Dhs ambulatory care network harbor ucla

Eliminating Scheduling NON-DHS Patients to DHS Outpatient Facilities

Advocacy Plan

Harbor-UCLA Medical Center Improving Patient-Centered Care

By Eliminating Scheduling NON-DHS Patients to DHS Outpatient Facilities

Nicole R. Codd

Mount Saint Mary University

July 16, 2017

The Problem

Harbor-UCLA hospital emergency staff is not efficiently identifying NON-DHS managed care patients and continues to schedule appointments that negatively effects patient-centered care and contributes to lost revenue for the medical center. When a patient arrives at the emergency room, a nurse performs the intake, and an ED registration staff obtains patients information to determine medical coverage to cover the ER visit. It is important to identify the medical coverage accurately and correctly because ED providers always advise a follow-up appointment after an Emergency Room visit.

The Emergency Department staff create appointments for NON-DHS managed patients that fill appointments that should be filled with DHS-managed care patients. When an NON-DHS managed care patient receive medical services at Harbor-UCLA Medical Center, the hospital does not receive any payment. NON-DHS managed care patients have primary care providers that receive capitation payments every month for medical services. Harbor-UCLA Medical Center are treating NON-DHS patients for free when they arrive at Harbor-UCLA outpatient clinic. At times, outpatient staff can recognize the error and redirect the patient to their primary care provider, which the patient can become irritated that leads to poor patient care. Harbor-UCLA Medical Center have at least 2% of NON-DHS managed care, self-pay and out-of-county that have appointments to outpatient clinics.

Harbor-UCLA Medical Center’s emergency department have over 7,136 visits per month with patients that have all different types of health insurance (DHS-Office of Planning; DHS Housing for Health). The emergency department accepts all insurances. However, Harbor-UCLA emergency department should only schedule follow-up appointments for DHS-managed care patients to improve patient-centered care and increase revenue.

Current Policy and Procedures for NON-DHS PATIENTS

The Emergency department have several policies in placed to avoid scheduling NON-DHS patients’ appointments to outpatient clients:

1. During registration, the Registration staff inputs NON-DHS primary care provider (PCP) information into the patient’s accounts and the information is available for Emergency department staff such as the doctors, nurses and clerks.

Problems with this procedure:

a. Registration staff not properly identifying the patients’ insurance correctly from the Health Care Eligibility Benefits. Registration staff putting incorrect information.

b. Clinical ED staff (providers, nurses and clerks) bypass the insurance information and schedule NON-DHS patients to outpatient clinics.

c. No indicator pop-ups to direct the clinical ED staff to view insurance information before scheduling NON-DHS managed care patient.

2. When the ED registration staff has identified the patient as a NON-DHS patient that ED registration staff will print out the Health Care Eligibility Benefits (270/271) statement with the NON-DHS patient’s primary care provider (PCP) and telephone. The ED registration staff will have attached a neon orange half sheet form to Health Care Eligibility Benefits (270/271) statement stating that “this is a NON-DHS patient DO NOT SCHEDULE A FOLLOW-UP APPOINTMENT”. The form will be placed in the patient’s chart by the ED registration staff for the ED clinical staff. Upon discharge of the NON-DHS managed care patient the ED clinical staff will provide the patient with the forms along with the discharge papers. The ED clinical staff will explain to the NON-DHS managed care patient who their primary care provider is to call for a follow-up appointment.

Problems with this procedure:

a. Many times, the ED registration staff do not provide the ED clinical staff with the print out of the Health Care Eligibility Benefits (270/271) statement with the NON-DHS patient’s primary care provider (PCP) and telephone with the attached neon orange half sheet form stating that “this is a NON-DHS patient DO NOT SCHEDULE A FOLLOW-UP APPOINTMENT”. The ED clinical staff will be unaware that the patient is a NON-DHS patient and schedule a follow-up appointment to a DHS outpatient clinic.

b. The ED clinical will bypass the form that is placed in the patient chart that provides the NON-DHS managed care form that has the information and schedule the NON-DHS patient a follow-up appointment to a DHS outpatient clinic.

DHS

3. After the first 2 procedure are completed, the ED registration staff manually placed a

Icon on all patients that are eligible to be schedule for follow-up appointments at DHS outpatient clinics.

Problem with this procedure:

a. Registration staff not properly identifying the patients’ insurance correctly from the Health Care Eligibility Benefits (270/271).

Currently, I work in the Financial Insurance Verification Unit; this unit financial clear patients accounts for outpatient clinics appointments. Many of Harbor-UCLA Medical Center’s patients have Medicare, unrestricted and restricted Medi-cal and special programs that cover specific medical conditions. When I have a NON-DHS managed care patient account to financial clear, I must call the NON-DHS patient to inform he/she will not receive medical services at Harbor-UCLA Medical Center. Then I inform the patient if they want to receive medical services at Harbor-UCLA Medical Center they have 2 medical coverage options:

1. The patient must obtain an authorization from their primary provider/insurance company to receive medical services at Harbor-UCLA Medical Center.

2. The patient can decide to contact Member Services or Health Insurance Company to change their primary care provider to Harbor-UCLA Medical Center managed care network to have access to DHS facilities.

About 50% of the time the NON-DHS patient will change their primary care provider to Harbor-UCLA Medical Center managed care network to have access to DHS facilities. The other 50% of the NON-DHS patients will cancel their appointment or become highly upset that they were not inform before they were schedule for an appointment for a procedure. It is important for Harbor-UCLA Medical Center’s Emergency Department to adopt this alternative, the RED BOX WARNING indicator it will clearly state *NON-DHS PATIENT* unable to schedule appointment; contact ED registration. If the ED provider insists on scheduling the appointment for this NON-DHS PATIENT that provider will enter their electronic signature to override the system to schedule that NON-DHS patient an appointment for the outpatient clinic. This is the best alternative to improve patient-centered care and increase profit at Harbor-UCLA medical center.

Opportunities and Barriers

The scheduling of NON-DHS managed care patients to DHS outpatient clinics has been an issue since managed-care was put in place starting in the 1990’s. The Department of Health Services are losing millions of dollars in scheduling /treating NON-DHS patients in DHS outpatient clinics.

The Department of Health Services administrators are completely aware of the issues of NON-DHS patients being scheduled and receiving medical services in DHS outpatient clinics. The administrators are in the process of developing a policy and procedure called RED, YELLOW, GO (GREEN) that will minimize/eliminate scheduling NON-DHS managed care patient to DHS outpatient clinics. The policy goes as follow:

RED: means do not schedule patient to DHS outpatient clinics

YELLOW: means under certain circumstances NON-DHS patients can receive medical services at DHS outpatient clinics. (1) The NON-DHS managed care patient would obtain an authorization from insurance provider. (2) If Harbor-UCLA Medical Center performed a procedure such as putting a cast on the NON-DHS patient, catheter or a colostomy bag Harbor UCLA Medical Center will be responsible to continue to provide medical services to that NON-DHS patient and would be schedule an appointment to DHS outpatient clinics. The NON-DHS patient would continue to receive treatment in DHS outpatient clinics until the treatment is completed.

GO (GREEN): means schedule the patient to receive medical services at DHS outpatient clinics.

During my interview with Jivaro Ray the Assistant Hospital Administrator IV of Ambulatory Care, the AIDS program and the Patient Access Center that includes Emergency Department, Urgent Care, Outpatient clinics Schedule Admission, Member Services, the Call Center, and the Financial Insurance Verification Unit. Jivaro Ray stated they are developing the RED, YELLOW GO (GREEN) to eliminate scheduling NON-DHS patients to DHS facilities. Mr. Ray stated they are still working on the exact details of this policy but is hopeful it should be implement within the next 6 months.

In my opinion, it is an excellent policy with 2 major flaws:

1. YELLOW: will allow NON-DHS patients to schedule appointments with an authorization from their managed care insurance provider. This will not work for NON-DHS patients that received medical services from the ED department and want to have a follow-up appointment in a DHS outpatient clinic. The policy for NON-DHS patient from ED department will not be granted. The YELLOW section of this policy is for NON-DHS managed care patient that were referral from their primary care provider that need medical services at a DHS outpatient specialty clinic. Also, if the ED department performed a procedure that requires follow-up treatment by law mandates that facilities/ provider to complete the treatment, however that NON-DHS patient will need to obtain an authorization during the duration of the treatment. The first treatment after the ED visit, DHS-Harbor-UCLA Medical Center will cover the expense, however continues medical services of that NON-DHS managed care patient eventually requires an authorization.

2. RED: the RED section of this policy does not guarantee that NON-DHS patients will not be schedule for follow-up appointments in DHS outpatient clinics from ED. There no procedure to the “RED” section in the policy. It must have a procedure in place to ensure that NON-DHS patient will not receive a follow-up appointment to DHS outpatient clinics.

Evidence

According to Harbor-UCLA Medical Center, Summary of Weekly Average Appointment Scheduled by Month, there been over 1,495 NON-DHS managed care patient scheduled for outpatient clinic appointments. Overall DHS Medical Centers (Harbor-UCLA, LAC-USC, and Olive View) provided outpatient medical services for 446,562 DHS managed care patients (DHS-Office of Planning; DHS Housing for Health).

Harbor-UCLA Medical Center provided outpatient medical services for144,310 DHS-managed care patients from July 2016-April 2017. Unable to obtain data of NON-DHS managed care patients that received medical services from outpatient clinic at Harbor-UCLA Medical Center during that duration of time. Managed care plans need to be managed properly to have a significantly lower medical loss ratio (87.7% vs. 90.6%) and a higher operating margin ratio (1.3% vs. -1.0%) (Mike McCue Virginia Commonwealth University—Department of Health Administration).According to Felix Aure Accounting Financial Officer III at Harbor -UCLA Medical Center stated, “providing medical services for a NON-DHS managed care patient can cost the hospital from $500-$15,000 depending on the medical services that the patient needs at the time.

From 06/13/17- 06/19/17 the ED staff scheduled 131 NON-DHS managed care outpatient clinic appointments. From the previous week 06/05/17- 06/18/17 the ED staff scheduled 121 NON-DHS managed care patient. No data if the NON-DHS patients received any medical services at Harbor (Harbor-UCLA Medical Center, Summary of Weekly Average Appointment Scheduled by Month). Nevertheless, that is 352 NON-DHS managed care patients that received outpatient clinic appointments that need to be available for Harbor-UCLA DHS managed care patients. The ED department provides medical services for approximately 7,136 patients and out of 7,136 patients about 1,500 are NON-DHS managed care patients and about 352 NON-DHS managed care patients may receive a follow-up appointment to DHS outpatient facilities.

Emergency Department

Outpatient Workload; Housing for Health

This graph shows how many DHS managed care patient receiving medical services in DHS facilities. According to Healthcare Atlas OSHPD, Harbor-UCLA Medical Center lies in Los Angeles County and its core market crosses into 0 other counties. Its average reimbursement rate for all payers is 33.3% cents on the dollar.

The Solution

After my interviews with Supervising Patient Financial Worker II of Emergency Department Registration and Member Services LaChandra Edwards, and Assistant Hospital Administrator IV Jivaro Ray it is evident it is a major issue in all facilities in The Department of Health Services. The Chief of Operation Azar Kattan and Chief Financial Officer Jody Nakasuji acknowledge that DHS facilities are losing revenue and not producing the most efficient patient centered by scheduling NON-DHS patient to DHS facilities. The focus needs to be on the ED department because this is the door that NON-DHS patients enter when they are schedule for appointments to DHS outpatient clinics. The RED, YELLOW, GO (GREEN) POLICY that management is trying to put in placed need one alternative to “RED”, which is the RED BOX WARNING indicator box.

It is not enough to state the patient is “RED” DON’T SCHEDULE A FOLLOW-UP

APPOINTMENT. This is the alternative that need to be added to this policy:

Red Box Warning Indicator

· The Red Box Warning Indicator will be an application that will be added to the Scheduling Book that will prevent/STOP any ED staff from scheduling NON-DHS managed care or any patient that does not meet the criteria to schedule an appointment at Harbor-UCLA Medical Center outpatient clinics.

· When an ED staff attempt to schedule an appointment for an NON-DHS managed care patient a Red Box Warning Indicator will appear on the screen restricting that ED staff from scheduling that appointment.

· RED BOX WARNING indicator will clearly state *NON-DHS PATIENT* unable to schedule appointment; contact ED registration.

· If the ED provider insists on scheduling the appointment for this *NON-DHS PATIENT* that provider will enter their electronic signature to override the system to schedule that NON-DHS managed care patient a follow-up appointment for an outpatient clinic.

The Red Box Warning Indicator alternative will eliminate /minimize the number of NON-DHS managed care patients schedule to DHS outpatient facilities. The Red Box Warning will guarantee that the ED clinical staff will not schedule follow-up appointments to NON-DHS managed care patients.

Target Audience

DIRECTOR OF HEALTH SERVICES

Mitchell Katz

CHIEF OPERATIONS OFFICER

Azar Kattan

--Master Plan / Space

--Utilization Management

DIRECTOR OF, OFFICE OF PATIENT ACCESS DEPARTMENT OF HEALTHE SERVICES

Shari Doi-Hatcher

Patient Access Department for DHS

ASSISTANT HOSPITAL ADMINISTRATOR IV

Ambulatory Care

Aids Program

Patient Access Center

NURSE MANAGER

Victoria Deguzman

Emergency Department Registration

Schedule Admissions

Member Services

SUPERVISING PATIENT FINANCIAL SERVICE WORKER II

Lachandra Edward

Emergency Department Registration

Member Services

The Logic Model

Harbor-UCLA Medical Center ED Department (NON-DHS patients)

PROBLEM STATEMENT: Harbor-UCLA hospital emergency staff is not efficiently identifying NON-DHS managed care patients and continues to schedule appointments that negatively effects patient-centered care and contributes to lost revenue for the medical center. PROGRAM GOAL: The Red Box Warning Indicator will minimize/eliminate scheduling NON-DHS managed care patient to DHS outpatient clinics that will improve patient centered can and increase revenue.

RESOURCES: Cerner is the world’s largest publicly traded health information technology company providing leading-edge solutions and services for health care organizations worldwide. Cerner will develop the Red Box Warning Indicator application to improve patient centered care.

ACTIVITIES

OUTPUT

SHORT-TERM OUTCOME

INTERMEDIATE OUTCOME

LONG-TERM OUTCOME

Minimize/eliminate scheduling NON-DHS managed care patient to DHS outpatient clinics

Adding an application to Orchid to stop the scheduling of NON-DHS patients to DHS clinics

NON-DHS will be directed to their own primary care provider due to ED clinical staff unable to schedule appointment to DHS clinics

Variety of appointments available for DHS managed care patients

Improve patient centered care and increase revenue. Eliminate NON-DHS patients’ apps.

Implementation of Red Box Warning Indicator

The continuous care of NON-DHS managed care patient in DHS clinics, according to HSR Health Services Research, “The presence of managed care organizations in a health care market may also generate competitive pressure that influences treatment patterns for patients’ market-wide. In the commercial health insurance market, managed care organizations compete among themselves and with other types of insurers for enrollees. Managed care organizations are able to offer lower premiums than other insurers by either selecting healthier enrollees, adopting more efficient practice styles, or lowering the fees paid to providers. Studies have found that lowering payments to providers is a significant source of savings for managed care organizations (Cutler, McClellan, and Newhouse 2000; Altman, Cutler and Zeckhauser 2003; Polsky and Nicholson 2003). But lower prices create pressure on providers to reduce costs, and the actions physicians and hospitals take in response to this pressure may affect treatment patterns for all patients (Impact of Managed Care on the Treatment, Costs, and Outcomes of Fee-for-Service Medicare Patients with Acute Myocardial Infarction).” NON-DHS managed care patients are taking away resources from DHS managed care patients that Harbor-UCLA Medical Center receives capitation payments for DHS patients each month. The Red Box Warning Indicator will be the perfect solution for ED staff not to schedule NON-DHS managed care patient to outpatient clinics.
When this policy is approved it should be implement within 6 months. The Red Box Warning Indicator will improve patient centered care and increase revenue. The Red Box Warning Indicator will be quick and to the point. To add this application to ORCHID it will be inexpesiv DHS as an ongoing contract with Cerner to add and delete applications when needed and approved administrators to make that request. When the Department of Health Services decides to use this policy; it will be implement at all of DHS Medical Centers and clinics.
References

Bundorf, K. 2004 Feb. Impact of Managed Care on the Treatment, Costs, and Outcomes of Fee-for-Service Medicare Patients with Acute Myocardial Infarction
www.ncbi.nlm.nih.gov/pmc/articles/PMC1360998/

DHS Office of Planning; DHS Housing for Health. (2017 July). DHS DASHBOARD. Retrieved from Harbor-UCLA Medical Center

http://Users/NICOL/Downloads/DHS%20Dashboard%20May%202017%20(2).pdf

Mount Saint Mary University. (2017) Policy Analysis Workbook

Stuckey, M. 2014 Sept. 11. California Healthline L.A. County Aims To Transform Health Care With New EHR System retrieved June 15, 2017

http://californiahealthline.org/news/la-county-aims-to-transform-health-care-with-new-ehr-system/

Edwards, L. (2017, July 13) Phone Interview

Ray, J. (2017, July 1-14) Email Interview

Aure, F. (2017, July 11) Email Interview

Suarez, H. (2017, July 2-14) Personal/Email Interview

Implementation of Red Box Warning Indicator in DHS Faclilities

Lay the groundwork for the Red Box Warning to LaChandra Edwards and Victoria DeGuzman

Present the alternative to JIvaro Ray; Need Jivaro to invite me to the the Monthly Busniness Meeting

(Workshop)

with Shai Doi-Hatcher

Attend the Monthly Busniness Meeting

(Workshop)

with Shai Doi-Hatcher

Adovocay for the Red Box Warning Indicator applicaiton to be install in Orchid to elimnate NON-DHS patients receiveing appointments to DHS'S clinics

Receive approval for the Implementation of Red Box Warning Indicator