Published in the September 2014 issue of Today’s Hospitalist
WHAT HAS LONG BEEN a major source of frustration for hospitalists “transferring patients from one hospital to another, quickly and easily “has become a top priority for hospital executives.
Why? With hospital margins and volumes inching down, executives are convinced that boosting transfers is a sure way to shore up finances. As San Diego, Calif.-based hospital medicine consultant Martin B. Buser, MPH, of Hospitalist Management Resources LLC, explains, hospitals nationally are already seeing census reductions of as much as 5%.
“They need to increase market share as quickly and dramatically as possible,” Mr. Buser says. “You want your hospital to be considered a regional referral center, which means giving the thumbs up to transfers.” And you don’t need to be a teaching hospital “to become a successful regional referral hospital,” he adds. “Large community hospitals are intercepting transfers that formerly went to universities because they can give better service and are more responsive.”
According to Mr. Buser, some client hospitals have realized a 15-to-1 return on every dollar invested in a new transfer center. But to be successful, he explains, hospitals need effective hospitalists, available specialists, bed control that reports open beds promptly and a “one-call solution.”
To realize that kind of success, some medical centers are hiring customer service experts, overhauling transfer protocols and even outsourcing the coordinating process of transferring patients to growing, for-profit companies.
Still others are working to improve personal relationships with outlying hospitals. All these efforts help ensure a steady stream of transfers “and mean big changes for hospitalists. Those can include more staffing, increased responsibilities, and new relationships with subspecialists and surgeons.
Consider the experience at the University of Virginia Medical Center in Charlottesville where George M. Hoke, MD, heads the 20-physician section of hospital medicine. The hospital began outsourcing transfers in June to a for-profit transfer center.
Now, when a hospitalist or emergency physician at a referring hospital calls UVA with a transfer request (1-844-GOUVATC), the person answering the toll-free hotline is halfway across the country.
That coordinator has no clinical training. Instead, his or her job is to use conference call technology to connect doctors at both centers, record and transcribe the interactions, and document how long it took the transfer to be accepted and completed. The goal is to get patients the right care as quickly as possible and to not lose referrals to competing hospitals.
According to Dr. Hoke, transfer volumes have now shot up from two or three a day to as many as eight, with hospitalists now accepting transfer requests from several other departments in addition to general medical patients. While that’s great news for executives, it has hospitalists devoting more time to transfers.
“Right now, we are scheduling a hospitalist whose primary responsibility is answering these calls and accommodating transfer requests,” Dr. Hoke says. “We hope that doesn’t last as we get more used to the new process. But so far, the amount of time we spend on this has increased exponentially.”
Hassles and suspicion
Across the country, hospitalists have had the same frustrations with transfers for years. Those on the sending end say it is a constant hassle to get someone to agree to accept a patient today, not three days from now when a bed may be open. You may waste hours playing phone tag, then have doctors on the other end insult your competence or question your intentions.
On the receiving side, there’s the nagging suspicion that smaller hospitals are looking to dump their difficult or uninsured patients, particularly when requests come on Fridays or before holidays. Doctors at large centers also hate being surprised when arriving patients are worse off or clinically different than advertised, adding yet more work to an already busy day.
“These cases are the exception and not the rule, and we have to get past feeling that we are being dumped on,” says Roy I. Sittig, MD, medical director of the hospitalist program and associate chief of medicine at the University of Connecticut Health Center in Farmington, Conn. The bigger problem, as he sees it, is that “the process to get someone in can be a labyrinth that is not user-friendly to referring providers.” Too often, there is no one number to call to get a transfer started. Then there’s confusion about whether to call an admitting hospitalist or a specialist.
In the case of academic centers, referring physicians often get a resident on the line, and residents don’t have the authority to accept transfer patients. “It often takes four or five phone calls before someone can get an answer,” says Dr. Sittig. “The word gets out that, ‘transferring patients to Hospital X is problematic and time-consuming,’ and physicians start taking the path of least resistance and start referring elsewhere.” In an environment where there are several tertiary centers to choose from, he adds, “it is critical to remain user-friendly and service-oriented so you stay competitive in attracting referrals.”
Left in limbo
Having one transfer center number to call is a good start, but it’s not the whole answer. A hospitalist in the 100-bed Cheshire Medical Center in Keene, N.H., Gerard Kiernan, MD, points out that at his facility, there is only one hospitalist in-house at night. There are currently no intensivists in-house on the weekend, and some subspecialists have only limited availability.
His hospital is about 90 minutes away from an academic center that is often full and needs to triage transfer requests. Dr. Kiernan says his most frustrating experience is reaching out to receiving centers and getting a “yes, but” answer because bed management at the receiving hospital isn’t able to predict with certainly when a transfer could take place.
When the answer is, ” ‘Yes, we’ll accept, but not until there’s a bed available,’ it’s like purgatory,” he explains. “We would prefer a firm ‘no’ because then we can start calling other places.”
Another problem can occur when Dr. Kiernan is worried that a patient may decompensate, but hasn’t yet.
“We are calling requesting a transfer, and they say, ‘But you haven’t had a disaster yet, why do you want the patient to come here?’ ” Dr. Kiernan says. “From their perspective, I am asking them to take a patient who might do fine when their hospital is full. But I am thinking that if this goes south, I want this patient to be in a place with more or different resources, and time may be of the essence.”
Part of the problem, he says, is that personnel at larger centers don’t always understand what it means to work in a smaller hospital that has more limited ancillary services like blood bank, respiratory therapy, lab and radiology.
“One thing that has been helpful is when people from the larger center moonlight down here as hospitalists,” says Dr. Kiernan. “They experience what it is like to make difficult judgment calls with low resources.”
Joseph Messina, DO, MBA, is a Charleston, S.C.-based hospitalist affiliated with Hospitalist Consultants’ ELITE Physician Services, an alternative to locum tenens with staffing for start-up hospitalist programs until permanent physicians are in place. As a traveling hospitalist, Dr. Messina knows firsthand how physician personalities and hospital cultures can either make transfers go smoothly or sabotage them.
“Some places say their ICU is overflowing, but bring them in anyway,” Dr. Messina points out. “In other places, your colleagues will ask, ‘Why did you accept this patient?’ Some hospitalists forget why they are there in the first place: to provide a service.”
Transfers work, he says, when the directive comes from the top and “the hospital CEO says they have to be better accepting transfers because they need more patients to keep their doors open.”
Competition also helps adjust hospital attitudes. When he recently worked at a small hospital in Georgia, Dr. Messina found it easier to transfer a patient to a hospital an hour away “in a city with several competing facilities “than to one only a half hour away, which was the only game in town. The closer hospital told him that he would have to wait three days for a bed.
Dr. Messina also thinks that health system integration should help. It is harder to put up barriers to transfer requests coming from colleagues, he points out, than from people you don’t know and may never work with again.
Hospitals working to secure more transfers can do a lot to foster good relationships, even when they are not part of one system.
In Canton, Ohio, for instance, the doctors and administrators at Aultman Hospital have quarterly meetings with the leadership of the five community hospitals that regularly refer patients. One item they always review is transfer problems.
“They tell us that maybe a vascular surgery case took four calls to get the patient over,” explains O. George Mitri, MD, medical director of the 20-hospitalist Aultman Internal Medicine.
Spending time to get to know other area hospitalists is also key. “Their patients end up on our service, and we want them to know who we are, what kind of service we operate and how we communicate back to them after they send us a patient,” says Dr. Mitri. “Now when we get a call, 50% of the time, we know who it is.” Moreover, “if you know the person on the other line, it’s hard to be rude or say ‘no.’ And when they know us, they are not going to lie to us” about how sick a patient really is.
Aultman Hospital operates its own in-house transfer center called “Aultman Access,” a streamlined operation that replaced another system “called “Aultman One Call” “that “didn’t work so well,” Dr. Mitri admits. One improvement is having only a few nurses answer the transfer line, instead of having many of them take turns. The hospitalist team also helped craft a better transfer protocol that does a more thorough job of gathering the information doctors need to make sure that transfer patients aren’t sicker than expected.
Dr. Mitri’s group is also discussing whether to reorganize hospitalist staffing to have a subset of hospitalists care for transfer patients, instead of rotating all 20 hospitalists through.
“Not all hospitalists are equally good at this work,” he points out. Dealing with transferred patients can demand top-notch communication skills, particularly when family members want to find a second treatment option.
“We may not have anything else to offer than has already been offered,” says Dr. Mitri. “Sometimes with transfers, you get families who are frustrated with the lack of progress at the other facility. They come with baggage, and communication can be more challenging.”
Who accepts transfers?
UConn has set up its own one-call transfer hotline dubbed “UCONN-MD.” Calling that hotline places the referring provider in a three-way conversation with not only a receiving provider but someone in the case management department who can weigh in on bed availability in real time.
The goal is to make a decision during that conversation on whether the patient can be accepted and, if so, to let the referring provider know when a bed will be available. If one is not immediately open, UCONNMD staff will call the referring hospital back when a bed is available so the patient can be transferred.
Right now, some UConn specialists continue to admit their own patients, Dr. Sittig explains. “Eventually, I see the model of care evolving to allow the hospitalists to care for virtually all medical admissions and transfers,” he says. “The hospitalists would then be coordinating patient care and freeing up the subspecialists to serve as consultants.”
At UVA, Dr. Hoke is also considering having hospitalists accept all medical transfers and call subspecialists to consult as needed. And to adjust to the higher transfer volume, the hospital may set up a hospitalist-staffed rapid diagnostic unit where transferred patients would be sent on arrival.
As for the new outsourced transfer center, Dr. Hoke sees both pros and cons. It’s taken the new company time to become familiar with the hospital, so hospitalists have spent extra time finding appropriate beds and lining up specialists. And receiving doctors are still looking for ways to ensure accurate, up-to-date condition information on all transferred patients.
On the plus side, Dr. Hoke explains that UVA needed to streamline its transfer time to better serve patients and referring hospitals. And outsourcing has saved the medical center money it would have needed to spend to update its telecommunications infrastructure.
“Our phone system is old, and it wouldn’t allow us to conference in the bed center and specialists,” says Dr. Hoke. Then there are all the data the transfer company can provide: how many transfers take place at what time of day for which diagnoses, and how long it takes to find beds.
“Some component of the decision to outsource,” Dr. Hoke says, “was being able to track all sorts of data elements and have accurate reports.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Outsourcing transfer centers
MANY LARGE ACADEMIC CENTERS have been running their own transfer centers for years. What’s new is that transfer centers are now being adopted for the next tier of referral hospitals: smaller academic centers and large community hospitals.
Also new is the growth of for-profit companies that hospitals can outsource their transfer center operations to. One is the Omaha, Neb.-based company DirectCall Patient Management Center, which started in 2002 and grew out of a medical helicopter company. DirectCall now operates transfer centers for 180 hospitals in nearly every state.
Another is Verihealth Inc., which is based in Petaluma, Calif. The company provides transfer center services to about 20 hospitals in California.
Why are these companies proliferating? Because in an era when inpatient margins and volumes are supposed to go down, grabbing more market share in transfers makes good business sense.
“This is all about creating the path of least resistance,” explains Kerin M. Zuger, MBA, DirectCall’s vice president. “With health care reform, it is going to get extremely competitive, and hospitals are going to have to streamline ways to get patients into their institutions.”
According to Ms. Zuger, every institution the company works with “has seen at minimum a 20% increase in referral volume.” Most larger hospitals have subspecialists respond to transfer requests, she says, while most midsized referral hospitals use a hospitalist model. Both models work as long as staff can handle the typical volume of calls.
For hospitals, outsourcing may look good because transfer centers are expensive to start, staff and operate.
“Setting up a transfer center is going to cost about $1.2 million to do right,” says hospital medicine consultant Martin B. Buser, MPH, of Hospitalist Management Resources LLC. “Outsourcing drops the price in half.”
Transfer centers offer one number to call and the ability to put the right people on the phone at the same time. And hiring a middle person tends to make transfers more cordial. That’s the rationale, Mr. Buser says, behind transfer centers recording every transaction.
“You sell it as medical-legal” and protection against dumping, he points out, “but the real reason is that surgeons are not going to explode and chew out the referring doc once they know they are being taped.” Outsourcing companies also help hospitals market their new 800 numbers, with outreach to referring hospitals, and they track transfer data.
What transfer centers don’t do is find beds for transferred patients. But they do shine a very strong light on bed management problems by reporting transfers that don’t take place because beds weren’t available.
That in turn leads executives to put pressure on everyone below them to fix longstanding bed management problems. Some hospitalists and specialists are being incentivized to respond to transfer-center calls within 10 minutes. New hospital policies are also stopping staff from playing what Mr. Buser calls “hide-a-bed” games, particularly when staff are about to go off-shift, that end up turning potential transfers away due to lack of capacity.
Mr. Buser says he worked with one CEO who was so gung-ho on accepting transfers that “every manager’s bonus is now based on ED throughput.”
Who gets transferred?
HERE’S AN URBAN MYTH passed from one generation of residents to the next: Small community hospitals just want to dump their uninsured patients on big hospitals.
When University of Pittsburgh hospitalist and assistant professor of medicine Janel Hanmer, MD, PhD, researched that issue, she found evidence of just the opposite: Uninsured patients get transferred less than insured ones. She and her research team also found that women were as much as 40% less likely to be transferred than men.
In a study published in the Jan. 20, 2014, issue of Annals of Internal Medicine, Dr. Hanmer and her colleagues analyzed data for more than 300,000 hospitalized patients discharged from more than 1,000 hospitals nationwide. They found that uninsured inpatients were between 20% and 40% less likely to be transferred to another hospital for four of the five most common medical diagnoses (biliary tract disease, chest pain, septicemia and skin infection) than patients with insurance. The interhospital transfer rate for all patients ranged between 2% and 5%, depending on the diagnosis.
Those conclusions ring true with hospitals hired by the Petaluma, Calif.-based Verihealth Inc., a for-profit company that runs transfer centers. According to COO Sean R. Sullivan, when a northern California hospital analyzed its Verihealth-run data, it found that acute transfers had a better payer mix than patients admitted through its own emergency room.
“Even though the service areas that the hospital was marketing the transfer center to had a poorer payer mix than its own county, the transfers they were getting were much better than what was coming through their own ED,” Mr. Sullivan says. “For three years, data have shown the same thing.”
According to Dr. Hanmer, the next steps for research would be look at the combination of ED and inpatient interhospital transfers. She would also like to see future studies tackle why fewer uninsured patients are transferred.
“Uninsured patients may not want to be transferred because they don’t want to have medical bills from two facilities as opposed to just one,” Dr. Hanmer says. “Or being transferred may mean more cost and inconvenience for your family.”
The evidence that women were transferred less often than men concerns Dr. Hanmel as well. Do the data indicate that doctors may discount how sick women are compared to men? Or are women and their families less aggressive in requesting transfer?
“Maybe it’s a self-check for yourself that you are being consistent with women and all your patients,” Dr. Hanmer says. “Would I think differently about transferring this patient if the patient were of the opposite sex?”