Pa­tient ad­vo­cates’ role expands to meet health­care’s in­creas­ingly com­plex de­mands

Modern Healthcare - - News - By Steven Ross John­son

LETICIA SO­LIS, a health ed­u­ca­tor with fed­er­ally qual­i­fied health net­work Al­taMed Health Ser­vices Corp., said some of her first ex­pe­ri­ences with the health­care sys­tem be­gan dur­ing her child­hood when she was try­ing to find her par­ents the ap­pro­pri­ate help for their chronic dis­eases.

Both of her par­ents spoke lit­tle English, and money was tight. She said those cul­tural and eco­nomic chal­lenges made it difficult for them to al­ways fol­low physi­cians’ in­struc­tions on man­ag­ing their health, which made their con­di­tions worse. “I saw my dad and mom strug­gle a lot eco­nom­i­cally and I saw that we were in need of some re­sources,” So­lis said.

So­lis be­gan ask­ing clin­i­cians ques­tions on her par­ents’ be­half and was able to find them so­cial ser­vices and other sup­ports. She said play­ing the in­ter­me­di­ary helped her par­ents bet­ter un­der­stand what doctors ex­pected while help­ing their physi­cians bet­ter un­der­stand the so­cial fac­tors that hin­dered them from bet­ter man­ag­ing their health.

That help her par­ents re­quired then to get the best med­i­cal care and sup­port is just as im­por­tant for pa­tients now, some­thing that more hos­pi­tals are fo­cus­ing on, par­tic­u­larly in a time when pop­u­la­tion health man­age­ment is gain­ing promi­nence.

The role of pa­tient ad­vo­cate has a long history in other coun­tries and has been found within pre­dom­i­nantly im­mi­grant pop­u­la­tions in the U.S. since the 1960s. But the role is at­tract­ing broader in­ter­est as the health­care sys­tem has be­come more com­plex.

For many health­care providers, the pa­tient ad­vo­cate has be­come a more in­te­gral piece of their care de­liv­ery strate­gies by ad­dress­ing both the med­i­cal and other fac­tors that im­pede pa­tients from im­prov­ing their health.

“What’s changed is the breadth of what you have to help ad­vo­cate for,” said Louis Malone, direc­tor of ser­vice ex­cel­lence at South Nas­sau Com­mu­ni­ties Hospi­tal in New York. “It used to be more about crea­ture com­forts that they needed help with. There’s a lot of com­mu­ni­ca­tion is­sues now that I think years ago were not there.”

In ad­di­tion to ed­u­cat­ing pa­tients, Malone

said many pa­tient ad­vo­cates are find­ing an in­creased need to learn more about hospi­tal fi­nan­cial poli­cies to bet­ter help pa­tients with billing is­sues or help them iden­tify re­sources to ob­tain health­care cov­er­age.

And the de­mand is so great that pa­tient ad­vo­cates hired di­rectly by pa­tients are be­com­ing more pop­u­lar as a means to nav­i­gate the health­care sys­tem (See story, p. 24).

What is a pa­tient ad­vo­cate?

The role of pa­tient ad­vo­cate can vary de­pend­ing on how a health sys­tem chooses to use their ser­vices.

So­lis of South­ern Cal­i­for­nia-based Al­taMed fell into the job, in which she pro­vides health education to pa­tients and works to ad­dress some of their needs be­yond med­i­cal care, while keep­ing clin­i­cians in­formed of those con­di­tions. When she be­gan work­ing at Al­taMed in 2006 as a med­i­cal as­sis­tant, she dis­cov­ered a siz­able por­tion of the sys­tem’s sicker pa­tients were dealing with many of the same so­cio-eco­nomic is­sues her par­ents had ex­pe­ri­enced. More than 60% of Al­taMed’s 300,000 pa­tients speak a lan­guage other than English and 80% are be­low the fed­eral poverty level.

So So­lis be­gan ap­ply­ing what she learned through her ex­pe­ri­ences with her par­ents, help­ing her Al­taMed pa­tients by giv­ing them in­for­ma­tion on ac­cess­ing so­cial ser­vices re­sources. Over time, clin­i­cians at the clinic where So­lis worked be­gan notic­ing im­prove­ments in their pa­tients’ diabetes and hy­per­ten­sion scores. When they were asked what they were do­ing dif­fer­ently, pa­tients would men­tion So­lis, re­sult­ing in her be­ing pro­moted to the job of health pro­moter.

Some providers still view their pa­tient ad­vo­cates as pa­tient re­la­tions rep­re­sen­ta­tives who mostly han­dle in­pa­tient com­plaints about a facility’s ser­vice or ameni­ties.

Other providers have gone be­yond that tra­di­tional scope, which lim­its ad­vo­cates to work­ing on the pa­tient’s be­half to set­tle such is­sues as billing con­cerns, an­swer­ing ques­tions about health in­sur­ance, or help­ing ad­dress cov­er­age dis­putes with health plans. Some ad­vo­cates also play parts in med­i­cal de­ci­sion­mak­ing by help­ing pa­tients and their fam­i­lies bet­ter un­der­stand treat­ment op­tions.

“To­day the nav­i­ga­tors I think are a lot more em­pow­ered. There is a high level of ac­count­abil­ity and a high level of res­o­lu­tion,” said Fouzel Dhe­bar, ad­min­is­tra­tive direc­tor of nav­i­ga­tion ser­vices at Stan­ford Health Care in North­ern Cal­i­for­nia.

Dhe­bar be­gan at Stan­ford in 1996 as one of a hand­ful of pa­tient re­la­tions ad­vo­cates whose role back then she de­scribed as be­ing fairly lim­ited to that of an un­of­fi­cial ombudsman to in­ves­ti­gate pa­tient com­plaints about ser­vice. To­day, Stan­ford has ex­panded the du­ties of the in­di­vid­ual ad­vo­cate as well as the pro­gram it­self, with a staff of more than 40 that serves ev­ery care unit and ranges from in­for­ma­tion desks to more spe­cial­ized care nav­i­ga­tors who help with sched­ul­ing ap­point­ments and gen­eral sup­port for newly di­ag­nosed can­cer pa­tients.

“I think our nav­i­ga­tors are now the air traf­fic con­trollers and re­ally are the glue be­tween the pa­tient, the provider, the care­giver and fam­ily mem­bers as well,” Dhe­bar said.

Pa­tient-sat­is­fac­tion scores in­di­cate there is room for im­prove­ment in hospi­tal-pa­tient en­gage­ment. CMS cost re­port data from Mod­ern Health­care Met­rics in­di­cate that just 51% of pa­tients in acute-care hos­pi­tals strongly agree they un­der­stood their care when they left the hospi­tal, though 43% agree that they did. Six per­cent dis­agree that they un­der­stood their care when leav­ing. In ad­di­tion, 87% of pa­tients said that they were given in­for­ma­tion about what to do dur­ing their re­cov­ery at home, mean­ing 13% of pa­tients did not.

Evolv­ing ex­pec­ta­tions

The chang­ing role that the pa­tient ad­vo­cate plays at sys­tems like Stan­ford has been part of a big­ger move­ment over the past few years to re­or­ga­nize and strengthen their part in the care de­liv­ery process, said Erica Ru­bin­stein, vice pres­i­dent of pa­tient ex­pe­ri­ence at Mount Si­nai Health Sys­tem in New York City.

Mount Si­nai was an early user of pa­tient ad­vo­cates, start­ing in the 1960s, a time when, Ru­bin­stein ac­knowl­edges, it

was tra­di­tion­ally viewed among both pa­tients and clin­i­cal staff as the de­part­ment to send all com­plaints.

A big part of the re­or­ga­ni­za­tion ef­fort has in­volved ed­u­cat­ing front-line clin­i­cal staff to bet­ter un­der­stand when it is most valu­able and use­ful to call on a pa­tient ad­vo­cate, Ru­bin­stein said, such as in cases in­volv­ing more com­plex pa­tients, or at times when an in­ter­me­di­ary is needed to fos­ter com­mu­ni­ca­tion be­tween dif­fer­ent med­i­cal care units.

“A lot of what we are dealing with are very com­plex co­or­di­na­tion-of-care is­sues,” Ru­bin­stein said. “A pa­tient may have a sur­gi­cal team, an on­col­ogy team, a res­pi­ra­tory team all work­ing to to­gether to care for them, and those teams may not al­ways be speak­ing to one an­other on any given day. Of­ten­times we’re called in to be the con­nec­tion be­tween those teams.”

Ru­bin­stein said Mount Si­nai’s ad­vo­cates are also play­ing an im­por­tant role in the sys­tem’s ef­fort to be­come the na­tion’s lead­ing model in pro­vid­ing care for trans­gen­der pa­tients, who of­ten face higher rates of dis­crim­i­na­tion in health­care set­tings com­pared with other pop­u­la­tions, which has led to larger health dis­par­i­ties. Pa­tient ad­vo­cates at Si­nai are con­duct­ing train­ing sem­i­nars for staff across the sys­tem on how to wel­come trans­gen­der pa­tients when they ar­rive for care.

Ru­bin­stein be­lieves such role tran­si­tions all tie into a change she has ob­served in the per­cep­tion of pa­tient ad­vo­cates among clin­i­cal staff, which she said was some­times con­fronta­tional in the past. She de­scribed the re­la­tion­ship these days as more co­op­er­a­tive, with clin­i­cians more will­ing to use the re­la­tion­ships ad­vo­cates have al­ready es­tab­lished with pa­tients to help them build bet­ter rap­port.

“We try to be that per­son for the pa­tient as a neu­tral party; we’re not di­rectly in­volved in their care, but we’re there to be their voice,” Ru­bin­stein said. “Our col­leagues who are front-line staff re­ally value that part­ner­ship, and we do see our­selves as part­ners.” ●

Leticia So­lis, a health ed­u­ca­tor with Al­taMed Health Ser­vices, coun­sels a pa­tient on how to bet­ter man­age her con­di­tion. The ef­fort has been part of the health net­work’s strat­egy since the 1990s to use com­mu­nity out­reach to pro­mote well­ness.

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