2014 Salary & Trends Report PPA

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2014 Professional Patient Advocate

Salary & Trends REpOrt

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Editor’s Note
www.patientadvocatetraining.com
PRESIDENT Steve Greenberg VICE PRESIDENT Carol Brault 301-287-2490 [email protected] EDITOR IN CHIEF Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN 954-254-2950 [email protected] MANAGING EDITOR Richard Scott [email protected] GRAPHIC DESIGNER Tara Zaino STAFF WRITER Steven Dashiell SENIOR MARKETING MANAGER Lindsey Harris SENIOR PRODUCTION MANAGER Joann M. Fato

An In-Depth Benchmark for Professional Patient Advocacy
I am privileged to introduce you to the first Professional Patient Advocate Salary & Trends Report, which has been produced by the Professional Patient Advocate Institute to provide an indepth look at the emerging practice of patient advocacy. This report will set a benchmark that professionals can use to explain their role and function, and the value they bring to consumers, health systems and payers throughout the care continuum. Today, with the focus on changing the culture of healthcare to a patient- and familycentered system, the industry is struggling to understand the unique needs that people have when they enter and transition through the fragmented healthcare system. Patient advocates are answering this call and ensuring that each patient has a voice and that care is organized to meet their needs. The only constant in the healthcare system is the patient; yet many times our patients are overlooked. As the shift of risk increasingly moves onto the consumer’s shoulders, they are realizing that they have to take a more active role in their health and healthcare. Consumers are approaching healthcare in a new way – more than ever, they are realizing that, as a person would not enter a court of law without an attorney, they need someone to accompany them as they navigate the healthcare system. This report details the broad scope of patient advocacy, as well as the role, functions and outcomes that are starting to define the practice. The report will help explain the value that advocates bring to individual patients, families, health systems, payers and employers. In addition to the results of our survey, you will find articles from advocates in practice that explain the important work they are doing. It is our hope that this report is used by advocates to explain the work they do so there is a clearer understanding of their role, the settings in which they work, and the collaboration they bring to patients, the healthcare team and the payer. The future of patient advocacy is bright and the practice continue to gain muchdeserved recognition. In addition, the practice is working to define itself in terms of standards of practice, a code of professional conduct and a national certification that will provide further guarantees to consumers. On behalf of the Professional Patient Advocate Institute, I would like to thank the professionals who contributed to the survey, those who shared examples of the work they do every day as an advocate, and the editorial and design team who produced this report. We look forward to keeping you up to date as the practice continues to emerge and evolve. If you have questions or comments about the survey, or would like to know more about the Professional Patient Advocate Institute, please feel free to email me at [email protected]

ADVERTISING
ACCOUNT EXECUTIVE Carol Brault ~ 301-287-2490 [email protected] FOR TEAM PRICING AND GROUP RATES, CONTACT: Carol Brault ~ 301-287-2490 [email protected]

Copyright Notice All contents of Dorland Health electronic products, other than those expressly otherwise identified, Copyright 2013 DecisionHealth. All rights reserved. Materials published in Dorland Health electronic products may contain other proprietary notices or describe products, services, processes or technologies owned by DecisionHealth or third parties. Please note that by publishing these materials, DecisionHealth is not granting any license under any copyright trademark, patent or other intellectual property right of DecisionHealth or any third party.

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN Editor in Chief, Dorland Health and Professional Patient Advocate Institute [email protected]

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Table of Contents
Editor’s Note............................................................................................................................................................... 3 Section I: The Survey in Review................................................................................................................................. 8
A. Introduction to the Survey. ..........................................................................................................................................9 B. An Exploration of the Survey Results......................................................................................................................10 i. Respondent Demographics...............................................................................................................................11 ii. Professional Background..................................................................................................................................12 iv. Employment, Title and Role. .............................................................................................................................13 v. Salary Status, Rates and Benefits.....................................................................................................................17 vi. Caseload and Case Length. .............................................................................................................................21 vii. Business Development and Outcomes Achieved. ............................................................................................22 viii. Licensure. .......................................................................................................................................................24 ix. Clients and Referrals........................................................................................................................................25 x. Practice Trends. ................................................................................................................................................27

Section II: The Emergence of Patient Advocacy: Leadership Contributions.......................................................... 30
The Rise of the Independent Patient Advocate...........................................................................................................31 By Beth Droppert, RN, BSN

The Relationship Between Patient Navigators and Case Managers. ........................................................................35 By Carol Santalucia, MBA and Sarah Fay, MBA

An Advocate’s Journey: The Bridge to Patient-Centered Healthcare.......................................................................38 By Anna Inglett

Consumer Driven Health Plans Usher in New Opportunities for Case Managers...................................................41 By Catherine Mullahy, RN, BS, CRRN, CCM

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Navigating the Healthcare System in Rural Areas: Why You Need a Personal Advocate.......................................45 By Gloria Peth

The Heart of Patient Advocacy: Excelling in Family-Centered Care.........................................................................47 By Ilene Corina

Advance Care Planning Advocate: ‘So, You Do What?’. .............................................................................................49 By Jane Markley Business Grows When You Put Your Personal Needs Aside.....................................................................................52 By Amy Cameron O’Rourke, MPH, CMC

Driving a Partnership of Patient Advocacy in Hospital...............................................................................................54 By Alice Ostrowsky and Laura Ostrowsky, RN, CCM, MUP

Delivering Long-Term Services to a Family in Need...................................................................................................57 By Marie Connolly

The Birth of a Professional Patient Advocate. .............................................................................................................60 By Victoria Rose, RN, BSN

Patient Advocates: The Emergence of Modern Day “Rainmakers”..........................................................................63 By Kathryn Gohman

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Dorland Health Media Electronic Product Terms and Conditions
Access and use of Dorland Health Media electronic products are subject to the terms and conditions set forth herein and all applicable laws. Dorland Health Media may revise these terms and conditions from time to time by updating this page. By downloading and/or using any Dorland Health Media electronic product you are agreeing to comply with and be bound by these terms and conditions. Copyright Notice All contents of Dorland Health Media electronic products, other than those expressly otherwise identified, Copyright 2013 DecisionHealth. All rights reserved. Materials published in Dorland Health Media electronic products may contain other proprietary notices or describe products, services, processes or technologies owned by DecisionHealth or third parties. Please note that by publishing these materials, DecisionHealth is not granting any license under any copyright trademark, patent or other intellectual property right of DecisionHealth or any third party. Restrictions of Use DecisionHealth owns a copyright in the selection, coordination, arrangement and enhance- ment of such content, as well as in content original to it. Various third party content providers have made available their intellectual property in these products and own the copyright in content original to it. You may not modify, publish, transmit, display, participate in the transfer or sale, create derivative works, or in any way exploit the content of any electronic product except as otherwise expressly permitted under copyright law without the express written permission of DecisionHealth and the copyright owner. DecisionHealth maintains the right at any time to change or discontinue any aspect or feature of its electronic products. Disclaimer Dorland Health Media electronic products are provided “as is” and without warranties of any kind either express or implied. Trademarks The trademarks, service marks, and logos (referred to herein collectively as “Trademarks”) displayed on Dorland Health Media electronic products are registered and/or unregistered marks of DecisionHealth. The Trademarks of third parties may also be displayed in Dorland Health Media electronic products and are the property of their respective owners.

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The Guide To Patient Centered Communication

Training, Tools and Connections for the Professonal Patient Advocate
The Professional Patient Advocate Institute is a community aligned around the common cause of providing advocacy for patients as they attempt to navigate the complex healthcare system. The Institute offers training, business resources, and connections to patient advocates to discuss challenges and share best practices with the ultimate goal of improving the patient experience.

AS A MEMBER OF THE INSTITUTE, YOU WILL RECEIVE:
• A subscription to the Case In Point Learning Network professional level, including monthly issues of Case In Point delivered via PDF to your in-box ($199 value) • A subscription to the Patient Advocate Report weekly e-letter • Invitations to the PPAI Networking Call held monthly • Tools and resources including articles and comprehensive reports • A 30% discount to the PPAI Annual Conference in December in Orlando, FL

THE OBJECTIVES OF OUR PROGRAM IS TO HELP YOU:
• Improve your skills and qualifications in the field of patient advocacy. • Provide better outcomes for your patients and clients. • Earn a certificate in the emerging advocacy field. • Gain necessary CE credits to maintain your credentials. • Stay up-to-date on the changes and advances in this niche specialty. • Create and maintain a profitable patient advocate business. • Access hard-to-find business tools to help you manage your practice and save yourself time.

Better Outcomes

Learn more at www.PatientAdvocateTraining.com
9737 Washingtonian Boulevard, Second Floor, Gaithersburg, MD 20878 (855)CALL-DH1 (225-5341)
21049

Healthier Lives

Section 1 The Survey in Review

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Introduction to the Survey
The 2014 Professional Patient Advocate Salary & Trends Report is the most comprehensive appraisal of the burgeoning professional patient advocate industry, which continues to expand within the wider healthcare system. The current overview provides clear-cut insights into the arena of professional patient advocacy, including demographics, professional background, current employment, title and role, salary status, caseload and case length, business development and outcomes, licensure, client referral, and overarching practice trends and current challenges. The 2014 Patient Advocate Survey identified several key trends that showcase the dynamic nature of the emerging profession: • Patient advocates are enhancing the patient ex perience. The 2014 Survey included a section on the significant outcomes that patient advocates are achieving within the healthcare landscape. The majority of patient advocates are reporting that they are improving the quality and effectiveness of the healthcare experience through the following areas: Improved the patient experience; ensured greater patient input into the treatment plan; increased patient satisfaction; improved communication among the healthcare team; developed individualized plans; provided patient-specific alternatives to the current treatment plan; and improved access to healthcare services. • Patient advocates are experienced, educated health-based professionals. Three out of five individuals who responded to the survey has been active within the healthcare industry for 20 or more years. Another 20 percent have been involved in the healthcare industry between 10-20 years. Regarding education, 91 percent of all respondents have obtained at least an undergraduate degree, and approximately two in five (39%) have obtained a graduate degree. • Patient advocates interface with a wide range of healthcare professionals. Included among the list of professionals with whom patient advocates interact are physicians, clinical nurses, social workers, therapists, and pharmacists. Professionals tangentially related to the healthcare experience with whom patient advocates frequently interact include attorneys and employers. • Patient advocates refer an array of products and services. At least one-third of respondents frequently refer at least one product or service in the following categories: community resources; medical providers or facilities; home health providers; specific medical providers or specialists; caregiving services; durable medical equipment; and medication. • Patient advocacy is a growing business model, and salary reflects that. According to the survey results, 41% of respondents earned more than $50,000 in annual salary (based on last year’s salary numbers). The majority, or 52%, earned more than $40,000 in annual salary, including 10% who earned more than $100,000. On the opposite end, approximately 41% of respondents earned less than $30,000 working as a patient advocate. As the profession grows, the lower-end numbers are expected to continue to rise. For more in-depth analysis and graphical displays of the full range of results, continue onto the subsequent pages. If you have any feedback, contact Managing Editor Richard Scott at [email protected]

About the Survey
The 2014 Patient Advocate Survey took place in 2013. The survey polled nearly 300 professional patient advocates.

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AN EXPLORaTION OF THe SURVeY ResULTs

An Age of Growth: The Emerging Practice of Patient Advocacy
Viewing it in a historical context, the practice of patient advocacy is still in its early stages – that is, when talking about patient advocacy from the standpoint of a real, workable business model where independent advocates (or advocacy companies) interact directly with patient populations. An article that the Professional Patient Advocate Institute published last year featured an interview with patient advocacy pioneer Trisha Torrey. In that article, Torrey remarked: “I’d say to anyone that is going into patient advocacy at this point, that we’re still all pioneers.” Today, that insight still rings true. As the profession grows, patient advocates continue to make inroads in enhancing access and improving the quality of healthcare for patients in need of these services. As part of this year’s survey, patient advocates were asked to name their most significant achievements in working with patients throughout the healthcare continuum. The majority of respondents had achieved the following outcomes: • Improved the patient experience. • Ensured patient input into the care and treatment plan. • Increased patient satisfaction. • Improved communication among the patient/healthcare team. • Developed individualized plans for the patient/family. • Provided appropriate resources/alternatives to the current plan of treatment. • Improved strategies to ensure appropriate access to services. As the responses show, patient advocates are, by and large, creating significant outcomes within the healthcare system. The ongoing, industrywide focus on patient-centered care, one that places a tremendous emphasis on value-based care and quality-driven outcomes, foretells that patient advocacy services are ripe to continue their rapid expansion. This report, compiled and published by the Professional Patient Advocate Institute, delves into the specific details, as well as the overarching trends, of the growing profession. The big-picture view that comes into focus is characterized by a young profession being propelled forward by experienced healthcare professionals, in addition to enthusiastic newcomers who view patient advocacy as the wave of the future. Read on for further defining characteristics of the emerging practice of patient advocacy.

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Respondent Demographics
The vast majority of respondents are female (90%), while the largest age group represented is the ages 55 to 65 (46%). The data shows that few young men and women are starting their careers in patient advocacy. Rather, the numbers show that the vast majority of patient advocates are transitioning from another profession or a related background in healthcare. Nearly 90 percent of respondents fell between the ages of 35 and 65, with approximately 79 percent falling between the ages of 45 and 65.

GENDER
9.9%

REGION

22.8%

27.8%

Male (9.9%) Female (90.1%)
17.3% 33.8%

90.1%

AGE
2.9%

RACE
.4% 1.7% .4% 1.7% 5% 11.2% .8%

7.1%

Below 25 (0%) 25-35 (2.9%) 35-45 (11.2%) 45-55 (32.8%) 55-65 (46.1%) 65-75 (7.1%) 75 or Older (0%)
90%

Asian (0.8%) African-American (5%) Caucasian (90%) Hispanic (1.7%) Native American (0.4%) Other (1.7%) Choose not to answer (0.4%)

46.1%

32.8%

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Professional Background
By and large, the profession of patient advocacy is comprised of many experienced individuals who have long toiled within the healthcare system. Three out of fives respondents (60%) answered that they have worked within the healthcare system for 20 or more years. Another 20 percent have worked within healthcare for 10 to 20 years. The most common background for modern patient advocates is the nursing profession. Squarely half (50%) of respondents have a nursing background. The second largest background within healthcare is case management (13%), followed by serving as a healthcare executive (8%), behavioral health (6%), and social work (4%). Approximately 8 percent of respondents come from a non-healthcare background as a layperson. According to the survey, other healthcare professions also serve as feeder groups for patient advocacy, including care management, billing, education, public health and, less commonly, employer settings and physicians. When it comes to the length of time professionals have been working in the practice of patient advocacy, nearly half (49%) have been involved for less than five years. About one in five (18%) have been involved in patient advocacy for less than one year. On the other end of the spectrum, nearly a quarter of respondents (24%) claim to have worked in the practice of patient advocacy for 15 or more years. Overall, the patient advocacy profession is full of well-educated individuals. Nearly four in 10 (39%) have obtained a graduate degree, and more than nine out of 10 (91%) have obtained at least an undergraduate degree. According to the results, 9 percent are currently pursuing a graduate degree, while 7% have obtained a doctoral degree and another 2% are pursuing a doctoral degree.

YEARS IN HEALTHCARE
3.2%

YEARS IN PATIENT ADVOCACY
9.6%

6.8% 8.2% 8.7% 13.2%

Less than 1 (3.2%) 1-5 (8.2%) 5-10 (8.7%)
59.8%

11%

31.2%

Less than 1 (17.9%) 1-5 (31.2%) 5-10 (17%)

10-15 (6.8%) 15-20 (13.2%) 20+ (59.8%)

13.3% 17.9% 17%

10-15 (9.6%) 15-20 (11%) 20+ (13.3%)

PROFESSIONAL BACKGROUND
Nurse Case Manager Healthcare Executive Layperson Behavioral Health Professional Social Work Care Manager Billing Professional Educator Public Health Employer Physician 49.7% 12.7% 7.7% 7.7% 5.5% 4.4% 3.9% 2.8% 2.8% 1.7% 0.6% 0.6%

CURRENT EDUCATION LEVEL
2.4% 2.4% High School Diploma (6.2%) Undergraduate degree/diploma (34.6%) Pursuing undergraduate degree (2.4%) 38.9% 9% Pursuing graduate degree (9%) Obtained graduate degree (38.9%) Pursuing dotoral degree (2.4%) Obtained doctoral degree (6.6%) 34.6%

6.2% 6.6%

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Employment, Title and Role
A tad shy of half of survey respondents are self-employed (44%), while another one-third (34%) worked for an organization as a full-time patient advocate. Interestingly, 11 percent of respondents report that they work as a volunteer patient advocate. As far as job title goes, about four in 10 (38%) refer to themselves as patient advocates, while about one in four (23%) consider themselves case managers. The survey drew an 8% response from professionals who call themselves nurse navigators, and a 5% response from patient activists. Nearly four in 10 respondents (38%) are members of the Professional Patient Advocate Institute, with AdvoConnection (27%) and the Case Management Society of America (27%) also drawing representation, among others. Again, the most common certificate or certification among respondents is from the Professional Patient Advocate Institute (27%), followed by the Commission for Case Manager Certification (21%), and a range of others that drew modest responses. More than two in five individuals who responded to the survey (41%) do not hold a certificate or certification from any organization. The most common setting among respondents is the independent/private practice, which garnered 36 percent of responses. The second most common setting is acute care, with hospital advocacy drawing 22% of responses. Other notable settings include the community setting (15%), managed care group health (6%) and the employer setting (4%). Today’s patient advocates specialize in a wide range of areas within the greater healthcare system, according to the survey results. The following specialty areas are the five most common for this batch of survey respondents: • Adult care (71%). • Senior/geriatric care (68%). • Disease management (31%). • Children/pediatric care (23%). • Education (23%)

PROFESSIONAL TITLE
Patient Advocate Case Manager Nurse Navigator Care Manager Patient Activist Patient Representative Geriatric Care Manager Eldercare Specialist Health Advisor Patient Navigator Healthcare Assistant Medical Advocate Social Worker Billing Specialist Physician 37.7% 23.4% 8.4% 5.4% 5.4% 3.6% 3.6% 3.0% 2.4% 2.4% 1.2% 1.2% 1.2% 0.6% 0.6%

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Employment, Title and Role
EMPLOYMENT STATUS
Self-employed Employed by an org. as a full-time advocate Volunteer patient advocate Employed by an organization as a part-time advocate Independent contractor Retired patient advocate Per-diem patient advocate 43.6% 33.8% 10.7% 4.9% 4.9% 1.3% 0.9%

Professional organiZations
Professional Patient Advocate Institute AdvoConnection Case Management Society of America American Nurses Association National Association of Healthcare Advocacy Consultants (NAHAC) National Association of Geriatric Care Managers Society of Healthcare Consumer Advocacy Institute for Healthcare Improvement None 37.5% 26.4% 23.6% 18.1% 12.5% 8.3% 4.9% 1.4% 25%

Professional Discipline(s)
2.5% 3.7% 0.6%

8%

Licensed Practical Nurse (3.7%) Registered Nurse (63%) 63% Social Worker (8%) Medical Doctor (0.6%) PhD (2.5%) None (24.1%)

24.1%

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Professional certificates/certifications
Professional Patient Advocate Institute Certificate Commission for Case Manager Certification RN Patient Advocates Certified Rehabilitation Nurse Social Work Certification ANCC Nursing Case Management Certification University of Miami Alfus Advocacy Certificate Commission for Disability Case Management Consumer Health Advocacy Certificate Disease Management Healthcare Liaison Credentialing Program Certified Professional in Healthcare Quality Cleveland State University’s Patient Advocacy Certificate Consumer Health Advocacy Capstone Certificate None 26.8% 21.3% 6.1% 4.3% 3.7% 3.0% 3.0% 2.4% 1.2% 1.2% 1.2% 0.6% 0.6% 0.6% 40.9%

Impact of certificate/certification
YES
Gaining advancement in your career Maintaining your position Securing patients/clients Impacting your salary Obtaining your position 45.7% 43.0% 40.3% 39.4% 38.4%

NO
54.3% 57.0% 59.7% 60.6% 61.6%

Work setting
Independent/private practice Hospital advocate Community setting Managed care, group health Employer setting Physician office Administration Managed care, government Long-term care, skilled care Legal arena Managed care, workers’ compensation Medical home Occupational health/employer setting Managed care, provider based 36.1% 21.7% 15% 6.1% 4.4% 3.4% 3.3% 2.2% 1.7% 1.7% 1.7% 1.1% 1.1% <1%

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Employment, Title and Role
Reporting structure
Clients Employer Director of care/case management Director of nursing Medical director Chief executive officer Chief operating officer Director of quality Chief financial officer Independent Advocate / N/A 19.6% 17.6% 11.7% 9.2% 6.7% 6.1% 4.3% 3.7% 1.8% 52.8%

Patient advocacy specialiZation
Adult Seniors Disease management Children Education Behavioral health Denial/appeals management Safety Quality management Insurance specialist Risk management Employee health/wellness Billing Compliance Integrated model Medical home Physician practice Education department Coding Social worker Certificate training Certification program 70.8% 67.9% 31% 22.6% 22.6% 18.5% 16.7% 16.7% 14.9% 13.7% 13.7% 13.1% 12.5% 11.3% 11.3% 8.9% 7.1% 6.0% 4.2% 3.6% 1.8% 1.8%

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PROFESSIONAL ROLE
Independent practitioner President/CEO Senior patient advocate Staff patient advocate Manager/Supervisor Director Business development Financial liaison Physician 35% 30.6% 9.4% 9.4% 6.9% 6.3% 1.3% <1% <1%

Salary Status, Rates and Benefits
As the profession of patient advocacy grows, it will continue to endure the normal challenges associated with a rising business. As this report shows, one of these is challenges is securing income. About 41% of respondents reported earning below $30,000 in the last calendar year. However, the encouraging data shows that more than half of respondents (52%) earned more than $40,000 working as a patient advocate last year. More specifically, 17% of respondents earned between $50,000-$70,000 last year, and another 24% earned more than $70,000 last year. A full 10 percent of respondents earned more than $100,000 last year working as a patient advocate. The numbers above are extra compelling, considering the strong income levels in particular, given that nearly four out of five respondents (77%) receive payments by billing the consumer directly. About a quarter of respondents (24%) received payments through a managed care organization. The most common rate charge among patient advocates falls among the $50-$75 per hour range, which garnered 35 percent of responses. More than two out of five patient advocates (23%) charge between $75-$100 per hour, with another 14% charging somewhere between $125-$200 per hour. When it comes to services that patient advocates provide as part of their offerings, more than two-thirds (67%) provide a free assessment to clients. About the same number (66%) offer unlimited phone calls for advice, assistance or other needs. An even number of patient advocates carry malpractice insurance, while a very small number of advocates (2%) report having been involved in a malpractice case.

Annual Salary
7.9% 11.3% 48.5% 12.6% Below $40,000 (48.5%) $40,001 - $55,000 (11.3%) $55,001 - $75,000 (12.6%) $75,001 - $90,000 (7.9%) $90,001+ (15.4%) 15.4%

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Salary Status, Rates and Benefits
ANNUAL SALARY
Below $30,000 $30,000-$35,000 $35,001-$40,000 $40,001-$45,000 $45,001-$50,000 $50,001-$55,000 $55,001-$60,000 $60,001-$65,000 $65,001-$70,000 $70,001-$75,000 $75,001-$80,000 $80,001-$85,000 $85,001-$90,000 $90,001-$95,000 $95,001-$100,000 More than $100,000 41.1% 3.7% 3.7% 1.9% 4.7% 4.7% 3.3% 4.2% 5.1% 4.2% 3.3% 2.3% 2.3% 2.3% 2.8% 10.3%

How do you receive payment for your services
4.1% 3.3%

hourly rate
2.1%

5.7% 5.7% 7.9% 35% 23.6% 76.4% 15.7% 22.9% 10.7%

Directly from the consumer (76.4%) Through a long term insurance company (4.1%) Thorugh a trust fund (5.7%) From a managed care organization (23.6%) From an employer-sponsored Health � Savings Account (HSA) (3.3%)

$50-75/hour (35%) $75-100/hour (22.9%) $100-125/hour (15.7%) $125-150/hour (7.9%) $150-200/hour (5.7%) $200+/hour (2.1%) I provide a bundled rate (10.7%)

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DO you bundle your services

wHich services do you bundle

30.1% Yes (42.1%) 57.9% No (57.9%) 65.8%

42.1%

67.1%

What benefits do you receive from your employers or pay for yourself?
Reimbursement for professional licenses Reimbursement for certificate program Reimbursement for board certification Monetary allowance for continuing education Reimbursement for formal coursework Annual review/compensation 401(k) Retirement benefits Medical insurance Life insurance Disability insurance Sick time different than vacation time Personal days Physician 37.9% 42.6% 17.8% 32.0% 30.8% 39.1% 48.5% 36.1% 75.1% 59.8% 47.3% 39.6% 42.6% 0.6%

paid vacation
4.5%

work setting
3.5%

13.9%

One Week (4.5%) Two Weeks (14.3%) Three Weeks (13.9%) Four Weeks (12.1%) More than Four Weeks (10.8%) I Am Self Employed (44.4%)
22.1%

6.5% 10.6% 57.3%

14.3% 44.4% 12.1%

10.8%

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Salary Status, Rates and Benefits
normal business hours
3.6%

Malpractice insurance

25.4% 42.5%

9-5pm (28.5%) 24/7 depending on clients’ needs (25.4%) 7am-3pm (3.6%) I set my own schedule (42.5%)
49.5%

50.5%

Yes (50.5%) No (49.5%)

28.5%

involvement with malpractice
1.5%

obtaining consent

18.9% Yes (1.5%) No (98.5%) 98.5% Yes (81.1%) No (18.9%)

81.1%

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Caseload and Case Length
As in other businesses that provide services directly to clients, the number and length of cases is important for professional patient advocates. According to the survey results, most patient advocates maintain high-impact practices among a stable number of clients. For patient advocates that maintain a caseload, nearly onethird (30%) operate between one to 10 cases at a given time. About 11% operate between 11-20 caseloads, while 8% carry between 21-30 caseloads. Looking further down the spectrum, 5% of patient advocates report carrying a caseload of more than 100 clients. Notably, 36% of respondents replied that they do not carry a caseload. When it comes to the average length of a client’s case, the answers fall fairly evenly across the spectrum. The most common case length is more than one year (28%), according to the survey results. The second most common case length (23%) occurs between one to three months. About 21% of respondents report an average case length of less than one month, 15% report an average case length of three to six months, and 13% report an average case length between six months and one year.

AVERAGE CASELOAD
1-10 11-20 21-30 31-40 41-50 50-100 100+ 36.4% 10.9% 7.6% 3.3% 2.2% 3.4% 4.9%

average length of case

12.9% 27.6% 15.3% Less than 1 month (20.9%) 1-3 months (23.3%) 3-6 months (15.3%) 6 months - 1 year (12.9%) 20.9% 23.3% Ongoing/More than 1 year (27.6%)

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Business Development and Outcomes Achieved
Patient advocates rely on a variety of marketing strategies and professional referrals to achieve their goals of business growth and expanding client bases. The most common ways that patient advocates gain new clients include: • Word of mouth (68%). • Previous clients (37%). • Hospitals (33%). • Attorneys (26%). • Community organizations (25%). While a good number of patient advocates are able to track their outcomes (49%), many are still seeking ways to track outcomes and utilize them as part of their marketing and outreach efforts. As the results about significant outcomes show, patient advocates have a lot of reasons to market their services. From improving the patient experience to strengthening the coordination of care across providers and settings, patient advocates report a wide range of benefits that they are providing to their clients, and to the healthcare system in general. The majority of respondents have achieved the following outcomes: • Improved the patient experience (78%). • Ensured patient input into the care and treatment plan (68%). • Increased patient satisfaction (67%). • Improved communication among the patient/healthcare team (65%). • Developed individualized plans for the patient/family (63%). • Provided appropriate resources/alternatives to the current plan of treatment (55%). • Improved strategies to ensure appropriate access to services (54%). Among the other significant outcomes that patient advocates achieved are: decreased the number of exacerbations, readmissions and setbacks; streamlined care and helped contain healthcare costs; and improved provider satisfaction, among others.

Significant outcomes achieved as a patient advocate
Improved the patient care experience Ensured patient input Increased patient satisfaction Improved communication among the patient/healthcare team Developed individualized plans for the patient/family Provided appropriate resources/alternatives to the current plan Improved strategies to ensure appropriate access to services 77.8% 67.8% 67.3% 64.9% 62.6% 55% 53.8%

Other outcomes achieved
Decreased exacerbations, readmissions and setbacks Streamlined care and contained costs Implemented systems for safe, quality, evidence-based care Developed a program to improve patient education Increased employee satisfaction 36.3% 35.7% 31.6% 31% 25.1%

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How do you acQuire clients?
Word of mouth Past clients Hospitals Attorneys Community organizations Employer organization Financial planner Nursing home/Skilled care Local advertising Place of workshop Projects from local, state or federal grants Unions 67.7% 37.4% 32.9% 25.8% 25.2% 19.4% 14.8% 14.8% 10.3% 8.4% 3.2% < 1%

can you measure outcomes

do you use outcomes as part of marketing materials

Yes (48.6%) 48.6% 51.4% No (51.4%) 46.3% 58.3%

Yes (46.3%) No (58.3%)

demonstration proJect involvement

33.1% 66.9%

Yes (33.1%) No (66.9%)

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Licensure
About half of patient advocates (49%) hold a professional license in the states in which their clients are located. The same number of advocates does not hold a professional license in their clients’ states. However, the majority (71%) report that they feel it is important to hold a professional license. Among patient advocates who do hold a professional license, nearly seven out of 10 (67%) pay for the license and the renewal themselves. About 6% of respondents report that their employer pays licensing and renewal fees.

licensure
2.4%

importance of licensure

48.5% 49.1%

Yes (48.5%) No (49.1%) Don’t Know (2.4%)

29.2%

Yes (70.8%) No (29.2%) 70.8%

how do obtain licensure
5.3% 6.1% Pay for license and renewal yourself (67.2%) 21.4% 67.2% Employer pays for your license and for� the renewal of each license (6.1%) I am planning on obtaining additional� licenses (5.3%) N/A (21.4%)

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Clients and Referrals
Amid the complex, interconnected healthcare system, professional patient advocates interact with a wide range of professionals. Not surprisingly, advocates report interacting with patients and family members most frequently (78%). Other professionals with whom patient advocates commonly interact include: • Physicians (59%). • Clinical nurses (50%). • Social workers (35%). • Therapists (respiratory, physical, occupational, speech/language; 32%). • Attorneys (25%). • Pharmacists (18%). • Vendors (15%). • Employers (12%). Additionally, patient advocates refer an array of products and services throughout the healthcare continuum, delivering multiple referral points across various settings, from longterm care and acute facilities to specialists and communitybased resources. The following services and products are those most commonly referred or used by patient advocates: • Community resources (67%). • Medical providers or facilities (65%). • Home health providers (56%). • Specific providers or specialists (52%). • Caregiving services (51%). • Durable medical equipment (39%). • Medication (34%). • Behavioral health providers or services (29%). As part of the survey, patient advocates were asked which products or services would help them achieve their job functions more efficiently and effectively. The top responses include: • Integrated documentation program (45%). • Education to learn about advances in healthcare (43%). • Patient teaching materials (43%). • Marketing tools (40%). • Checklists to stay organized (36%).

FreQuent interactions
Patients and family members Physicians Clinical nurses Consumers Social workers Therapists (Respiratory, physical, occupational, speech/language) Attorneys Pharmacists Vendors Employers 77.8% 58.5% 50.3% 45% 35.1% 31.6% 24.6% 17.5% 15.2% 11.7%

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Clients and Referrals
client location
12.3%

Only in the state I live (65.5%) 22.2% 65.5% Regionally: In surrouding states (12.3%) Nationally (22.2%)

Product and service referrals
Community resources Medical providers/facilities Home health providers Specialists/Specific providers Caregiving services Durable medical equipment Medication Behavioral health services Long-term care services Assistive technology devices Insurance products Nutritionals Pediatric products/services 66.9% 64.9% 55.6% 52.3% 51% 39.1% 33.8% 29.1% 25.2% 18.5% 13.9% 11.9% 6.6%

Products and services that improve Job performance
Integrated documentation program Educational resources to learn about advances in healthcare Patient teaching materials Marketing tools Checklists to help stay organized Powerpoint presentations that explain patient advocate services Brochures and other marketing tools Website development Public relations consultant 44.9% 42.9% 42.9% 40.4% 35.9% 32.7% 32.1% 29.5% 20.5%

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Practice Trends
This section covers current challenges patient advocates are facing, and also identifies the direction in which patient advocates see the profession going in the immediate future. Respondents pinpointed some of their most pressing challenges, which include many obstacles related to growing and maintaining one’s business. Top challenges include: marketing to prospective clients (41%); explaining the role of a patient advocate to the healthcare team (40%); building a patient advocacy business (36%); overcoming time constraints to fulfill work (34%); and finding resources to meet the needs of clients (25%). When it comes to the top trends patient advocates are finding in their growing profession, on-the-ground professionals are seeing: Employers using a patient advocate to improve health/wellness (71%); Consumers’ use of a medical savings account to pay for advocacy services (61%); payer reimbursement for advocacy services (46%); reimbursement from local, state and federal agencies for advocacy services (46%); and tax deductions for individuals using advocacy services (41%). When it comes to ongoing professional development, patient advocates highlighted several areas that they view as critical to their continuing education needs. The top issues include: legal issues (56%); patient engagement techniques (43%); marketing (37%); ethical issues (35%); behavioral health (35%). In addition, we see that patient advocates prefer to receive their continuing professional education through webinars/teleconferences (59%); online activities (54%); and annual conferences (48%).

Trends in patient advocacy
Employers using a patient advocate to improve health/wellness Consumers’ use of a medical savings account to pay for advocacy services Payer reimbursement for advocacy services Reimbursement from local, state and federal agencies for advocacy services Tax deductions for individuals using advocacy services 70.7% 60.7% 46.4% 46.4% 41.4%

What differentiates patient advocates from other healthcare professionals?

do you have a network

20.9% 49.8% 38% 62% 29.3% Yes (62%) No (38%)

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Practice Trends
Biggest challenge as a patient advocate
Marketing to prospective clients Explaining role to healthcare team Building advocacy business Time constraints to fulfill work Finding resources to meet client needs 40.6% 40% 35.9% 33.5% 25.3%

Patient advocacy preparation
Background of individual’s professional discipline No formal preparation; used personal experiences Enrolled in/Completed a course on patient advocacy Conducted independent research Received education from employer 43.2% 22.7% 21.6% 8% 4.5%

Preferred method of continuing education
Webinars/Teleconferences Online activities Annual conference Home study activities Local professional organization meetings Live meeting outside of work setting Live meeting in the work setting 59.3% 53.7% 48% 45.2% 38.4% 24.3% 18.1%

Professional development areas
Legal issues Patient engagement techniques Marketing Ethical issues Behavioral health Clinical issues Grantwriting Motivational interviewing Financial planning Management issues Recruitment and retention 56% 43.4% 36.7% 34.9% 34.9% 28.9% 25.9% 24.1% 18.1% 17.5% 9%

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Improve your skills and effectiveness as a patient advocate and earn a Certificate in Patient Advocacy with the Certificate in Professional Patient Advocacy–Online Training Program
The Professional Patient Advocate Certificate Online Training Program is a comprehensive education program aimed at enhancing training for those already in this specialized field or those interested in entering the emerging practice of patient advocacy. Focusing on the concepts of patient advocacy to improve patient education and satisfaction, the program will help independent advocates, healthcare organizations and payers meet the needs of their clients with efficient, effective care. The Certificate Program is an advanced course that is open to all professionals with a baseline level of healthcare experience. Additionally, the Certificate Program serves as a point of entry for professionals who want to transition into this new role, providing a course of study that builds on an existing body of knowledge.

Upon completion of the training program participants will receive:
› A Certificate as a Professional Patient Advocate › A Professional Patient Advocate Institute logo for use in your letterhead and other business materials › A Lapel pin for professional identification › Eleven contact hours will be provided for completion of the course for the following disciplines: Nurses, Certified Case Managers, Disability Management Specialists, Social Workers, Psychologists, and Behavioral Health Counselors. Other disciplines will be considered on an individual basis.

To start your curriculum today, please visit www.patientadvocatetraining.com
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Section 2 The Emergence of Patient Advocacy: Leadership Contributions
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The Rise of the Independent Patient Advocate
By Beth Droppert, RN, BSN

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he birth of the independent patient advocate profession is a recent phenomenon in the United States. Although I have been doing this work for family and friends for several decades, it wasn’t until 2006 when I read an article about a company in Philadelphia that was doing this work for individual patients that I thought I might actually make a business of it. In 2008 I co-founded a company that today has 10 RNs, one physician’s assistant and two insurance advocates. Although we are one of a growing number of companies with many different types of advocates, there are not many statistics (until this very report) available to help us understand this emerging field. When the phone rings, we never know how or if we might be able to help who is on the other end of the phone. People call us for all type of reasons. But mostly, they are frustrated, stuck or don’t know where else to turn in their healthcare journey. Or they think that there is a better way to handle their situation and they want to learn how to do so. Jessica’s family called us from the hospital after she had been diagnosed with botulism and hospitalized for several months. Jessica, 39 and a professor at a local university, was frustrated. Although highly intelligent, she was unable to speak due to her condition and was having trouble being heard – literally and figuratively. Her family, who lived out of town, knew that recovery was still months away and wanted someone to help Jessica recover her voice and choice in all the medical and emotional decisions that lay ahead of her. Jessica’s uncle, who had been employed in the healthcare industry, found us by doing online research. One reason we were successful in supporting Jessica’s goals for recovery is that we had a team of people, both our AHA advocates as well as the providers and outside resources, completely focused on what Jessica wanted. We were able to have the providers describe options to contribute to recovery and what the potential trade-offs would be. I often think that advocacy is really a “communications job.” Advocates figure out where there are gaps in communication, which includes what is said and what is understood by both the patient and the provider(s). Everyone knows that the system is fragmented. It is our role as advocates to make sure that everyone is on the same page in terms of understanding what the patient’s goal is and what the options are to reach that goal. Sometimes it is a matter of identifying gaps in knowledge, understanding, and what the provider

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is recommending versus what the patient’s value system is to reach consensus on the action plan and how to address transitions, especially into or out of the medical system. For many patients, these gaps can be deadly. In 2013, hospital medical errors became the third leading cause of death in the United States. Preventable medical errors led to 210,000-400,000 deaths in the hospital1, making medical errors the third leading cause of death behind heart disease and cancer, according to the Centers for Disease Control and Prevention.

Who Hires Patient Advocates
Patients hire advocates for a variety of reasons: they want a professional with a medical background who understands the system and can identify priorities, and chart the typical course of what a particular medical condition, event or diagnosis might be. Or a patient feels like they might not be receiving an accurate or full picture from their doctor, but aren’t sure. They don’t know what is reasonable to ask for or even how to ask for something as simple as their own medical record. And according to a study published in Health Affairs in 2012, there may be cause for this uncertainty. The vast majority of physicians completely agreed that they should fully inform patients about the risks and benefits of interventions. But overall, approximately one-third of physicians did not completely agree with disclosing serious medical errors to patients and almost one-fifth did not completely agree that physicians should never tell a patient something untrue.2 Sometimes, the advocate’s role is to seek out other information, or put information into context. Take Eldon, who was 68 and living on a farm when a family friend contacted AHA for our help. With only one kidney, he was naturally distraught when his doctor gave him news that his remaining kidney had cancer, had to come out and there would be no other alternative the doctor would consider. This would mean lifelong dialysis. Eldon wanted a second opinion and another option. He wondered if he was being given only one option because of his insurance situation. The advocate found a doctor who came up with a strategy to cut out the cancer, save the kidney and return Eldon to the life he loved. Although Eldon didn’t know where to start on his own to find another alternative, he felt that there should be one. Many patients still don’t understand that’s even a possibility.

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Employers are another client segment for advocates. Employers typically hire advocates for other reasons: They want to support employees but don’t want to cross the privacy line. Employers want their employees to be focused on improving their health so they can return to work, or they want their employees to have someone who can think through all the scenarios so the employee can remain functional even through a health crisis for themselves or for family members. For example Mike, 62, was working as a CFO when he suffered a stroke and was transferred to a Seattle-area hospital where a portion of his skull was removed. Many decisions regarding surgery and rehabilitation would ultimately impact Mike’s ability to recover. A critical part of Mike’s recovery was to ensure he could immediately start rehabilitation, but that was dependent upon rebuilding his skull using a manufactured piece. Receiving this piece, however, would take time and the hospital wanted to move him to a nursing home. Mike’s wife knew a delay would limit his ability to undergo rehabilitation. The employer hired AHA, immediately calling a care conference with Mike’s surgeons, insurance carrier, and his entire family to determine a course of action. Within three days the manufacturer provided the skull piece (due to the advocate’s intervention), had the surgery and began rehabilitation. He did so well that today he is back at work in a part-time capacity.

• Listening and providing feedback to questions, concerns or fears. • Working as a liaison for the family. • Accompanying patients to doctor appointments. • Being at the hospital with the patient. • Organizing and/or locating medical records and information. • Recording medical information and discussions with the health care team. • Researching credible medical information.

An Expert Resource
Advocates help identify and arrange additional services that patients may need, including: • A second opinion. • Supplemental healthcare support. • Eldercare placement. • In-home care. • Rehabilitation services. • Out-of-town services.

What Patient Advocates Do
Because patient advocates are hired directly by the patient and/or the family, advocates can perform a variety of tasks and provide consultation. Advocates normally do not provide medical advice, make medical decisions or provide direct patient care (they do not practice medicine, even if they still keep their medical license up to date). In general, advocates typically do consulting-type work, including the areas listed below.

Who Is an Independent Patient Advocate?
Although there are not yet national standards or recognized credentialing for patient/health advocates, people doing this work generally fall into two categories: Professional (medical, legal or related background) or Non-Professional. Professional advocates are typically nurses, doctors, social workers and physician assistants. Some have a legal or insurance background. We know that the profession is growing because increasingly more companies and job listings have shown between a 150-3,000 percent job growth for health advocates, patient advocates and nurse navigators between 2006 and 2013.3 Nurses and doctors who enter this field do so to help people and know that their medical experience can provide a unique perspective for patients. They also feel very comfortable working with the medical team and can relate to the pressures that they face because they have experience working within the system. However, the differentiation between independent advocates and advocates/navigators or patient representatives that

Services Include
• Evaluating a patient’s goals, no matter how complicated the healthcare issue(s). • Translating medical language, concepts and choic es. • Coordinating meetings with specialists. • Interpreting medical bills and insurance. • Contacting the insurance company. • Acting as a patient’s sounding board.

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work for the hospital is that independent advocates serve the patient only, so they have a different focus and motivation. We have found that providers generally appreciate seeing an advocate accompany a patient to a doctor appointment. This is not surprising, given a Consumer Reports study of primary care physicians which found that nearly 80 percent of doctors thought taking a friend or relative to your office visit could be beneficial, but only 28 percent of patients reported doing so.4 Having another set of ears to listen and make sure everyone hears each other for the common goal of the patient’s better health works. The advocate’s role is not to challenge the doctor but to work in concert with the healthcare team to explore all options, make sure the patient’s wishes are front and center, and to help the patient be as well informed as possible.

References
1. Journal of Patient Safety, September 2013 - Volume 9 - Issue 3 - p 122–128 2. Health Affairs, February 2012 31:383-391 3. www. indeed.com 4. What Doctors Wished Their Patients Knew, Consumer Reports, February 2011 Note: All patients mentioned in this article have given AHA permission to share their stories.

What’s Next for Advocates
It is difficult to change what you don’t measure. That is why this report on salaries and trends is so very important to our field. We currently do not have large studies to demonstrate the differentiated value of independent advocates. Although there are studies that show economic savings and return on investments and greater health outcomes for programs that use navigators to remove barriers or nurses serving as care coordinators for high utilizers of healthcare, we need more data to prove the value of this emerging field. Our clients value the time they save, the better health they enjoy or their wishes that are followed at the end of their life, which we facilitate. As more people hire advocates the field will continue to grow, and we see no end to the possibilities of advocates specializing in specific areas: by condition (like cancer) or service offering (such as medical navigation, billing, insurance appeals, etc.). Stay tuned to this exciting, emerging market takes shape.

Beth Droppert, RN, BSN, co-founded Allied Health Advocates in 2008 with the goal making available private health advocates to all patients who want to have a voice in their own health care decision making. After her 40-year career as a nurse, entrepreneur and clinical trial consultant, Beth wanted to create a company that would provide the same expert navigation, insight and health care results she was providing to her family and friends. Today, Allied Health Advocates has 10 RNs, 1 physician assistant and two insurance advocates who cover Washington state. Web: www.ahadvocates.com. AHA Advocates meet monthly to confer on cases and receive updates on the patient advocate industry and business. From left to right: Linda Chitty, RN, ; Dita Appelbaum, RN, MS; Beck Royer, PA-c; Peggy Anderson, RN; Beth Droppert, RN, BSN; Molly Lanzinger(licensed insurance broker); Robin Shapiro, AHA co-founder; Mary Pope, RN, MBA.

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The Relationship Between Patient Navigators and Case Managers
By Carol Santalucia, MBA and Sarah Fay, MBA

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ver the last few years, patient navigation has taken the country by storm. Pioneered in 1990 by Dr. Harold Freeman, patient navigation focused on the critical window of opportunity to save lives from cancer by eliminating barriers to timely care between the point of suspicious finding and resolution by diagnosis and treatment. When patient navigation was first implemented in Harlem, five-year breast cancer survival rates went from 39 percent to 70 percent. Since its inception as a community-based intervention program, patient navigation has expanded and transformed into a nationally recognized model that extends well beyond cancer care. While many have seen the benefits of patient navigation, including enhanced patient satisfaction, improved outcomes, and a better bottom line, the topic still strikes a chord with some. Many navigation programs have been home grown and shaped by the needs of the community or institution within which the navigator resides – meaning there has not been a universal definition for navigation. While that may be the case, common themes across programs include: • Providing focused, personal assistance for patients. • Identifying and addressing barriers to seeking or receiving care. • Moving patients along the care continuum in a more timely manner. • Connecting patients to community and medical resources. You may be reading this as a case manager thinking “that’s what I do.” And you are correct – some of what you do does fall under this jurisdiction. In fact, the first step to truly understanding patient navigation is to think of it as a process, rather than a person. That process includes many people on the care team – the patient navigator is there to fill in the gaps, own the process and reduce the burden of overwork for members of the care team, such as yourself.

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healthcare system and community. On the patient’s behalf, a lay navigator may coordinate appointments and screenings and work with case managers or social workers to remove barriers a person faces to accessing timely care, such as transportation. Clinical navigators often take the form of a nurse, social worker or case manager. The nurse may assist patients with treatment and prevention-related tasks and apply their clinical knowledge to help patients understand treatment and care options, as well as discharge instructions. The social worker may provide counseling for individuals and family members, as well as assistance in determining eligibility for specific programs and services. Most recently, we have seen the introduction of insurance navigators. Insurance navigators are strictly related to the Health Insurance Marketplace created as part of the Affordable Care Act. These navigators provide individuals and families with a list of insurance options they qualify for in the Marketplace. Once the individual or family chooses a plan from the options presented to them, the insurance navigator can help them enroll in their plan of choice.

Navigation and Case Management
The Case Management Society of America defines case management as a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. Outside the walls of a hospital, a navigator’s primary purpose is to decrease disparities, thereby increasing access to timely care. The focus on disparities outside the walls of the hospital is a major distinguishing factor between patient navigation and case management. However, when inside the walls of a hospital, their roles can overlap. As a case manager, you play an important role in removing barriers for patients. You provide a powerful service that assists patients. For example, if you work within the emergency department you work with patients as they come into the ED and leave the ED. You may help coordinate care that is associated with their discharge instructions, but what happens when that patient is directly admitted through another unit? In some cases, the case manager or social worker

Types of Navigators
There are three main types of navigators in the market today – lay, clinical and insurance. Essentially, lay and clinical patient navigators serve as an intermediary between patients and the many layers of our healthcare system. Lay patient navigators have no clinical background and help connect patients to different resources and information in the

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from that unit will handle the patient, meaning a patient could have several different case managers working with them throughout their healthcare journey. The lay patient navigator acts as a point person for the patient regardless of where they are in the continuum. The navigator acts as a point of contact for a patient at any point of their journey in our complex and often confusing healthcare system – whether they are an inpatient, outpatient or someone in the emergency department. The navigator’s role is to help the patient directly when possible and when within their scope of work. If not possible, or outside of their scope, the navigator triages the patient to the appropriate resource or person, including the case manager.

Conclusion
There is great value in both case management and patient navigation. That value extends beyond the patient and into both the care team and the organization. But for this value to become fully realized it is imperative that case managers and patient navigators work closely together. For this collaborative team work to be most effective, it is important that the case manager, social worker and patient navigator roles are well defined in each other’s eyes. This will ensure that there is no duplication of efforts and that each work within their proper scope toward the ultimate goal – removing barriers and increasing access to timely care for all patients.

How Does the Navigator Help Case Managers?
Think of the lay navigator as an extension of case managers. Ask yourself, what pieces of the puzzle are not being addressed currently because you have too much on your plate? For example, maybe you are coordinating a patient’s care or transportation once an appointment has been made – but is someone facilitating that appointment on behalf of the patient to ensure compliance with their discharge instructions? Or is that left in the hands of the patient? And, if so, is the patient following through with those instructions? A lay navigator can facilitate those appointments and begin to identify barriers, such as transportation, which may require your involvement. When the lay navigator and the case manager have a good working relationship, the navigator knows when it is necessary to refer an issue to the case manager, thus eliminating some of the burden on the case manager. In this scenario, everyone is performing at the top of their scope. Ask yourself, does everything you do to reduce barriers and increase access to care require your license and knowledge? The lay navigator is a lower-cost resource that allows you to work at the top of your scope and on items that truly require your knowledge and skill level. For example, when a lay navigator identifies a barrier, such as medication costs, they should notify your team immediately. And when you as the case manager identify the appropriate resource for the patient based on their eligibility, the lay navigator can coordinate the logistics. This allows you to move on to another patient that requires your knowledge and skill.

Sarah Fay, Director of Operations, of CHAMPS Patient Experience / Santalucia Group, has more than seven years of experience in the healthcare industry, including health policy, communications and patient experience. With a passion for patient navigation, Sarah has successfully led and coordinated navigation programs focused on improving the patient experience while also improving provider business objectives and finances. Contact: [email protected] Carol Santalucia, Vice President, of CHAMPS Patient Experience / Santalucia Group, is a seasoned healthcare leader with a passion and commitment to enhancing the patient experience. She and her team assist healthcare organizations with creating patient-centered cultures, improving the patient experience as measured by CAHPS, and developing and implementing patient navigation programs. Contact: [email protected]

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An Advocates’ Journey: The Bridge to Patient-Centered Healthcare
By Anna Inglett
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n 1999, I started Putnam to focus on providers and their need to navigate the revenue cycle and reimbursement landscape. For them, failure to capture every dollar meant financial ruin. In fact, those that didn’t either met protection through the bankruptcy courts or merged with larger health systems; they still do today. We had teams that would deploy on site and work through insurance, government, auto and patient A/R trying to milk out every dollar that was owed. We made a ton of money doing it. At times, however, we were nothing more than that proverbial little hamster who, for hours, would spin through thousands and thousands of accounts; correcting errors and rebilling; writing appeals to argue denials; skip tracing patients who had moved long ago; battling the insurance companies and Medicare/Medicaid; and researching and giving money back that was overpaid. At the same time, we were trying to build a better system to stop problems from occurring. Although we tore apart and rebuilt processes, implemented skill position training and helped providers learn how to communicate better with their “customers,” the business of healthcare remained a big black hole full of “junk in and junk out.”

diseased lung. He too, died 11 days later from complications of the surgery. At least we were able to explore the possible outcomes of each option; he made the decision about what he felt was best for him. Months later as I was helping my sister-in-law with my brother’s affairs, I totaled up his medical bills at $1.1 million and he owed not one red cent. His service to our country and the horrible wounds he suffered as a result entitled him to free healthcare the rest of his life. Coupled with a 30-year career with the postal service, Steve had excellent healthcare his entire life. While I was grateful that his family would not be burdened with paying these bills, I thought, “How many families don’t have these same privileges, including access to second opinions or a higher level of care?” Having spent many years helping providers chase down their dollars, it was time to help patients learn how to maximize their healthcare dollar and empower themselves as to how it was to be spent. In 2009, we introduced Putnam Health Advocates. Today, Putnam Health Advocates helps consumers and their families navigate and manage their healthcare experience. We review and audit medical bills; manage insurance payments, denials and appeals; negotiate with providers; care and case management; diagnosis research; Rx pricing comparison; assisted living coordination; nursing home research and transitional services; and aid and assistance. We have programs designed for consumers, attorneys, employers, providers and insurance companies. Our services are offered nationwide. Since our inception in 2009, we have helped many patients and their families find solutions to myriad challenges they face when navigating through their journey. Often, they are confused and overwhelmed with trying to make fluid decisions without real data and rely instead on emotion as the driving factor. As advocates, our strengths lie in bringing order and structure to chaos so decisions can be made effectively. Structure and order involves helping our clients access real-time resources that support the improvement and quality of care; empowering them to speak-up regarding their care; understanding and containing care costs; and improving their healthcare experience. Our youngest patient has been three days old and our oldest, 93. We have been called by families following a trauma accident to their loved one and met them in ICU; the family of a 51-year-old stroke survivor we met in rehab; a morbidly

Working Amid Modern Miracles
Don’t get me wrong, healthcare is an exciting industry. Miracles happen every day through the skills of physicians and nurses; new medicines and therapies are discovered daily through the extensive research of companies and foundations; many diseases can now be managed as chronic illness; and we are living longer and more productive lives as a result. However, my experience tells me that consumers/ patients either feel distrustful and not fully comfortable with their healthcare experience, or they are completely trusting of everything their provider has to say, including the plan of care. From these two perspectives, advocacy was born. In 2008, my brother Steve (a medically retired Vietnam War Marine) was diagnosed with stage II lung cancer. Thirty years prior, my father, a WWII and Korea Naval Veteran, was diagnosed with lung cancer and died seven days later. I remember it like it was yesterday: “Daddy, let’s go get a second opinion,” I asked. “No, honey, they know what they are doing.” Sadly, the cancer was so advanced that it didn’t matter. I took Steve to MD Anderson in Houston where he underwent radiation and finally, without any options left other than to do nothing, he had a pneumonectomy to remove the

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obese patient who had been in the hospital for eight months following surgery for a broken femur; an honorably discharged veteran who was going to be sued by the hospital for a medical bill; sons who needed to let their at-home dying father go and didn’t know what to do; a client in extreme pain who needed hip replacement surgery with a limited insurance policy. The cases go on and on. But in each one we have never wavered from our objective, which is to bring order and structure to chaotic situations, improve the quality of care, access needed resources and contain care costs. We are proud of that. Finally, we have recently been certified by the Centers for Medicare and Medicaid Services as one of the Certified Application Organizations for the Affordable Care Act. As a volunteer, we look forward to helping consumers access health insurance, some for the very first time. The future for

healthcare advocacy is bright and full of promise and opportunity. We will need lots of passionate problem solvers, and many patient advocates.

Anna Inglett is the President of Putnam Health Advocates, located in Tampa, Fla. Anna is a graduate of Florida State University with a degree in Rehabilitation Sciences. Her 30-year career has been spent entirely in healthcare, beginning as a therapist with spinal cord injured, stroke and TBI patients. She also spent time as a healthcare executive recruiter and, since 1999, the owner of several companies relating to billing, collections and advocacy. Web: www. putnamhealthadvocates.com | Contact: [email protected]

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Consumer-Driven Health Plans Usher in New Opportunities for Care Managers
By Catherine M. Mullahy, RN, BS, CRRN, CCM

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here is nothing static about healthcare in America today. From the major overhaul it received at the hands of The Patient Protection & Affordable Care Act (PPACA) to new technologies and healthcare models like accountable care organizations and the patient-centered medical home, consumers need a serious navigation tool and guide to steer their way through the system. One area which places increased healthcare responsibility in the hands of consumers is Consumer-Driven Healthcare Plans (CDHPs). Also known as high deductible health plans (HDHPs), they are offered with health savings accounts (HSAs), which give consumers an incentive to be more prudent in their healthcare decisions and behaviors. For care managers, CDHPs have introduced additional opportunities to help all sectors of the system – consumers/employees, plan sponsors/employers and unions, managed care organizations, and healthcare providers, including hospitals and physicians. To benefit from the new opportunities associated with CDHPs, care managers need to understand how they work, why they are becoming so popular and what role they can play as all parties seek to reduce their costs and facilitate better patient outcomes and a healthier America overall.

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which means a terminated employee can elect to have his/ her HSA funds transferred to another HSA administrator. HDHPs require plan members to remain abreast of the funds in their HSAs. If their funds are depleted before their deductibles are met in a given plan year, the plan member must make up the difference until their plan deductible is met, at which time the plan operates like a traditional preferred provider organization (PPO) plan. In other words, the plan then assumes the cost of covered services and the plan member contributes a pre-set cost-sharing amount until the maximum out-of-pocket spending limit is attained. Then, the plan pays 100 percent of the costs for covered services. Coverage for preventive health services, such as annual physical, medical screenings and vaccines, is provided on a “first-dollar basis,” not as part of the deductible. In addition to t he HDHP/HSA variation, there are other forms of the CDHP. They include plans whereby employees can customize their coverage by selecting benefits from an online menu and balance their deductibles, premiums and copayments based on their specific needs, age, health status, etc. Additionally, there are plans wherein the CDHP is offered as an option within a traditional insurance plan. Some of the Blue Cross/Blue Shield (“The Blues”) are selecting this option which provides variables for drug formularies, hospital networks and benefit choices which determine the premiums. In this instance, too, the employees assume the financial risk and cost overruns above the employer’s fixed contribution.

How Consumer-Driven Plans Work
Currently, there are nearly 15.5 million Americans enrolled in an HDHP/HSA. The HDHP has an annual deductible of not less than $1,250 for an individual or $2,500 for family coverage. Its annual out-of-pocket expenses can’t exceed $6,250 for self-coverage or $12,500 for family coverage. Employers offering HSAs must make comparable contributions to their HSAs for all of their participating, comparable employees in a given coverage period. The benefit to employers is that their contributions are not deductible. Plan members/employees benefit from being able to make their contributions using pre-tax dollars. The HSA funds can be used to pay for deductibles, co-pays and services not covered by their health insurance. The HSA funds can’t be used to be for premiums unless they are for qualified long-term care. Additionally, HSA funds can be used to defer income according to annual contribution limits and also to pay for eligible retiree medical premiums. Another major advantage of the HDHP/HSA is that plan members can roll-over the remaining funds in their HSAs to the next plan year to reduce and/or eliminate their share of the deductible in subsequent years. HSAs are also portable

The Trend To Consumer-Driven Care
A Towers Watson survey found that 70 percent of large companies in America expect to offer HDHPs linked with HSAs in 2013. Already, and based on Towers Watson/National Business Group on Health Study, 41 percent of U.S. companies are offering these plans. Contrast this figure to the estimated 2 percent 10 years ago. Why the growing trend toward CDHPs? The primary driver has been the savings these plans afford employers. Specifically, the Towers Watson/National Business Group on Health Study found that companies with 50 percent or more of their employees in an HDHP/HSA, incurred $1,000 less per employee that companies without these plans. It is projected by a Rand Corp. report that by 2022, 50 percent of all employees covered by an employer-sponsored health plans,

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including those for employees working in government, would be covered by an HDHP/HSA. Already, many of the nation’s leading providers are offering CDHPs. They include Aetna Inc., The ChoiceCare Card, Definity Health, Destiny Health, Flexible Benefit Service Corp., HealthAllies Inc., Healthmarket, Humana Inc., Lumenos, MyHealthBank Inc., Self Insured Plans Inc., Vivius and numerous Blue Cross/Blue Shield plans (“The Blues”).

ployers or entering into a contractual outsourcing arrangement. Another major shift in our nation’s demographics is a cultural one. Our population is much more multicultural, as evidenced by a current trend to more communication information in two languages (English and Spanish). Hospitals, in particular, are providing their information in English and Spanish to reflect our growing Hispanic population. There are also many other ethnic groups for whom English poses a language barrier and the emphasis on having professionals able to communicate complex medical information to different ethnic groups is a real need. Once again, case managers, who understand different languages, as well as associated cultural nuances that exist for different ethnic groups, will be sought after for these critical skills. The influx of advanced medical technologies and the associated terminologies also are proving a major hurdle for consumers. They need a caring professional to explain what an MRI, CT scan or EKG is and why it is important for a patient’s specific medical situation. Apart from these factors, there is also the matter of health illiteracy. In the past, the U.S. Department of Education conducts a survey to measure the public’s health literacy. Its findings are not encouraging. In a prior survey, it found that 36 percent of American adults have only basic or below basic health literacy skills. Here again, care managers can be important patient advocates, educating them and helping them understand various health and medical terms. More so than physicians, care managers generally are perceived by patients as more approachable and accessible.

Are Americans Equipped To Be Responsible Healthcare Consumers?
The question that remains relating to CDHPs is, “How well prepared are Americans to be more responsible for their healthcare?” Also, “Will they, in fact, be more prudent healthcare consumers when they have more skin in the game?” In 2010, the Deloitte Center for Health Solutions issued a survey which found that only 23 percent of consumers believe they know how the healthcare system works. That was three years ago and before healthcare reform and the broader application of CDHPs. We can only imagine that a higher percentage of consumers are more confused today than ever before. Care managers can be the life preserver consumers need to better understand our bloated healthcare system and effectively access the services and optimum care they deserve.

The Greater Need Creates New Opportunities
Not only have CDHPs and healthcare reform created a greater need for the guidance and support of case managers, but there also are other market conditions driving increased opportunities for care managers. For instance, our nation’s demographics are changing. Today, we have Americans living longer and with more chronic conditions, from diabetes and obesity to hypertension. Based on U.S. Census data, in 2011, 77 million Americans turned 65 years of age. It is projected that by 2020, the average life expectancy will be 100 years or more. Imagine our current healthcare system accommodating all of those people with all of the medical conditions that come with aging. Add to that the increased responsibility being placed on younger workers with the prevalence of CDHPs and it isn’t hard to realize that case managers will be in much greater demand. Not only will consumers contract for case management services directly, but employers looking to contain their share of employee medical costs will implement a case management program either by having on-staff case managers for the largest em-

Americans Whose Health Is Already Compromised
Without question, healthcare education and help with navigating the system will become vital. Here’s where the knowledge, experience, compassion and patient advocacy of care managers will become critical. This is especially true for individuals facing a certain medical conditions and/or diagnoses directly or for a covered family member. For example, imagine the parent of a child born prematurely with developmental delays caused by cystic fibrosis. The child may be eligible for a state-intervention program, but will the parent know this without the help of a healthcare professional? Consider all the different agencies that may need to be contacted (i.e., Children with Special Health Needs, Aid to Families with Dependent Children, state-administered

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cash grant programs, etc.). What about the patient who has end-stage renal disease? Will he/she know that Medicare automatically becomes their primary funding source after 18 months of dialysis even if the individual is still working but just for services related to the renal condition? Then there are those Americans with disabilities, such as blindness or other physical limitations, for whom federal and state programs exist. In all these instances, the experienced care managers can be a tremendous resource to the patient and his/her family as well as the plan sponsor. Yes, it will take a care manager who is willing to navigate through the system and all the hurdles it provides when trying to access coverage and programs for their patients. However, isn’t that what a caring care manager strives to do and wants to do? In addition, the convoluted government billing and report formats are challenging for professionals, let alone a lay person with no experience or knowledge of these systems. A care manager’s role would extend to offering assistance in this area as well.

Closing Remarks
In sum, the role of the care manager in a system of consumer-driven healthcare is more essential than ever. With the heightened responsibility, however, also comes an opportunity to advance one’s career and assume more responsibilities, and/or perhaps shift one’s practice to that of serving patients directly in the community as community-based care manager in a private practice. In either case, the position of care manager gains higher status and recognition as an indispensable link between patient and the optimum care, especially when the patient is in a more accountable role as in the case of being covered by a CDHP. For care managers who crave more direct interaction with patients and the opportunity to really serve as a patient advocate, the new era in healthcare, along with reform legislation and CDHPs, present tremendous prospects for greater career satisfaction, growth and financial rewards.

Meeting PPACA Requirements
While patients are a prime beneficiary of the care manager’s increased role, so too will other sectors of the healthcare system benefit. PPACA has introduced new requirements which will hold providers much more accountable for their performance. The reduction of preventable hospital readmissions is clearly one of the new PPACA changes which will require providers to better manage the follow-up care of recently discharged patients. It will be in their best interests to particularly pay close attention to those individuals who fall within the highest incidence of readmissions (i.e., surgical patients, those with chronic obstructive pulmonary disease, cardiac conditions and/or congestive heart failure). Care managers can support these patients, monitor their compliance with post-discharge treatment plans, and help encourage their compliance in order to prevent a medical setback and readmission.

Catherine M. Mullahy is one of the healthcare industry’s foremost leaders in advancing case management standards and practices. Her consulting firm, Mullahy & Associates LLC, provides case management training and advisory services to case managers, nurses and students in settings that include managed care, hospitals, long-term care, government agencies, physicians’ offices and institutions of higher education. A sought-after lecturer, she is best known as the author of The Case Manager’s Handbook, now in its Fifth Edition. Web: www.mullahyassociates.com | Contact: [email protected] gmail.com

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Navigating the Healthcare System in Rural Areas: Why You Need a Personal Advocate
By Gloria Peth

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here are specific challenges that come with working as a personal advocate/navigator in rural areas. My expertise is in the area of rural midwest Missouri. Currently, advocates do not have a standard of care, thus we are expected to educate ourselves and investigate curriculums offering teaching programs. My personal challenge is working in a rural environment with limited resources. When a patient or family member comes to me, it is my duty to know all the outlying local healthcare personnel and hospitals that will give my patient the best possible care. Our small town sits in between two of the best medical cities in the Midwest: St. Louis and Kansas City. Unfortunately, it is a grueling three hour drive to either location, especially for an individual who is ill. Therefore, options must be carefully weighed. We also have access to Columbia, Mo., which is an hour away. Advocates need to understand the strengths and individuality of each hospital and attending physicians. Another challenge in our area is that it’s one of the most popular tourist towns in the Midwest, Lake of the Ozarks. Over 1 million people visit in the summertime. This resort town is surrounded by a lake with a shoreline the size of California. With boats up to 47-feet long, you can imagine the kind of trauma that presents itself to the local ER. Unfortunately, many of these traumas must fly to urban trauma centers. Family members standing by are extremely confused and frightened. Having access to a local advocate gives assurance and comfort to all involved in injuries and illness in a rural setting.

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can be confusing. Individuals have trouble understanding or remembering the important information correctly. I always encourage patients to bring a family member if they can’t afford an advocate. I believe that insurance companies will eventually cover this service because it will help cut down medical errors and discourage the industry of medicine to not execute procedures that are unnecessary. Even more difficult in our town is the lack of specialists in our local hospital. It is my duty to visit my patient in the hospital and make sure all their needs are being met. Sometimes patient’s pain management can be difficult to monitor and assess for the families. As an advocate I can communicate with the nursing staff, who in turn will speak with the attending physicians. Patients at the most prominent of hospitals still need bedside monitoring by an advocate or a family member I can negotiate the inroads of the medical system for my patients and its overwhelming landscape of medical terms, uncertainties, and treatment options, including critical care cases, terminal illness and hospice care. The goal of my advocacy practice is to honor the needs of my clients with compassion and to present to each one a distinctly outlined advocacy plan catering to their individual needs. That plan must be flexible and constant, flexible as the circumstances change but constant in their trust of me. With trust and belief together, we can navigate each client’s healthcare competently.

Establishing Standard Guidelines
I believe that advocates need to clearly define their services and work on a sliding scale. No two cases are alike, nor are income levels. Because our town is a tourist area, there are many underserved individuals who need help with payment. With the new healthcare system, more people will be seeing doctors. Therefore, it is our responsibility to be clear in our practices and not confuse an already perplexing system. I directly take responsibility and serve as a personal advocate by attending appointments with my client’s primary care physician or specialist. I am the ears, eyes and memory for my patients. So often, even the simplest doctor’s appointment

Gloria Peth, a personal healthcare advocate, began in healthcare by volunteering in hospitals, taking care of family and friends in a health crisis. Gloria was involved in the creation of Medical Missions for Christ Community Health Care Center in Camden County, Mo. The goal was to start a free healthcare clinic for people who did not have health insurance, Medicaid or Medicare. The venture started over seven years ago and stands today, still helping and taking care of the underserved. Gloria envisions her life design to navigate others through their healthcare dilemmas. Web: www.advocateofhealtcare.com | Contact: [email protected]

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The Heart of Patient Advocacy: Excelling in Family-Centered Care
By Ilene Corina, President PULSE of NY
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ive a man a fish and he eats for a day; teach a man to fish and he eats for a lifetime. How many times have you heard a family member say, “I wish there were something I could do to help”? Last year as I left the hospital room of a patient with a volunteer advocate (in training) I asked the advocate-to-be if he really wanted to be the person who sits next to the patient and watches him sleep for six out of the 10 hours he is at the patient’s bedside. After all, that is what patients are supposed to be doing: resting. The volunteer told me he didn’t want to do that and thanked me for making him realize it. Instead, his advocacy can be directed toward the patient’s family. As a care coordinator he can make sure the patient has around-the-clock support, under his guidance. As patient safety advocates for PULSE of NY, our role isn’t always to sit at the bedside. That is a very small part of what we do. We encourage the patient’s friends and family, who will be visiting anyway, to be the patient’s advocates. Two or three times a year PULSE of NY holds workshops called Family Centered Patient Advocacy Training. These workshops focus on the community of friends and family who are able to rally around a patient and become advocates. As care coordinators we encourage the family or friends of the patient (rather than someone unfamiliar) to take over as advocates when the primary advocate can’t be there. Family advocates play an important role in keeping the patient safe. The benefits are that they know the patient; they want to be there with the patient; and they want to feel useful. Family advocates learn about hospital-acquired infections and the importance of using soap and water and hand sanitizers, not just for the doctor and nurses, but also for the advocates and even the patients. They learn about wiping the room down with antibacterial wipes, how to avoid falling, and why falls happen. They learn that while the general rules and policies taught to hospital staff (such as medication delivered in the original wrapper, and checks of names and birthdays to ensure the clinician has the correct patient) are designed to keep

patients safe. The Joint Commission, which accredits and certifies more than 19,000 healthcare organizations and programs in the United States, reports that there are still as many as 40 wrong site surgeries each week. Alice, one of our volunteers, called me about her own mother’s hospitalization out of state. Ready to battle the system about the care her mother was receiving, we played out what might happen if she used that confrontational approach. We teach that as a family-centered advocate you can “catch more flies with honey than with vinegar,” and that is the way to start. You can always move up the chain of command if the patient still isn’t getting the appropriate care. All our programs are collaborations, working with the people who use the health system as well as the people who work in it. Our workshop was developed following principles laid out in the book, Family Centered Patient Advocacy Training, written and published by PULSE of NY, in collaboration with world leaders in patient safety and experts in the fields of diagnostic errors, medication errors and anesthesiology safety, amongst others. A few times a year we meet with special-interest groups, which include young mothers (exploring their experiences being alone during birth and learning what scares them), patients with disabilities, and families who care for Alzheimer/ dementia patients. I have spent many hours as an advocate for transgender patients, and have seen what it’s like to be a curiosity for medical professionals. Our primary focus is patient’s safety and communication. There is a lot to be said for being a patient’s personal advocate. But when the advocate’s clock stops, the advocacy must continue. One way to help ensure full delivery of the patient’s care plan is to include his or her entire community.

Ilene Corina was selected as one of Modern Healthcare’s 100 Most Powerful People in Healthcare of 2009. She is a 2010 graduate of the American Hospital Association Patient Safety Leadership Training where she developed Long Island’s first Patient Safety Advisory Council. She is the president and founder of PULSE of New York, a grassroots patient safety advocacy group that was formed in 1997. Contact: [email protected]

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Advance Care Planning Advocate: “So, You Do What?”
By M. Jane Markley

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can’t tell you how many times I have been asked, “Now what is it that you really do?” Patient advocacy and advance care planning are two concepts that are not on the forefront of most people’s minds. Even members of the healthcare profession have difficulty with the two disciplines. When combined together it can seem awkward or uncomfortable to people. Who in their right mind would want to spend their days talking about death? If that is your belief, then you are “dead” wrong.

step, but it is just that: a step in the process. Unfortunately, over the past 20 years there has been very little change in the advance directive percentages. Patients wait for their provider to bring it up and providers rarely bring it up sometimes due to their own discomfort with the subject, out of lack of time to have the conversation, or out of their inability to be paid for the work. Whatever the reason, it just isn’t happening. Thus, the role of the advance care planning advocate was born. You may ask, if providers aren’t being paid for this type of work, why would you? And the answer is because there is a need as perceived by the consumer. In many cases, that need is seen by those people who have had a bad experience with family or friends. People who have watched loved ones go through horrible times whether receiving too much or too little care. People whose loved ones died in a hospital hooked up to machines after a long protracted illness, rather than being able to die at home. People who saw a family torn apart when there were divergent opinions related to a patient’s care desires. The people I have spoken with all say that they want control over decisions made about them and want to make sure their family understands their wishes and will comply. As more and more people have these unsatisfying experiences they seek to mitigate similar issues from occurring in their own life and the lives of people whom they love. One example is a woman whom I’ll call Jean. She had extremely strong feelings about how she wanted to be cared for if something untoward occurred to her. She had heard of Betty Long and her Guardian Nurses out of Philadelphia, a patient advocacy team who do an outstanding job. So, she contacted them via their website query. Betty, in turn, contacted me for two reasons: 1) I focus specifically on what Jean needed: advance care planning, and 2) Jean was located in Vermont, outside of their area. I connected with Jean via email initially, sent her some reading materials, and we set up a plan to meet and discuss her thoughts. Obviously, Vermont isn’t right next door to my Maryland office so we planned to meet via Skype. Thank goodness for modern technology. Actually being able to speak with Jean and to see her and her family was most helpful. Through the course of two online discussions held over a six-week period, as well as discussions they had between themselves offline, she was able to work through what was important and reasonable for her. Once she had these conversations, had identified her durable power of at-

It’s About Life, Not Death
Advance care planning is about life and how someone wants to live that life well and fully for whatever time they are given. It allows someone to think through, discuss and reflect on their goals, values and beliefs regarding their life and their future healthcare decisions. It’s about empowering them to make decisions and share those decisions with key people who can support and promote them. It’s about identifying those key people who can speak for them if they cannot. As an advocate I help them to understand the planning process and why it is so important to them, specifically: for what they are planning, their options based on their healthcare status, the range of choices open to them, the dynamic nature of the process, and the importance of discussing and communicating their wishes with family, friends and healthcare providers. This entire process eventually results in their ability to put together a written plan known as an advance directive. Yet although the advance directive is extremely important, it is not the only value proposition. The communication with friends, family and providers that goes on during the process is invaluable to all and, along with the written documentation, provides the basis for decision making when and if the individual is no longer able to speak for themselves. So, you may ask, that is all fine, good and noble, but isn’t this supposed to be done within the healthcare setting, such as when people are admitted to the hospital? Yes, by law anyone admitted to most healthcare institutions is required to be asked about their advance directives. But tell me, since the document completion isn’t the only component of this type of planning, how is the necessary conversation supposed to be accomplished by an admission’s clerk at a very stressful time? The Patient Self Determination Act of 1991 was a great first

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torney for healthcare (DPOAH), and determined that he was willing to assume the role and understood her wishes, she shared her thoughts and plans with her physician to get his input. She then completed her advance directives, using the Five Wishes from Aging with Dignity, had it witnessed, and shared copies with her family, her DPOAH, and her physician so that they all had the same information. Jean’s example is a textbook one. She knew what she wanted and didn’t want. She brought her family together to have the conversations, included her provider, put it in writing, and shared the final document with everyone. Things don’t always happen just that way. Take “Steve,” for example. He was an 80-year-old man with a large extended family and multiple medical problems. I learned about Steve before I met him. I received a frantic call from a colleague one Monday morning saying that his father, Steve, was in the hospital yet again and he still didn’t have an advance directive. He asked if I could meet with him and his brother to discuss how they could help their Dad and stepmother through the development of one. We met and I explained the process to them, expressing the importance of their role in facilitating my meeting with their father and stepmother as well as the importance of including all of their siblings in the understanding of what was going to be going on. They set up my first meeting with their father at the rehabilitation center later that week after his discharge from the hospital. I met with Steve and his wife and we talked about his experiences and what was important to him. He mentioned that he had never talked about death before. I learned that Steve believed that he had completed an advance directive when he was admitted to the hospital in the middle of the night. He couldn’t remember what it said and he didn’t even have a copy of it. I made certain that he was provided a copy so that we could use it as a basis to further discuss his wishes. We talked about what it was that he thought he wanted to do with the time he had left and what steps could be put in place to accomplish his goals. Steve’s parting comments from our first meeting were, “This wasn’t so hard. It’s a shame I didn’t do this earlier in my life.” I met several times with Steve and his family, reviewing his thoughts and helping him to clarify his wishes and goals. After much thought and review, he decided that he liked the advance directive that he had signed that evening in the hospital, so we had copies made for his family and his physician. Our family meeting was planned and all the children were invited. As it turned out the three sons were there and

the two daughters were unable to join us. I reminded the sons to share everything with their sisters and Steve made a point of meeting with both of his daughters the following weekend to make sure that they heard his desires directly from him. Although advance care planning isn’t only for the elderly, many of my clients, like Steve, only find me at the end of their days. The good news is that Steve was able to achieve several of his goals at the end of his life, which he laid out in our discussions. Things like seeing his grandkids play ball and attending a family wedding. He had originally only wanted to talk with his sons about his wishes because he knew his daughters would want treatment for him that he did not want. By bringing them into the conversation he was able to preclude any issues from occurring when he died several months later. Let me reiterate. Being an advance care planning advocate is about life and giving people some control over how they live that life. It is about getting people to think and talk about what matters to them now and in the future. It’s about empowering the individual to take control. Clients come to me from a variety of sources: referrals from colleagues, networking with friends, speaking in public forms, and presentations to professional groups. It usually happens when an individual realizes that they can take control and have the right to “have a say until the end of their day.”

M. Jane Markley is a consultant with over 30 years of experience in healthcare, including direct clinical care, ethics, strategic planning, quality assurance, administration, program management, and technology. President of M Jane Markley Consulting, LLC, she works with individuals, families and groups to help them understand the importance of advance care planning for themselves and their loved ones. Active in her profession, she is past president of the National Capital Healthcare Executives, the local chapter of ACHE, and a former Chairman of the Ethics Committee of the National Naval Medical Center, Bethesda, Md. Currently, she participates in ethics committees in the Washington, D.C., area and is a member of the International Society of Advance Care Planning & End of Life Care. She speaks internationally and is a guest facilitator in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md. Contact: [email protected]

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Business Grows When You Put Your Personal Needs Aside
By Amy Cameron O’Rourke

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are managers and patient advocates are misunderstood in the marketplace. Many families need help navigating the medical systems, but do not know our profession exists to help them.

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“How do people find out about you?” “Where were you when I needed your services?” How many of you have been asked those questions? How to get the word out about our profession is one of our biggest challenges to growth.
Referrals are our primary source of immediate and long-term business. How do you “get” referrals? How do you generate enough confidence in your professional associates that they push hard enough to have their clients call you? Our work is very relational. It’s not enough to have professionals “know“ you are out there for your business to grow; you have to cultivate those professional relationships. Your professional associates must believe in you so much that they are passionate about having their clients call you. CPAs, attorneys, therapists are identified professionals; when someone says you need to see a tax accountant, you immediately know the skills that professional possesses and you understand the services that will be provided. You know what they can do for you. Not so with care management and patient advocacy – we are still a young, misunderstood profession. Many people think they know enough to handle the care on their own, even in the midst of a crisis. They simply don’t know what they don’t know. Which means you need your professional associates to convince clients for you how much the client needs you.

This meeting was to take place on a Saturday morning and there was no promise of payment for my time. Everything in me wanted to say “No!” I work hard, it was Saturday morning and I wasn’t even getting paid. I knew I would be more bothered if I didn’t go, than if I did, and my business mentor told me I had to go. We had a wonderful meeting with this gentleman and both the attorney and I connected with him and with each other. I asked her to call me anytime, as I felt that we helped him in a way together that we couldn’t have individually. I have never forgotten that experience – since then, when I am able to put my self-centered needs aside and respond positively and quickly whenever someone calls for help, it is returned tenfold. The referrals this attorney has sent us over the years is in the hundreds; her firm has grown and her attorneys send many, many clients to us. The attorney practically forces her clients to call us. She tells her clients she has a red phone in my office and she really does (I have her on speed dial as well). I send many clients her way with as much conviction as she does for me. We are committed to every person in their firm and they are committed to us. We call each other for information, advice and have weathered several rough spots with difficult clients. Our clients feel that commitment when they begin to work with our trusted referral sources, and they don’t hesitate to tell their friends about it.

How Does This Happen?
Almost 14 years ago, I received a call from an elder law attorney asking me if I would be willing to meet with a client of hers. The attorney needed a care manager’s perspective on her clients’ mental status as he was asking her for help in changing some of his legal documents.

Amy O’Rourke is founder and president of The Cameron Group, a Professional Geriatric Care Management company in Orlando, Fla. She founded the company in 1999. Mrs. O’Rourke has over 30 years’ experience in healthcare, 24 years specifically in the field of aging. She holds a master’s degree in public health from the University of South Carolina, and a master’s certificate in gerontology. She has been a certified professional care manager since 1999 and serves on the national board of the National Association of Professional Geriatric Care Managers. Web: www.thecamerongroup.us | Contact: [email protected] thecamerongroup.us

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Driving a Partnership of Patient Advocacy in the Hospital
By Alice Ostrowsky and Laura Ostrowsky, RN, CCM, MUP

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ll employees at Memorial Sloan-Kettering are expected to be patient advocates. While it is everyone’s job to help patients receive the best possible care in a timely manner, the specialized skills and expertise of the case managers and patient representatives are often needed to overcome obstacles to appropriate care. These obstacles can crop up at any time in the course of care from the point of entry through the various transitions along the continuum. Obstacles to access and continued care can also occur during interruptions to or changes in insurance or to limitations in what insurance can cover. As insiders we know that healthcare today is complex. For patients and their supporters this complexity can at the very least be confusing, but in many cases it is also anxiety-provoking, frustrating and even frightening.

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patient feels valued. As one patient expressed, “I was made to feel like a person with cancer not a cancer patient.” Both case managers and patient representatives recognize that the patient is a partner in the healing process. It is our job to make sure that all members of the team share this understanding. The case managers focus on problem solving, coordination of services and patient education. The patient representative’s primary focus is on patient rights and resolving complaints. Case managers and patient representatives have developed a collaboration that we feel provides a unique mechanism for patient advocacy. This collaboration may be invisible to the patient. Much of what we do is performed behind the scenes. We challenge the traditional silo mentality, blurring boundaries to achieve what is best for the patient. Our shared belief that being territorial is counterproductive in healthcare is a win for patients. We do the research and serve as the patient’s GPS. It is all about sharing information to maintain momentum and prevent delays. The goal is to provide patients with quality care delivered expeditiously. This may entail negotiating with payers to assist patients to obtain needed services. It includes educating patients and caregivers about their rights and options so that they can make informed decisions about their care. Sometimes it entails educating providers as well so they can present patients with appropriate options and effectively manage their expectations. Patients seeking assistance, information and clarification are often referred to patient representatives or case managers. They may be calling about access to care or insurance coverage. They may have questions about appointment scheduling or complaints about red tape, the approval process or their bills. Rather than send them to patient accounts, scheduling or physician referral, we take the information, do the research and the process of behind-the-scenes triage begins. The patient is saved from multiple phone calls, calling department after department. We respond with answers, a plan and any required contact information. More complicated solutions are reached through multidisciplinary planning or family meetings.

A Partnership of Patient Advocacy
The patient representative role is synonymous with advocacy. The stated mission is to “to help create quality healthcare experiences for patients and families by helping to prevent and resolve conflict.” Case managers are also patient advocates but that role is not as clear to the observer. Ostensibly they represent the hospital, managing resource utilization, while justifying admission and continued stay to prevent denials. Their role as discharge planners may be viewed through the lens of minimizing length of stay. In reality they are advocates for patients coordinating services and helping to implement a safe transition to the next level of care. How do these two groups partner to promote advocacy? Advocacy begins with listening to what our patients have to say. This requires more than excellent listening skills. True advocates must read between the lines, explore the patients’ needs and values to identify both their expressed and unexpressed concerns. This can be a triage function and may involve referral to other disciplines. Coordination of services, consistency of message and a focus on the patient as a person, not just a diagnosis, decreases anxiety and most importantly helps to forge a partnership between the patients and the provider. When it works, the

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Laura Ostrowsky, RN, CCM, MUP, is the director of case management at Memorial Sloan-Kettering Cancer Center. Laura was granted the prestigious award of National Case Manager of the Year in 2012. She boasts more than 30 years of healthcare experience. Laura joined Memorial Sloan-Kettering Cancer Center in 1999 as Director of Case Management and Discharge Planning. She has expanded the program to include Case Management functions in outpatient and emergency services, and created a patient advocacy program for patients seeking out-ofnetwork cancer care. Contact: [email protected]

Alice Ostrowsky is the senior patient representative at Memorial Sloan-Kettering Cancer Center. Alice has worked with Memorial Sloan-Ketteringfor 10 years. She has covered both inpatient and outpatient services in neurology, neurosurgery, pain and palliative care, as well as several other oncology and surgical services. She has assisted in consultations with the ethics committee and with new staff training. Alice has previously worked as a rehabilitation counselor, where she provided direct service to individuals in recovery from alcoholism and substance abuse, before moving away from direct service to become a clinical supervisor in an intensive psychiatric rehabilitation program.

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Delivering Long-Term Services to a Family in Need
By Marie Connolly
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hortly before Christmas of 2012 I had a call from a young man looking for help with his parents, both of whom had dementia and were living in their home. They had been needing help for several years and their son (whom we’ll call John) was at his wit’s end. The week prior to calling me his mother had been hospitalized and had her gallbladder removed. She had been sent to rehab and discharged a few days later. She disliked being there and demanded that he bring her home. The evening she was discharged, both Mom and Dad got into an argument that became physical. The son told me he thought he was going to have to call the police. When I told him the police would likely take them to the emergency room to be evaluated, rather than to jail, is the moment I think he decided to hire me. I often wonder how John ever managed to do this and work and have a family. I have practiced patient advocacy for several years, and the amount of care and attention this couple required was overwhelming to me.

for Scope of Treatment). His son has been working with an elder law attorney getting all the legal issues with POA and such updated. He is also beginning the application process for applying for some VA benefits to which they are entitled. Mom, it appears, has recovered from her gallbladder surgery. Her recovery was hard and long. Her dementia interfered with any attempt to help her or make suggestions that would make anything easier or safer. Both Mom and Dad love to tell stories of their past. This is what has always drawn me to work with seniors: their history and their stories. One of the caregivers is hoping to start video-recording their stories. Neither have left their home since Christmas day. And now it is time for Mom to see her primary care physician. That is the next challenge. The medical community is not used to working with a private patient advocate. Some have welcomed the help with open arms. Other providers have been very skeptical about the role I am playing. The relationship I have built with their son has been based on trust and my years of experience. The services I provide can be more expensive than many clients expect. But what is the cost of caring for elderly family members? John has taken tremendous amount of time off from his job. He has a wife and a toddler. With help from an experienced patient advocate, he has returned to work, and now has time to spend with his wife and daughter. He is able to see his parents on a regular basis, and not be quite so overwhelmed with providing care. Ed. Note: The following update was provided by the author as the story above concluded further. Dad was discharged from hospice in May. With a diagnosis of Failure to Thrive he was not able to meet the continued criteria. He had suffered a number of falls while under the care of hospice and his behaviors were becoming more and more disruptive in the home. He and his wife continued to argue and both had fallen during these arguments. Their son had a very difficult time agreeing that they needed to be separated and one of them needed to go to assisted living. Dad was hospitalized for a short period of time. There was one failed admission to a memory care assisted living community. He reacted violently when he realized he was locked in. He was returned to the hospital for further medication management. He was admitted to an assisted living memory

A Closer Look: Creating Positivity
I have been working for this specific couple for five months. The good news is that there is stability with the nonmedical homecare providers. We have changed companies one time and it has taken a number of changes in the caregivers in the home, before we found the right staff. Medication management is going well. This I have found to be one of the biggest holes in the full continuum of care. After skilled home health care leaves, who is managing the medications? I have chosen to provide this service, as long as I am actively working with the patient and have a one-on-one relationship with the patients’ physician. Dad just recently started home hospice services. I made this request to his physician, because Dad voiced such a strong desire to never go to the hospital again. He was not fond of nurses, and always worried that the hospital would make things worse. Recently we were able to do some much-needed home modification, such as rails at the stairs entering their home and a stair lift to the basement, where Dad spends most of his time. Recently, his son and I completed a MOST (Medical Orders

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To a Patient Advocate, A Letter of Thanks
The following letter from “John” displays the power of Marie’s efforts in patient advocacy. I’m so glad that I hired Marie to help our family. She has made such a difference. I was at a crisis point with my elderly parents. Mom had just returned from the hospital after gallbladder failure and a four-day stint in a nursing home for rehab, which she hated. She has dementia, which makes dealing with a hospital stay quite challenging for her. My Dad also deals with severe pain and his own dementia issues. When my Mom returned home, both her and my Dad’s issues escalated quickly in several ways. At this point, I had missed nearly three weeks’ worth of work due to Mom’s hospital stay and it was close to the holidays. I was extremely stressed and didn’t know where I would turn next. I had in-home care in place and had been managing my parent’s lives for about three years at this point. I had reached a breaking point. Thankfully, I found Marie. She was able to come on board very quickly to help manage my parent’s situation. She started managing many of the day-to-day issues I had been dealing with for years, including doctors, medications, caregivers and daily household needs. She provided a path forward and a plan for my parents and took a huge amount of stress off my shoulders. Marie has been able to help me navigate new benefits and is very familiar with the health systems that can be so tough to navigate. Marie is now an integral part of our care team and I have been able to return to work and to spending time with my wife and daughter. Her caring interaction and dynamic management of my parent’s situation has allowed them to remain at home where they really want to be. She has made all the difference to our family and I’m so very grateful for her help.

care community that had 24 hour nursing and would take patient with “behaviors.” He had one incident on the first evening when he was admitted to this community, but has settled in and is doing very well now. He has gained weight, he wears his oxygen most of the time, and his cognitive function has improved. Mom remains at home with daily homecare visits. She has become very pleasant to be around and seems very content being in her home. She admits she misses her husband, but realizes he is better off where he is. Meanwhile, their son has been able to relax, not worry that there is always a crisis waiting to happen. He and his wife recently found that they are having twins, a boy and a girl in February.

Marie Connolly is a professional patient advocate and founder of Guiding Light LLC. Drawing on her 35+ years of experience, Marie advocates for her patient’s best interests within the complexity of the health care system, resolving issues related to both the medical and administrative pillars of healthcare, and ensuring that patients get the best care for the lowest out-of-pocket cost. Marie facilitates clear communication between the patient, the patient’s family and health care providers to ensure a clear understanding of care options, and to reduce fear, frustration and anxiety. Contact: [email protected]

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The Birth of a Professional Patient Advocate
By Victoria A. Rose

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atient advocacy has always been a part of nursing, and so even when I left the profession as a paid member many years ago, I continued advocacy for myself, my family, friends and co-workers. As the saying goes, “Once a nurse, always a nurse.” The need for an independent voice when disease or injury strikes us, I believe, has always been needed. It is only now that we have been able to carve out a specialty that the public can recognize and seek out due in large part to the difficulty the average consumer experiences navigating our complicated and expensive healthcare system.

him a short respite from caring for his wife. Mr. S, as I will call him, was the full time caretaker of his wife. As their trust grew in me and I gathered experience with my client and the family, it became clear that advocacy for all of them would be a significant part of my job. This formerly active and physically fit woman now had difficulty with all activities of daily living and had a shuffled gate along with limited stamina. So I slowly increased her activities to include more walking, interaction with her horse and her dog along with spending more time outside in the environment she loved. As her endurance improved we were able to leave the property and take walks in the nearby town along the Delaware River and short car rides through the surrounding country side along with an occasional picnic. To improve and try to maintain her ability to remain active during the day, I encouraged the family to have her evaluated for an exercise program to provide overall strengthening and endurance. Being an athlete myself, I also knew the positive psychological effects of exercise and thought that it might help her to relieve some of the stress and frustration she was feeling due to the limitations of her disease. Through our combined efforts we were able to establish an exercise routine that Mrs. S enjoyed and helped immensely in her overall wellbeing. My focus was also on Mr. S who, after several years of caring 24/7 for his wife, had begun to fail. Even with an increase in my time with Mrs. S, the demands of caring for his wife while the disease quickly progressed were beginning to take a toll on his health and well-being. I tried, on a regular basis, to suggest to him and to his family that he needed more help in the home, and eventually one of his granddaughters was able to come in two days a week to complement the three days I was with them. I also suggested to Mr. S that he join a caretaker support group so at least once a month he could share his experiences with others facing similar challenges. But it was a hard sell to this proud man of Scottish decent to talk about his struggles with strangers in a support group. So I became his confidante, as well as to other members of the family. It was very difficult for this husband of 65 years to admit that he could not withstand the awesome responsibility of caring for someone with this disease. Even when I suggested that he read the “36 Hour Day” he was reluctant. I copied a couple of pertinent pages describing exactly what he was

Inspiration Drawn from Hardship
Four years ago, after 25 years in real estate and finance, I found myself unemployed, and within three weeks diagnosed with breast cancer. My first focus had to be my diagnosis. I did my research and employed my advocacy skills to understand my situation and then to find professionals to treat me with whom I could feel confident. After my surgical treatment was completed and my hormonal therapy had been initiated in conjunction with my chosen oncologist, I began thinking about my next career move. I spent time exploring several possibilities with no obvious match. Then one day one of my sisters called me and asked if I would be interested in providing companion services for a woman with Alzheimer’s. I knew the family and the area since I had grown up in the community, but I had never officially met the woman in question or her spouse. I agreed to meet them at my sister’s behest. The family lives in southern Hunterdon County just outside of Lambertville, N.J., on a small farm. The woman and her spouse were in their early 80s and had been married for 65 years since they were teenagers. They were an active family, which included skiing, horseback riding, golf, cycling, swimming and world travel. The couple and their children, grandchildren and great grandchildren all live in the area and are a very close family. They pride themselves, especially the patriarch of the family, as being self-sufficient. Needless to say, asking for outside help was out of their comfort zone. I met the couple in their home and spoke with both of them about their needs and decided to sign on and see if it was a fit for me as well as them. Initially, I was to provide companion duties two days a week for a couple of hours to allow the husband to do errands outside of the home and to give

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experiencing so he could see how others had followed the same path and the resulting consequences, but he could not relinquish his promise to his wife to care for her in their home. When the day finally arrived that Mr. S and his health hit a brick wall and he had to be hospitalized, he still thought that somehow he could recover and continue his care of Mrs. S. But it was not to be. His health did not improve sufficiently for him to return home. The family decided that Mr. S would move out of the home and live with one of the daughters so he could hopefully regain his health, and 24-hour care personnel would be engaged to care for Mrs. S in the home. Mr. S and the family also decided that the time had come to take Mrs. S off of all medication due to the profound deterioration in her ability to function and to engage hospice services in addition to the 24-hour care personnel. After nearly 14 months with this family, I left their service, and Mrs. S died two months later in her own home with her family by her side.

After a lifetime away from nursing, at least officially, I realized the skill set I still possessed and the impact it could have on people faced with the daunting challenge of caring for a loved one with a serious health condition. At that, I decided that I would embark on the next phase of my career, and put my experience and dedication to work as a professional patient advocate.

Victoria A. Rose, RN, BSN, graduated from Gwynedd-Mercy College in Gwynedd Valley, Pa., and recently completed the Professional Patient Advocate Certificate Training Program. Ms. Rose has had successful careers in nursing, healthcare regulation, real estate and finance. She and her husband reside in Central New Jersey close to the Delaware River. Contact: [email protected] com

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Patient Advocates: The Emergence of Modern Day “Rainmakers”
By Kathryn Gohman

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patient advocate brings specialized expertise of the healthcare system, as well as excellent research and communication skills, patience and compassion, to patients who are scared, need immediate answers and are looking for alternatives. The patient advocate who handles disputes, claim appeals, abuse and fraud issues is asked to assist, intervene and fight for their clients. Each phone call that a patient advocate receives from a consumer requires the advocate to accept ownership of the consumer’s request and, to the best of his/her knowledge, resolve the issue presented.

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The Patient Advocate at Your Side
The advocate who deals with the healthcare conflict issue presented to them by a consumer must be familiar with the latest healthcare guidelines in order to get the patient the best answers available or to save the consumer the most out-of-pocket dollars. By reviewing a provider bill for errors or by finding errors on the Explanation of Benefits generated by the insurance company after their review of a claim for payment, a patient advocate can raise questions, not challenges, when issues arise in this area. A patient advocate can make the difference between ensuring a patient gets his medical claims paid correctly and the patient having to pay his hospital or doctor bills out of his own pocket. Because the healthcare system is so complex, the consumer who has a health insurance policy and submits claims needs a patient advocate at his side. Just as it is known that most hospital bills have errors in them and need to be reviewed by an experienced advocate, so do Explanation of Benefits generated by the insurance company.

A recent call received from a frantic consumer was in regard to a bill for $5,000 for the services of a surgical assistant at a surgery which had occurred five months prior. The claim was denied by the insurance company. The consumer was afraid she was going to have to pay the bill out of her pocket and wanted the help of a patient advocate to investigate this claim. After calling the insurance company and finding out the surgical assistant who had submitted the bill was not in network with the insurance company nor did he have a National Provider Identification number which is required, the insurer denied the claim. The patient advocate next tracked down the surgical assistant’s billing company to verify no charges were due now or would be due in the future on this same bill. The advocate requested the billing company send a statement showing the $0.00 balance owed to the patient. The consumer was relieved and sent an email praising the work done and, requesting the advocate “send me a bill.”

Navigating the Healthcare Maze
A patient advocate receives many requests requiring the patient advocate to locate immediate answers. One wellknown job site describes the job of a patient advocate as “the horse whisperer of modern healthcare.” What a good description of the role of a patient advocate acting on behalf of consumers. A patient advocate bridges the healthcare system locating the correct answers to questions such as: • Can you help me find the best cancer doctor to help patients with stomach cancer? • My mother is being released from the hospital and the hospital won’t let her go to the nursing home we have chosen for her, insisting she give the hospital Power of Attorney and be admitted to the hospital related nursing home. What can I do? • Can you find me a good nursing home that accepts Medicare will accept my father as a patient? • Can you oversee the care of my mother who is in a hospital not located near her family? • Will you oversee the insurance company’s payment of the medical bills for my son’s operation? • How do I file a complaint against a provider? • Do I qualify for free medication and how do I apply for it? • Can you file an appeal for me for a medical claim that was denied?

Resolving Errors in Your Hospital Bill
Today, many patients still accept their doctor’s bill for services at face value, never questioning whether what they are billed is correct or not; likewise, today’s consumer finds it easier to accept the Explanation of Benefits they receive from their insurance company as being correct than to question charges they believe are incorrect. Many times there are deficiencies in both types of paperwork, and engaging a patient advocate to review these statements can benefit the patient. The patient advocate’s job is to question each and every charge not paid for by the insurance company or any charge that is questionable, by calling the insurer and discussing how and why a payment was not made.

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Previously Unheard Of Options for Denied Medical Claims
The patient advocate’s role is to know of or locate options that will bring advantage to the patient after or before he has pursued all available options on his own with respect to medical claims for procedures and hospital stays. A consumer decided to hire a patient advocate after he received denials by his insurance company for medical claims for a trial spinal cord stimulation system implant, as well as denials on two separate appeals. The patient did not know that the claim had been denied since neither prior authorization for this procedure was ever submitted to the insurer, or available documentation proving medical necessity. The doctor terminated his position from the practice shortly after the patient’s surgery and his staff had overlooked submitting these documents with the charges for the surgery. The patient advocate, knowing the rules of the new Affordable Healthcare Act, submitted the claims to Maximus, the HHS oversight agency that impartially will review claims that have been denied on appeal by an insurance company. The patient advocate and the insurance company were notified that Maximus overturned the denied appeals. The insurance company was required to pay all claims, which then allowed the patient to proceed with the implant of the actual stimulator he needed.

be able to get him a better deal on his sinus surgery. He had already gotten the medical codes and was given a dollar amount that he would pay in cash for the day surgery. After the patient advocate contacted the hospital and advocated on the consumer’s behalf, the hospital immediately reduced the total out-of-pocket costs the man owed by another 35 percent. In total, the consumer received 65 percent off the normal charge for the day surgery by paying cash and having a patient advocate at his side.

In Summary
Many people are becoming aware of the role of the patient advocate in the healthcare network. Recent newspaper articles this year are informative and are opening the eyes of the consumer as they explain the role of the advocate and exactly how they can bring benefit to a family, especially one that has a special needs or handicapped family member. College programs and certification programs have started to advertise the type of courses they offer which benefit individuals who desire to become patient advocates. Just recently, a committee was formed to set up the criteria for certification of patient advocates. This is a big step. Looking forward, the future seems very bright.

Negotiating Discounts on Provider Balances
One of the top areas patient advocates who handle provider billing, insurance concerns, Medicare problems, etc., have to deal with is negotiating provider bills on behalf of clients. The purpose being to reduce the out-of-pocket costs owed to a hospital or provider for services provided. In California, the hospitals recognize that some patients want to save money on their hospital bills and the hospitals need cash to expand or purchase new equipment. The consumer is given the choice of paying their bills as a non-insured consumer or an insured consumer, whichever gets them the least out-ofpocket balance and then offering a 40 percent discount if they pay this balance within a stated time. Negotiating on behalf of a client is an exciting challenge to a patient advocate. In other cities, this option offering such incentives to get patients to pay their bills quickly is rarely heard to be offered. The patient advocate receives daily requests to reduce hospital bills. Negotiating on behalf of a client is an exciting challenge to a patient advocate. A referral call was received from a consumer that heard that a patient advocate might

Kathryn Gohman is a patient advocate and CEO of Dallas-based Patient Advocate Group, which is recognized by the Better Business Bureau as an A+ rated business. Kathryn who advocates for patients nationwide started to follow her dream to be a nursing supervisor studying at Iliinois Wesleyan University. Still wanting to get into the healthcare field, she purchased a software program and started electronically filing doctors claims. The doctors wanted her to take care of their patients’ insurance and healthcare problems in addition to the providers. The idea of being a patient advocate arose and Kathryn followed her dream. Patient Advocate Group resolves healthcare issues of concern and, locates the answers patients need to make complex healthcare decisions. Primarily, “rainmakers” who get answers for clients who need help quickly; we respond to all questions or direct the individuals to the right organizations that can help them find the answers. Contact: [email protected]

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Earn a Certificate in Hospital Patient Advocacy to Better Serve your Clients
Upon completion of the training program participants will receive:
› A Certificate, suitable for framing, that recognizes the completion of the Certificate In Hospital Patient Advocacy Training Program. › A logo showing that you have completed the Certificate in Hospital Patient Advocacy by the Professional patient Advocate Institute on letterhead or other business materials. › A lapel pin for professional identification.

The healthcare system is complicated, fragmented and costly. As a result, today’s consumer is looking for direction and unbiased advice they can use to allow them to have a voice in their care as well as having someone who can assist them in making informed decisions. To meet this need, the emerging practice of hospital advocates are in place in hospitals across the country. The Hospital Patient Advocate Certificate Program is an E-learning course that you can take at your own pace and is aimed at enhancing training for those involved in the specialized field of hospital patient advocacy. The goal of the program is to focus on the concepts of hospital patient advocacy and to assist advocates in improving the patient and family experience, which is one of the elements hospitals and others organizations, must meet as a core component of value-based purchasing. In addition, this program will reinforce the role of hospital advocates in ensuring that patients and their families have a safe and empowered in-patient stay. The e-learning program is open to all who want to learn about this emerging field of hospital patient advocacy.

To enroll in the Certificate in Hospital Patient Advocacy Online Training program, please visit www.patientadvocatetraining.com
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