Tag Archives: telephone triage articles

Selecting a Nurse Triage Consultant

AccessNurse, A TeamHealth Company

By Gina Tabone, MSN

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:

  1. Only collaborate with subject matter experts who respect that patients come first.
  2. Understand that executive endorsement is imperative for success.
  3. 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 gina_tabone@teamhealth.com.







Telehealth Nursing Practice

LVM Systems

By Traci Haynes, MSN, RN, BA, CEN

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).

The quality of healthcare outcomes through patient-centered, collaborative care. Click To TweetState boards of nursing define the scope of nursing practice for each state. Each nurse must be knowledgeable of their state’s Nurse Practice Act and the rules and regulations involving their practice within their state of residence.

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:

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.LVM Systems logo

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





Make Your Office Available for Patients 24/7


Help doctors reduce costs, retain patients, and take fewer after hours calls on their own

By Charu G. Raheja, PhD and Ravi K Raheja, MD

In the new world where patients are requesting on-demand access to doctors and healthcare providers, how can offices or hospitals remain competitive and provide access to healthcare 24/7? The past two years have seen a proliferation of telemedicine, including on-demand physicians that evaluate and prescribe over the phone. Various market research companies predict a growth rate between 15 and 25 percent a year, and according to research analysts and companies, such as Zion Research, the United States’ telemedicine market is expected to reach approximately $35 billion by 2020.

The results are not surprising. Limited access to physicians and caregivers has been a common complaint among consumers. Year after year, emergency departments continue to see patients that should have been handled by family doctors or other outpatient clinics. Some of these patients are now opting to speak to a telemedicine doctor – even if that doctor is not their established doctor – in the hopes of avoiding an unnecessary ER visit.

From the point of view of the patient, both going to the ER and speaking to a telemedicine doctor are reasonable when no other options are available. Imagine, for example, a mother with a newborn that has a low-grade fever or a sixty-five year-old man who is coughing up blood. How do they decide if the symptoms require an emergency visit or if it’s okay to wait until the next business day for the doctor’s office to open? The solution for physicians is twofold: implement technology to ease the patient’s access to offices and make sure the patient has access to a healthcare partner at all times.

The goal of technology is to allow patients to text and communicate with the office using a smartphone app instead of having to leave a message with a front desk and waiting for a callback. Being able to text simple issues such as appointment requests or medication questions gives patients the freedom to go about their day and conveniently keep a lookout for the office’s response. For the office staff this also gives the added advantage of being able to prioritize their responses to the patients. Texting back also guarantees contact with the patient, which saves the staff from wasting time with missed phone calls. Call centers can help doctors by offering them such apps and solutions to improve the patient experience.

As for having a healthcare partner available, a nurse triage line is a great solution for offices where doctors don’t want to take the responsibility of handling all the calls on nights and weekends. Triage nurses are able to handle over 80 percent of the calls without the need to contact a doctor. Having nurses available gives patients the comfort of knowing they have an option through their provider when a health symptom surfaces. For a patient, an emergency is anytime he or she doesn’t feel well. Having a trained nurse who works directly with their doctor’s office can provide them with needed reassurance, prevent further complications, save them from an unnecessary ER visit, and ensure continuity of care.

TriageLogicCharu G. Raheja, PhD is the chair and CEO of the TriageLogic Group. Ravi K. Raheja, MD is the COO and Medical Director of the TriageLogic Group. Founded in 2005, TriageLogic 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. For more information visit www.triagelogic.com and www.continuwell.com.

Patient Symptoms and Outcomes


Nurse triage is a perfect bridge to provide 24/7 access for patients to ask questions without adding a significant burden for the doctors.

By Charu G. Raheja, PhD

Often times, as adults, we think we are better than children in determining if our symptoms are serious enough to require further care. As a result, many of us deny very serious symptoms. We think the severe headache is just a migraine. Or that the chest pain is not caused by a heart attack – that only happens to other people. However, we tend to be more cautious when it comes to our children. We often ask for advice when our children have a cut, suffer a fever, or are crying inconsolably.

The truth is that it is more difficult to be objective about our own symptoms than the symptoms of our loved ones. We don’t always want to interrupt our day to find out we have a minor problem, but we do tend to worry when it comes to family members, especially our children. As nurse manager Marci Lawing observed, “Adults will try everything without any assistance and usually only call their doctor or nurse triage line as a last resort. Parents, on the other hand, tend to be a lot more proactive about calling right away if their children experience unusual symptoms.”

We studied treatment advice data from our nurse triage call center for the months of April, May, and June 2016 and compared the triage advice given to adult callers and the advice given to patients ages one and under. In those three months, nurses triaged close to 42,000 callers. About 9,200 were adult callers, and 9,400 were babies under the age of one. Surprisingly, adults had a significantly higher rate of ER referral and a much lower incidence of home care advice.

Compared to the entire population, here is what we discovered about patients 18 years and above:

  • Less than one-fourth of adults are given home care, in comparison to about one-half for the overall population.
  • Adults have a high ER referral rate: one in every three adults is sent to the ER, compared to one in six for the overall population.
  • In both the adult and child groups, about one in three needed to follow up with a doctor’s office within twenty-four to forty-eight hours.
  • We also observed that by following the protocols, nurses most often sent adults to the ER for pain symptoms, particularly chest, abdominal, and back pain.
  • Breathing difficulty and post operation complications were also one of the top five reasons why adult patients were sent to the ER.

Next, we compared the disposition of adult callers to that of babies ages one and under. We initially predicted that babies would have the highest incident of ER or urgent care dispositions, with newborn having the highest rate of ER referral. Because of the different nature of care advice for newborns, we separate newborns between up to sixteen weeks and babies between seventeen weeks and one year.

The results of this comparison are surprising. Contrary to what we predicted, we found babies are sent to the ER at a much lower rate than adults. The results are:

  • More than half of the babies were given home care advice. This is more than double the percentage of adults given home care advice.
  • Babies have a relatively low ER referral rate: only one in nine babies are sent to the ER.
  • Newborns have a higher incidence of being sent to the ER than babies, but this rate is still much less than adults. Roughly two in every eleven babies are sent to the ER, compared to almost one in three adults.
  • Finally, as one would expect, the reasons babies are sent to the ER are very different from adults. The top five protocols used by nurses when they determined the baby needed to go to the ER or urgent care were cough, vomiting (with or without diarrhea), wheezing (non-asthma), and head injury.

This surprising result on the higher proportion of adult callers being told to go to the ER also brings into question whether the age of the caller makes a difference in ER referral rates. Are older adults more likely to be told to go to the ER than younger adults? I divide the adult data in three groups: eighteen to forty year old, forty-one to sixty-five, and over sixty-five years of age. Again, the results are surprising. Most people would expect that the older adults to be the most likely to be sent to the ER. The oldest adult groups were in fact the least likely to be told to go to the ER at only 29 percent.

The data in this article aligns with the general observation that adults tend to wait until they are decidedly sick before calling for professional medical advice. Parents, on the other hand, seem to be much more proactive about calling as soon as unusual symptoms surface, allowing nurses to give home care advice or send babies to the doctor before the symptom becomes a serious condition. Of course, it is possible that the adult population is overall more sick than the baby population since the data does not allow us to measure the overall health of the caller prior to the symptom that led them to call the nurse.

This study also presents the top five protocols used on each group when the nurse determined an ER visit was needed. While not everyone calling with the above symptoms needs to go to the ER, patients need to be told by their primary care providers that these top five symptoms could be the sign of a serious illness and they might need to contact a medical professional for assessment. Nurse triage is a perfect bridge to provide 24/7 access for patients to ask questions without adding a significant burden for the doctors. In addition, patients tend to be more comfortable calling a nurse because nurses are trained to provide comfort and evaluate if a symptom even requires a doctor visit. Doctors, on the other hand, tend to be seen as someone to contact only when you are truly sick, discouraging patients from calling.

If medical facilities implement proper education in the office and access to high quality nurse triage or another form of telemedicine, patients are able to access a trained medical professional and be directed to the appropriate level of care, providing reassurance or preventing morbidity and mortality. In addition, providing a telehealth advice line when the office is closed allows patients to stay with their providers and receive continuity of care.

TriageLogicCharu G. Raheja, PhD is the chair and CEO of the TriageLogic Group, founded in 2005. TriageLogic 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. For more information visit www.triagelogic.com and www.continuwell.com.

Health Navigator Adds Spanish and German

Healthcare is confusing enough for consumers, but language barriers increase the complexity. That’s why Health Navigator expanded the language capabilities of its diagnostic platform to include Spanish and German translations to increase access to telehealth solutions for providers and patients. This makes it easier for non-English speaking patients to utilize e-health tools and applications, ensuring greater accuracy when they use virtual care.

According to David Thompson, MD, founder and CEO of Health Navigator, the expanded language capabilities demonstrate the agility, flexibility, and accessibility of the Health Navigator platform. Providing a multilingual platform also broadens Health Navigator’s ability to work with international clients and deliver the same product capabilities regardless of language.

“We are making it easier for healthcare providers to engage and facilitate communication with patients along the healthcare continuum,” said Dr. Thompson. Additionally updates are in progress to add simplified Chinese and French language capabilities to the Health Navigator platform. The new language translations are available immediately to Health Navigator clients and are easily accessible through the application programming interface. There is no additional charge for secondary language functionality for Health Navigator clients.

[Posted by Peter Lyle DeHaan, PhD for AnswerStat magazine, a medical healthcare publication from Peter DeHaan Publishing Inc.]

Emerging Health Coaching Programs Address Multi-Morbidities

LVM Systems

By Mark S. Dwyer and Heather Jacobs

According to the US Centers for Disease Control and Prevention, chronic disease contributes to more than 75 percent of our national health expenditures. Persons with chronic health conditions account for 84 percent of all healthcare spending in the United States and are the most expensive users of healthcare services (Anderson, 2010). Furthermore, according to the Agency for Healthcare Research and Quality persons with multiple chronic conditions cost up to seven times as much as those with only one chronic condition (AHRQ, 2006).

Historically, care plans were designed to independently manage single chronic conditions such as heart failure, COPD, diabetes, adult asthma, pneumonia, and others. These early care plans effectively helped care coordinators assist patients in managing one chronic condition at a time.

But what about patients with multi-morbidities?

A better way was needed to address patients who suffered from two, three, or more chronic conditions. Until now, addressing a patient’s multiple needs meant managing the patient in multiple care plans. Doing so resulted in duplicate calls, redundant questions, and repetitious sharing of health data.

The 2013 AMA recognition of obesity as a chronic disease has further extended the need for integrated care management. Obesity is at epidemic levels throughout the United States. (See part two of Traci Haynes’ article on obesity). Often this directly relates to other chronic conditions such as diabetes, making it no longer realistic to manage these conditions independent of each other.

To address this, comprehensive health coaching programs enable RN care coordinators to manage the health of multi-morbidity patients. These plans help identify the appropriate surveys to complete with the patient, the information to send, the health statistics to gather, and the goals to set, all within a single call. This allows care coordinators to use their critical-thinking skills to identify the appropriate information to share during any call.

How it Works: Patients are enrolled into a single, dynamic care plan that can be customized to meet each patient’s unique needs and multi-morbidities. Once enrolled, contacts between the patient and care coordinator are scheduled as needed as opposed to following a rigid fixed frequency.

As part of the initial and annual follow-up calls, the care coordinator can gather baseline data, medication adherence, and other health information that does not change often. The baseline data allows the care coordinator to assess the patient’s needs regarding multi-morbidities, service needs, adherence to basic self-management, and desire to change behaviors.

There are two primary plan frequencies to consider: comprehensive and high frequency. The comprehensive plan is designed to follow-up with the patient on a less frequent basis (such as, quarterly) while the high frequency plan involves contacting the patient on a more frequent basis (perhaps weekly or monthly). Both plan frequencies address medication adherence, standards of care, and optional goals.

Based on updated standards of care, the care coordinator uses surveys to gather data on the HEDIS and disease-specific medical care standards, as recommended by the corresponding accrediting organizations and authorities. In addition to surveys defined for each disease state, the system also includes the Zung Depression survey and Diabetes Distress Screening (DDS17).

Once the appropriate data is gathered, the care coordinator can access appropriate resources as needed. This information is shared with the patient using email, text, or paper format. Many of these health information topics are authored by the AAFP (American Academy of Family Physicians) or MedlinePlus.

Two other key surveys involve goals and medications. The goals survey is optional on any encounter or may be used as a standalone contact to work with the patient in setting goals and evaluating progress. Although the medications survey is also an option as a stand-alone contact – to work with patients on medication adherence, education, and needed resources – it is recommended to update it with each encounter.

Key reporting tools are available to assist with patient assessment and streamlined call processing. Reports can give care coordinators a quick way to view the patient’s health history, lab values, appointments, and goals. In support of this, an adherence scorecard report alerts care coordinators to any behaviors that need to be addressed during the contact. If desired, the patient’s physician can be notified if the patient opted in or out of the program, any goals identified, DDS17 results, depression screenings, and the patient’s adherence to the standards of care.

Key Components: A comprehensive health coaching program should include the following components:

  • Patient Engagement: A centralized tool to turn referrals into interactions and facilitate the connection and coordination of care across the patient care continuum.
  • Self-Management: Built-in tools to teach patients self-management behaviors, including medication adherence, and self-monitoring (peak flows, blood glucose, weight, and so forth). Medication errors can be avoided with the program’s reconciliation and adherence tools.
  • Patient Goals: Identify care gaps using health risk assessments and surveys to set relevant goals with the patient. Track progress and refer to network providers or community services based on the patient’s benefits.
  • Behavior Change: Drive change with health coaching tools aimed at both the patient and family members. Ongoing contact and consistent messaging managed by the outreach scheduling tool are critical to permanent behavior change.
  • Improved Outcomes: With timely intervention, paired with healthy patient and family engagement, patients are readmitted less often and are more satisfied with their care.
  • Measure Results: Trend readmission rates provide clinical outcome reports to track enrollment and demonstrate success.

In light of the country’s aging population and overall poor diet, the likelihood of individuals needing multi-morbidity care management services in the future is likely to grow. Fortunately, emerging health coaching programs provide the infrastructure upon which to effectively improve care, education, and behavior modification. The result can provide healthier outcomes for patients, increase customer loyalty, and positively affect an organization’s bottom line.

LVM Systems logoMark S. Dwyer, COO, and Heather Jacobs, manager of client services, both at LVM Systems, providers of Poly Plan, a health coaching program that provides the infrastructure to effectively improve care, provide education, and encourage behavior modification. For more information, contact Heather at heather@lvmsystems.com or 480-633-8200 x333.

Risk Stratification Necessitates Nursing Coordination

By Gina Tabone

The Dictionary of Modern Medicine defines risk stratification as “the constellation of activities, i.e. lab and clinical testing used to determine a person’s risk for suffering a particular condition and need – or lack thereof – for preventive intervention.” Any discussions concerning risk stratification must then, include how identified patient needs will be managed and coordinated. Categorizing those most at risk is useless if there is not an actionable plan in place to provide 24/7 treatment.

In order to accomplish this, several items need to be addressed. These include:

  • Coordination of care
  • Active communication
  • Continuous access to care
  • An understanding that now may be the time to consider partnering with an external team of caregivers to provide care for all patients regardless of their determined risk level

In today’s healthcare world, the familiar saying, “the right hand doesn’t know what the left hand is doing” is often true. Health systems are complex, multi-specialty organizations that can offer patients multiple services and interventions on any given day. The following scenario helps illustrate this:

Recently, a COPD (chronic obstructive pulmonary disease) patient was being discharged from an inpatient setting after being treated for an acute respiratory infection. On day two of her seven-day admission, a Foley catheter was inserted due to a sudden onset of urinary retention. Urology has not been able to identify the cause of the retention; as a result, the catheter will remain in place when the patient is discharged.

Nowhere in the discharge instructions was there any mention of the catheter or how to care for it. When the patient’s daughter asked the discharging provider what she needed to do with the catheter once they left the hospital, she was shocked by the response: “What catheter?” That was not what she expected to hear, nor did it make her feel confident about taking her mother home.

This patient was identified in her electronic medical record (EMR) as a high-risk patient and has three comorbidities. She recently suffered a stroke that compromised her entire left side and had been hospitalized twice within the past twenty-five days. There was no indication that a designated care coordinator was involved in the patient’s plan of care.

Not only would the patient’s overall health status have benefited from dedicated coordination efforts but so would the ability to contain the costs of her ongoing care and reduce preventable readmissions. When questioned about care coordination oversight of patients, the assigned RN was not aware of any such role at this facility. That explains a lot.

The importance of the EMR has been proven and is universally recognized. In this case, every provider involved in the provision of care documented each encounter in the patient’s EMR. The problem occurred when some of the caregivers failed to read crucial details in the record. While clinicians are busier than ever and often limited with their time, it is vital that they dedicate the time needed to gain a comprehensive view of the patient’s health status. If this does not happen, care simply cannot be effectively coordinated. Taking the time to read all of the information included in an EMR will not always be a reasonable expectation, but there is a solution.

Care coordinators need to be assigned to navigate care, communicate prioritized information, and advocate for patients when necessary. The patient mentioned above is an example of a high-risk patient. The level of acuity in this scenario represents the level of acuity found in 15 percent of the population. The alarming fact is that while only 15 percent of patients are stratified as high-risk, their care consumes more than 80 percent of overall healthcare spending. Delegating registered nurses as care coordinators to offer constant access to the supervision of chronic and acute health needs is the essence of optimal patient outcomes. The tool that makes this possible is the EMR.

Patients at high risk need ongoing care coordination that is consistent and predictable. The fact that most of the population is not high-risk does not necessarily imply there is no need for harmonious care. Mid-risk and low-risk patients also are best served by a coordination of care that focuses on either maintaining or improving current health status.

However, designating a workforce of RNs to be accessible 24/7 is not always feasible. Many organizations are challenged with having enough bedside nurses available for basic 24/7 staffing requirements. These nurses often cannot be spared to care for patients calling in from a remote location. Secondly, having RNs available if patients call may not be economically feasible for cost-conscious organizations. Granted, this does not apply to the higher-risk patients but rather to those who would benefit from speaking to a clinician as needed.

Patients often do not know what they should do when they are ill or require medical care, especially when their provider’s office is closed. While it is common for patients to seek immediate treatment, it is not always necessary to receive care at an emergency department (ED) or urgent care. Directing patients to the most appropriate level of care fosters optimal utilization of clinical resources.

Often, a trained triage nurse can offer symptom-specific interim care and guide patients to an appointment with their provider the following day as a safe option. No one wants to go to the ED if it is not necessary and end up having to incur expensive co-pay costs. Healthcare organizations need to include remote medical care for all risk levels when developing a strategy to provide access to care. Maintaining and improving the health of low-risk patients has the potential to generate revenue that can support and sustain other necessary care coordination expenses. With this it is easy to see that care coordination is the best option for both the patient and the organization.

We did not arrive at the current state of healthcare overnight. It has been a gradual evolution. As such, the necessary changes will not happen overnight, either. A reform effort such as risk stratification is a great example of an initiative designed to improve patient outcomes without compromising the practices that positively affect patient and population health.

Today’s healthcare consumers are treated by a variety of providers, often at different locations, and sometimes in different networks. The role of an RN care coordinator is critical to managing the entire continuum of care for patients. The EMR allows the RN to know what is occurring in real time and to make sure that treatment plans are being implemented as intended. They also are able to identify gaps in care and hold all members of the interdisciplinary team accountable.

Many organizations are in the process of designing care coordination departments, but as with the development of any new program, there are challenges that may prove detrimental to patient care. Now is the time to consider working with a medical call center so that the transition is smooth, with minimal risk to patients. Triage nurses are available 24/7 to care for high-, mid- and low-risk patients on demand. Technological capabilities also enable the transmission of information directly to the individual’s EMR.

Risk stratification is long overdue, and it is here to stay. To achieve the desired outcomes, be sure that qualified telephone triage nurses are involved.

Gina Tabone, MSN, RN-C, is the vice president, strategic clinical solutions at TeamHealth Medical Call Center.

How Can Nurses Handle and Document Office Patient Phone Calls?


By Ravi Raheja

Many physician practices have nurse staff in the office available to take patient phone calls during the day. While office nurses may already have the necessary medical training, doctors often worry about making sure their nurses give appropriate care advice to patients. Many physicians spend countless hours training nurses on how to ask all the relevant questions, especially as new nurses join their team. Other physicians take frequent breaks in between patients to answer nurse questions about how to handle certain calls.

What is a good solution to help providers ensure that nurses ask all the relevant questions to guarantee patient safety and at the same time document the interaction? The solution is to use standardized telephone triage medical protocols in the office. These protocols are available in book form or in an electronic format.

It is very important to have protocols at all times. Daytime protocols for doctor’s offices act as a checklist for the nurses to use when handling patient phone calls during office hours. Making some investments in setting up protocols for office nurses can save time and money. First, they ensure nurses ask the right questions and not miss anything when handling patient calls. Second, they decrease liability because the call and the protocols used are documented.

Offices need to make a decision on whether they want to use telephone triage books or electronic protocols. Books tend to be cumbersome and difficult to use. Nurses also need to adjust to new books every time a new version is released. In most cases, nurses end up leaving the books on the shelves instead of using them because of the time it takes to follow their guidelines and then manually document the call.

Electronic protocols for daytime offices are available that are easy to teach and use and can be integrated with EHRs. In addition, the vendor is responsible for updating the questions and the care advice, allowing nurses to adopt seamlessly as new guidelines become available. As a result they can save valuable nursing time in following the protocols and in documenting the information. The savings on nursing time and ease of adoption will usually offset additional costs of purchasing electronic guidelines.

Questions to ask when selecting an electronic protocol vendor:

  • Does the software use the daytime gold standard Schmitt-Thompson protocols?
  • Can the triage information be copied or securely integrated with the office’s EHR?
  • How easy is it to learn the software? What is the training time to learn it?
  • Who trains your office nurses? What happens if you have a new nurse? Do you need to pay extra to train nurses that join later?

As doctors know, medical mistakes can cause serious issues to a patient’s health. Establishing systems in place to ensure patient safety is a key aspect of a well-functioning practice.

TriageLogicRavi Raheja is the Medical Director of TriageLogic. Founded in 2005, TriageLogic is a URAC accredited, physician-lead provider of high quality telephone nurse triage services, triage education, and software for telephone medicine. Their triage solution includes integrated mobile access and two-way video capability. For more information visit www.triagelogic.com.


Remaining Objective on Difficult Triage Calls


By Ravi Raheja, MD

As a healthcare professional, providing quality care to patients is the number one priority. Most patients are friendly and thankful for the advice and care given, but occasionally a caller can be angry, frustrated, or rude. Though difficult at times, it is important for triage nurses to resist the urge to react negatively.

Nurses must be sure to remain objective by realizing the caller’s anger or frustration is most likely not directed toward them but the situation in general. So, how can a triage nurse overcome labeling a patient as difficult when emotions are running high?

As a triage nurse it is important to attempt to understand the cause of the patient’s behavior. Many times the patient is upset or overwhelmed by pain, worry, or stress. He or she may not know how to effectively communicate symptoms or feelings and become frustrated.

When a nurse fails to empathize and labels a patient as “difficult,” the quality of care can be negatively impacted. Instead of being happy to help, the nurse may talk over the patient in an attempt to be heard or lose interest in the patient’s needs. Neither scenario will accomplish the goal of triage nursing, which is to help the patient attain the safest level of care.

Here are seven tips to help refrain from letting judgments hinder quality patient care:

  1. Breathe:Slow down, take a deep breath, and give the patient time to express themselves.
  2. Empathize:Everyone wants his or her feelings acknowledged. Saying things like “I can understand how you feel that way,” and “I see this is frustrating to you. I am here to help,” can comfort the patient and assure that he or she is being understood.
  3. Address the reason for the patient’s behavior: Once the nurse acknowledges the patient’s feelings and the emotions settle a bit, it’s easier to get to the real reason for the call.
  4. Ask questions:Engage the patient by asking questions to find out exactly what the problem is and what solutions might be possible.
  5. Document facts using objective statements:Refrain from recording judgmental words such as “rude” or “argumentative.” Instead, note actual behaviors such as “patient spoke in a loud, fast voice, and frequently interrupted the nurse.”
  6. Focus on patient care:Rushing the patient off the phone can compromise care. Although difficult calls are uncomfortable, take time to help the patient.
  7. Involve the patient in developing the care plan:Make sure the patient is able and willing to comply. Perhaps a patient is too upset to drive safely to the hospital or is a mother with no one to help with her small children at the ED. Offer alternatives to ensure the safest recommendations for the patient.

Triage nurses hold great responsibility when it comes to patient care. When a nurse follows these steps while handling a difficult call, the patient will get the best possible response. Though challenging at times, the triage encounter should always lead a patient to the best possible outcome and leave a nurse feeling confident they provided the standard of care.

TriageLogicRavi Raheja is the medical director of TriageLogic. Founded in 2005, TriageLogic is a URAC accredited, physician-led, provider of telephone nurse triage services, triage education, and software for telephone medicine. The TriageLogic group serves over 7,000 physicians and covers over 18 million lives nationwide. For more information visit www.triagelogic.com.

A Future Look at Triage Call Centers

LVM Systems

A reliable healthcare model for value and outcomes versus volume and revenues

By Mark Dwyer

Imagine the year is 2030. The Cubs have finally won a second World Series. Private companies are shuttling people to the moon. And Garth Brooks has launched yet another comeback tour.

Voice controlled computers, self-driving cars, and nanotechnology are no longer just theory. Finally, technology has done what it promised so many years ago. No more tedious typing and key-boarding classes, paying exorbitant car insurance fees, or washing windows every spring.

Amidst all the change, one thing remains constant – the triage call center. Sure the technology has changed. Newer phones and telephony interfaces exist. Video conferencing and chat windows are now the rage. But despite these changes, the heart and soul of the triage call center remains the same. And it lives within the person of the highly-skilled triage call center nurse.

To the stressed-out mom whose crying newborn cannot be consoled or the scared elderly man alone at home experiencing gut-wrenching abdominal pain, the call center nurse will continue to provide the same heartfelt care she has for the better part of the last forty years. Her calming voice, empathic concern, and level of knowledge will be what the caller really needs. The cold touch of a lifeless computer screen, even if artistically designed, will never replace human interaction.

Technology is critical to our daily lives. Without it, the world as we know it would cease to exist, but too often the warmth and support provided by the triage call center nurse is overlooked by the bean counters who seek discernable ROI. If ever healthcare had a model for value and outcomes versus volume and revenues, the triage call center is it – both now and in the future.

LVM Systems logoMark Dwyer is chief operations officer at LVM Systems, providers of healthcare call center software.