Telephone triage nurses play a
critical role in suicide prevention and serve as the first point of contact for
callers in need of immediate assistance. According to the CDC, 123 Americans
die by suicide every day, and for every person who dies from suicide every
year, another 278 people think seriously about it but don’t kill themselves.
As the demand for mental health
services grows, practices are turning to outsourced telephone triage call
centers to support their practices. Call center triage nurses trained in
treating patients with mental illnesses are better prepared to intervene and
often alleviate lengthy interruptions to the normal call flow of a practice.
In moments of crisis, connecting
with a trained triage nurse can deescalate the suicidal crisis and provide
immediate help. It is never easy to talk about suicide, but it is crucial for
triage nurses to be comfortable talking about suicide in the same way they talk
about chest pain. How they handle each call can be life-changing for the
Triage nurses need to find a connection with the patient,
find the patients local emergency assistance numbers, and be ready to involve
all resources available to help prevent this patient from harming him/herself.
It is essential for the triage nurse to be sympathetic,
non-judgmental, and accepting. The caller has done the right thing by getting
in touch with another person. No matter how negative the call seems, the fact
that it exists is a positive sign, a cry for help.
Triage nurses always have the caller’s safety in mind. They
combine both clinical judgment and emotional connections to assess the
patient’s situation to identify possible mental health issues.
Even though remote triage nurses typically can’t see their
patient, they must develop that all-important trust quickly and by means other
than visualization for the caller to open up and be honest with the nurse. Not
all patients can accurately describe their condition, history, medical
conditions, or other pertinent information. The telephone triage nurse must decipher
Sometimes the patient needs emergency treatment, while other
times they are reaching out for someone to talk with and work thru difficult
situations like substance abuse, economic worries, relationships, sexual
identity, getting over abuse, depression, mental and physical illness, and
Just talking about their problems for a length of time gives
some suicidal caller’s relief from loneliness and pent up feelings, an
awareness that another person cares, and a sense of someone understanding them.
Also, as they talk, they get tired and their body chemistry changes. These
things take the edge off their agitated state and help them get through a bad
night. Suicide calls can be difficult, but with proper training, protocols, and
disposition, telephone triage nurses save lives, one call at a time.
Ravi K. Raheja, MD is the CTO and medical director fo the TriageLogic Group. Founded in 2005, the TriageLogic Group is a URAC accredited, physician-lead provider of high quality telehealth services, nurse triage, triage education, and software for telephone medicine. Their comprehensive triage solution includes integrated mobile access and two-way video capability. The TriageLogic group assists their clients with value based care and serves over 7,000 physicians and covers over 18 million lives nationwide. For more information visit www.triagelogic.com. and www.continuwell.com.
Emergency Room (ER) overcrowding
is widespread in hospitals, creating delays and diversion from those who need care
the most. According to a recent article, “Compounding the problem is the alarming
trend of a decreasing number of ERs and an increasing number of ER visits.”
All too often, injury or illness appears without warning for patients. For hospitals trying to control overcrowding, the obvious solution is to redirect patients who don’t need to be in the ER to more appropriate paths for care. Who then determines if it’s necessary for a patient to go the ER? Most people aren’t trained medical professionals, and as a result, they worry and end up in the ER for non-urgent symptoms.
Patients faced with uncertainty
about where to go, all too often, end up calling the ER department and receive a
standard response: “We are not allowed to give advice over the phone. If you think
you have an emergency, please hang up and call 911. If you think you need to see
someone, you can come to the emergency room or call your doctor.”
So, who do you call?
One hospital in Oklahoma, with a similar issue, wanted to change this process. What if they provided a nurse triage line that would be available to receive calls from the patients calling the ER? Having the reassurance of a triage nurse could help decrease the number of people in the ER for non-emergency reasons.
This would provide patients with
quick and easy access to a trained medical professional to assist in determining
the appropriate next steps based on their symptoms and medical history. Also, since
the nurses work independently from the hospital system, the nurses would provide an objective opinion increasing
The results were inspiring. The nurses significantly decreased unnecessary emergency room visits. A random survey of about 520 patients uncovered their plans before talking to a nurse. This helped determine the effectiveness of the system.
Out of 240 patients who were planning to go to the ER, 42 percent of them were diverted to a lower level of care, including 17 percent that received home care needing no additional follow up actions. This translated into a savings of at least 215,000 dollars in unnecessary ER visits, not to mention providing peace of mind for patients being able to stay home and rest.
Better Health Outcomes
The benefits didn’t just stop at ER costs savings. Consider the patients who called into the nurse triage line and were not intending to go to the ER. Some medical conditions are considered emergencies because they require rapid or advanced treatments.
Surprisingly, close to 20 percent of the patients who called into the nurse triage line had symptoms that were serious enough to warrant a visit to the ER. Without the nurse line, the outcomes for these patients could have been life threatening or fatal.
While nurse triage has shown significant
effectiveness in an outpatient setting, this preliminary data shows even greater
promise to expand this model to emergency rooms around the country.
Providing local communities with a nurse triage program not only prevents unnecessary ER visits and saves on healthcare costs, but it also ensures patients get appropriate care when a serious symptom arises. For the hospital, this increases goodwill in the community while addressing the overcrowding of the ER: a win-win all around.
Dr. Charu Raheja is the co-founder and CEO of the Triage Logic Group. Charu’s personal struggles and triumphs with her health define both her personal and her professional mission. Most recently, her experience in overcoming a life-threatening health event led her to launch the Continuwell brand. The TriageLogic Group provides telehealth software, mobile communication solutions, and services to large medical centers and businesses around the country. It is part of the Women’s Business Enterprise National Council (WBENC), and it covers over 25 million lives nationwide. Visit www.TriageLogic.com or contact Amy Smith at 888-TEAMTLC for more information.
While job burnout may not seem like a serious issue, it can produce critical circumstances when it involves a physician. Reports claim doctors experiencing burnout have higher levels of divorce, depression, alcohol and drug addiction, and suicide.
Additionally, they have lower levels of clinical care quality and patient satisfaction and higher levels of medical errors and malpractice risk. Medical errors are estimated to be the number 3 cause of death in the United States and annual costs for medical mistakes are estimated to be between 17 and 30 billion dollars. The U.S. healthcare system cannot afford the financial effects of physician burnout.
Better Work-Life Balance
When a physician is on call after office hours or during the weekend, they often receive patient calls interrupting personal time with family or getting needed rest. It would be easier to manage if these calls were rare, but the reality is, patients need access to healthcare professionals 24/7 to avoid unnecessary ER visits. Many of these patient calls regularly result in advice that could have been given by a nurse.
Technology can help minimize the burden. Utilizing telephone nurse triage, physicians can ensure that patients are receiving prompt, quality care based on standardized protocols combined with custom orders. As a result, many physicians who use telephone nurse triage find that their phone doesn’t ring as often after hours, they’re able to spend more time focusing on their patients during office visits, and they can be confident everything is properly recorded in the computer for efficient billing.
There is no single solution to eliminate physician burnout. Providing work-life balance education early in their careers and offering continuing education and assistance for stress management can help many doctors. Additionally, telephone nurse triage provides a flexibility that allows physicians to adjust their schedule more easily to create a better work-life balance and avoid burn-out.
Dr. Ravi Raheja is the medical director at TriageLogic, which is a leader in telehealth technology and services. The company’s goal is to improve access to healthcare and reduce costs by developing technology for providers and patients, backed by high-quality nurses and doctors. The TriageLogic group serves over 9,000 physicians and covers over 18 million lives nationwide.
Telemedicine has been a medical buzzword for several years, and the variety and depth of services provided have grown dramatically during this time. There is little argument that telemedicine is a great way to supplement traditional medical practices.
One of the biggest hurdles for doctors is that their time with patients is limited. In a traditional office setting, doctors have a nurse start a patient visit before the doctor comes in. Nurses take vitals, talk to patients, and evaluate their needs before a doctor walks in the room. The same type of process needs to be designed for telephone medicine, with the difference being that the nurse will do her job over telemedicine, just like the doctor.
First, some practices have nurses in their office taking patient calls and scheduling visits with a doctor. When managing these calls, the nurse needs to perform two tasks. First, the nurse must evaluate whether or not the patient needs the doctor at all or whether the nurse can help the patient over the phone with home care advice. Second, the nurse must document patient symptom information before making the appointment for the patient to speak with a doctor.
This is where having a good platform to document patient calls and ensure standard protocols comes in. This can ensure patient safety and help make the process efficient. Medical protocols such as Dr. Schmitt and Dr. Thompson’s protocols ensure a standard care every time a nurse takes a call. These protocols are also available electronically, making them easier to use as compared to textbooks. The electronic protocols can also allow the care advice to be documented directly on the patient chart for review by the physician during the telehealth visit.
However, not all doctors offering telehealth services have their own nurses always available to answer patient calls when they first come in. An alternative for these doctors is to hire a telephone nurse triage service. A nurse triage service can serve as an extension of the office by providing patients with a trained nurse to evaluate patient symptoms and determine what actions to take.
What sets a high-quality telephone nurse triage service apart is the ability for the physician to have custom orders and preferences built into the system so that the nurses can act as a true extension of the physician. A high-quality nurse triage nurse service is also able to schedule the patient appointments for those patients who need an appointment.
Providing patients with access to triage nurses can also be helpful for those doctors who don’t have the ability to provide telehealth services 24/7. If given the appropriate instructions, triage nurses are typically able to resolve over 50 percent of the callers’ issues without the need of a doctor.
Figure 1 comes from a survey of over 35,000 patient phone calls. In over 50 percent of the cases, the nurses were able to resolve the caller’s medical symptoms by giving them home care advice. These nurses were also able to determine which callers required a physical visit to an urgent care or an ER (in an event of an emergency, such as symptoms of a potential heart attack).
Telephone nurse triage allows a practice’s telemedicine program to work seamlessly, whether the office is open or closed. Setting up a nurse triage system where nurses use standardized protocols to answer patient questions increases the productivity and profits for your practice.
When your nurses use triage protocols, you can have the confidence that they are asking the right questions and not missing anything. The basic patient information, the protocols used, and the nurse notes can also be used as a quick reference for the physician prior to the telehealth visit similarly to the notes that the doctors receive when their nurses see a patient before them during a physical office visit.
Charu Raheja, Ph.D., is the CEO of TriageLogic a leading provider of quality, affordable triage solutions, including comprehensive after-hours medical call center software, day time triage protocol software, and nurse triage on call. Customers include both institutional and private practices. If your hospital or practice is looking for information on setting up a nurse triage service, contact TriageLogic to get a quote or set up a demo.
Broadly speaking, telephone triage is a form of pre-hospital clinical care, albeit by phone. All clinical care implies a standardized approach and system components, similar to any other clinical subspecialty.
Telephone Triage Decision-Making Safety Research
The task of telephone triage involves assessing symptoms of invisible patients with a range of emergent to non-acute symptoms. As telephone triage clinicians we must insure the safe, timely assessment, and disposition of patient symptoms via the phone. Our challenge is to get the patient to the right place, at the right time, for the right reason.
In 2013, I authored a review of literature on telephone triage with a team of experts. We found that patient safety is a persistent topic in telephone triage research. Reviews of past research did not differentiate between clinicians’ and non-clinicians’ respective safety.
For example, four groups of decision makers—both clinician and non-clinician—perform aspects of telephone triage: physicians (clinician), nurses (clinician), emergency medical dispatchers/EMD (non-clinician), and clerical staff (non-clinician). We compared the four groups, reviewing studies between 2002 and 2012, looking for evidence of safety: complete systems and safe dispositions—that is, timely access to appointments.
Safety is likely related to the clinical expertise of the decision maker. While clerical staff and EMDs were not found to be safe, nurses had the highest percentage of safe dispositions, followed by physicians. While telephone triage nurses have minimal systems, traditionally, physicians have little or no training, telephone triage guidelines, or standards; frequently they do not document calls.
In 2016, I conducted an informal online survey of RNs visiting teletriage.com. The survey explored RNs general perceptions of the quality and safety of system components: standards, training, guidelines, and EMR. Respondents to this anonymous survey were encouraged to be candid. Results of the 132 respondents are combined (36 were managers/administrators and 96 were staff nurses).
My purpose was to get a general idea about clinicians’ perceptions of safety and quality of telephone triage system components. Although the survey was informal and small, there were some interesting results, discussed below. Clearly, after fifty years, there is still a need for improved system components and training in telephone triage.
Type of Facility:The largest number of respondents worked in clinics and offices. It was surprising that hospitals were ranked second, followed by clinical call centers. It is unclear where exactly in hospitals telephone triage is taking place.
Populations Served:Most nurses served both pediatric and adult ages. A small number served pediatric populations exclusively.
Standards Usage:Most respondents had standards for telephone triage; the quality is unknown.
Type of Training:Most respondents had some training, with the majority having on-the-job training, and thirty-six having on-site training. Six respondents had no training. Training appears to be variable in content and quality.
Training Quality:Respondents ranked training quality as excellent: 29; above average, 43; average, 44; fair, 7; or poor, 3. Training content is unknown—whether in clinical decision-making or operation of electronic software—the first being a clinical skill and the second a technological skill.
Type of Guidelines:Respondents use electronic only, 59; both paper and electronic, 32; paper only, 33; or no guidelines at all, 8. Minimally, every facility should have at least paper guidelines.
Consistent Use of Electronic Guidelines:Respondents used electronic guidelines all the time, 49; most of the time, 36; half the time, 3; or rarely, 3.
Electronic Guideline User Friendliness:Respondents ranked electronic guidelines user friendly all the time, 15; most of the time, 66; half of the time, 7; occasionally, 2; or never, none.
EHR User Friendliness:Respondents found the EHR as user friendly all the time, 13; most of the time, 61; and half the time, 9.
Telephone Triage Outcomes
Given the conditions of uncertainty and urgency in our practice, it is concerning that malpractice cases still often involve the following failures and system error:
Use of clinically unqualified staff to assess symptoms
Failure to speak directly to the patient
Inadequate preliminary assessments
The survey summarized above presents rudimentary evidence of existing system failures, which is defined as “Failures of systems, processes, or conditions—intended to prevent errors from occurring—that might lead people to make mistakes.” Identified system errors include “wrong person, wrong task,” “Wrong match of plan to problem,” or “Failure to use any plan” to prevent error (Institute of Medicine). What’s needed is to provide quality guidelines, quality training, or complete system components.
It is reasonable to assume that, at a minimum, safety (good outcomes) begins with using qualified staff that is supported by a complete system: What is a system? A set of detailed methods, procedures, and routines formulated to carry out a specific activity or solve a problem. Donabedian defines quality as structure and process that results in safe, quality outcomes.
Structure: Quality System Components
Qualified staff in adequate numbers
The Nursing Process
Outcomes: Safe outcomes are timely, that is, coming early or at the right time.
If a malpractice lawsuit occurs due to patient death or harm, telephone triage expert witnesses will request to review the following components of your system:
Job qualifications and description
Standards (policies and procedures)
Call documentation (EMR)
Two initial recommendations based on these research projects are:
Clinicians should manage symptom-based calls: Using non-clinicians to manage symptom-based calls may produce an unintended consequence of error. In the interest of safety, we recommend that nurses or other clinicians take symptom-based calls directly.
Improve current nurse-staffed clinical call centers: While more complete, clinical call centers still need improvement: formal standardized training and improved call center and practice standards. To date, no independent peer-reviewed research has shown electronic decision support software to be reliable or valid. Some researchers have found that nurses are not actually using the electronic guidelines as instructed. The study indicated that, even when using guidelines, nurses still under referred 10 percent of patients.
Since 1984, Sheila Quilter Wheeler, RN, MS has pioneered the field of telephone triage through guideline development, conference development, research, expert witness, and consulting work. Her company, TeleTriage Systems, is located in San Anselmo, CA
Being a “digital immigrant,” whose knowledge and comfort with mobile apps is admittedly deficient, over the past thirty years I have championed the value of a traditional, phone-based nurse triage call center. If I need clinical help (or vendor assistance, for that matter), I still prefer a phone call to interact with a person.
To me, texting, emailing, tweeting, or communicating by any other non-voice-to-voice method, not only can be cold, impersonal, and incomplete, it is often intimidating. Despite claims to the contrary, the developers of many mobile apps have compromised ease-of-use for faster programming and meeting product release deadlines.
The Triage Nurse Callback Queue: The follow-up call queue is of weighty value especially when new patients call and all of the call center nurses are busy speaking with other patients. Here, assuming the call is of a non-critical, low-acuity nature, a non-clinical staff member could advise the patient that no nurse is currently available and he or she would gladly add the patient to the nurses’ callback queue once some initial information is gathered.
Web or Mobile App Requests for a Nurse Follow-up Call: For some, enabling the patient to send a summary of their conditions via a smartphone app would be the logical starting place for a phone app interface. Many hospital call centers have begun accepting this kind of communication.
Using the triage nurse callback queue for outbound calls to the patient enables the nurse to review the text sent via the mobile app. Once reviewed, the nurse calls the patient back to engage in a more in-depth conversation regarding the details of the patient’s symptoms.
As always, if the patient is experiencing critical symptoms, they should always be instructed to hang-up and dial 9-1-1 or proceed to the nearest emergency department.
Prioritizing Calls in the Callback Queue by Acuity: The best way to verify that each call added into the nurse callback queue has been assigned an appropriate acuity level would be to have all calls reviewed, assessed and, if needed, adjusted by acuity. To facilitate this, many sites have a charge nurse responsible for managing the queue throughout the day, making sure the highest acuity requests remain listed at the top of the “requests received for nurse call-back” queue.
But this is an article on mobile apps. Isn’t there a way to review and assign an appropriate acuity level with a technological solution instead of needing to manually review each request using a process that requires the addition of more staff?
Natural Language Processing: A more technologically advanced option would be to utilize one of the industry’s natural language processing (NLP) mobile apps. An NLP system can read, at the time of the initial call, the notes captured by the non-clinical, front-end intake person or directly by a call center nurse. The NLP can then interpret the notes into their clinical equivalents, assess the acuity of the call, and send the call to the follow-up queue or make it available to the nurse, in both cases with the appropriate acuity level.
There are systems that can automatically assign an acuity ranking to each call before adding it to the nurse callback queue. If the call is being handled directly by the call center nurse, this same information can be provided directly to the triage call center nurse to help direct her guideline selection. Doing so substantially reduces the time needed to manage the queue. Instead, the charge nurse could be used to provide greater value to patients by handling additional live triage calls.
Again, if needed, these calls could be assigned a higher or lower acuity level by the charge nurse monitoring the queue. When functioning correctly, the auto-feed, queue-sorting algorithm should take into consideration newly added calls every two to three minutes. Generally, callbacks should be made within thirty to forty minutes of receipt of the initial request.
Live Chat Technology: Another option traditional nurse triage call centers are beginning to embrace is utilizing live chat technology to enable the patient to directly interact with a triage nurse within just a couple of minutes of the initial inquiry. Here, via the chat function on most computers and smartphones, the patient can simply enter a brief description of his or her symptoms and send it to the call center. A triage nurse opens the chat, reads the patient’s notes, and then enters an educational or directive note back to the patient again in the chat window.
The nurse’s reply, along with the patient’s initial message, is returned to the patient for further review. If the patient is satisfied with the nurse’s response, he or she simply closes the open chat link. Otherwise, the chat can continue. Once the final message is sent, click to close the chat window. Be sure to follow organizational HIPAA privacy rules.
Using the chat function can be a great productivity benefit because a single nurse can manage multiple chats simultaneously. Just be sure, if chat is implemented in the call center, clearly segment each caller’s or patient’s data from all others to avoid inappropriately sharing personnel health information (PHI) with the wrong individual.
Self-Assessment via Guided Questions: Another mobile app gaining popularity in the telephone triage world is often referred to as a symptom checker. This app provides patients with the ability to self-assess their symptoms using a web or phone-based app. These programs typically begin by providing instructions for using the app and the site’s privacy rules.
When the patient is ready to begin, two diagrams appear, one male and one female, with several body regions defined (such as upper right leg, lower left leg, neck, etc.). The patient can rotate the body to indicate the concern has something to do with an area on the back. Once the body region is identified, the patient clicks on it to display a list of symptoms from which to choose (for example, muscle ache, sunburn, laceration, etc.).
Typically, these programs present a user-friendly interface with self-triage guidelines or some other healthcare information pertaining to the issue the patient is having. If the patient prefers to speak with a nurse, some of the more advanced symptom checker apps will enable the patient to request a follow-up call from a call center nurse.
The patient’s request is added to the nurses’ follow-up call queue. The process continues from there, processing the request much like the steps for chat follow-up interactions, except that the subsequent contacts take the form of phone calls instead of chat texts.
Photo of Wound: This is a surprisingly simple, yet significant feature of many remote apps tied to triage call centers. One of the greatest challenges of performing remote patient triage is the inability to see the patient’s symptoms or problem visually. By adding the ability to share a photo with the call center nurse, the patient can greatly enhance the nurse’s ability to successfully triage the issue.
It is true. A picture is worth a thousand words. These photos are typically shared as jpg files and are stored as part of the patient’s overall triage encounter record.
Video of Patient Behavior: Another visual tool available from some vendors is the ability to send and store a video of the patient’s behavior. Describing lethargic or manic behavior or the uncontrollable crying or hysterics of a toddler is often difficult for a highly stressed parent. Enabling the nurse to watch a brief video of the patient’s current activities can greatly improve the nurses’ ability to correctly assess the patient’s health issues.
Video-Based Doctor Visits: The last application is a rapidly growing phenomenon that spawned an entire new industry to address what many believe to be one of the greatest challenges of Obamacare: providing insurance coverage to twenty million Americans, while struggling with a major shortage of primary care physicians throughout much of the country.
Through governmental action such as the ACA, millions more Americans were provided government subsidized healthcare. Unfortunately, the vast majority of individuals who initially enrolled in the new programs were those of greatest ill health and costliest conditions. These individuals were also largely without a primary care provider. Consequently, the over-crowded, already backed up emergency departments across the country became even more congested with individuals who had nowhere else to go to receive the healthcare they needed to stay alive. Video-based doctor visits provided a partial solution.
The sharpest players in the healthcare triage call center niche will be those who devise a strategy to integrate with these video-based physician practices, performing both pre and post-visit calls and doing follow-up case management calls to these individuals.
The future is here. Either embrace it or miss this current wave—or might it be a tsunami?
Mark Dwyeris a 30-year veteran of the healthcare call center industry. Mark is in his sixteenth year at LVM Systems where he serves as COO. LVM Systems provides healthcare call center software. For more information or a demonstration of LVM’s call center solutions contact Carol Zeek, regional VP, sales, at 480-633-8200 x279 or Leann Delaney, regional VP, sales at 480-633-8200 x286
Patient Care is Non-Negotiable, and Contacts Centers Can Play a Key Role
By Gina Tabone, MSN, RNC-TNP
Changes to the American political scene are upon us and most certainly will have an impact on the provision of healthcare. Regardless of party affiliation, there are several healthcare reform objectives that need to remain in the forefront by future government leaders. Examples include enhancing quality of care, interdisciplinary coordination and collaboration, better utilization of available resources, gaining efficiencies, and reducing the per capita cost of healthcare.
Focusing on these concepts will contribute to the goal of improved outcomes for both individuals and overall patient populations we serve. The benefits achieved must continue regardless of who is leading the country. Nurse triage as a component of an integrated medical call center is a pivotal intervention and no longer optional.
The world of medical call centers (MCCs) has finally gained the recognition and credibility in the healthcare marketplace that many of us have been trying to expound for two decades. Centralized medical call centers are rapidly emerging as the backbone of health systems because they are integral in achieving better patient outcomes.
The new administration has wisely sought healthcare advice from the most innovative physician leaders in America. Toby Cosgrove of Cleveland Clinic and John Noteworthy of the Mayo Clinic were invited to meet with President Trump to share their thoughts on the Affordable Care Act (ACA) and suggest ideas to plot the best plans for the future.
Concerns were expressed that the current model needs to focus more on patient health and wellness and less on the avalanche of paperwork. This has negatively affected the day-to-day responsibilities of clinicians who are held accountable for reporting on hundreds of quality indicators. These points of contention are agreed upon by most caregivers. Cleveland Clinic and Mayo Clinic have improved patient access, outcomes, and satisfaction by integrating state of the art integrated call centers with clinical access across their multi-state enterprises.
Hopefully, their example will resonate and continue to motivate other organizations to rapidly integrate outsourced or optimized in-house MCCs as a proven solution for reaching the three goals of the triple aim: improving the patient experience of care, improving population health, and reducing the per capita cost of healthcare.
Improving patient experience of care requires open access channels to care. Access means that patients are able to receive the most appropriate level of care needed, in a time best determined by specially trained nurses guided by evidence-based tools. The patient learns to expect reliable advice, taking into account their current health state and is consistently available day or night. Gaps in care are eliminated and delays are avoided, leading to favorable patient outcomes and higher reimbursements in a fee-for-value model. When patients’ well-being is enhanced, everyone gains—most especially the patients. MCCs can stake a claim for making that happen.
The year 2017 will have many organizations taking a close look at their operations and making tough choices about what functions are best accomplished internally and which ones can be entrusted to an outside partner. IT is a department that is being outsourced by some of the largest hospital systems in the country. Patient financial services is another service with options for outsourcing where the benefits to an organization outweigh the costs incurred. Incentives for meeting targets are common. Last, there is a surge by strategic decision makers to explore nurse triage services being performed by an outside call center partner.
The common denominator in all three areas where outsourcing is increasing is the fact that there is a reliance on human capital and all of the contingency costs that goes along with being an employer. High labor costs often consume up to 70 percent of many call centers’ operating budgets. Outside partners can assume the responsibilities with greater efficiency and better outcomes for a lower cost. There is also the possibility that many vendors are willing to assume some of the risks associated with the successful attainment of goals.
The choice to retain, outsource, or develop a hybrid of both is a multifaceted decision that is reserved for leaders at a higher level than the call center. Organizations have to thoroughly evaluate the options to determine which one best aligns with their mission, vision for the future, and strategic plans.
MCCs are branching out and taking on a variety of responsibilities that are well suited to be conducted remotely and reliant of state of the art technology and a dedicated work force. Once the technological infrastructure is created, the MCC can be enhanced to take on additional functions. Appointment scheduling is the most common task of many MCCs and often happens in tandem with the strategy of centralization. Electronic medical records (EMR) products have customized templates embedded with providers’ schedules that are used for office visits, imaging, or procedural appointments. Outbound calling campaigns are often conducted in conjunction with scheduling for appointment reminders.Without measurement there is no possibility for improvement. Click To Tweet
Centralizing all medication refill requests is emerging as a successful addition to many MCCs. Call center technology such as CRM (customer relationship management) allows for requests to be tracked, acted upon, and measured to ensure established targets are met in a timely manner. Without measurement there is no possibility for improvement. Patients can expect a standard process for medication needs and a defined time for responses or resolution. Medication management and compliance is critical for optimal outcomes, so implementing a process that fosters it is a good idea. Patients stratified as high risk garner the most advantages, which contribute to maximum reimbursements for medical treatments.
MCCs have taken on the significant task of not only caring for the acute needs of primary care patients, but the chronic needs of vulnerable high risk patients as well. Successful coordinating and transitioning of care is central to every health system’s strategy for sustainability today and growth tomorrow. Nurses are the clinicians assigned to figure out how to morph from case management to transitional care coordinators.
Regular communication between the patient and the caregiver is vital and is often by telephone, text, or email. Training the newly created care/transitional nurses in the fundamentals of remote patient care is imperative and is based on the standards of care for telephone triage nurses. The practice of triaging the acute symptoms has branched out and will serve as the starting point for nurses involved in coordinating care.
It is up to those of us established in the medical call center industry to continue to proclaim the unlimited value of a MCC to the healthcare industry. In many healthcare organizations more than 10 percent of employees spend the majority of their day doing their job on the telephone. The benefits of centralizing and consolidating the work they do are undeniable.
C-suite leaders must accept the fact that medical call centers are no longer considered an expense but an investment with impactful ROI (return on investment).
Initially there were call centers, then access centers, followed by contact centers, and in 2017 we are engagement centers. The task at hand is to capture the limited attention of decision makers and educate them on the role MCCs play in a fee-for-value system and the distinct results that are possible. The future may be uncertain, but there remains a need for products, services, and expertise that bring the call center to the forefront of patient care.
Gina Tabone, MSN, RNC-TNP, is the vice president of strategic clinical solutions at TeamHealth medical call center. Prior to joining TeamHealth, she served as the administrator of Cleveland Clinic’s Nurse on Call 24/7 nurse triage program.
The goal of every triage call is to make a patient feel comfortable and heard, while at the same time collect the critical information from the patient and get them to the appropriate level of care based on their symptoms.
Step 1: Introduce Yourself. Use your first name, title, and the practice or physician you represent. It’s imperative for you to clearly identify yourself and state your credentials as a nurse employee of the practice for which you work. When you introduce yourself, you create a relationship.
Step 2: Collect Demographic Information. Before you are ready to hear your patient’s concerns, you will need to know some of this basic information. Age, gender, and other data will affect your triage protocols, so be sure to collect all the necessary demographic information. This information is needed so it can be put in the appropriate chart and followed up.
Step 3: Gather Medical History. Get a brief medical history so you do not miss any important surgeries, medications, or relevant medical information from the recent months or years. You’ll want to know your patient’s medical history before they detail the current issue.
Step 4: Let the Patient Talk. Now that you’ve armed yourself with all the necessary information you need to proceed, let the patient speak freely about their current concerns. Be an active listener. That means you don’t just listen, but you participate in the conversation by asking any probing questions needed to ascertain a full description of their complaint.
Step 5: Document the Assessment. Once you’ve listened carefully to the patient, document your assessment carefully with the necessary details.
Step 6: Choose the Right Protocol. With the right triage protocol, this step can be fast and efficient.Be sure to document the answer to each question and make any additional notes needed.
Step 7: Get the Patient to the Right Level of Care. Now that you’ve followed the protocols and completed the assessment, you’re ready to recommend the level of care your patient needs. Be sure to speak clearly and at a pace the patient can follow while you detail every step they need to take.
Step 8: Give Relevant Care Advice. Provide solutions based on their symptoms in order to help them find the best path to care.
Step 9: Make Sure Your Patient Knows When to Call Back. Confirm the patient fully understands your triage advice and knows when and who to follow up with.
You can’t underestimate the power of empathy. Over 80 percent of patients who call in to their physician’s office may not need urgent care, but they all urgently need empathy, someone to listen, and someone to care. That’s the role of the triage nurse. In addition to being a good clinician, a critical thinker, and making sure everyone stays safe, you are also there to provide empathy and care advice to help patients.
Marci Lawing, RN BSN, is the clinical nurse manager at TriageLogic LLC. TriageLogic’s online learning center is available free of charge to telephone triage nurses and teams as an educational resource and practical training guide. Along with course videos, coursework includes class notes, related articles, and learning materials. You will receive a TriageLogic Telephone Nurse Triage Certification for each completed course. Managers can also set-up teams and check their individual nurses’ progress in the course.
Healthcare reform has placed pressure on organizations to provide access to clinical care in a manner that improves patient outcomes while appropriately utilizing resources. Nurse triage, a proven mechanism for achieving these goals, can be made even better with the help of a nurse triage consultant.
If you are considering working with a medical call center consultant, your organization is already a step ahead because you recognize the value of industry expertise. As a responsible leader, you will likely select a consultant who can meet your needs, direct your efforts, and ensure success for your call center, organization, and ultimately you. Remember, your reputation is on the line. Your best interests are served by selecting a consulting group that is established, knowledgeable, and intuitive in respect to remote clinical care. When you’re looking for advice about a specific subject, there is an inherent intelligence that only comes from someone with personal and professional experience in that area. Medical call center expertise is not only a reasonable requirement, but also a vital factor to consider when hiring a consultant to develop a new medical call center or enhance your existing one.
Centralized call centers are rapidly emerging as the backbone of health related systems. Nurse triage offers patients direct access to 24/7 clinical care. The patient populations served by nurse triage programs include primary care, behavioral medicine, diabetics, recently discharged, and chronically ill. The scope of service is vast and so is the network of caregivers. The call center and services offered, both clinical and non-clinical, do not exist in a vacuum. To be successful there needs to be an endorsement from the C-suite of the medical call center and its value in achieving strategic goals. Executive leadership needs to encourage staff in IT, telephony, nursing, informatics, marketing, and compliance to emphasize that their expertise is essential to the realization and effectiveness of improved access and patient satisfaction.A healthcare contact center nurse triage consultant provides objectivity & achieves success. Click To Tweet
A medical call center nurse triage consultant provides an objective lens and is able to envision not only what success will look like, but also what needs to be done to attain it. There is no better combination of talents than a consultant who has both medical call center experience and the experience of being a clinician, namely a nurse. Nurses make a commitment to serve the need of the number one benefactor in healthcare: the patient.
Every piece of technology must be selected and implemented with the expectation of a streamlined communication pathway that results in successfully meeting the patient’s needs. Patients primarily prefer contacting providers by phone, texts, or emails. There is also an expectation that whenever illness strikes, a skilled clinician is waiting to help them. That is a reasonable expectation.
Ensuring that patient preferences are understood and provided for is a top priority for healthcare executives. Satisfied patients are often engaged patients, which often lead to improved health outcomes. Improved outcomes result in a better state of health for individuals and the population as a whole. Patients tend to rate their care more favorably and reimbursements are ultimately higher, resulting in the healthcare organization remaining sustainable.
Spending time on-site with a medical call center nurse triage client requires a team effort and ultimately one common goal: optimal patient care. A consultant is provided with a panoramic view of many facets of the operation with a focus on access, clinical care, potential for success and the patient experience. Each health system is distinct, but there is no denying that there are underlying commonalities. Consider these three recommendations when selecting a medical call center consultant:
Only collaborate with subject matter experts who respect that patients come first.
Understand that executive endorsement is imperative for success.
The supreme benchmark that we all must achieve can be found in the answer to a single question: Is what I am doing improving the patient experience?
Gina Tabone MSN is a medical call center nurse triage consultant who teams with various healthcare organizations to develop and optimize medical call center services that exceed patient, provider, and employee expectations. Contact her at firstname.lastname@example.org.
Health advice has been telephonically dispensed since the advent of the telephone. An often-told story identifies the first telehealth interaction occurring when Alexander Graham Bell placed a call to Mr. Watson, his assistant, requesting Watson to come help him with an injury to his hand.
Today, in our ever-changing healthcare environment coupled with advancing technologies, new methods of interacting with patients and delivering care continue to evolve. Telehealth, in support of the Institute for Healthcare Improvement’s (IHI) triple aim, has demonstrated improved access, quality, and cost-efficiency of healthcare delivery and has resulted in an increased demand for telehealth nursing practice (TNP).
Although TNP had not been recognized as a distinct practice area early on, the breadth and scope has advanced throughout the years. TNP has had a major presence in the United States since the 60s, in Canada since the 70s, and the UK beginning in the 90s.
In the last half of the 70s, health maintenance organizations (HMOs) began using telephone triage and advice services as a gatekeeper, in an effort 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 retain their market share. And once again in the early to mid-90s, managed care organizations further expanded telehealth services for demand management, recertification, and referral authorization.
Present day, the ever-increasing incidence of chronic illness and multi-morbidities, as well as the associated rise in healthcare costs, has led to the role of telehealth nurses providing surveillance and monitoring for disease management, care management, case management, care coordination, and clinical prevention programs.
The registered nurse is the appropriate provider of telehealth nursing services as recognized by both the American Nurses Association (ANA) and the American Academy of Ambulatory Care Nursing (AAACN) who also recognize TNP as a nursing subspecialty of ambulatory care nursing. The application of the nursing process when providing patient care has always pointed to professional nursing practice.
Telehealth is used as an umbrella term to describe the wide range of services delivered across distances by all health-related disciplines. The following definitions were approved and adopted by the AAACN’s Telehealth Nursing Practice Special Interest Group (TNP-SIG) in 2003:
Telehealth: “The delivery, management, and coordination of health services that integrate electronic information and telecommunications technologies to increase access, improve outcomes, and contain or reduce costs of healthcare” (Greenberg, M., Espensen, M., Becker, C., & Cartwright, J., 2003. Telehealth nursing practice SIG adopts teleterms. AAACN Viewpoint, 25(1), 8-10).
Telehealth Nursing: “The delivery, management, and coordination of care and services provided via telecommunications technology within the domain of nursing” (Greenberg, Espensen, Becker, & Cartwright). Telehealth nursing encompasses all types of nursing care and services using one or more types of telecommunications technologies: telephone, fax, electronic mail, internet, video monitoring, and interactive video.
Telephone Nursing: “All care and services within the scope of nursing practice that are delivered over the telephone” (Greenberg, Espensen, Becker, & Cartwright).
Telephone Triage: “An interactive process between nurse and client that occurs over the telephone and involves identifying the nature and urgency of client healthcare needs and determining the appropriate disposition” (Greenberg, Espensen, Becker, & Cartwright).
In 1999, the National Council of State Boards of Nursing (NCSBN) proposed the Nurse Licensure Compact (NLC), allowing “mutual recognition” of a nursing license between member states. Enacted into law by each participating state, member states allow a nurse that resides in and possesses a current nursing license in a state that is a member of the NLC to practice in any of the other member states without obtaining additional licensure in that state. An excellent video provided by the NCSBN can be found on their website and is titled “The Nurse Licensure Compact Explained.” Currently, twenty-five states are involved in the NLC.
Telephone Nursing Practice certification was offered by the National Certification Corporation (NCC) from 2001 to 2007. In all, over 1,200 nurses were nationally certified. Nurses who are currently certified through NCC can maintain their certification by meeting NCC’s recertification requirements.
In 2007 AAACN adopted the position that TNP has been and continues to be an integral element of ambulatory nursing. In their role as an industry leader, AAACN continues their support of TNP. Today the Ambulatory Certification Review Course and the Ambulatory Care certification exam include a telehealth component.
AAACN further supports TNP with its own telehealth track at their annual conference, as well as providing many resources for TNP including:
Endorsement of “The Art and Science of Telephone Triage: How to Practice Nursing Over the Phone,” written by Carol Rutenberg, RN-B, C-TNP, MNSc and M. Elizabeth Greenberg, RN-BC, C-TNP, PhD.
Competencies for TNP as defined by AAACN in 2004 identify the behaviors and outcomes specific to providing efficient, effective, evidence-based care. These include:
Professional Knowledge: managing clinical calls using the nursing process and demonstrating critical thinking skills in assessing the needs of the caller.
Interpersonal Skills: establishing a trusting relation in order to elicit accurate information and using effective interpersonal communication skills to engage in a therapeutic interaction.
Technical Skills: adapting to equipment efficiently in order to perform the TNP role and using decision support tools (such as, guidelines, protocols, algorithms, and care pathways) to address caller needs to identify actual and potential health risks.
Documentation of Telehealth Encounters: accurately recording the interaction reflecting the actual or potential health needs, which become part of the EHR.
Personal and Professional Development: responsibility for attaining and maintaining the knowledge and skills necessary to function in the TNP role (AAACN, 2011).
TNP improves access to healthcare for our patient populations. It increases the quality of healthcare outcomes through patient-centered, collaborative care, and decreases the cost of care by meeting the needs of patients with timely and appropriate resources.
Traci Haynes, MSN, RN, BA, CEN, is the director, clinical services at LVM Systems, Inc.