Patients reap the benefits of demand management
Nurse triage provides valuable service
It’s a well-honed truth in economics that if there is a limit to supply, then you need to limit demand as well. That simple premise formed the basis for the "patient demand management" explosion that burst on the scene about two years ago, when payers felt overwhelmed by patient demand and thought they could reduce necessary costs by cutting back unnecessary patient demand.The first fruition of this effort came in the form of nurse triage — banks of nurses on telephones who helped patients find the primary care physicians they needed or helped them determine which physician or health setting would be most appropriate. Also, in some cases, the nurses could guide patients to less expensive self-care.
Now these systems are branching out into much broader applications, attempting to answer the patient demands that are more unique to today’s managed care environments, such as dealing with patient discontent over gatekeepers, chronic disease management issues, and even checking in on patients on a routine basis.
"We have plans in lots of places looking to replace their gatekeeper system," says Marci Theil, MD, vice president and medical director of Access Health, a nurse triage company in Denver. Access Health, says Theil, is the largest of the triage systems in the country. Their clients include Humana, InterMountain Health, Oxford Health Plans, and numerous Blue Cross entities.
Nurse triage is a technology that can assist a health system in making that transition from strict primary care gatekeeper requirements. "Our nurses can act as guides because they are equipped with the computer and all the up-to-date, readily accessible information," Theil says. "The nurse has access information needed to guide that person to the right place. Nurses don’t make diagnoses, but they can figure out what condition might be present that they can’t rule out."
Here are specifics of some new trends in patient demand management:
• Direct access to specialists. This system allows nurses to direct patients to specialists if it is needed, rather than having them go through the primary care physicians first. "We use a very sophisticated computer technology system to match patients and providers," Theil says. The system looks at both clinical and demographic factors. For example, a patient may need retina care, and he or she may prefer a physician on the south side of the city. The system will ferret out the specialist(s) best suited by specialty and location.
The system at Access Health relies on more than a basic protocol-driven lexicon, but rather a "binary branch chain logic system," which is essentially an extensive decision tree algorithm self-guided through computer links. Ideally, many of these systems’ architects hope to incorporate patient medical records into these systems so those factors can be used in the triage process as well.
• Emergency department referral management. Enrollees get their copayments waived if they call a nurse first, even if the nurse recommends they go to the emergency department. They have their emergency care covered either way, but if they have time to call a nurse first to get the referral, their copayment is waived.
• Incorporation of chronic disease management and proactive patient management.
Access Health’s products include systems for asthma, pregnancy, diabetes, and cardiac management. These triage systems go beyond patients calling in when they need help; nurses actually take the initiative to make routine checks on patients.
Other vendors have additional specialist referral networks. National Health Enhancement Systems in Phoenix touts a triage program, as well as specialty referrals and follow-up care in geriatrics, pediatrics, women’s health, and behavioral health. The firm also can add patient satisfaction survey services, points out Connie Riffel, senior vice president at National Health.
"Nurses make outbound calls to patients once they are enrolled and stratify them according to their level of severity," Theil explains. Nurses provide educational interventions and recommendations of care for chronic diseases based on national guidelines and physician guideline interaction.
In a capitated environment, physicians have much to gain from nurse triage support networks, triage developers contend. Sometimes independent practice associations or physician-hospital organizations invest in these systems; in other instances, payers foot the bill. The triage systems can help reduce unnecessary office visits, route patients to the right place at the right time, and improve chronic care patient compliance — all substantial benefits, particularly if you’re dealing with strict capitation payment limits.
"Chronic diseases are very difficult to care for," Theil points out, noting that chronic disease is a feared resource-buster in many capitation agreements. "Physicians don’t have all the time to do all the education that is needed. Large amounts of education are needed for diabetics, asthmatics, and others regarding lifestyle, self-identifying risk factors, and avoidance of aggravating circumstances."
In the triage system, nurses launch care for chronic disease patients with a welcome call to new enrollees. During this call, nurses take patients through an illness and risk assessment, looking for areas that might be helpful up front. Those who are at risk for certain diseases, or those who are already in need of disease management, can be identified early. The system is equipped to measure resources used and other patterns over time so costs and utilization can be more accurately projected.
[Editor’s note: Here are several companies that offer demand management systems: Access Health, Denver. Telephone: (303) 443-4600. Health Decisions International, Golden, CO. Telephone: (800) 403-0099. National Health Enhancement Systems, Phoenix. Telephone: (800) 345-3342. Nurse on Call, Norcross, GA. Telephone: (770) 453-9170.]
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