Experts discuss the pros and cons of various ways of encouraging patients to return HST equipment on schedule. Patient goodwill toward fellow sleep apnea candidates may be key to avoiding disruptive delays.

Home sleep testing (HST) can have a number of benefits for both patients and sleep medicine practices, including faster results, increased patient volume, and convenience. However, patients returning HST devices late (or not at all) is a problem sleep medicine centers and administrators of HST devices routinely encounter. “If a patient doesn’t return an HST, or returns it late, it may inconvenience the next patient scheduled for the device,” says Kermit Newman, CPA, MBA, president and CEO of Advanced Sleep Medicine Services Inc.

Sean Heyniger, CEO and president of SleepMed, echoes the sentiment. He says, “A breakdown in the providers’ or health systems’ HST process will absolutely affect access to appropriate patient care and overall outcomes.”

Lee A. Surkin, MD, FACC, FCCP, FASNC, board certified sleep physician and president of Carolina Sleep, the sleep division of Carolina Clinic for Health & Wellness in Greenville, NC, and founder of the American Academy of Cardiovascular Sleep Medicine, also affirms, “If [a patient is] late in returning it or doesn’t return it at all, the monitor can no longer be used in the care and evaluation of the next patient for which that monitor is scheduled.”

From signed agreements to returned mailers and patient education, there are a number of solutions that can help sleep centers ensure timely return of equipment.

Patient Education and Consent

Proper patient education and outreach may be the most important means of ensuring HST device return. At the 19 Southern California locations of Advanced Sleep Medicine Services, the HST model consists of having a patient come to a lab for an in-person training session and to be issued the HST device, Newman explains, and the patient returns the equipment the following day. Newman says, “We have a personal connection between the technician and the patient and a scheduled return time, and we have few late or lost devices.”

SleepMed, a manufacturer and provider of HST, is an outsourcing partner for sleep medicine practices to manage the issuing and returns of devices. “At SleepMed, we find that the more patient outreach and engagement we have, the better our outcomes in retrieving the device in a timely manner and getting patients the care they need,” Heyniger says.

According to Marsha Fulton, RPSGT, director of operations at Atlas Sleep Diagnostics, a consent form as well as precise communication with the patient about return expectations are key. Fulton explains that a consent form should outline device education, as well as include specific return details, including the date of issue, the date and time the device needs to be returned, and the cost that would be billed to the patient (if any) if the device is not returned.

Fulton says the sleep tech issuing the device should be firm when the device is given and openly communicate the time and date the equipment should be returned, in addition to the policy for devices that are not given back.

Surkin, who is a Sleep Review editorial advisory board member, also says patient education and an explicit written agreement are the best strategies. After a period of trial and error, the process Surkin has established in his practice is as follows: Surkin or a member of his medical staff outlines what the HST monitor is for and what the functions are; outlines the medical applications and what they hope to gain from testing to engage the patient and create a partnership; and finally has the patient sign an agreement regarding the issued device.

Surkin says the agreement should note that the patient is solely responsible for the care and utilization of the monitor while it is in their possession, as well as note the time, date, and the designated practice for return. Additionally, the agreement should include an addendum that the patient agrees to be responsible for the replacement costs of the monitor and note the specified cost. “Once I carefully engaged with the patient in conversation, instilled a partnership relationship with them, clearly outlined when and where the monitor was to be returned, and had them sign an agreement that would enforce a fee to the patient to replace the monitor, I had no additional problems with getting the monitors back,” Surkin says.

Also, clear communication with a patient about why prompt HST device return can be beneficial can be key. Heyniger says, “When a patient understands that a quicker diagnosis and immediate treatment will change their health, and ultimately life, compliance and timeliness are much easier. There must be a commitment from our team and the patient to be successful. It’s a symbiotic process and relationship.”

Reminder Calls and Messages

Technology can be another useful tool. Reminder calls, e-mails, and text messages can be economical ways to follow up with patients and remind them of the return date. Advanced Sleep Medicine Services employs the use of automated reminder calls, text messages, and e-mail confirmations, which Newman says have improved the timeliness of returns.

SleepMed also uses reminder methods to touch base with patients. Heyniger says, “We are engaging patients to drive rapid response, but this requires constant attention and technology platforms. We use several methods to ensure HST returns are done in a timely manner. We use IVR [interactive voice response], SMS [short message service or text], secure e-mail, and outbound care managers.”

Backup Testing Devices

A significant problem created by nonreturn, or late return, is not having an adequate supply of HSTs for other patients. For this reason, Fulton recommends sleep centers have an emergency backup. “If you don’t plan for a disaster, then you’re more likely to have one,” Fulton says.

Newman says that Advanced Sleep Medicine Services tries to limit any problems with adequate inventory of devices, but he emphasized that it does depend on patients to return devices as agreed to. Newman says, “It’s prudent to have a backup device for the situations where a patient does not return the device as scheduled. We try to keep an adequate inventory to handle the normal situations. If we do have a lack of devices, we can often get the needed device from one of our other locations.”

But due to the cost of keeping an extra HST on hand, a backup device may not be a viable solution for every practice. If a sleep medicine practice has only one monitor, Surkin says it may not have enough patient volume to justify more than one or it may lack the financial means for additional equipment. “A backup device is going to cost money… .I don’t know how realistic it would be to recommend that practitioners keep a backup,” Surkin says.

He adds, “Whether we had just one or 10 of them, it’s still very important to retrieve that item. [The amount of inventory] would not result in any change in the conversation that we would have with the patient regarding the return of the monitor that they are going to take home.”

Overall, the choice to keep additional inventory will be based on a practice’s needs and financial resources, but it may be a sensible option to minimize financial loss. “Insourcing or outsourcing HST device returns requires systems and partnerships to make it cost-effective and clinically effective. Lost inventory will be part of what happens when deploying HST into your facility or practice, so manage your return expectations and plan appropriately to minimize your financial risk,” Heyniger says.

Extended Hours and Drop Boxes

An additional option for HST return can be extended office hours as well as drop boxes for after-hour returns. Advanced Sleep Medicine Services offers after-hours drop-off for patient convenience. “Keeping the returns process as simple as possible is important. Extended daytime and evening availability for returns, as well as drop boxes in some locations, have worked well for us,” says Newman.

Prepaid Mailers and Pick-Up Services

For shipping of HST equipment back to a sleep center, the use of shipping companies that provide a pick-up service, as well as prepaid labels or packages, can offer added convenience for patients. SleepMed provides patients with return prepaid USPS and FedEx options. At Atlas Sleep Diagnostics, if a patient expresses difficulty with returning the HST device at a specific date and time, then a return-mailing label is offered.

package mailing

Some sleep centers have found that providing prepaid return packaging to patients increases the likelihood that HST devices are back in time for the next patient.

At Surkin’s Carolina Sleep, the practice also offers prepaid postage mailers, which can be of particular benefit to patients who do not live close to the practice. The staff of Carolina Sleep also adds tracking to the packages or requests delivery confirmation. “We have had multiple situations whereby we provided a stamped container or box for the patient to return the monitor by mail,” Surkin explains. “If…we are providing a postage paid container to return it in, we would then have my staff contact the patient the next day or the day that we expect the device to be placed in the container and then returned or placed in the postal service. We call the patient to remind them and get confirmation they’ve done that.”

Late Fees

The assessment of late fees is an additional option for sleep centers to consider. However, its effectiveness and the choice to assess late charges will depend on the practice. Fulton says in a traditional sleep center where the patient’s intention was to be seen for a sleep problem, asking for a credit card to be held on file in the event a late fee is charged may be well received. Alternatively, if the HST program is run out of a nontraditional sleep center and the patient may not have originally sought out an HST, asking to keep a credit card on file for the device may impact whether the patient takes it home. “Taking a credit card up front or not poses a risk for both sides. Thus, this is something that should be thought over and trialed before rolling it out patient/clinic-wide,” says Fulton. “Ultimately, the goal is to screen and test and diagnose patients, and send the message that this is a method to help more patients sleep better, feel better, and live better. Making it all about business can turn patients off!”

Advanced Sleep Medicine Services had a policy of late fees in the past but it did not work well, Newman says, largely because it was a managed care environment with limitations on fees that can be assessed. Newman says, “Now we emphasize a personal approach and ask the patient to make a commitment to us to return the device on time, and we tell them that we are counting on them. This policy has worked well.”

If a sleep center opts to include a late fee in a customer agreement, sourcing HST to a third-party manager may be a better alternative. “If you need to charge a late fee to encourage timely returns, consider outsourcing HST to a vendor to improve patient experience and put your focus toward the services at which you excel,” Heyniger says. “From a business standpoint, the financial ramifications of late or no return of HST devices show that it’s likely a better decision to use an outsourcing partner to manage this for you.”

Timely Returns for Optimal Patient Care

Overall, there are a number of options for sleep centers to use to ensure timely return of an HST device, but simplicity may be the best policy. “Having a choice or two is often all we need to offer a patient,” Fulton says. “Set standards, make sure your staff follow them, and be confident in your delivery of said standards! Patients are looking for direction and will generally comply with the options they are given.”

Her clinic staff also tells the patient that the device is scheduled to go out with another patient the following day in order to create a sense of urgency. Fulton says, “If the cost of the device doesn’t get them, then the infringement on another’s time might. Either way, the odds are in your favor!”

Newman says the prompt return of HST devices can be resolved by people, not technology. Newman says, “We are basically asking people nicely to please bring back our devices, telling them that we are counting on them, and that if they don’t bring back the device, it will cause problems for the next patient.” He adds, “It has been working fairly well.”

In Surkin’s professional experience, the return rate of HST equipment to his practice has been excellent, a fact that he attributes to patient communication. “As far as late returns, there have not been—to my knowledge—any late returns that have been so late where it has impacted the preparation of that monitor for the next patient use,” Surkin says. “[In my experience] when you have the proper conversation with the patient and engage them as partners in this process, that solves 95% of the problem.”

Ashlee Gora, senior marketing manager of sleep at HST device maker ResMed, says, “In our experience working with labs as they incorporate a home sleep testing offering, one of their principal concerns is managing their fleet of HST devices, which represents a sizable investment. We have heard a number of ideas. But the most effective method that we have gleaned from our labs is explaining to the patient that if they don’t return the device when instructed, another patient’s tests must be postponed and rescheduled. Goodwill seems to trump the legalism from the smallest private labs to large academic centers.”

Cassandra Perez is associate editor for Sleep Review. CONTACT [email protected]