By Mark Dwyer

Three years ago, I wrote an article for the September 2017 issue of AnswerStat titled Video-Based Doctor Visits. At the time, I proposed video-based doctor visits as a solution to address the shortages of primary care physicians. Little did I know it foreshadowed a much greater need for virtual visits in 2020 due to the Coronavirus pandemic. COVID-19 made scheduling face-to-face doctor visits nearly impossible. 

Not only has the pandemic increased the need for video-visits, but our aging population and a declining supply of primary care physicians have also increased our healthcare shortfalls. According to the updated 2020 projection from the Association of American Medical Colleges (AAMC), by 2033, the United States will have a shortage of as many as 54,100 to 139,000 physicians, with primary care representing between 21,400 to 55,200 physicians.

In many areas of the country, there are not enough primary care physicians to handle the patients physically able to come into an office setting. However, that is not the only concern resulting from the shortage. An estimated two to four million people need doctors, nurses, and healthcare providers to make house calls. Unfortunately, the number of physicians and health practitioners who make house calls has also significantly decreased over the years. According to the Health Resources & Services Administration (HRSA), telehealth is especially critical in rural and other remote areas that lack sufficient healthcare services.

Telehealth to the Rescue

A recent HHS report found that virtual visits accounted for over 43 percent of Medicare fee-for-service primary care visits in April 2020. That compared with far less than 0.1 percent in February 2020. The HHS reported that virtual visits continued to be frequent even after in-person primary care visits resumed in May of 2020. The continued use of virtual visits indicates that they are likely to be a more permanent part of the healthcare delivery system.

Telehealth visit solutions have the power to change the way we provide and receive healthcare for the better.

An article in Becker’s Hospital Review, January 20, 2021, further supported telehealth’s permanence. “We have been talking about telehealth for nearly thirty years, and in the year 2020 especially, the need for virtual health services has escalated globally.”

The recent actions of Amazon bear this out. Another article in Becker’s Health IT on March 17, 2021, stated, “Amazon is launching its virtual medical service Amazon Care for its employees in all fifty states and Washington, D.C., this summer, with plans to expand the offering to other employers later this year.” Amazon would not pursue virtual visits if they did not believe they were here to stay and sure to be profitable.

A McKinsey’s survey in April 2020 found consumer adoption of telehealth has skyrocketed, with almost 70 percent of in-person visits canceled in the United States. Canceling in-person visits has helped in decreasing the transmission rate of COVID-19 and limiting exposure to patients. Patients are rapidly transitioning to telehealth, with 76 percent of survey respondents suggesting that they were highly or moderately likely to use telehealth going forward.

According to a Mayo Clinic article on May 13, 2020, even before the COVID-19 pandemic, video technology helped doctors connect with people in rural locations. More than half of U.S. hospitals and medical centers now use telehealth in some way. The Mayo Clinic found that most people report a positive experience with online visits. 

Mayo further identified that many people also say the real-time consultation can be just as effective as an in-office visit. In addition, while social distancing remains needed during the COVID-19 pandemic, video visits for medical care offer a way to access timely care without leaving home.

The Call Center’s Role

So how can the call center play a vital role in offering telehealth services?

Triage call centers focus on getting patients “the right care—at the right time—at the right place.” Adding virtual visits as a triage endpoint for immediate, real-time appointments expands the call center’s services while providing enhanced customer service. The most successful organizations that offer triage call centers will be those with a strategy to integrate virtual visits. Telehealth benefits include convenience, access to care, better patient outcomes, and a more efficient healthcare system.

Finally, during his recent Senate confirmation hearings, Mr. Becerra indicated his support for permanent telehealth expansions. According to a February 25, 2021 article in Politico, Mr. Becerra said he wants to boost technology accessibility and is committed to permanently expanding payment policies that have increased virtual health during the COVID-19 pandemic.

To learn more about implementing a telehealth program or integrating it with your existing efforts, reference telehealth.hhs.gov/providers/getting-started.

Mark Dwyer is a thirty-three-year veteran of the healthcare call center industry and the COO at LVM Systems. LVM provides healthcare call center solutions that support nurse triage, disease management, behavioral health intake, patient transfer, and referral/marketing services, including consumer-centered web products.

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Traci Haynes, MSN, RN, BA, CEN, CCCTM

The need for care management continues to grow exponentially in the United States. The ever-increasing number of chronic conditions in both adults and children has placed greater demand on healthcare resources and services. US healthcare spending reached an all-time high of 3.81 trillion dollars in 2019, with a predicted growth to 4.01 trillion dollars this year. 

In a report from the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary, healthcare spending is expected to grow by 5.4 percent from 2019 to 2028. This prediction will result in healthcare spending at 6.19 trillion dollars and will account for 19.7 percent of the gross domestic product (GDP), up from 17.7 percent in 2018.

The Center for Disease Control and Prevention’s (CDC) National Center for Chronic Disease Prevention and Health Promotion indicates that six in ten adults in the US have a chronic disease and four in ten adults have two or more. The CDC also estimates that about 25 percent of children in the US, ages two to eight, have a chronic health condition. They report that a concise list of risk behaviors causes many chronic diseases. These include tobacco use and exposure to secondhand smoke; poor nutrition, including diets low in fruits and vegetables and high in sodium and saturated fats; lack of physical activity; and excessive alcohol use.

Care Management

Many of the complications of the most common and costly chronic conditions such as heart disease, stroke, diabetes, COPD, obesity, and asthma could be prevented or better controlled. Also, many individuals who struggle with multiple conditions often have combined social complexities. Even the most clinically astute patients find it difficult to navigate complex and fragmented healthcare systems, especially when the responsibility falls to the individual alone without adequate support or partnering. This difficulty in navigating healthcare systems often results in inefficiencies, increased costs, and poor outcomes.

The Agency for Healthcare Research and Quality (AHRQ) states that “Care management is a promising team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. It also encompasses those care coordination activities needed to help manage chronic illness.

In 2012, The American Nurses Association (ANA) stated that “Patient-centered care coordination is a core professional standard and competency for all nurses, and should be the foundation for all care coordination programs.” They also said, “Nurses need to position themselves within the interprofessional team to perform this core nursing process and contribute to better patient outcomes.”

Doing this involves systematic, organized teamwork, including the patient and family, and requires communication among all participants.

Currently, care coordination is one of the National Quality Strategies of the National Quality Agenda. A coordinated effort involving an interprofessional team with the patient and their family can help achieve the Institute of Healthcare Improvement’s Triple Aim goals of better care, better health, and reduced costs.

As part of their triple aim interventions, the AHRQ supports identifying populations with modifiable risks, aligning care management services to the needs of the population, and identifying, preparing, and integrating appropriate personnel to deliver the needed services.

Contact Center Support

The contact center can play a vital role in managing and improving the patient’s condition. By routinely checking on the patient at predetermined intervals and monitoring the individual’s plan of care, the contact center can communicate with the interprofessional team providing a picture of the patient’s current and recent status at that particular point in time. 

Using telecommunications can provide invaluable connectivity to monitor patients and provide a meaningful 24/7 service for clinical assessment capability and episodic care and interventions, should the need arise. And now more than ever during these unpredictable times, individuals both with and without chronic conditions, are avoiding or delaying preventative and needed care.

Nurses provide invaluable expertise in coaching, educating, and improving an individual’s self-management skills, thereby increasing the quality of care, resulting in better outcomes. They are also able to provide an assessment of symptoms and recommend interventions, often decreasing exacerbations.

The ANA, the American Academy of Nursing (AAN), the American Academy of Ambulatory Care Nursing (AAACN), and the American Organization of Nurse Executives (AONE) each contribute resources for care coordination in the form of position statements, white papers, frameworks, policy briefs, core curriculum, and courses. There are also effective models and tools, along with hospital and community-initiated programs.

Conclusion

Contact center care management is a win-win-win. It’s a win for healthcare systems, the providers (interprofessional team), and most importantly, patients.

Traci Haynes, MSN, RN, BA, CEN, CCCTM is director, clinical services at LVM Systems.

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By Traci Haynes

The COVID-19 pandemic has placed telehealth at the forefront in providing healthcare services. It has forced changes in the environments in which clinicians typically practice. Individuals who, under non-COVID-19 conditions, would seek access in an emergency department (ED), urgent care, or healthcare providers’ office are now avoiding these settings.

And with community spread, the Centers for Disease Control and Prevention (CDC) recommends alternatives to face-to-face triage and visits in an office setting if screening can take place via telehealth (that is over the phone, through patient portals, or online self-assessment tools). A recent report from Frost and Sullivan suggests that telehealth will increase by over 64 percent nationwide this year and continue to increase in the years ahead.

The Agency for Healthcare Research and Quality (AHRQ) defines telehealth as “the use of telecommunications technologies to deliver health-related services and information that support patient care, administrative activities, and health education.” It typically consists of a two-way, real-time interaction over distance between a patient and a clinician using audio or visual technology. 

Telehealth or Telemedicine?

Many consider the terms telehealth and telemedicine synonymous and interchangeable. However, telemedicine can describe a more limited set of remote clinical services such as diagnosis and monitoring.

In recent years, telehealth has become more recognized, especially in the aftermath of natural disasters (such as hurricanes, tornados, earthquakes, floods, and blizzards), when seeking routine care can be dangerous for both clinicians and patients. There was a tremendous uptick in telehealth interactions following Hurricanes Irma, Maria, and Harvey in 2017. Crises tend to increase the urgency of telehealth needs. 

Using telehealth in rural communities to bridge the healthcare gap delivering routine care or providing access to specialists that typically exist in more urban areas is well known. Telehealth also makes services more readily available or convenient for individuals with limited mobility, time restrictions, or transportation issues.

Furthermore, telehealth can help communicate with and coordinate care for individuals with chronic conditions in supporting self-management as well as assist with earlier interventions in the face of impending exacerbations. 

Social Distancing

The critical need for the recent social distancing between providers and patients has driven increased demand for telehealth. In response to the pandemic, the Trump administration has expanded access, albeit temporary, with changes to telehealth reimbursement policies. 

Beginning March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) allowed more than 80 additional services through telehealth. Clinicians can bill immediately for dates of service on or after March 6, 2020. According to CMS, it will now pay for telehealth services under the Physician Fee Schedule at the same amount as in-person services. 

Healthcare providers, including physicians, nurse practitioners, clinical psychologists, and licensed clinical social workers, are now able to offer telehealth to Medicare beneficiaries, including standard office visits, mental health counseling, and preventive health screenings. Medicare often is the early adopter for changes in reimbursement, with other health plans following their lead. 

A May 9, 2020 report in Modern Healthcare, said that Providence went from 700 video visits a month to 70,000 a week. New figures from Blue Cross Blue Shield of MA reported that daily claims for telehealth grew from approximately 200 to more than 38,000 in May. A May 26, 2020 article in FierceHealthcare reported experts predicting 1 billion telehealth visits by 2021, and currently almost half of practicing physicians are now using telehealth appointments. 

With this shift in practice, healthcare providers will increase their use of telemonitoring devices to measure blood pressure, pulse oximetry, heart rate, temperature, and weight readings. Telemonitoring also will assess EKG tracings and views of the retina and tympanic membrane, as well as other data to diagnose patients.

Emergency Department

There is growing concern about the decreased number of ED visits for emergent situations such as acute myocardial infarctions, cerebrovascular accidents, and other life-threatening situations. Recent statistics, as reflected in emergency medical system calls, offer evidence of increased deaths at home. EDs also report that patients are waiting too long to seek care, and as a result, have often suffered irreversible damage. 

An article in HealthDay News on May 20, 2020 reported that U.S. EDs are seeing about half as many heart attack patients as usual. The data from Kaiser Permanente Northern California included 4.4 million patients. In looking at records from January 1 through April 14, they found that the weekly rate of hospitalizations for heart attacks decreased 48 percent. Moreover, fewer individuals with pre-existing cardiac conditions went to the ED from March 4 through April 14, when compared to pre-COVID-19 timeframes from the year before.

Telehealth Nursing Practice 

Telehealth, in support of the Institute for Healthcare Improvement’s (IHI) triple aim has shown improved access, quality, and cost-efficiency of healthcare delivery and has resulted in an increased demand for telehealth nursing practice (TNP). 

A medical call center with TNP registered nurses (RNs) using decision-support tools provide recommendations for care at home or accessing a higher level of care based on the caller’s symptoms. RNs do not give a diagnosis, nor do they prescribe medications, although in certain situations, RNs can provide refills or e-prescribe medications based on physicians’ orders. 

The breadth and scope of TNP have advanced throughout the years. It has had a major presence in the United States since the 1960s, in Canada since the 1970s, and the UK beginning in the 1990s. 

In the last half of the 70s, health maintenance organizations (HMOs) began using telephone triage and advice services as a gatekeeper to control consumer access to care. In the 80s, hospital marketing departments used telephone triage as well as physician and service referrals, class registration, and health education and information services to attract and keep their market share. Once again, in the early to mid-90s, managed care organizations further expanded telehealth services for demand management, recertification, and referral authorization due to the ever-increasing incidence of chronic illness and multi-morbidities as well as the associated rise in healthcare costs. 

Present-day, the COVID-19 pandemic, has led to the role of telehealth nurses providing triage, surveillance, and monitoring for disease management, care management, case management, care coordination, and clinical prevention programs.

Conclusion

The use of telehealth has grown exponentially during this pandemic. It has filled a much-needed void in providing qualified medical care by clinicians without the necessity of commuting to a higher level of care. It has proven positive outcomes and high degrees of satisfaction. Telehealth is convenient and accessible, and while an option for many medical situations, it is especially important to know of its reliability during a public health emergency.

Traci Haynes, MSN, RN, BA, CEN, CCCTM is director, clinical services at LVM Systems.

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By Mark Dwyer

Healthcare call centers face unprecedented challenges in response to the Coronavirus (COVID-19) pandemic. At a time when efficient call processing is even more critical than usual, due to increased call volumes, call times have lengthened. Much is attributable to the plethora of misinformation individuals have readily available to them over the internet, via the media, and from family and friends. Now, not only do call center nurses need to calm the caller, they must correct the caller’s misunderstandings.

Add to this the pace at which medically valid updates occur. Triage call centers must keep up with the weekly, and sometimes daily, changes to the guidelines for handling possible COVID-19 calls.

COVID-19 has generated tremendous activity related to telehealth as a method of triaging and treating those who are infected. Given that COVID-19 symptoms can vary from very mild to severe and that the virus spreads through close contact, telehealth can be a powerful tool in combating the crisis.

Health center providers may now deliver in-scope services via telehealth to individuals who have not previously presented for care at a health center site and who are not current patients of the health center for the duration of this public health emergency. These include triage services with or without initial consultations. Some of the specific changes include:

• Continuation of zero member liability (such as copays and cost-sharing) for care that is delivered via telehealth.
• Any services provided virtually will be eligible for telehealth coverage.
• All prior authorization requirements for telehealth services will be lifted for dates of service from March 17, 2020, through June 30, 2020.
• Telehealth services may be delivered by providers with any connection technology to ensure patient access to care.

New Telehealth Policies Expand Coverage for Healthcare Services

Numerous states have taken steps to waive their requirement that a physician is licensed in the state to provide care to patients through their declarations of statewide emergency. More states are sure to follow.

According to Gregory A. Hood, MD, an internist in Lexington, Kentucky, who is on the advisory board of Medscape Business of Medicine, “The waiving of state licensure requirements should help ease a number of stress points of the current crisis in ways that benefit society.”

Healthcare providers, supported by states and payers, can leverage telehealth in ways not possible in previous epidemics to triage, diagnose, and treat patients while effectively protecting healthcare workers and reducing the spread of the disease. States that have broad authority as payers can play a crucial role in driving the use of telehealth as a method of treatment by implementing reimbursement policies that enable providers to offer virtual care services to patients.

Like many other aspects of the United States’ healthcare industry, when COVID-19 ends, the healthcare call center will never be the same. We will work smarter, more efficiently, schedule more creatively, and support more remote staff. We will embrace telehealth, tele-triage, and telemedicine with video calls, chat, and online physician consults.

More insurance companies will reimburse for online physician visits enticing more to participate. Triage call centers may also have more opportunities to work with EMS and police stations to help triage patients. Finally, data sharing will increase to the patient’s PCP into their EMR records or other approved endpoints. Data aggregation and reporting will enable call centers to analyze better yearly trends leading to heightened prediction and prevention of disease. 

COVID-19 has forced healthcare to look at all aspects of its care delivery system. May we all be the better for it. 

Mark Dwyer is a veteran of the healthcare call center industry and serves as COO of LVM Systems.