Headquartered in Arizona, Banner Health is one of the largest nonprofit health systems in the country. The complex system owns and operates 28 acute-care hospitals. It also has Banner Health Network, an accountable care organization (ACO) of physicians, hospitals and services caring for local communities. Further, it operates Banner University Medicine, academic and employed physician groups, long-term care centers, outpatient surgery centers and an array of other services.
Banner Health manages approximately 70,000 referrals per year, including approximately 34,000 incoming patients from community hospitals and competitors. Transfer volume growth since 2016, however, had started to decline from 13.7% to 2.4% in 2018. Staff noticed this decreasing referral volume and set out to determine its causes and identify ways to reverse the trend.
“We discovered that transfers on average took more than three hours – 198 minutes – due to the lack of standardized processes and communication difficulties,” said Charley Larsen, RN, RN senior director at Banner Health Transfer Services. “This included multiple phone calls between our physicians until the right physician at the appropriate facility would receive the necessary information to approve the admission.”
During that extended waiting period, the referring physician could have called a competitor and transferred a patient there instead, which Banner discovered often happened. Staff estimates that, in 2018, Banner was losing 600 patients a month to competitors, due in part to slow transfer approvals and admissions, which created a frustrating process.
Staff further estimated that if this trend continued, Banner would lose $40 million in annual revenue from those missed transfers. It was clear that an intervention was needed.
“We want to continue these process improvements and growth trajectory and have set an ambitious target of 30 minutes for an approved transfer – and a single phone call to approve the admission and arrange transportation.”
Charley Larsen, RN, Banner Health Transfer Services
“Identifying where delays were occurring across Banner’s large network was a challenge using our existing technology,” Larsen recalled. “Identifying the referring physician and institution as well as the cause for a transfer delay or cancellation required free-text searches in our electronic health record. This lack of a standardized, reliable database to manage such information made raising awareness of the problem and changing behaviors among our physicians difficult.”
The need for a simplified, standardized transfer process was further driven home after Banner Health participated in a six-hour disaster preparedness drill with the Federal Emergency Management Association. Banner and other hospitals in the Phoenix region simulated evacuating their patients to other facilities in the wake of a natural disaster.
“Several hours into the drill, my team and I had not been able to agree on a patient-load balancing plan and had yet to begin any simulated transfers,” Larsen said. “Competitors, however, were calling us during the drill requesting simulated transfers to Banner Health facilities saying they were able to admit 85% of their own patients within their networks.”
The drill was eye-opening. Banner is the largest system in the market, and it did not know how many patients it could admit after four hours. It was far from prepared and it knew some changes would have to be made promptly.
After exhaustive research, Banner Health Transfer Services’ Chief Medical Officer Dr. Jason Brown and Larsen co-wrote a 45-page white paper about the importance of transfer services and the multimillion-dollar financial impact of losing hundreds of transfers from the Banner network.
“Around this time, I met with one of the network’s senior executives and cautioned her about the patient volume and potential revenue loss,” he remembered. “The executive, who also reviewed the white paper, quickly garnered support from the rest of our leadership staff, who agreed to invest in a transfer-center improvement initiative.”
A major element of the project involved upgrading Banner’s technology to a modern transfer-center solution. Apart from the lack of reporting capabilities, the legacy technology was difficult to use and was not designed to support efficient transfer-center operations.
“We reviewed several technology solutions, but there was a dearth of solutions offering the required ease-of-operation or reporting capabilities to track transfer activity and performance that Banner Health needed, until I found Central Logic, which is exclusively designed for transfer centers,” Larsen said.
Part of the reason Central Logic’s solution appealed to Banner Health was that it could track and enable real-time reporting on important transfer information and metrics, such as time to transfer, real-time facility capacity, real-time provider schedules, cancellation rate, consult rate, lost rate and transportation times.
“Not only was this information easily available, but our team could quickly analyze trends to identify potential bottlenecks or other emerging challenges,” Larsen said. “However, rather than choosing a system based on a product demonstration alone, I spoke with my counterparts at numerous health systems where Central Logic had been successfully implemented and used for many years.
“Every organization we spoke to said the biggest win from Central Logic is the data,” he continued. “Now that we are live, we are seeing that for ourselves. We can see exactly where our transfers are going, who is involved, and where the improvement opportunities are.”
MEETING THE CHALLENGE
Due to the patient volume and revenue losses, Banner Health wanted to implement the new transfer-center technology as soon as possible. Despite its implementation during the winter holiday season, and a separate EHR remote-hosting project occurring at the same time, Banner Health was able to go live with Central Logic in January 2019, a month sooner than average for a comparable network of Banner Health’s size and scope, Larsen reported.
“The solution is used by our two transfer center teams, one for Arizona and the other for the facilities in our Western region,” he explained. “We began this initiative with 75 employees, but grew to more than 400 over the year, due to the significant increase in patient volume, but also because our team members were conducting outreach with community hospitals and doctors to let them know about our new capabilities.”
With the new technology, Banner Health’s teams have complete oversight of transfer operations, including times, locations and providers.
“Now, agents are able to provide answers and insight for our referring physicians more quickly, increasing their productivity,” he said. “Communication also has been streamlined. Agents have a comprehensive view of facility capacity and provider schedules, so there are fewer phone calls to arrange a transfer and less uncertainty over the appropriate physician to approve an admission.”
In many health systems, patients are transferred from an ED in a community hospital to the ED of the receiving hospital for triage to another facility.
“This inefficient process can delay care and can also overwhelm an already busy ED staff,” Larsen explained. “Thanks to our enterprise-wide visibility, we are able to direct more transfers and admissions directly to the facility where patients will be receiving needed specialty care, instead of delegating those duties to the ED.”
With agents having improved visibility, Banner Health plans to continue to improve balancing patient loads between its facilities. It will conduct additional outreach to patients who were referred to a competitor’s facilities to repatriate them into the Banner Health network.
“Through the process, Central Logic served as a trusted advisor for us, instead of just a technology vendor,” Larsen said. “They shared strategies and best practices gleaned from their work with other health systems with high-performance transfer centers and helped us avoid missteps as they overhauled our processes.”
Just six months after the new technology went live, Banner Health was already on an upward trajectory with referral volume. It estimates referral volume for Banner facilities will grow by 16.5% for 2019, thus adding 3,308 more patients than the previous year, during which the network lost an estimated 716 transfers to competitors.
“This was possible due to the real-time visibility over our facility capacity and physician schedules and more efficient processes to transfer patients, which means fewer required phone calls and less waiting and frustration for our referring physicians,” Larsen said. “In total, we reduced transfer time on average by 67 minutes. We want to continue these process improvements and growth trajectory and have set an ambitious target of 30 minutes for an approved transfer – and a single phone call to approve the admission and arrange transportation.”
With an estimated $8,000 contribution margin per patient transferred or retained through a transfer, the additional patients will increase revenue by more than $26.4 million for Banner Health, Larsen said. As such, the investment into Banner Health’s Transfer Services paid for itself in just 152 days, he added.
ADVICE FOR OTHERS
“Ensure the technology covers the entire health system and offers real-time visibility into facility capacity and physician schedules, so your transfer center can offer quicker answers to referring physicians and arrange consult calls efficiently,” Larsen advised. “Also essential is accurate and reliable analytics with the ability to easily generate many different types of performance reports about patient transfers, retention [and] lost rate, including information about the time and locations involved.”
Before implementation, Banner Health understood how the shrinking transfer volume was impacting its network’s revenue and its referring providers, but could not deliver reliable reporting to senior leaders because the transfer center systems were not fully integrated and existing software at the time did not offer very robust analytics.
An organization’s data needs to be rock solid to tell a story, not only about the challenges and risks, but also the opportunities for growth and repatriation – for example, facilitating the patient’s return to the network, Larsen said.
“Transfer services often are viewed as a niche service, but they really shouldn’t be,” he said. “As health systems merge and grow and form these mega networks, they have to understand the value transfer services offer in supporting that growth and ensuring financial sustainability.”
With the new technology, plus the changes made to the transfer center and processes, he concluded, Banner Health is going to make the most out of this opportunity to expand the organization’s footprint and improve care quality in the communities it serves.
Email the writer: [email protected]
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