HMGTY 240 DISC PART 1

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a relatively new profession that’s seen major growth as demand for advocates has increased over the past decade, says Trisha Torrey, founder and executive director of the Alliance of Professional Health Advocates (APHA), a membership support organization for indepen- dent patient and health advocates in the United States and Canada.

She says APHA has grown from 30 members when it was founded in 2009 to more than 600 today.

But what is the incentive for hospitals and health systems to work with these additional team members in healthcare?

Working with patient advocates could be a critical component to ensuring your patients’ medical and financial engagement at your organization.

atient advocates—individuals who guide patients through healthcare experiences, including care goals and financial responsibilities— are increasingly becoming part of patient care teams.

That includes on-staff patient counselors inside hospitals, as well as independent patient advocates,

P Engagement | Patient Advocates

HAPPY PATIENT, HAPPY HOSPITAL: INCREASE PATIENT ENGAGEMENT WITH ADVOCATES Patient and financial advocates are increasingly becoming part of patient care teams. Don’t miss the opportunity to boost patient engagement through advocacy.

By Alexandra Wilson Pecci

24 healthleadersmedia.com n March/April 2019

Engagement | Patient Advocates

“You could hang out your shingle tomorrow and say you are a patient advocate,” she says.

However, that is changing. In May 2018, the nonprofit Patient Ad- vocate Certification Board certified its first cohort of board-certified patient advocates who passed a na- tional exam. The Patient Advocate Certification Board certified 337 patient advocates in its first two exam cohorts.

In addition, APHA runs the on- line AdvoConnection Directory, which helps patients find an ad- vocate based on their needs and location. Torrey says about half of APHA’s members are included in the directory, and in order to be listed, advocates must meet certain criteria, such as having liability insurance, certification, or a background check.

Despite the profession’s growth, not all patients can afford to hire a team of people to guide them through their healthcare journey. Independent advocates’ rates range from a low end of $75–$100 per hour, to a high end of more than $400 an hour, says Torrey.

Such costs may be prohibitively expensive for some of the neediest patients.

Bayer agrees that the people with the greatest need for an advo- cate are often those who can afford it the least.

“I think when it comes to clar- ification around care and getting your concerns addressed, it tends

How advocacy works Advocacy work can be divided into two broad categories: patient ad- vocacy, which helps patients nav- igate health-related issues; and financial advocacy, which helps patients deal with billing, insur- ance, and other money matters.

Some advocates are unpaid family members or friends who ac- company the patient to medical ap- pointments, while some work for a hospital or health system as part of the patient experience or ombuds- man departments.

Advocates who work for hos- pitals and health systems help patients navigate the care they re- ceive within that system, as well as any associated financial responsi- bilities. They do so for all patients, free of charge, as part of their in-hospital services.

Stephanie Bayer, JD, senior di- rector of patient experience at the Cleveland Clinic, says, “Though it is required to have processes for patients to raise concerns without reprisal, it is not reimbursed.”

Still others work for nonprofit advocacy organizations, like the

Patient Advocate Foundation, which is funded through grants and donations. PAF services cost nothing to patients, says Christine Wilson, vice president for advo- cacy communications for the National Patient Advocate Foundation, the advocacy affiliate of the PAF, which is a nonprofit that helps patients with chronic, life-threatening, and debilitating diseases to access care.

Patients can also hire advocates who are indepen- dent professionals. These independently hired advo- cates work for the patient, and patients pay for the advocate’s services out of their own pocket.

Advocacy’s growth Because the independent advocate profession is so new, there aren’t currently any educational or certifi- cation requirements, says Torrey.

TAKEAWAYS

> Advocates can help foster communication between patients and providers.

> Welcome external advocates as an extra layer of protection against noncompliant patients and unpaid bills.

> Work with advocates to make sure patients understand their care plans and financial responsibilities.

“I THINK [ADVOCATES ARE] ALWAYS NEEDED, ESPECIALLY WHEN PEOPLE

DON’T HAVE THE HEALTHCARE BACKGROUND TO UNDERSTAND THIS COMPLEX [HEALTHCARE] LANGUAGE.”

healthleadersmedia.com n March/April 2019 25 STEVE DEBENPORT/GETTY.COM

instance—can only help patients when it comes to improving their outcomes and possibly avoiding readmissions, says Torrey.

“To have someone that’s keep- ing that person from being readmit- ted with no cost to the hospital?” Torrey says. “That’s enormous.”

Similarly, financial advocates can handle medical bills when the patient is not equipped to do so.

“If somebody is overwhelmed by their bills, they tend to set them aside. They don’t deal with them, especially if they’re sick,” Torrey says. “They can’t process them.”

Once a financial advocate steps in, though, the hospital can work with the advocate to set up patient payments.

“It may be the only way [health- care organizations are] going to get paid,” Torrey says. “Much better to deal with a financial advocate who can make sure you get a check than to just watch somebody go bank- rupt and you never get paid at all.”

nurse call button that took too long to answer, or be an annoying extra person in the exam room.

But that perception has changed, says Torrey. Bayer adds that hospitals should welcome advo-

cates the same way they welcome family members. “I think anyone who can help clarify goals of care

and clarify expectations would be welcome to the con- versation,” Bayer says. “Hospitals want our patients to have good experiences in addition to strong and qual- ity care.”

For instance, advocates can make sure patients un- derstand and follow discharge instructions, potential- ly reducing complications and readmissions. Torrey says there isn’t research specifically linking patient advocates to better outcomes, but data suggests that engaged patients have lower adverse events.

For instance, research published December 2018 in The BMJ finds that a program including parents as active participants in pediatric unit rounds at eight hospitals reduced preventable adverse events by 38%.

Bayer says that Cleveland Clinic is currently ex- ploring quantifying the success of their ombudsman office, which serves as the role of a patient liaison, but doesn’t have data it can share yet.

Having an advocate on hand who keeps patients engaged in their care—who understands and en- sures compliance with discharge instructions, for

to be the people that have lower levels of medical literacy [with the greatest need], which also tend to be people who don’t have a lot of resources,” she says.

That’s why it’s important for hospitals and health systems to not only welcome independent ad- vocates and those from nonprofit organizations, but also offer these services themselves.

“I think any advocate is im- portant, whether it’s the hospital side or independent,” says Bayer. “I think they’re always needed, especially when people don’t have the healthcare background to un- derstand this complex [healthcare] language.”

Welcoming advocacy Torrey says in the early days of inde- pendent patient advocacy about a decade ago, most clinicians “want- ed little to nothing to do with us.” The perception was that advocates would be tattletales, reporting every

26 healthleadersmedia.com n March/April 2019

Engagement | Patient Advocates

“If a doctor or nurse or another care provider feels that they’re not able to connect with the patient, or the patient doesn’t have that same level of understanding, they can call us, and we can come bedside and help,” Bayer says.

Similarly, hospital or system-based financial advo- cates and counselors (the terms are often used inter- changeably, depending on the organization) can help patients feel supported financially while helping the organization get paid.

For instance, the financial counselors at UCHealth in Colorado do more than set up payment plans for patients.

Its roughly 65-person financial counseling team also provides patient education about costs and pay- ment responsibilities; state and financial assistance program screening; and financial assistance pro- gram application help, working closely with patient representatives and social workers, says Matt Kelly, UCHealth’s senior director of patient access. In addi- tion, financial case coordinators are embedded within some of its oncology and transplant departments to help patients navigate the complex and ongoing finan- cial responsibilities that come along with cancer and organ transplants.

Plus, “many UCHealth locations provide social workers who can meet with patients and assist them with both financial concerns as well as additional ser- vices outside the hospital,” he says.

Lipkis-Orlando says that the patient advocates at Massachusetts General Hospital sometimes intervene with financial matters, actually helping patients to lower, eliminate, or delay a bill in the interest of “pos- itive patient relations.”

She says the hospital’s multidisciplinary Patient Revenue Advocacy Group meets monthly to review cases where patients have requested that their bills be reduced or eliminated.

Wilson agrees, saying the PAF doesn’t have adversarial relation- ships with hospitals or insurers; rather, they have productive partner- ships and good relationships with everyone they work with, resulting in positive outcomes for all parties.

“Instead of a patient who’s got a pile of bills that they won’t even open, you’ve got somebody who’s helping them understand what those bills are, how to pay for them, [and] working with the hos- pital and provider,” she says.

In-house advocacy Since patients often have complex care needs and their care is fol- lowed by multiple teams, some- times communication among providers may be challenging, or patients may not fully understand what the care team is telling them, says Robin Lipkis-Orlando, MS, RN, NE-BC, director of the office of patient advocacy at Massachusetts General Hospital.

Other times, patients and care teams have differing opinions about the best path forward, and patient care advocates can help mediate. “What we do more and more is help to foster communi- cation between patients and their medical teams,” she says.

In addition, internal advocates can engender patient loyalty and positive experiences.

“Advocates can help make sure people return—that people get what they need and feel comfort- able and come back to us again,” says Bayer.

Cleveland Clinic’s ombuds- man’s availability is advertised throughout the hospital, from the admission booklet to brochures, and is available any time patients need extra guidance.

“We’ll make sure they are get- ting information in a language that is clear to the patient and their family to allow them to make the right decisions for them,” Bayer says. “An important component of

a good patient experience is mak- ing sure that we are part of that clarity of the communication.”

She points out that hospi- tal-based advocates can deliver quick results for patients because they have intimate knowledge of the system where they work; they know who and where to go to get patients’ needs met.

If a patient is unsure about a treatment and wants to look for other options, internal advocates can sometimes direct the patient to other services that are provided within the system. They also work closely with other partners with- in the organization, like bioethics and spiritual care, meeting the ho- listic needs of patients.

At Mass General, the patient care advocates are also clinicians— nurses and a social worker—which means they can help translate some of the medical terminology a patient is struggling to under- stand or talk to a care team on the patient’s behalf. They visit patients at the bedside and can accompany patients to medical appointments.

Internal patient care advocates are also helpful to doctors and nurs- es. If a care team is concerned that a patient needs additional guidance, they can contact the ombudsman or advocacy office right away, rath- er than let potential problems or miscommunications fester.

“[IT’S] MUCH BETTER TO DEAL WITH A FINANCIAL ADVOCATE WHO CAN MAKE SURE YOU GET A CHECK THAN TO JUST WATCH SOMEBODY GO BANKRUPT AND

YOU NEVER GET PAID AT ALL.”

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They can also be the patient’s eyes and ears at the bedside, urg- ing providers to double-check a medication or wash their hands upon entering the room. Such in- terventions shouldn’t be viewed with skepticism on the part of the hospital, though, says Torrey. In- stead, it’s just one extra layer of safety checking that’s provided at no cost to the facility.

“What does that do but cut down on errors?” Torrey asks.

Independent financial ad- vocates can also be a boon for patients and hospitals. While hospital-based advocates can help patients navigate medical expens- es from their own organization, in- dependent financial advocates can take a more holistic approach to a patient’s financial needs. Wilson says most of the patients that the PAF works with are seeking some type of financial help.

Independent advocates can do things like organize and review bills from multiple settings; ensure bills are correct; work to get insurance claims approved; or make sure pri- mary and secondary insurances are being used to their fullest.

Whether an organization employs its own advocates or welcomes conversations and en- gagement with outside advocates, it’s clear that a growing number of hospitals and health systems see the value of having an extra person available to guide patients through their clinical and finan- cial responsibilities.

“Our goal is to make sure that health outcomes are the best they can be, and having patients and families understand and collab- orate with us in their care is the best way to have good health outcomes,” says Lipkis-Orlando. “Sometimes you need people to help you to do that.”

Alexandra Wilson Pecci is the revenue cycle editor at HealthLeaders. She can be reached at apecci@ hcpro.com.

important role regarding the “longitudinal component of care.”

“I think the independent advocate probably is most helpful when a patient has a very complex situa- tion and they’re seeking care from multiple sources,” she says.

Because of that independence, privately hired ad- vocates can work with the patient across care settings, and throughout their entire journey, with whatever elements of their care they need.

Independent advocates, Torrey says, do “whatever it takes to help the patients feel like they are driving their own healthcare decisions, getting the most out of the system, and hopefully, improve their outcomes. Even if the only outcome is the patient feels better [about their experience], that’s a good outcome.”

If they find that a high bill was coupled with care that didn’t go as planned, “we will do our best to find some way to meet patients’ re- quests,” she says.

Other times, she says the advo- cates will ask financial services to put a bill on hold while they inves- tigate the quality of a patient’s care.

Independent advocates can help too While hospital-based advocates play a role in facilitating care within a particular organization, Bayer says independent advocates can have an

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