Urgentcare issue 1

May 2015

balance your patient loads 6 Tips

for patient surveys

Why You Should Market to Hospitals

Covering the Business of Delivering Care • Latest News • Management • Compliance • Patients • Technology • Revenue

Everything you need to run a successful Urgent Care Center.

www.urgentcaremagazine.com Subscribe today for your free copy and e-newsletter.

See us at Booth 640 The National Urgent Care Convention April 27-30, 2015

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In This Issue...

04 SURVEY SAYS Technology delivers data to transform patient satisfaction into patient loyalty.

08 CUTTING IN LINE Appointment software delivers new and happier patients.

14 BROADEN YOUR HORIZONS Marketing urgent care centers to healthcare systems and specialists.

24 BREAKING DOWN BARRIERS Delivering appropriate cultural and linguistic services.

28 FLIPPING THE SWITCH Smoothing the rocky transition to ICD-10

18 CARING OUT LOUD Customer service pays dividends.

31 CLOUD COVER Cloud computing is an IT strategy to match

03

EDITOR’S NOTE Welcome to the inaugural issue of Urgent Care Magazine! We’re launching this publication at a time when the urgent care industry is growing exponentially and changing rapidly. It’s our hope that Urgent Care Magazine’s non-clinical focus will help you optimize your business for success and profitability. To that end, we are committed to delivering information that’s both timely and actionable. That’s why every feature article will include first steps or next steps you can take to implement the business practice discussed.

In each issue, we’ll bring you articles on a variety of management, technology, patient experience, revenue, and compliance. In this issue, “Caring Out Loud” delivers a compelling case for implementing a common-sense customer service approach to improve the patient experience. You’ll better understand how to use appointment software to balance patient loads after reading “Cutting in Line.” Dr. Michael Boyle, who literally wrote the book on urgent care (“The Healthcare Executive’s Guide to Urgent Care Centers and Freestanding EDs”), offers guidance on how to market your urgent care center to hospitals and specialists – and why doing so can increase your bottom line. And if you’re nervous about the move to ICD-10, you’ll appreciate the advice of payors, software specialists, and coders in “Flipping the Switch.”

I invite you to reach out and let me know what pressing issues impact your urgent care center, and what articles you’d like to see in the pages of Urgent Care Magazine.

Drop me at note at editor@urgentcaremagazine.com. I look forward to this journey, and to bringing you information you can use.

Sally E. Smith Editor

Publisher Howard Borgen Editor-in-Chief Sally E. Smith

Contributors Michael F. Boyle, MD, MBA, FACEP Susan Cooper John Kulin, MD

Advertising Director Chris Sanford

Copy Editor Beth Taylor

Art Director Stephanie Bergman

Circulation Director Michael Evan

UC Medica, LLC Robert Rosen, CEO Urgent Care Magazine, Vol. 1, No. 1, May 2015. Published by UC Media, LLC. 734 Walt Whitman Road, Suite 307, Melville, NY 11747. Copyright (c) 2015 by UC Media, LLC. All rights reserved.

Nothing may be reprinted in whole or in part without written permission of the publisher. Editorial queries and information should be sent to editor@urgentcaremagazine.com. Products advertised are not endorsed by Urgent Care Magazine and views expressed are not necessarily those of Urgent Care Magazine. All correspondence to Urgent Care Magazine will be treated as unconditionally assigned for publication and copyright purposes and as subject to Urgent Care Magazine’s right to comment editorially. Subscriptions to Urgent Care Magazine are complementary to qualified subscribers.

Subscribe at www.UrgentCareMagazine.com. POSTMASTER: Send change of address to Urgent Care Magazine, 734 Walt Whitman Road, Suite 307, Melville, NY 11747. Periodicals postage paid at Melville, NY and at additional mailing offices.

Printed in the USA.

TECHNOLOGY

SURVEY SAYS...

BY SUSAN COOPER

Technology delivers data to transform patient satisfaction into patient loyalty “I’m

satisfied with my cellular carrier, but I’m not loyal to it. So if there’s a better offer, I’m going with it,” says Deborah Eastman, chief customer officer at Satmetrix, developers of a software-as-a-service application that helps companies evaluate various points along the customer journey. That’s why she advocates that urgent care centers raise the bar, striving for patient loyalty instead of settling for patient satisfaction.

But whether you’re gauging satisfaction or loyalty, you can’t rely solely on anecdotal evidence. You need reliable data and a filter through which to interpret that data. The best source of this data? Patient surveys.

Satmetrix, together with Fred Reichheld and Bain & Company, conducted the research that led to the Net Promoter Score (NPS) metric, which measures customer loyalty. Patient surveys can include a variety of questions, but the one that matters is, “How likely is it that you would recommend our urgent care clinic to a friend or colleague?” On a scale of 0 to 10, those who give an urgent care center a 9 or 10 are considered promoters, those offering 7s or 8s are passives, and those who deliver scores of 0 to 6 are considered detractors. The NPS is determined by subtracting the percentage of detractors from the percentage of promoters.

Eastman says that the recommendation question “had the strongest correlation between what people said through survey responses and what they subsequently did with their buying behavior.” That matters because it is one gauge of the future health of the business. “Financial data show historically how you’ve performed,” Eastman says. “Net Promoter shows how well you’ll do in the future based on customer loyalty.”

According to Eastman, NPS is powerful because it’s intuitive.

“Everybody in the business knows the importance of improving the number of promoters and decreasing the number of detractors,” she says. “It helps to improve a patient-centric culture.”

But a good patient survey doesn’t stop with the recommendation question. “Try to understand what drives that Net Promoter Score by asking additional questions,” advises Eastman. “You want to understand how every part of that experience affected that patient’s loyalty or satisfaction.”

Paul Faraclas, senior vice president of patient experience solutions at Symphony Performance Health, agrees. “When you

look at whether or not somebody will recommend you, it takes into account all of the factors that came to play in their minds,” he says. And not all factors are created equal.

“Different factors mean different things to different people,” Faraclas says. “Reasons not to recommend will vary from patient to patient. It could be only one thing made them dissatisfied.”

To amplify patient responses, Eastman suggests asking about the cleanliness of the waiting room, the wait time, and the patient’s interaction with various staff members. Reviewing the results against a backdrop of operational data is useful. “Look at how long a patient was there, whether they’re a member of the medical group or not, and whether there might be other attributes,” she advises. That information is a guide to patient experience gaps. “You can finetune the experience to enhance patient loyalty,” she says.

Faraclas says that understanding the patient’s experience retrospectively is just one part of the equation. “Do something intra-service, where the patient or family member is able to provide you with data,” he advises. “This allows you to have service recovery while it matters.”

“The ideal is to be able to be aware of anything that would be concerning to the patient in real time,” says Faraclas. Learning about a patient’s discomfort or frustration after the visit “doesn’t do a lot of good except to fix things moving forward,” he says. Instead, he suggests that someone on the urgent care center’s leadership team have a relaxed conversation with a patient’s family member to gauge how the visit is progressing. “You can drill into some of the components of underperformance or dissatisfaction and take action on it,” he says. Without qualitative interaction, he says, how can you judge whether a score of 85 or 88 is better?

When it comes to surveying patients, Eastman says that there are two approaches. She chalks up traditional market research methods, like phone interviews and paper-based surveys, as “old school.” “The data is aggregated and reported periodically,” she says. On the other end of the spectrum are cloud-based services that enable urgent care clinics to look at survey data in real time. “You can slice and dice it in multiple ways to get to the heart of the matter,” she says.

Faraclas calls technology an enabler in gauging patient satisfaction and loyalty. “All technology in healthcare should serve as an enabler to accelerate taking effective action,” he says. To that UrgentCareMagazine.com

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“If there are patterns of underperformance, you have a problem. It could be patient perception, but it’s still a problem.”

end, he notes that patients can be surveyed in the urgent care setting on a tablet or via a cell phone app, or after the visit using survey software and authentication.

Faraclas notes that Symphony Performance Health began using authenticated electronic surveys in 2003. “Authentication means that you have a real patient provide feedback, as opposed to someone who goes to a message board,” he says.

Once you receive real information from real people, analytics can turn meaningless data into meaningful information. “You need to be able to measure and easily analyze data so you can prescribe action,” Faraclas says. A management team may notice a pattern for patients who fit a certain demographic, who were diagnosed with a particular problem, or who saw a specific provider. “If there are patterns of underperformance, you have a problem,” says Faraclas. “It could be patient perception, but it’s still a problem.”

Software-as-a-service technology platforms can quickly get to the heart of that problem.

“Technology can do upfront analysis for you,” says Faraclas. “Based on what you learn, you can have an informed discussion with that patient, see if there is follow-up, and take the next steps,” he says.

Software that features real-time analytics presents the opportunity for urgent care center staff to mitigate a patient’s negative experience. The software can be set to send email or text alerts when certain criteria are met. “It gives you the ability to assign followup to a staff member and hold them accountable,” says Faraclas.

Both Eastman and Faraclas say that an urgent care center can get up and running with survey software and analytics within a week or two. “It should take a half hour to go through training and understand the power of the system that’s going to allow them to take action,” Faraclas says.

As for cost, Faraclas says there are many variables, but an estimate is “a couple of dollars per returned survey.” He cautions, “It could be more expensive if you don’t do it,” both in terms of repairing your brand and in staff recruitment and retention. ■

“All technology in healthcare should serve as an enabler to accelerate taking effective action.”

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6 TIPS FOR SURVEYING If you’re ready to survey your patients or are revisiting your existing survey methodology, here are some tips from the experts: 1. Email surveys are the most reliable. “They give you the least bias,” Satmetrix’s Deborah Eastman says. “With face-to-face or phone surveys, people don’t want to hurt other people’s feelings.” That’s why it’s critical that urgent care centers have accurate contact data for patients, she says.

2. Speed is of the essence. “Surveys should be done immediately to get richness of data,” Eastman says. “If you wait even a few weeks, the patient will say the experience was okay, but not give you any meaningful insight.”

3. Leave room for free responses. Symphony Performance Health’s Paul Faraclas says that the value of a survey comes as much from free form text as it does from standard metrics.

4. In order for patient surveys to be an effective tool, there has to be commitment by leadership and by the management team to improve the patient experience, Eastman says. “If you’re not going to take action on the data, don’t do it.” She adds, “Our philosophy is around what you do with the data, not how you collect the data.”

Faraclas shares that sentiment, cautioning that a patient satisfaction survey is a “check the box exercise” unless there’s a commitment to follow up. Survey results should lead to an action plan, he says, one that’s “people, process, or person-specific.”

5. Faraclas advises to survey continuously. “Staff changes. Laws change. The area changes. You have to be on top of everything,” he says. Faraclas cautions that the goal of surveying isn’t to have the highest score, but rather to continually improve the patient experience. “You’re constantly revisiting everything you do to have a pulse on what’s taking place, and see if there is anything that needs to improve,” he says.

6. Remember that an urgent care clinic can do everything by the book and still get negative feedback from patients. “Part of caregiving is the patient’s perception of their experience,” Faraclas says. “And perception is reality.”

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TECHNOLOGY

Cutting In Line

APPOINTMENT SOFTWARE DELIVERS NEW AND HAPPIER PATIENTS

BY SALLY E. SMITH

U

rgent care was slow to take off in Massachusetts, but as it did, CareWell Urgent Care wanted to have its foot on the accelerator.

According to David Low, director of marketing for CareWell, “We were looking to differentiate ourselves in the market. We asked, how can we provide services that others aren’t currently providing?” One answer was pre-registration software.

CareWell, which currently has 10 locations and six more in the works, has been using the cloud-based ER Express for year.

Low says CareWell “tested in one location for a month and quickly expanded to all of our centers. We now don’t open a center without ER Express coming with us.”

Sahil Patel, president of ER Express, says that urgent care centers that utilize pre-registration software communicate that they offer both choice and convenience. “Patients can get an appointment at a location that’s convenient to them,” he says.

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Depending on how the facility is licensed, Patel says that preregistrations may be offered as “book an appointment,” “hold your place in line,” or “call-ahead seating.”

Whatever the terminology, it can seal the deal with a new patient, says Stacie Pawlicki, director of marketing for InQuicker self-scheduling solutions. “A Google study found that eight out of 10 patients go online to see where to access care,” she says. “Sixtyfour percent are comparison shopping between different facilities.”

Pawlicki says that urgent care centers don’t typically have ways for potential patients to transact with them prior to a visit. “Display an inventory of appointments, and patients transact with an urgent care center before they arrive in the waiting room,” she says.

The Deciders Scheduling software enables urgent care center staff to determine when to offer appointments and how many appointments to offer.

Low says that CareWell’s practice managers decide when to accept online appointments – how many per day and how many per hour.

“As we get busy, they have the ability to turn the appointment process on or off,” he says.

Pawlicki says that some InQuicker partners “saw a crazy amount of patients coming in for flu season. They wanted to shut the system off for a few hours, and they could do that.”

For urgent care centers with multiple locations, pre-registration software can balance patient loads. By opening up appointment availability at certain locations and restricting others, Patel says

Depending on how the facility is licensed, pre-registrations may be offered as ‘book an appointment,’ ‘hold your place in line,’ or ‘call-ahead seating.’

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“clinics are decongesting their waiting rooms.” A patient may opt to drive an extra 10 or 15 minutes for an appointment at a location that’s not busy rather than taking her chances as a walk-in at the closer clinic.

Similarly, hospital systems with urgent care clinics often use registration software to decongest emergency rooms and move people to urgent care, says Patel.

Increased Patient Satisfaction Pawlicki says that patients appreciate the convenience of being able to make an appointment. “They have control over their healthcare experience,” she says. “Instead of having to make a phone call or showing up and having to wait, they have 24-hour access.”

CareWell’s Low says patients are more satisfied with their urgent care experience. “They like having the ability to make an appointment when we open,” he says. “They can get in and get out before work without having to wait.”

But Low warns that communicating to patients without appointments is integral to keeping everyone happy. “When a walkin patient arrives and there’s an appointment in front of them, our front desk staff tells them that we take appointments and that there will be someone coming in who is seen first,” he says.

Low says that CareWell finds that the ability to make appointments online has particularly benefited the company’s occupational medicine practice. “Employers can make appointments for their employees,” he says.

Logistics and Deployment ER Express offers its online scheduling tool on a private label basis, meaning it is part of an urgent care center’s website. Patel says that urgent care centers “don’t want to redirect patients to a third-party site.” Having invested in website development, he says urgent care clinics want to “give patients a destination” where they can also promote services like wellness visits, occupational medicine, and flu shots.

There are typically two aspects of registration software: the customer-facing piece and the operational piece. For the public face of the clinic, ER Express delivers a customized website plugin. Patel says, “We discuss marketing design, provide a graphic artist’s rendering, and then design the buttons, the web page, and

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the color scheme” to match the clinic’s branding. The clinic copies and pastes the computer code into its website, and the code generates interactive buttons that show the first available appointments at various locations.

With InQuicker, patients access appointments from a dedicated webpage on the InQuicker site, though the API and InQuicker widget can display available appointment times on the urgent care center’s website. Pawlicki says each center’s InQuicker webpage is search engine optimized, and that the company uses pay-per-click advertising to drive local traffic to the webpage. “We build dedicated pages that only show their available inventory,” she says. “They can configure those pages to match their brand.”

In the ER Express system, when a patient clicks on an appointment time and location, the system generates a reservation form that asks her why she’s coming in and that includes necessary disclaimers. Once the patient clicks “submit,” she receives a printable confirmation ticket.

Not everyone who tries to register gets the go-ahead, though.

Patel’s team conducts a risk management assessment with the clinic for “explainers and disclaimers.” “We have a set of acuity filters built in that will flag symptoms,” he says. “The system may tell the patient that, based on what you’ve told us, you need to call 911 or go to the ER.” On the operations side, the clinic logs into a web-based software panel. With ER Express, when a patient books an appointment, the system sends two automated alerts to the clinic, via HIPAAcompliant fax, phone call, and/or text message. Patel says the system is configured based on staff input. “They may want a fax alert sent to the front desk and a text to the practice manager,” he says.

If the urgent care center gets slammed, InQuicker can help keep patient dissatisfaction at bay. “Patients sometimes need to be seen out of turn,” Pawlicki says. Those whose appointments will be delayed can be sent automated emails or phone calls to come in later. “Patients can continue waiting at home,” she says.

Low says that implementing pre-registration software was painless for CareWell. “It’s quick to set up on the back end,” he says. “It only took a two-hour phone call with practice managers.”

Both Patel and Pawlicki emphasize that success depends upon the buy-in of leadership and staff. “When we work with a partner and they’re going to go live, we interact with a clinical lead, a

IN THE MARKET? “If the staff isn’t actively managing the system, or if a patient says they checked in online and the staff gives them a shoulder shrug, then it isn’t going to be successful.”

If you’re in the market for registration software, here are three things to keep in mind: 1. Ensure that the registration software is secure, using SSL and 128-bit encryption, and that it is compliant with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).

2. Make sure that you’re ready for mobile. ER Express’ Patel says that, for long-term clients, 50 to 70 percent of patients are using mobile devices to book appointments. “Health systems that have a well-designed mobile site have higher levels of mobile engagement and a higher conversion rate,” he says. He’s quick to note, however, “We can’t take someone with a poorly designed mobile site and turn them into someone with a 50 percent conversion rate.”

3. Not only should you understand the scheduling system, but those deploying the system should understand healthcare. Patel says, “We sit down with the practice manager and ask them to detail their patient’s clinical process. If we don’t understand their workflow, we can’t design a good intake process.”

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“Scheduling software should be viewed as part of a larger strategy of making the clinic the destination of choice.”

marketing lead, and sometimes a executive lead,” says Pawlicki.

Patel says buy-in is critical. “If the staff isn’t actively managing the system, or if a patient says they checked in online and the staff gives them a shoulder shrug, then it isn’t going to be successful,” he says.

He refers to a “suits vs. scrubs” approach to bringing staff on board, and says that his team includes a nurse trainer. “Nurses want to hear from a fellow nurse that this is going to work,” he says. “They want to ensure that it won’t disrupt clinical procedures or routines.”

While the system can be deployed in four to six weeks, Patel recommends that clinics new to the system start off slowly, going live after a two-month pilot program.

In contrast, Pawlicki says that InQuicker launches in six to eight weeks, and that while the company works with centers that want to pilot the software, “We recommend more than one site going live. With multiple locations, they’re able

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to see the most success and to see how the community responds,” she says.

Costs vary depending on software developer. ER Express charges a flat monthly fee per clinic with no set-up fees. InQuicker charges a set-up fee and annual contract that’s rolled into one monthly fee.

Only the First Step Having the software is one piece of the puzzle. Spreading the word is another.

“The urgent care clinic has to market it,” says Patel. “If they don’t market it, they won’t get ROI.” He suggests promoting the availability of appointments or online check-in via Facebook, direct mail, patient handouts, and even refrigerator magnets.

“Get it in front of patients,” he advises.

Pawlicki says InQuicker is heavily invested in marketing an urgent care center’s self-scheduling service. “We host an implementation call and work with them to figure it out,” she says. InQuicker

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also provides urgent care centers with creative assets, such as postcard templates, billboards, digital ads, and email blasts.

“We market ourselves as ‘walk-in or by appointment,’” Low says. CareWell utilizes pay-per-click online advertising campaigns that urge patients to “Book your appointment now,” and engages patients via social media.

“Patients can book appointments from our Facebook page,” he says.

Patel is quick to put the role of preregistration software into perspective. “It’s part of the equation, but not necessarily the whole equation,” he says. “If you offer online reservations but the waiting room is dirty, or if you offer appointments but people have to wait to be discharged,” those are issues that need to be addressed. Instead, scheduling software should be viewed as “part of a larger strategy of making the clinic the destination of choice,” he says.

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ER Express | Example Screenshots for Urgent Care Magazine

ER Express | Example Screenshots for Urgent Care Magazine (all examples are from a fictional patient) Screenshot 1: The reservation monitor

The reservation monitor for ER Express enables administrators to quickly adjust the flow of patient reservations.

ER Express | Example Screenshots for Urgent Care Magazine Screenshot 2: Editing the blackout schedule

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The Urgent Care center’s manager can easily open and close reservation times in the ER express system.

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Broaden Your Horizons

BY MICHAEL F. BOYLE, M.D., MBA, FACEP

MARKETING URGENT CARE CENTERS TO HEALTHCARE SYSTEMS AND SPECIALISTS Urgent care center success is often dependent on a quality reputation, visible signage, locations adjacent to high vehicular traffic volume, and aggressive marketing (1).

With increases in competition and healthcare reform, urgent care center owners need to consider additional pathways to success, including direct marketing to hospitals, healthcare systems, and specialists. These relationships become mutually beneficial with referral of urgent care center patients to the hospital or specialist and reciprocal directing of lower acuity patients to the urgent care center. Expansion of clinical services, including complex wound care, occupational medicine, wellness programs, and post-discharge care further increase marketability for the clinic.

Clinical integration with health systems provides several benefits, including access to advanced technology, marketing, capital, and electronic medical records.

Integration occurs via affiliation, joint venture, or employment.

URGENT CARE VS. EMERGENCY DEPARTMENT CARE Urgent care facilities provide unscheduled evaluation and treatment for minor illness or injury. Urgent care centers often expand services to include immunizations, occupational medicine, health promotion, sports and executive physical examinations, physical therapy, and wellness (such as smoking cessation and weight loss) (1,2).

Minor illness and injury care is often provided at a lower cost compared to emergency departments, with urgent care centers delivering similar quality, greater convenience, and higher patient satisfaction (3, 4).

Emergency departments have been the safety net in health services for those patients that are uninsured or underinsured. Patients with similar complaints cared for in emergency departments compared to urgent care clinics are charged substantially more (5). Emergency department charges are skewed by hospital cost shifting and unreimbursed care. In addition, these charges often exceed actual collections by over 70 percent due to contractual write-offs, Medicaid, Medicare, and bad debt from self-pay patients. Urgent care centers, on the other hand, have much lower overhead and provider costs, resulting in an overall lower cost structure along with lower Medicaid and self-pay populations. Use of emergency departments versus urgent care centers varies by geographic location, social class, and payer status. Comparing the cost of care (without any testing) for a patient with a simple sore throat, the following are average costs to the patient.

CASH CLINIC RETAIL CLINIC URGENT CARE PRIMARY CARE EMERGENCY ROOM

$45-55 $65-75 $100-120 $120 >$200

The above pricing strategy plays a major role when population healthcare expands and less focus is placed on fee-for-service reimbursement. In addition, patients desire ease of access (location, parking, travel distance), and lower costs with similar quality (1, 3, 5).

MARKETING FOR HOSPITAL AFFILIATION The first step in the marketing process is defining the key contact individuals in the hospital, including the emergency department medical director, hospitalist director, and an administrator (preferably a decision maker at the vice president level or higher). Hospital-based physicians, including emergency department and hospitalists, are solid partners for the urgent care center and may become critical allies for hospital affiliation. These individuals make or break the relationship or affiliation.

The focus for the urgent care center owner as she or he speaks with the emergency department director is salesmanship as a solution rather than competition for minor illness and injury care (5). This solution could include referral of low acuity emergency department overflow and follow-up rechecks for hypertension, cellulitis, packing changes, and suture removals. It is critical that all parties understand the purpose of the urgent care center is not meant as a medical home; long-term relationships along with chronic care are not the focus of

the site. Fostering the relationship with the emergency department director also helps with quality monitoring. The urgent care center often refers patients to the emergency department for further care, admission, or imaging. Feedback to the urgent care center regarding these patients should include any challenges or problems occurring with the referral, unexpected negative outcomes, or outstanding performance.

Often, patients with higher acuity complaints, including chest pain, abdominal pain, and neurologic symptoms, require referral to the hospital. Many of these could be directly admitted to a hospitalist’s service. If the urgent care center has the ability to contact a hospitalist, the emergency department may be avoided, potentially preventing delays and patient holding (patient boarded in the emergency department). This process often requires greater testing on the part of the urgent care center.

Health system partnership may allow for expansion of a robust imaging center for the urgent care center. The combination of imaging and urgent care provides a dual marketing benefit. Utilization of the imaging center provides marketing for the urgent care and vice versa (1). This concept may be implemented to reduce volume loss from other competitor imaging programs, but it is an expensive alternative and service duplication should be avoided.

When hospital administrators and urgent care center owners consider affiliation, it must be done with care and the relationship developed at “arms-length� to avoid Stark issues. A joint venture or affiliation with a private urgent care center must be of mutual benefit. Hospitals often offer integrated medical records, access to

The first step in the marketing process is defining the key contact individuals in the hospital, including the emergency department medical director, hospitalist director, and an administrator (preferably a decision maker at the vice president level or higher).

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information technology, potential access to capital for expansion, and referral gateways for admission and specialty care. Systems need to understand that urgent care operators provide a “middle option” in the patient care spectrum outside of the emergency department and primary care offices (5).

These programs include affiliation, co-branding, joint venture, or ownership. Affiliation may be a simple agreement between the two parties with rights to advertise the relationship or co-branding where the urgent care center may list the hospital affiliation on signage. The hospital or healthcare system may also provide marketing support, information technology or support, access to capital, integrated electronic medical records, and assistance with referrals to primary care physicians, specialists, and hospital admissions. Joint venture extends the relationship where both parties share in the facility profit and management. The final option is employment, where the hospital purchases the urgent care center site and has full management as an employer.

MARKETING TO SPECIALISTS Similar to hospital relationships, urgent care centers often need specialists for follow-up of patients requiring further care. The most common specialties required are orthopedics, ophthalmology, wound care surgeons, and family physicians. Rather than competition, the urgent care center can be seen as a relief valve for family physicians, covering office overflow, after hours care, and wound care.

Ensuring that a patient’s return to the family physician’s office for continued care is critical, along with the referral of new patients for chronic medical care. By gaining the trust of the ophthalmologist, the urgent care center can increase its care for eyes, including minor foreign removal and corneal burring with the back-up support of the specialist. Complicated wound care may be referred to the wound care surgeon for final excision, complex debridement, and hyperbaric care. The urgent care center may get referrals from the wound care surgeon, including simple abscess drainage, wound checks, and packing removals. These relationships result in a sustainable business model and combat competition.

Telemedicine is becoming significant competition for minor illness care with a price point of about $49 (6, 7). Injury care is difficult or impossible to manage over the phone, especially with laceration repair, abscess drainage, and orthopedic splinting. This concept is implemented via “proceduralist” nurse practitioner and physician

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assistant staff. The idea involves providing advanced training for nurse practitioner and physician assistant staff in higher levels of wound repair, including z-plasty, subcuticular suturing, and cosmetic repairs. These skills can then be aggressively marketed to the local public, family physicians, specialists, and emergency departments.

MARKETING VIA POPULATION HEALTHCARE Finally, population healthcare focuses on health maintenance and care coordination. Hospitals will seek out urgent care centers developing wellness programs that include diabetes education,

Specialty and primary care physician relationships assist in obtaining reliable follow-up for patients with specific needs, but also may become an income stream for referral from these specialists to the urgent care centers. weight loss, and smoking cessation. In addition, screening with diabetic foot evaluation and smoking cessation education provide billable interventions. Post-discharge clinics (early evaluation after hospital discharge) provide early evaluation of recently hospitalized, high-risk patients within two to three days of a hospital stay. The evaluations focus on patient education and may reduce hospital readmission (8, 9). Setting up a program at the urgent care center provides an off-site geographic benefit and patient convenience. Hospital readmission of Medicare patients may become unreimbursed events and result from medication noncompliance, lack of patient understanding of the disease process, and failure to obtain timely follow-up appointments (9). These programs may reduce readmissions by ensuring medication and discharge instruction compliance, and establishing definitive primary care physician follow-up appointments.

CONCLUSION Urgent care centers market themselves as a solution for minor illness and injury care by touting speed of service, quality of care, lower costs, and higher patient satisfaction. They provide an alternative to the emergency department, an area for post-discharge follow-up, and an expanded footprint for the healthcare system. Urgent care centers benefit from affiliation with orthopedists, ophthalmologists, wound care surgeons, and primary care providers.

Specialty and primary care physician relationships assist in obtaining reliable follow-up for patients with specific needs, but also may become an income stream for referral from these specialists to the urgent care centers. Significant expansion into wound care, including complicated laceration repairs and abscess drainage, assist in decongestion of the hospital based emergency department, and also maintains services that cannot be accomplished via telemedicine. Mutually beneficial relationships provide revenue to all parties.

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REFERENCES: 1. Boyle, MF. Kirkpatrick, D. 2012. The Healthcare Executives Guide to Urgent Care Centers and Freestanding EDS. Healthleaders media: Danvers, MA. 2. Urgent Care Association of America (UCAOA) 2014 Benchmarking Survey retrieved 11/18/2014 from http://www.UCAOA.org/2014Benchmarking.

3. Gangler, A. (2009) Milk, Bread, Newspaper…and a Flu Shot? Money. 38(1):1-7.

4. Mehrotra, A, Hangsheng L., Adams, JL et al. Comparing Costs and Quality of Care at Retail Clinics with That of Other Medical Settings for 3 Common Illnesses.

Annals of Internal Medicine. 9/1/2009, 151 (5), p321-W.109.

5. Bedner, J. 2014. The Era of Urgent Care: This Growing Model Bridges Gap Between Primary, Emergency Care. Business West. 31(5), 46-48.

6. Desjardins, D. (2014). Telemedicine going mainstream. Medicine on the Net (MED NET), 2014. 20 (8): 1-3.

7. Eramo, L (2014). HEALTHCARE on Demand... An Expanding World of Telemedicine Raises New Questions for HIM Professionals. Journal of AHIMA (9): 26-30.

8. Park H. Branch L., Bulat T., Vyas B., Roever C. Influence of a transitional care clinic on subsequent 30-day hospitalizations and emergency department visits in individuals discharged from a skilled nursing facility. Journal of the American Geriatrics Society. 2013. 61 (1): 137-42.

9. Leppin A. Gionfriddo M. Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Medicine. 2014. 174 (7):1095-107.

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Caring Out L CUSTOMER SERVICE PAYS DIVIDENDS

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Loud

BY SALLY E. SMITH

T

he most frequent complaint from patients in an urgent care setting?

According to Jake Poore, founder and president of Integrated Loyalty Systems, it’s depersonalization. “People say, ‘I’m not a person, I’m an ailment,’” Poore says. “You don’t ask me what name to call me, yet I go into Starbucks, order a Grande, and they ask my name. Then the next time I walk in, they call me by name.”

Surely, Poore implies, urgent care centers can offer as much personalization as a coffeehouse. Or communicate as clearly as a restaurant in Western Massachusetts.

Poore recalls that he and a colleague had dinner at the farm-to-table restaurant Hope & Olive in Greenfield, Mass. “We walk in the door and there’s a chalkboard that welcomes us and lists all of the dishes and the farm each ingredient came from,” he says. “That hits you on the way in. On the way out, there’s a doorbell and another sign. This one says, ‘Did you enjoy your meal? Let the kitchen staff know.’”

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“The consumer-driven health market will change how providers compete…. Now they can only win when the consumer wins too.”

Calling the experience a “microcosm of consumerism,” Poore says that the restaurant’s approach is a stellar example of finding a way to explain something complicated in language people understand, all while making a personal connection.

MOVING TOWARD CONSUMER-CENTRISM Urgent care centers have been at the forefront of breaking down barriers between a traditional, highly structured healthcare delivery system and the people who use its services. Indeed, urgent care has been a primary driver of consumer empowerment in the healthcare marketplace.

And those consumers are increasingly savvy. They have free health and fitness apps at their disposal. They have social media at their fingertips. They have more skin in the game with higher deductibles and co-pays. This creates consumers who are proactive in their search for personalized, convenient, and affordable care.

According to a 2014 report by management consulting firm Oliver Wyman, “The consumer-driven health market will change how providers compete…. Now they can only win when the consumer wins too.”

Dr. Louis Strauss, medical director of Baystate Health Urgent Care, understands how closely customer satisfaction is tied to an urgent care center’s bottom line. “Urgent care is a low-margin business. If you don’t have enough patients coming through the door, you’re not going to survive very long,” he says.

30 MINUTES? According to Poore, a second consistent complaint about urgent care is that it takes too long. Yet, “They’ll have waited 30 minutes,” he says. Customer frustration about wait times arises not from the timespan involved, but from failing to set expectations, Poore says. Patients expect that “urgent” care will be delivered quickly.

“When a medical assistant tells a patient that he’ll get her test results and check back on her ‘shortly,’ she thinks ‘shortly’ is five or ten minutes. When the MA comes back two hours later, we’ve shot ourselves in the foot,” he says.

Strauss agrees. “What brought them to urgent care is getting in, getting seen, and getting out quickly. With urgent care, convenience is first and foremost.”

It took Strauss awhile to realize how closely patient satisfaction is tied to wait times. When reviewing wildly variable survey results about patient happiness with the doctor, Strauss says, “We couldn’t make hide nor hair of the results. The doctors were the same. The support staff was the same. We finally determined that all measures of patient care went up or down depending on average wait times.”

But it is the perception of the wait time that can wreak havoc with an urgent care center’s reputation. “You want people to keep coming back,” says Strauss. “You want them to post on Facebook, “Even though I had to wait 30 minutes, they made me feel wonderful.”

GREAT EXPECTATIONS Poore, who spent close to two decades at the Walt Disney Company helping 65,000 employees implement a shared vision of customer service, says that in an urgent care setting, a “win” results in patient loyalty. “Loyalty comes from consistently meeting my expectations on the clinical side of care while exceeding my expectations on the personalized side of care.”

But in healthcare, “the biggest problem is not meeting and exceeding expectations,” Poore says. “The biggest problem is that we don’t set expectations.” While the rest of the world is honing in on personalization and customization, “we’re still trying to get our act together on quality and safety,” he says. “That gets us in the game, but it doesn’t differentiate us.”

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“Loyalty comes from consistently meeting my expectations on the clinical side of care while exceeding my expectations on the personalized side of care.”

THE POWER OF PEOPLE Poore, who has worked with more than 250 healthcare organizations to develop roadmaps for excellence in customer service, says that urgent care centers can offer unique value propositions in three areas: people, processes, and physical setting.

When it comes to the urgent care environment, “People have an expectation of quality,” Poore says. “Can I easily park my car? Are there fingerprints on the door?

Is the center clean? Do they speak to me in a language I can understand? Do they have chairs that I’d seat my child or my grandmother in?”

But he warns that new equipment and comfortable chairs aren’t enough. Instead, it’s people who can transform the customer experience.

“As a consumer today, I have a choice,” says Poore. “I’m going to go to the urgent care center that includes me in the experience.

It’s not just what you said; it’s how you make me feel.”

Poore says making a customer feel great is simply a matter of operationalizing common sense. For example, he says, “If you have three people at the desk and it’s not busy, put one person at the door to greet people. They do that at Chili’s.”

But that’s just the beginning. Poore says that urgent care centers should formulate a plan for personalized care based on the community served. He says too many urgent care centers take a “spray and pray” approach to customer service: “Spray on all of these ideas and pray that one of them hits home.”

Instead of assuming you know what’s right for the patient, Poore says you should ask. “Every zip code we go to, we ask, what would you like your physicians to wear?

To ask? To say? What would you like in the waiting room? Would you like a TV? What should be on the TV? How should our doctors address you? Should they introduce themselves? Should they have their names on a lanyard?”

“If you have three people at the desk and it’s not busy, put one person at the door to greet people. They do that at Chili’s.”

THE FIRST FIVE STEPS Integrated Loyalty Systems President Jake Poore advises urgent care center professionals to look at their people, processes, and physical setting through the patient lens. To get a jumpstart on improving customer service, you can adopt these five practices: 1. Greet patients with a sense of urgency. “The words ‘urgent care’ build expectations,” says Poore.

2. Ask patients, what name should we call you? “Using their preferred name drives their intent to return,” Poore says.

3. Knock and wait for permission to enter the exam room. It’s now their room. “A hotel housekeeper has a master key, but she’d never enter a room without knocking,” reminds Poore.

4. Sit with the patient, but never on the exam table. “If you’re looking at the EHR and turn your head to talk to the patient, you give literal meaning to the term ‘cold shoulder,’” says Poore. “If you stand above the patient, you give literal meaning to the term, ‘looking down your nose.’” When you sit with the patient at eye level, they perceive you as being there 30 percent longer, he notes.

5. Thank the patient. “Say, ‘We know you have a choice in healthcare.’ Thank the customer for choosing you,” says Poore.

HUMAN. CLINICAL. HUMAN. Poore advocates a veritable sandwich of patient interaction. “Enter on the human,” he advises. If the patient is a firefighter, ask about rescuing cats in trees. If the patient is a student, ask about this semester’s classes. Then, transition into the clinical.

But acknowledge that they have already explained their complaint. Poore suggests saying, “Do you mind telling me your story of why you’re here? You already filled out the paperwork, but I want to hear it from you.” At the end of visit, reconnect on a human level. Touch on something you previously discussed, like this term’s tough calculus class. “Then, thank the customer for choosing you,” says Poore.

PUTTING THEORY INTO PRACTICE Strauss’ Baystate Health Urgent Care has implemented consumer-centric strategies.

He describes a typical patient experience at Baystate.

“The experience begins from the moment a patient walks through the door.

It is a beautiful, open environment. The waiting room is impeccably clean. Clutter is nonexistent, and there aren’t old magazines piled up. The plants are healthy and dusted.

“The first thing a patient sees is a greeter sitting behind a desk. The greeter smiles and asks, ‘How can I help you?’”

“The patient is registered and given an idea of how many patients are ahead of

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them. The greeter never estimates the wait time because that’s highly variable. Creating appropriate expectations is key to keeping people happy.

“The staff member in the front office enters identifying characteristics into the computer. The record might say, ‘Sandra Jones is wearing a pinstriped suit and a yellow hat.’”

“Now that the medical assistant or nurse knows the patient’s identifying feature, she can walk straight up to the patient in the waiting room and say, ‘Hi, Ms. Jones, I’m Cindy.’

“Once the patient is in the exam room, she’s told how many patients are ahead of her. When possible, we try to get some of the workups started. If she’s likely to need an x-ray, the medical assistant will ask the doctor to do a quick exam.

“That’s not always feasible, but if it is, I’ll tell the patient I’m just poking my head in for a minute to determine if she needs an x-ray. While I’m examining her ankle, I’ll tell her that there’s still a patient ahead of her, but that I wanted to check her ankle to keep the process speedy. This not only facilitates keeping people moving, but also communicates that you recognize that their time is valuable.

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“We always talk up the next person that the patient is going to see. ‘Ellen the nurse is going to do your vital signs. She’s great.’

Or, ‘She has a soft touch with the needle so don’t worry about it.’

As you hand the patient off to the next contact, there’s an air of quality and confidence that everyone is working as a team.

“If the patient doesn’t need workups, when I walk into the exam room my nametag is clearly visible. I introduce myself and acknowledge the patient. I shake their hand and sit down while I’m talking to them. I explain what I’m doing when I examine them.

‘I’m going to push on your belly.’ ‘This is where your spleen is.’

‘This is where your right ovary is.’ People like that. They like an explanation when you’re going to touch them. It doesn’t take any extra time because you explain while you’re doing it.

“After explaining to the patient what’s going on and the treatment plan, I give them discharge information, a handout on what happened at the visit. This helps protect you legally, but it also reminds the patient what you said. They’ll be happier because if they didn’t hear what you said, they’ll think you didn’t tell them.

“At the end of the visit, if I have time, I try to walk the patient out to the waiting room. If I can’t do it, a medical assistant will. It’s an opportunity to get the patient established with other services.”

MITIGATING THE NEGATIVE

Strauss is the first to acknowledge that it isn’t always possible to keep patients happy.

“Some people are unhappy when you deny them narcotics or refuse a prescription for antibiotics when they think they need them for their cold,” he says. “But, if they otherwise had a great experience, they’re less likely to be angry.”

GETTING FROM HERE TO THERE Patients can spot inauthenticity a mile away.

According to Strauss, for the consumercentric focus to pay dividends, it has to infuse the urgent care center’s culture. In order to do that, “You really need buy-in from the staff,” he says. “If this comes from on high, people won’t necessarily buy into it.”

Strauss acknowledges that there’s “a certain amount of eye-rolling whenever a

new thing comes along,” but discussions that focus on the kind of care staff members want to provide to patients and how to do the right thing for patients all of the time will make staff members stakeholders in the process. From there, he says, “There must be clear expectations about how staff members should behave with patients,” he says.

Strauss emphasizes the importance of explaining your patient experience vision to potential employees. “It’s key to explain your expectation and see if they’re buying into it. You can hire the best doctor in the world, but if he doesn’t buy in, it’s going to hurt your business,” he says.

Strauss says that improving the customer service does more than drive traffic to an urgent care clinic. It decreases staff turnover and makes staff recruitment a breeze. “The patient experience is also an employee

experience,” he says. “If you create a pleasant experience for the patients, you’ll have better staff retention. People will come into work happy and enjoy their work more.”

OPERATIONALIZING COMMON SENSE Think only about “patients,” and you’ll do so at your peril. The quality of customer service found at an urgent care center can mean the difference between soaring revenues and red ink.

Strauss says that the strategies Baystate has implemented are “not rocket science.” Still, he says, “It’s easy for them to get lost in the day-to-day shuffle of providing patient care.”

Or as Poore says, “It may be common sense; it’s just not common practice.” ■

RESOURCES Jake Poore, founder and president of Integrated Loyalty Systems, says You Say More than You Think by Janine Driver (2011, Harmony, ISBN 978-0307453983) is a mustread for every urgent care professional.

In 2014, Management consulting firm Oliver Wyman published “The Patient-to-Consumer Revolution,” which postulates that the technology sector’s interest in healthcare has created “Health Market 2.0.”

You can download the report at http://www.oliverwyman. com/content/dam/oliver-wyman/global/en/images/ insights/health-life-sciences/2014/October/The-PatientTo-Consumer-Revolution.pdf

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BREAKING DOWN BARRIERS

BY SUSAN COOPER

Delivering appropriate cultural and linguistic services

W

hen a patient walks into Integrity Urgent Care Clinics, he’s sure to be understood, and he’s sure to leave with a clear understanding about what happened during his visit and what he can expect after discharge. That’s because the Colorado-based centers are committed to delivering what accreditation body The Joint Commission refers to as CLAS, or Culturally and Linguistically Appropriate Services.

According to CEO Lori Japp, PAC, one of the ways Integrity Urgent Care Clinics delivers CLAS is through providing interpreting and translation services.

“Anytime a patient comes in where English is not their language of choice, we use a translation service,” she says. For patients that are hearing impaired, “we have a group in town that will come in and do sign language.”

According to the U.S. Census Bureau, 19.2 million people between the ages of 16 and 64 have limited English proficiency, which amounts to nearly 10 percent of U.S. adults. That’s why the very first patient interaction should start with an assessment of communication practices. Japp says that, sometimes, patients will “look at you with

a blank stare or a look of frustration, which will clue you in that there is some type of language barrier.” If the language can’t be readily identified, a visual language card can help. “Then call interpretation services,” says Japp.

In Japp’s experience, “The strong majority of folks who don’t speak English will bring someone with them” who does speak the language. But she warns against relying on a patient’s friend or family member – or even a staff member – to relay information.

“With bilingual staff members, we have to make sure they’ve gone through training and have passed an internal audit process to make sure they’re able to translate medical terminology appropriately,” she says.

Dr. Christina Cordero, associate project director for The Joint Commission, echoes that sentiment, saying that it’s critical for urgent care centers to develop a system for language services, whether it is a staff interpreter or phone or video services. “You don’t want to rely on family and friends, untrained or unqualified individuals, to perform interpreting services on behalf of the organization,” she says.

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“WITH BILINGUAL STAFF MEMBERS, WE HAVE TO MAKE SURE THEY’VE GONE THROUGH TRAINING AND HAVE PASSED AN INTERNAL AUDIT PROCESS TO MAKE SURE THEY’RE ABLE TO TRANSLATE MEDICAL TERMINOLOGY APPROPRIATELY.” Cordero does admit that it can be difficult to find the balance between implementing CLAS and maintaining a patient-centered approach to care. “Some patients decline using translation services, and would rather use a family member,” she says. While some organizations ask patients to sign a waiver, Cordero says it’s important for the urgent care center to have its own interpreter present in order to mitigate risk. “Have both people in the room to make sure the family member or friend is accurately interpreting,” she advises.

MORE THAN TRANSLATION Providing patients with the proper translation or interpretation services is crucial, but the spoken word is only one aspect of CLAS. For some patients, the written word can present a barrier to healthcare. According to the U.S. Department of Education, 14 percent of U.S. adults can’t read, and 21 percent read below a fifth grade level. And the National Assessment of Health Literacy found that only 12 percent of adults have health literacy proficiency.

GETTING STARTED Lori Japp, PA-C, CEO of Integrity Urgent Care Clinics, identifies five steps that urgent care centers can take to deliver Culturally and Linguistically Appropriate Services (CLAS): Assess communication practices. Review everything from the front desk check-in process to the discharge process, and identify any gaps. “Look at each point of contact as a risk assessment,” Japp says. She suggests analyzing the greatest communication gaps and assigning numbers according to risk. Work on the highest numbers first.

1

Research other plans.

“The Joint Commission’s Roadmap for Hospitals is a great tool and can be adapted to an urgent care setting very easily,” says Japp. [see resource list]

2

Research local services.

“Look at the interpretation services and sign language services in your area,” suggests Japp. “Develop a protocol to determine whether your own team members have qualifications to act as interpreters.”

3

4

Set expectations. “Develop your own workflow and set of expectations for each point of contact,” says Japp. “Asking team members for their input helps them buy into the process.”

Monitor and evaluate.

Ask for feedback from the staff and feedback from patients. “Always focus on continuous improvement,” says Japp.

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A patient’s literacy-related clues might include stating that she’s forgotten her glasses or asking to take paperwork home and return later. One approach is to implement a policy where staff asks each patient if he or she would like help with paperwork, while another is to discreetly inquire whether a specific patient needs assistance.

Integrity Urgent Care Clinics also places an emphasis on accessible written materials. “Our informed consents are in several different languages,” Japp says. “And we try and structure all of our discharge instructions for a fifth grade reading level. We avoid a lot of medical terminology that people aren’t familiar with.”

Japp says that the discharge process is critical. At Integrity Urgent Care Clinics, the provider “closes the loop,” reviewing discharge instructions with the patient and fielding any questions the patient has. “Then the medical assistant will go back in,” Japp says. “She takes the printed discharge papers and goes over the diagnosis, treatment plan, and medications again.”

Patients who don’t speak English and those who don’t have health literacy proficiency aren’t the only people who should be accommodated by CLAS. Some patients may have cultural- or religion-based modesty issues that might make it inappropriate for providers of a different gender, or those who are older or younger than the patient, to deliver care. Other patients may have dietary restrictions that impact the types of medications can be prescribed.

The Joint Commission advises those in a healthcare setting to ask patients about other needs that might affect care, and then work to accommodate those.

WALKING THE WALK Talking the talk (in the correct language) is one aspect of CLAS, but walking the walk is another. In order to pave the way for appropriate communication at every touch point of a patient’s visit, management needs to clearly demonstrate its commitment to CLAS. This means setting policy, conducting trainings, and providing resources to ensure that patients’ cultural and linguistic needs are met. For example, Japp says, “Leadership needs to ensure that their ancillary staff knows that it’s standard protocol to call interpretation services.”

Leadership extends to an urgent care center’s hiring practices.

According to The Joint Commission’s standards, ambulatory care center leadership and staff should reflect the cultural and linguistic diversity of the population it serves. Then they should be trained.

When it comes to translation services, for example, Cordero says staff should “know how to get the services they need,” including information about how to call the appropriate person and any relevant access codes.

As for the cost of providing CLAS, the buck stops with the urgent care center. “It’s not something that we bill the patient or the insurance company for,” says Japp. “I’ve seen where team members are afraid to call the translation service because they know it costs more money,” Japp says, “but it’s our responsibility to deliver safe, compassionate care.”

■

RESOURCES The Joint Commission has a number of resources that urgent care centers can adapt in order to improve their patient communication practices. The Joint Commission’s guides and roadmaps can be used as self-assessment tools and educational resources. They include: “A Crosswalk of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care to The Joint Commission Ambulatory Health Care Accreditation Standards” Downloadable from http://www.jointcommission.org/ assets/1/6/Crosswalk_CLAS_AHC_20141110.pdf

centers, the roadmap can act as a springboard to create an urgent care center’s CLAS plan. Appendix E contains a wealth of resources for culturally and linguistically appropriate guidance and material.

It is downloadable from http://www.jointcommission.org/ assets/1/6/aroadmapforhospitalsfinalversion727.pdf “Advancing Effective Communication, Cultural Competence, and Patient- and Family- Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community” Downloadable from http://www.jointcommission.org/ assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf

“Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals” While much of the material is not applicable to urgent care

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FLIPPING THE SWITCH

SMOOTHING THE ROCKY TRANSITION TO ICD-10

WRITEN BY. SALLY E. SMITH

BY SALLY E. SMITH

In 1962, sociologist Everett Rogers theorized that adopters of a new innovation or idea could be categorized into one of five groups that form a bell curve: innovators, early adopters, early majority, late majority, and laggards. While we identify as a nation of innovators and early adopters, when it comes to ICD-10, the U.S. is indisputably a laggard.

The World Health Organization endorsed the tenth revision of the International Classification of Diseases in 1990. The Netherlands and the Czech Republic adopted ICD-10 in 1994. Australia got up to speed in 1999. Canada came on board in 2000 and China in 2002. In the U.S., the Centers for Medicare & Medicaid Services (CMS) kicked the proverbial can down the road until Congress took a whack at it, inserting an amendment to a 2014 bill that delayed ICD-10 implementation until at least October 1, 2015. Last July, the U.S Department of Health and Human Services issued a rule finalizing October 1, 2015, as the transition date.

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Given the repeated delays, it’s not surprising that stakeholders are skeptical, taking an “I’ll believe it when I see it” stance.

THE SQUEEZE ON CODERS Betty Hovey, director of ICD-10 Development and Training for the American Academy of Professional Coders (AAPC), says that the exponential increase in the number of codes in ICD-10 will put the squeeze on coders. “In ICD-9, we’ve got about 12,000 codes. With ICD-10, there are 70,000 codes for diagnoses,” she says. “The granularity of how they’re looking at diseases is different.”

Hovey cites otitis media (an ear infection) to illustrate. “One code in ICD-9 is now four codes in ICD-10. There’s one code for the right ear, one code for the left ear, one for bilateral, and one for unspecified,” she says.

“Think of how many kids come into urgent care with otitis media,” Hovey says.

During the transition to ICD-10, “a coder will have to look it up every time. How long will that take?”

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Injuries have the potential to become even more problematic for urgent care centers thanks to the requirement for external cause codes, says Hovey. Called “E codes” in ICD9, they’re classified as B, W, X, and Y codes in ICD-10.

Hovey says that the foundation for accurate coding begins in the first encounter.

“When a patient shows up in pain and tells you that they fell, you should note when they fell, how they fell, where they fell, what they were doing when they fell, and if they were working when they fell,” she says.

Multiply the absence of that kind of information by the number of injured patients an urgent care center sees, and “imagine what that would do to your coder’s productivity and flow,” says Hovey.

THE IMPACT ON REIMBURSEMENTS The problem could snowball, impacting not only the coder’s flow, but also the urgent care center’s cash flow. In Hovey’s scenario, if a

“When a patient shows up in pain and tells you that they fell, you should note when they fell, how they fell, where they fell, what they were doing when they fell, and if they were working when they fell.” patient fell and has a fracture in the right radius shaft, without the proper external cause codes issues could arise with insurance subrogation. “If they fractured their radius in the grocery store, the insurance company will say, ‘Maybe I shouldn’t be paying for this,’” says Hovey. If it happened when they were at work or if they were in a car accident, the insurance company might balk, Hovey says.

Hovey is quick to note that not every payor will require external cause codes. Because CMS isn’t making external cause codes a national mandate, “If your payor today doesn’t want the E codes, they probably won’t want them in ICD-10,” says Hovey.

Hovey says that it’s difficult to predict the transition’s impact on timely payments, but she suspects that those predicting a doomsday scenario are overreacting. “A payor could say that they’ll automatically deny claims that don’t include cause codes, but then what would happen?” she asks. “How many appeals would they get? If you think it through logically, they’d have to have the manpower to handle all of those rejections,” she says.

Annie Boynton, former communications director for the Regulatory Implementation Office for UnitedHealth Group, agrees that cooler heads should prevail. Boynton, now an independent consultant, says, “No payor wants to see reimbursement delays as a result of ICD-10. That’s not the goal.”

Saying that UnitedHealth began working on ICD-10 implementation in early 2009, Boynton opines that the future is impossible to forecast. “They don’t know what they don’t know,” she says. “You can have the largest implementation team and spend millions of dollars, but no on knows how it’s going to affect reimbursement or if it’s going to affect reimbursement in the future.”

POINTING FINGERS According to Boynton, when it comes to ICD-10, payors have their proverbial ducks in a row. “If there’s a payor out there that isn’t ready, I’d be shocked,” she says. “They took it seriously. They saw the potential. They started doing something about it.”

On the other hand, she says, “Providers didn’t take it seriously and they still haven’t.” Boynton is particularly concerned about small practices, namely those with one to three physicians. “They’ve hinged on delay after delay. They’re betting that it’s going to be delayed again, but there’s nothing that’s pointing in that direction.”

Beth Olivieri, coding manager for EMR software company DocuTAP, disagrees. “The biggest challenge will not be that the providers aren’t ready or the EMR isn’t ready; it will be that the

insurance company will not be ready.” She believes that the claims adjudication process will slow to a crawl and reimbursements will be delayed, and advises urgent care centers to have cash reserves on hand.

TALK TO YOUR PAYORS But when it comes to advising urgent care centers to prepare for the ICD-10 transition, payors and coders see eye-to-eye.

“We tell our clients is run reports, find out who your big payors are, and get on the phone,” says Hovey. “Payors don’t want to be surprised. Neither do you.” While it’s impractical to call everyone, Hovey says to question those that have the biggest impact on your bottom line. “Ask, what are the codes you’re going to be looking for?

What’s important to you?”

Saying that accounts receivable delays will lengthen as the adjudication process drags on, Hovey concludes, “If you can settle anything beforehand, you’re ahead of the game.”

Olivieri concurs. “Differentiating between which carriers want ICD-9 and which want ICD-10 is important,” she says. “You have to make adjustments depending upon what the carrier wants.”

Boynton agrees. “The time for adversarial relationships between payors and providers has to end. If the payor hasn’t reached out to the provider, the onus is on the provider to reach out to the payor.”

At the same time, Boynton says that payor communication isn’t a substitute for ICD-10 preparedness. “If a provider isn’t ready and hasn’t done their own planning, a payor isn’t going to waive a magic wand and make the provider ready,” she says.

TALK TO YOUR VENDORS Boynton says that it’s equally important to keep lines of communication open with vendors. Reaching out to third-party billing vendors, EMR vendors, and others will contribute to a smooth transition.

In the same vein, Boynton recommends talking to “any vendor that’s dependent upon diagnostic information or codes, such as immunization registries and birth registries.”

DocuTAP’s Director of Product, Darin VanderWell, echoes the need to communicate with vendors. “Everybody’s talking about payor-readiness, but there are third-party issues,” he says. Citing an example of an urgent care center sending out laboratory specimens to external reference labs, VanderWell notes that an order message is often accompanied by a diagnosis. “Will labs or radiology vendors be ready, or will they lag behind?” he asks.

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REVENUE VanderWell reports that the company’s EMR software is firing on all cylinders. “Even after the delay in 2014, we decided to get ready from a technology perspective,” he said. “Last year, we integrated a third-party terminology vendor into our application to help identify diagnoses in our system to comply with ICD-9, ICD-10, or SNOMED.” VanderWell says that DocuTAP has done extensive testing in conjunction with its clearinghouse partner, Zirmed, to move claims from DocuTAP to Zirmed to payors. He notes, “We’ll probably do some more end-to-end testing, but we feel solid about our testing with Zirmed.”

TRAIN YOUR PHYSICIANS Hovey says that physician documentation training is an important piece of the ICD-10 puzzle. “You can have the best coder in the world, but if the note doesn’t have the right information, you’ll have a problem,” she says. AAPC delivers documentation improvement training onsite and online. The organization also provides documentation assessments. “We take providers’ notes, code them, and give them a report about what they’re documenting now and how they need to adjust their documentation,” she says. “Usually they just need to tweak their notes a bit.”

One helpful hint? “Adjectives are very important,” says Hovey. “ ‘Acute,’ ‘chronic,’ ‘right,’ ‘left’ – adding those words into the notes is critical.”

ADDRESS STAFFING NEEDS Boynton suggests training or hiring additional staff or outsourcing some coding during the transition period, which she defines as “between October 1 and who knows when.” She points out that “the capability for dual processing is going to be critical,” as service dates after September 30 must be coded in ICD-10, but service dates prior to that will require ICD-9.

DocuTAP’s Olivieri expects the transition to take about a year, but predicts that dual processing will be here to stay. “State workers’ comp carriers are HIPAA exempt so they can choose whether or not to use ICD-10. ICD-9 might not go away for a long time, depending on what your state wants,” she says.

PRACTICE AND TEST Hovey is a proponent of dual coding in ICD-9 and ICD-10. “The more you do it, the less scary it is,” she says. “Practice, practice, practice.”

She also says that testing is “hugely important, and advocates testing “with any vendor who will test with you.” Hovey also recommends that urgent care centers participate in CMS testing via CMS local contractors.

THINK ABOUT PATIENTS Although organizations are preparing for ICD-10 with leadership, business processes, technology, and staffing, Boynton notes that impact on patients is rarely considered. “Patients are going to recognize that something is different,” she says. “When they see a new explanation of benefits or when there are reimbursement delays, the first place they’re going to go is to the provider’s doorstep, asking, ‘What did you do wrong?’” Urgent care centers should have a plan in place to deal with patients’ questions.

BEHIND THE CURVE? For urgent care centers that are behind the curve in their ICD-10 implementation plan, Boynton recommends running a utilization report or frequency report through the center’s EMR system to determine the most frequently used ICD-9 codes. “It’s the 80/20 rule,” Boynton says. “The top 25 codes are probably going to account for 80 percent or more of the organization’s revenue.” She recommends running a comparative analysis for ICD-10, which will provide a clearer roadmap for documentation improvement.

ALL HANDS ON DECK Boynton warns that the transition to ICD-10 is a marathon, not a sprint. “There’s a big misconception that the work will be done on October 1, but the work doesn’t begin until the stroke of midnight on September 30,” she says. “Until then, we’re simply still in the planning phases.”

According to Hovey, “ICD-10 takes all hands on deck. It’s not just a coder issue. It’s not just a physician documentation issue. It’s not just an administration issue. It’s not just an IT issue.”

Still, Boynton says, at the end of the day, an organization can have followed the book to the letter and still wind up with reimbursement impacts and payment delays. “Nobody has a crystal ball,” she says.

“We’ve never seen this type of implementation on this wide of a scale in this country before.”

RECLAIMING THE EARLY ADOPTER MANTLE If the U.S. has been one of sociologist Everett Rogers’ laggards when it comes to ICD-10, it may yet be possible to reclaim the early adopter mantle. The World Health Organization is revising 1994’s ICD-10, and will unveil ICD-11 in 2017. According to DocuTAP’s VanderWell, “You’ll occasionally hear chatter about the U.S. scrapping plans to adopt ICD-10 and go straight to ICD-11,” he says. “From a technology perspective, even if they kicked the can that far down the road, we’d be well-positioned for ICD-11.”

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The American Academy of Professional Coders (AAPC) offers a number of ICD-10 resources to both members and non-members, including an implementation tracker and a digital newsletter, ICD-10 Tips and Resources. Visit http://www.aapc.com for more information.

DocuTAP offers a free white paper, “How to Prepare Your Urgent Care for ICD-10,” at http://docutap.com/how-to-prepare-your-urgent-care-for-icd-10

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MAY 2015

UrgentCareMagazine.com

LAST WORD

Cloud Cover

AN IT STRATEGY TO MATCH OUR DISRUPTIVE SPECIALTY

S

BY JOHN KULIN, DO

cience fiction writer William Gibson once wrote, “The future is already here – it’s just not evenly distributed.” Urgent care may be grounded in this galaxy, not another, but I think the sentiment holds. Urgent care physicians are fundamentally reimaging the future of medicine. They’re renegotiating delivery models to offer patient-centered, business-minded health care that meets the consumer economy head-on. It’s fast, convenient, and efficient; it charges rates much lower than emergency departments; and it preserves EDs as theaters for life-threatening emergencies. Yes, the future has arrived, and I call it urgent care. To distribute it, urgent care needs a disruptive IT strategy to match.

My organization, the Urgent Care Group, has experienced tremendous growth over ten years working with a cloud-based IT strategy. We leverage a well-integrated suite of EHR, RCM, and analytics that have scaled with our practice and implemented seamlessly with new locations and new doctors. They’ve made us more successful, more efficient, and as a result, even more focused on patients. I encourage all urgent care “futurists” to consider the power of the cloud.

As you grow, the cloud provides quick, easy, and affordable set-up and adoption. The Urgent Care Group expanded to a second clinic with no initial capital expenditure. That was critical during the recession. We were easily able to on-board and connect new providers and rollout features practice-wide, while preserving practices’ autonomy and ability to tailor features. We plugged into our network quickly, with immediate access to all the benefits of a “network effect,” like practice management visibility and automation, to effectively manage resources.

The cloud can help prioritize patient throughput, especially during peak times. Boom hours are a fact of life in urgent care,

particularly after hours and on the weekends. It’s especially true for our group in the summer, when vacationers descend upon southern New Jersey’s beaches and our offices. The cloud reduces document management with digital check-in, paperless workflows, and patient communication via the patient portal that integrate seamlessly.

Documentation accelerators within the EHR like diagnosis order sets increase speed and efficiency and integrate procedures directly into our RCM’s billing tab, eliminating lost charges.

Perhaps most importantly for a high volume practice, IT needs to takes on the revenue cycle. That means maintaining insurance packages; enabling real time eligibility checks; performing claims follow up, denial management, and posting; and scrubbing claims based on network knowledge so that you submit claims cleanly, the first time. Integrated payment processing and flexible payment options optimize time-of-service collections. Real-time transparency and reporting easily identify and resolve outstanding A/R issues.

For the Urgent Care Group, that’s added up to a 30% increase in collections and a DAR rate that’s fallen by more than half.

Urgent care is booming. That’s the thrill of this exciting, emerging field. Our specialty meets the demand for access to care in ways that fundamentally disrupt the old guard. For the Urgent Care Group, cloud-based services have helped underscore our field’s commitment to speed, convenience, and thoroughness in our own offices. The cloud connects us to performance, and to our patients. It’s a disruptive model that mirrors our own specialty.

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UrgentCareMagazine.com

May 2015

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DECISIONS BACKED BY DATA. “The most valuable thing about DocuTAP Analytics is the ability to slice and dice the data however we need. We can dive all the way down to the visit level to find out what’s going on in A/R, coding, reimbursement, or visit trends.

We see exactly which days are busy at which clinic, so we can now staff strategically.

Because 80% of expense in an urgent care is staffing, we must manage it well. We can do that effectively because of the transparency of data available to us.

With the help of Analytics, we were able to identify a more sustainable business model.

We identified that a tremendous amount of resources were allocated to services making up only 10% of our reimbursement.

Analytics also cuts down on end-of-month closing because our accountant can pull reports within minutes instead of hours.”

— BRANDON PENICK Chief Operating Officer First Med Urgent Care

SEE DOCUTAP ANALYTICS UP CLOSE. CALL US FOR A ONE-ON-ONE DEMO. 888.538.0775 | docutap.com/UCM

Crafting a better urgent care experience.

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