Teletriage offers opportunity for expanding scope of access
San Diego system aims at managed care function
Teletriage is an increasingly prevalent buzzword that signals a new and ideally more efficient way for members to access their health systems. And with this new system, there’s good news: Competent telephone screening can deflect inappropriate use of the emergency department (ED) and other resources while helping those in urgent need get medical care more quickly and easily.
Having patients or health plan members call a designated phone number and explain their medical question or complaint to a trained clinician who then instructs them on the appropriate course of action is increasingly seen as an effective strategy for health systems and managed care organizations.
As fledgling telephone triage operations throughout the country work out the bugs associated with start-up, access managers would do well to consider how they can become part of this health care trend one that’s a sure bet to grow along with managed care and capitation.
With patient access the only 24-hour department in most hospitals, what better place for a teletriage service to be based? If your access department already has clinical components such as a preadmission testing center, it may be the logical choice for teletriage. Either way, there could be an opportunity for you to expand your sphere of influence along with the scope of your department.
At Palomar Pomerado Health System in San Diego, a physicians’ answering service established in 1990 spawned a new nurse triage system in 1996 that promises to evolve into a teletriage operation serving the health system’s self-funded insurance plan and other managed care contracts. After making it through a year of growing pains, "we feel we have a jump competitively," says Louann Parker, RN, assistant administrator for ancillary and support services. "There is tremendous potential. What a wonderful way to make sure patients access care on the proper level."
As the triage operation grows in size and scope, it’s working out the myriad clinical, administrative, and funding challenges along the way, explains Parker, who oversees the health system’s admitting department, among other duties. Building on six years of experience answering physicians’ telephones during off hours and the resulting expertise in the methodology and processes of handling large volumes of calls the program added a nurse triage system last year.
"We signed up 25 physicians, hired staff and a manager, and located [the triage system] at the health system’s corporate office," Parker says. Meanwhile, she adds, the physicians’ answering service continues to serve about 200 physicians, who like the familiarity of having hospital operators rather than an outside answering service answer their calls.
There were switchover problems and "a lot of growing pains" associated with the new nursing triage venture, she says. "The handoff between the answering service and the triage was difficult." Some doctors had an account with both, Parker explains, and the answering service had to determine what was a clinical problem and what was just a message to be taken.
In response, the health system physically combined the two entities, moving the answering service, which had been located in one of the system’s hospitals, to the central office, and began to build a department, she says. "We let the nonclinical staff handle the messages, then hand over the call to the clinical side."
Palomar Pomerado is now in the process of evaluating the cost of the service. To have a registered nurse spend time on the phone with callers is "very, very expensive," Parker notes. "It’s generally accepted that it costs from the low 20s [in dollars] to the high 30s per call, and physicians don’t want to pay that much."
Designed with the hope that it would be a revenue generator, the triage service must at least break even, she says, to avoid the suggestion that the hospital is paying for physician referrals. With that in mind, the health system began discussions with staff on how to reduce costs and still keep service at a high level.
"We’re now implementing alpha-pagers so that rather than having a call come in and putting a page out to the physician, we can actually alpha-page the message to him," Parker says. "It cuts down the number of transactions."
Cost-saving was part of the reason behind the proposal to have the triage system serve the health system’s own employees, who are members of its self-funded insurance plan. "In most literature on the subject, we see that 30% of ED visits can be avoided with triage services," she says. "We’re thinking, if we use this service for our own system, we can save by ensuring that only appropriate patients come to the ED."
In such an arrangement, the triage nurse could be empowered to give authorization for an ED visit rather than calling a variety of physicians or determine that it’s not needed, Parker says. The accounting process involved is "an interesting challenge," she adds. "We can figure out how many ED visits employees have on an annual basis, because we know what comes through our ED."
Employee use of the triage system can be monitored because the staff obtain demographic information during the call and can access the account in the computer, Parker says. "So we can say, Typically, our employees visit this many times and, conservatively, we save 30%’" when a visit is avoided.
This process can be extrapolated to any number of capitated plans, she notes. "The potential is there to really offset the cost of an appropriate visit and get hold of a person who really needs to get treatment early."
Like most triage programs, the one at Palomar Pomerado uses software in this case, Health-Line Systems that provides nurses with an algorithm of questions to ask callers about their complaints to make sure all possibilities are covered. Some national protocols have been established, and there are several such software packages available, Parker notes. Other programs include AccessHealth and National Health Enhancement.
Still, she adds, regulations haven’t caught up with the new frontier of teletriage, so the health system is looking at clinical practices in relation to state Board of Registered Nursing requirements. "The state board hasn’t established protocols for this kind of service, which is sort of in between hospital [nursing] and physicians’ practice [nursing], which have different standards," Parker explains. "To make sure we don’t have nurses practicing outside the proper scope, we have a medical director who reviews protocols." The system’s vice president of medical affairs serves as triage service medical director.
For the triage nurses to order lab tests and prescriptions functions outside the usual nursing scope the health system is setting up a standardized procedures protocol, following the nursing board’s requirements. It spells out under which circumstances it’s OK to call in a prescription or order a lab test. "We’re practicing in a nontraditional setting that hasn’t been available very long, so we need to make sure that our nurses are practicing within the guidelines of the Nurse Practice Act."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content