions staff used to have a list of questions and a set of criteria to check off when potential clients called, Tecca says. "The amount of work they had to go through for each patient was much more substantial before they changed the process to a simple Where are you? Can we send somebody out there?’" Tecca says. That change has shortened the time admissions staff spend on the phone, improving their productivity.
Hospice organizations can assess their productivity by looking at outcome indicators and other performance measures. For example, one measure might be the percentage of patients who are visited within 24 hours of receipt of the referral; another might be the percentage of these potential clients who are visited, Tecca says. "What percentage see an admission nurse within X period of time?" Tecca asks. "You can do correlations between those indicators and other measures of quality to try to understand whether it does matter that you get out to visit the patients quickly."
Another productivity improvement strategy, and a way to cut costs, is to have someone in the intake process involved with claims processing or vice versa, Tecca suggests. "So when it comes to following up on claims, concerns, or understanding [payment] details, you have a person, and not an entirely different department, who can come up to speed with this patient’s details," Tecca says.
Bring intake, claims processing together
The logic is that during the admissions process there would be someone to check Medicare, insurance eligibility, and other financial details in order to streamline the admissions process and make things easier for clients, she adds. "So one individual who knows enough about patients and billing from the beginning will be involved in insurance verification," Tecca says. "Then if problems come up concerning the billing process, it’s useful for somebody, an RN or someone else involved with both sides, to help out with the claims processing and insurance verification details."
• Create a best admissions model for the organization.
At the back end of the admissions process, a hospice organization should determine how admissions visits are done, Tecca advises. "About half of agencies use an admission nurse model, where an admission specialist goes out and does all of the admissions," Tecca says. "An admitting specialist will no longer do typical visits, and will spend two to four hours rather than 45 minutes to two hours at each visit."
The alternative strategy is to have a primary nursing model in which one nurse visits the patient during the admission process and then follows that patient throughout the patient’s care, Tecca says. "That model may create productivity challenges because those nurses have to manage some two-hour and one-hour visits, along with smaller visits," Tecca notes. "Really, it’s my observation that which one of those two models works best depends on the overall philosophy and strategy of the organization," Tecca says. "Both can do really well from the standpoint of patient care and productivity."