Role of Telephone Care in the Spectrum of Clinical Care
BAL HARBOUR, Fla. - Studies have shown that many pediatricians provide up to 25%, and for some 40% of their clinical care by telephone, according to Hanna Sherman, MD.
"Many changes have occurred in telephone care over the past 10 years. And many of those changes affect pediatricians in primary care practice," said Sherman, who is medical director of Night Train Pediatrics at Children's Hospital in Boston. Night Train is a medical triage facility within the hospital.
Medical call centers started about 10 years ago to address after-hours needs, but physicians found they could be useful during the day. An estimated 35 million Americans now have access to formal telephone triage call centers; that number is expected to reach 100 million by 2000.
"For anybody who has a capitated contract in their office, you know that telephone care is a critical part of their management system. It saves you considerable money by making sure the patients receive proper care without having to come into the office," she said here at the 34th Annual Postgraduate Course, Perspective in Pediatrics, sponsored by Miami Children's Hospital.
It is estimated that one pediatrician receives roughly 10,000 patient telephone calls a year, she added, 15% of those will be after hours. Most pediatricians delegate their daytime calls to staff, usually nurses. Sherman said the goal is to provide the best, most efficient care possible, while limiting liability.
The telephone contact falls into five categories: demand management; case management; disease management; population management; and health and wellness promotion.
Demand management is a patient-generated telephone call. The patient calls because he or she is concerned about possible illness or injury.
"In case management, the patient has already had contact with the provider. That could be in your office. It could be in an emergency room or with a specialist, like a hospital clinic, or following a hospital admission," she explained.
A case manager will continue patient care by telephone. These calls can be follow-ups to see how they are doing, to find out if they are taking their medications or following doctor's orders or following up with their appointments.
Disease management involved patients with chronic conditions, such as asthma, diabetes or heart disease, who may do better with more intervention, monitoring and education.
Populations at risk, such as young mothers and those with low socioeconomic status may benefit from follow-up by telephone care, rather than letting them fall through the cracks.
Health and wellness promotion enables the practice to continue education efforts that were started in the office - as well as provide health reminders - such as the need for immunizations.
No matter who initiates the encounter, the care provided over the telephone is similar to any care that would be provided in a direct patient encounter, Sherman said.
"The person on the telephone, whichever clinician it is, is going to do a history and assessment. They are going to come up with a working diagnosis. It will not be as complete a diagnosis as you would make if you could actually touch that patient, do a lab test. But you develop a working or a tentative diagnosis. And come up with a care decision and make some recommendations," she explained.
Nurse telephone care can improve access to care because it lowers the barrier for the caller, especially for those who do not want to "bother" the physician. "They are concerned, and they think several times before they place that call," she explained.
However, when they realize they are calling a nurse, they do not hesitate. "So it actually improves the access, and the office gets kids sooner who are sick, so that they can get the care that they need. It also clearly reduces the cost of care," she said.
Patients have concerns, however. They want to know that the care they get from a nurse is quality care, that telephone calls will be answered promptly and that they can have access to a physician if they are uncomfortable with what the nurse told them, she said.
Physicians can address some of that by making sure there are enough telephone lines and people to staff those lines. And by making sure that "nurses have a good knowledge base and can answer their questions."
She said developing practice guidelines and standardizing telephone care can help address these concerns and limit liability. In addition, a physician should be available if needed.
"In our medical call center we cover for 340 physicians in the Boston area. That is about half a million patients. And we require, obviously, that each of the practices still have a physician on call every night. So if our nursing staff needs to reach them, they can. Our nurses are able to handle 90% of the calls without contacting a physician."
"But if a patient says to the nurse, I am not comfortable with what you told me, or I would really prefer to speak to a physician in my practice, my nurses do not hesitate. They do not see themselves as denying patients access to either an evaluation in the emergency department (ED) or urgent care center, or just speaking to their own physician. They are there to facilitate that they are getting the care they need, and to identify the appropriate care, she explained.
At Sherman's call center, about 50% of the patients who call after hours can be managed at home, about 30% are told to go to the doctor's office the next business day, and about 12% are referred into an emergency department.
"Sometimes that number is even lower. Some physicians in practice, because of their managed care contracts and the capitated plans they participate in, want to screen and preapprove any ED referrals," she said.
Once the nurse decides a child needs to go to the ED, she will contact the physician on call, and the physician will do a second-level triage.
The role of the triage nurse is to identify the problem. That can be more difficult than it sounds because parents often identify one problem as key, when it is actually something else. For instance, a parent might complain of a child's fever because that is what the caregiver sees as the problem, when actually, the child is experiencing respiratory distress.
"The way our system works is the parents call their physician's office, get their answering service. The answering service then faxes us the message, rather than paging it out to the doctor. We do it that way, because we find that it assures us that we are receiving most of the patient calls. Initially, we had direct answer, with a voice mail backup, and we found that we often did not get messages from the patient. That they felt we had abandoned them and they did not leave a message or it was not interpretable and we could not call them back. Now we receive a fax message and that gets prioritized," she explained.
The nurse will identify the problem, then decide what kind of clinical care or evaluation is necessary, how soon that care is necessary - whether it can be provided the next day in the doctor's office or the patient should go to the ED - and provide care advice, and follow-up.
The follow-up is critical because patients need to know when and why to call back for more help. Patients are often asked to call back, if they find another sign or symptom in their child that concerns them. "And at many call centers, such as ours, nurses will place follow-up calls. So they will continue the home management," Sherman added.
When evaluating a pediatric call center, make sure the center uses registered nurses, not LPNs. The nurses should have some type of formal training because telephone triage is not taught in nursing school. Sherman also advised against using recent graduates of nursing school because they often do not have pediatric experience.
"We require a minimum of three to five years of pediatrics," she said.
A medical director is also needed, Sherman stressed. "Not all commercial call centers actually have a physician actively involved with the call center. All of the centers involved with academic hospitals do. But not the commercial ones," she said.
Finally, make sure that clinical guidelines are rigorously used for all calls and that there is a risk management program that looks at clinical outcomes. "You do not want a nurse sending most of her patients to the ED, and another nurse not sending them at all. You want to make sure that it is a standard course to come to a uniform decision about any give clinical situation," she explained.
"I do believe the role of telephone care will continue to expand, as we continue to need to contain the cost of medical care," she said.
For more information:
- Sherman H. Current status of pediatric telephone care. Presented at the 34th Annual Post Graduate Course, Perspectives in Pediatrics. Feb. 5-11. Bal Harbour, Fla.
- Marosits M J. Improving financial and patient outcomes: The future of demand management. Healthcare Financial Management August 1997;43-44.
- Sorum C. Mallick R. Physicians Opinions on Compensation for Telephone calls. AAP [serial online] Vol. 99 No. 4. 1997 April 4;4:(3): [9 screens]. Available from: http://www.pediatrics.org/cgi/content/full/99/4/e3
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