Using Nurse Triage to Improve Care and Decrease Costs: Options for ACOs and Medical Organizations

By Charu Raheja and Ravi Raheja

The Centers for Medicare and Medicaid have taken a major step towards controlling soaring healthcare costs by starting the Accountable Care Organization (ACO) movement. According to their Website “ACOs are organizations formed by groups of doctors and other healthcare providers that have agreed to work together to coordinate care for people with Medicare…these organizations enter into agreements with CMS, taking responsibility for the quality of care they provide to people with Medicare in return for the opportunity to share in savings realized through high-quality, well-coordinated care.”

The potential benefits for these ACOs are huge. In essence, they are able to share in the cost savings from better-coordinated care and decreased overall costs. So, how can ACOs (and organizations planning to become ACOs) save on care costs?

These organizations need to find the sources of inefficiency and poor care coordination and fix them. But where to start? Start by looking at simple strategies. Make sure that each person gets the care they need at the right place and the right time.

Every patient encounter starts with a phone call. The first step is to make sure the people answering the phones triage patients efficiently and effectively. In order for ACOs to show cost savings, it is crucial that they invest in an effective nurse triage service or program. There are many clearly documented benefits of nurse triage including better patient access, coordinated care, and cost savings.

Nurse triage allows for more efficient use of healthcare resources. In addition, it gives patients better access to providers even if they are not seeking emergency care, which can improve patient satisfaction, prevent future complications, and allow providers to educate patients.

So, how do you set up a nurse triage system? First, consider two types of calls: day calls and night calls. Day calls are simple because offices are open, and the nurse can ask the patient to come in, if needed. As a result, daytime protocols are shorter and simpler to document. Night calls are more extensive because doctors’ offices are closed. These calls demand more extensive protocols and documentation. They also require nurses to be able to contact the doctor on call, if necessary.

Second, the evolution of new technology has made several cost-effective options available. They are: do it yourself in-house (and hire your own nurses), outsource to a nurse triage center, or use a combination of in-house and outsourcing.

Do it yourself in-house: start your own call center: Starting your own call center involves setting up the call center infrastructure. The requirements depend on the scale and number of calls received. For daytime calls, many physician practices choose to have their own staff nurses take calls using daytime triage protocols. These protocols are available in book form or electronic format.

For night calls, the requirements include hiring an experienced call center manager, purchasing triage software for nighttime protocols, and hiring clinical and non-clinical staff to answer the phones and handle patient phone calls. Having your own system also gives your staff the flexibility to perform multiple tasks in addition to triage, such as physician referrals, scheduling, disease management, class registration, and surveys.

However, before proceeding, count the cost. Setting up a call center requires a high initial investment. It is labor intensive for the nursing department and requires human resources and IT involvement. In addition, setting up multiple functions is a long-term project with a slow return on investment. Moreover, there are significant differences in terms of hardware requirements and capabilities with various software programs, so it is important to do your research and speak with a variety of vendors.

The organizations most likely to succeed with this approach are larger organizations with high call volumes, which expect to handle over 50,000 triage calls a year. These companies are the right fit because they already have some call center infrastructure and they just need to add to it. The high call volume also allows the center to use nurses’ time efficiently.

Outsource to a nurse triage center: In this option, the organization outsources the nurse triage function to an outside vendor. The vendor provides access to a call center infrastructure that patients can call and talk with a nurse when they have clinical questions and concerns.

The advantage of this option is that it has a relatively low upfront start-up cost. The organization does not have to train its own nursing staff, and there is no need for human resources and IT staff. Since the outside vendor is already taking calls, startup is quick, and there is an immediate return on investment. In addition, vendors may have more experience and expertise in the niche area of triage, resulting in better care for patients.

The disadvantages are also clear. First, you have less direct control over the nurses. Second, some nurse triage vendors cannot integrate with electronic medical records. For the best outcome, you need to be careful about interviewing and make sure you are comfortable with your vendor. In addition, costs may vary significantly depending on the vendor and the quality of the service you receive. Still, assuming you have done your homework in interviewing and discussing costs, outsourcing can be a good option for small to medium-sized practices.

Use a combination of in-house and outsourced services: This is a model in which an organization uses its own nurse triage software and nurses during high call volumes and outsources the triage to a service during low call volumes. A combined model has the potential to improve services and decrease costs. Most triage centers lose money when the call volume is low because nurses are idle while waiting for phone calls. By outsourcing during those low volume times, the call center can continue to provide service at a reduced cost. This combination can be accomplished seamlessly with the call center technology, integration engines, and communication platforms available today.

The advantage of this model is that it allows the organization to continue to provide the same level or increased levels of service. At the same time, this allows the organization to decrease its operating costs and work within a given budget while maintaining their current infrastructure and resources. These organizations may also be able to expand into other areas of call center work to increase revenues.

At the same time, this model requires finding the right partner with the technology and service-level knowledge to implement a combined model. It is important the partner is able to work seamlessly with the technology and the notes to the physicians so that there is no interruption in patient care. Physicians also have their own practice-specific needs, and those requests need to be followed by both parties consistently. Therefore, it is crucial to select your partner carefully. Make sure you interview and discuss your software and services with your partner before making a commitment.

This model is best for organizations with existing nurse triage infrastructure and are being faced with budget cuts.

Conclusion: Soaring healthcare costs and increasing incentives from government organizations are making it crucial to look for ways to improve the allocation of patient care. Nurse triage is a solution that can dramatically reduce medical calls by making sure patients are getting the care they need at the right time. Not only does it reduce costs, it also improves patient satisfaction because it gives patients access to a supportive and knowledgeable person who can help them.

Charu G. Raheja is chair and CEO of TriageLogic Management, and Ravi K. Raheja is director of sales and technology at TriageLogic Management. For more information and additional resources, email Charu.

[From the October/November 2012 issue of AnswerStat magazine]