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Case Study: TeamHealth Medical Call Center Drives Utilization of Appropriate Care for Pediatric Client

The Challenge:

One goal among health care organizations is to appropriate level of care treatment for patients. For a large pediatric TeamHealth client in California, one aspect of consistent care is appropriate level of care when care is needed and to allow their physicians to service those needs whenever possible.

To achieve this goal, the following objectives needed to be met:

  1. Reserve Emergency Department referrals exclusively for patients who require that level of care.
  2. Direct parents/caregivers to follow up with their child’s physician network PCP in cases where waiting until the office re-opens is a clinically viable solution.
  3. Utilize existing client facilities staffed with pediatric resources whenever possible, if imminent care was required after hours.

The Solution:

The client’s after-hours children’s clinic is considered a hybrid urgent care facility with ‘ED-type’ capabilities. The facility is staffed weeknights, weekends and holidays. TeamHealth worked closely with the client to refine referral directives related to specific patient conditions and outcomes and this facility’s ability to deal with more clinically complex cases. TeamHealth met with the client’s business and clinical leaders regularly to review clinical cases and discuss refocusing the ‘post-triage’ process as it related to the appropriate referral of the patient depending on the care needed. These meetings resulted in:

  • The creation of an actively managed “Exceptions List” to the guide the RN’s to refer to the after-hours children’s clinic or defer to another client location, depending on the care needed
  • Refinement of TeamHealth internal system processes
  • Backline communication established between TeamHealth RN’s and client staff in the after-hours children’s clinic for appointment purposes.

The Results:

  • During the next 12 months, 91% of all referred callers were directed to a client facility. The other 9% of referred callers were comprised of parents and caregivers that refused a referral or were undecided (6%), or decided to go to a different non-client facility (3%).
  • The number of ED referrals also dropped significantly.

“We look forward to continuing our partnership with TeamHealth to provide excellent after hours care to our pediatric patient population.”
– Client Manager of Clinical Operation

High Level Detail

Detailed Breakdown

By |June 29, 2016|Case Study|Comments Off on Case Study: TeamHealth Medical Call Center Drives Utilization of Appropriate Care for Pediatric Client

Change is the Only Constant

Change is the Only ConstantIn the year 535 BC, Greek philosopher Heraclitus declared, “The only thing that is constant is change.” For many of us working in the healthcare industry, we wholeheartedly agree that these timeless words continue to ring true, year after year. The word ‘change’ evokes a different response from each of us – but what exactly is change? How is change manifesting itself in today’s healthcare environment and how can we, as leaders, incorporate the implications of change into our organizational cultures?

Webster’s Merriam Dictionary defines change as: 1. To become different; 2. To make (something or someone) different; 3. To become something else. Change is a modification to the process of doing something. In many cases, the modification is made in hopes of creating a better outcome. Often, the expectation of positive change is put on us without tangible evidence to support a better outcome. Today’s healthcare leaders rely on innovators and thought leaders who ‘think out of the box.’ Their role is to introduce variations (changes) to current practices that will ultimately improve patient outcomes, engage their workforce and contribute to the goals of the organization. Identifying and implementing these variations are vital if we hope to improve outcomes. For example, without changes within the healthcare industry, there would never have been advancements in immunizations, birth control and organ transplantation. No change typically means no growth, and no growth is not a sustainable option for any organization.

There are many examples of changes occurring in today’s healthcare environment. The stimuli for most of the modifications are the requisites of the Affordable Healthcare Act. A list must include: healthcare for all, coordination of care, fee for value of care and accountability for outcomes. Programs such as post-discharge call backs, 24/7 access to clinical care, integrated communication via electronic medical records and robust patient satisfaction efforts are all outcomes affected by changes that have evolved in an effort to comply with the new regulations. The collateral benefit is quality, efficiency and exceptional care.

Mention the word ‘change’ to employees, and in many cases, the reaction is predictable. We have all observed rolling eyes, defensive comments, irritation, anxiety and one characteristic response to change – resistance. Change represents the unknown, which can be very intimidating. Those in charge of healthcare organizations need a long-term change management strategy for their organization and the people affected by it—a strategy that encompasses all aspects of the change, from conception through completion.

A leader who is sincere, humble and willing to admit to a level of personal angst when going through changes will have more success with overall buy-in efforts from all levels of an organization. Reminders of past organizational achievements often convince employees to give the ‘change’ a chance. It will hopefully strike a positive chord with front line staff as well, reminding them that they have dealt with change before with positive results. Directly involving those most impacted by the changes is a great way to gain support and alleviate concerns. It is crucial to communicate the fact that the changes occurring are designed to improve patient quality, become more efficient and enhance both the patient AND provider experience.

Change is here to stay; we can count on that. Many of us may not be as open to change, but we can do our best to understand what initiated it and, more importantly, how our role in the process has the potential to influence the accomplishment of organizational goals.

In the famous words of Heraclitus, “The only thing that is constant is change.”

Gina Tabone, MSN, RNCGina Tabone MSN, RNC
Vice President Strategic Clinical Solutions
TeamHealth Medical Call Center

By |June 6, 2016|Blog|Comments Off on Change is the Only Constant

Nurse Triage – Don’t Leave Home Without It

Nurse Triage - Don't Leave Home Without ItA few months ago, I took some time off to spend a rejuvenating week at the beach. The sun was hot and bright, the waves were churning and the breeze was refreshing. Everyone around us was on vacation and relishing the fact that they did not have to wake up to an early morning alarm, attend a meeting or meet a deadline. There was no mention or thought of work from any beachgoer–except for me.

Don’t get me wrong; it was not a bad thing to be thinking of work while on vacation. It was quite the contrary, in fact. See, I am a nurse, and I work in the one constant specialty of healthcare: after-hours nurse triage. On three separate occasions, my fellow vacationers shared stories with me about how their lives or the lives of their loved ones had been saved or drastically improved—simply by having access to a nurse while they were on vacation.

It made me proud.

One morning, an elderly woman was strolling down a sandy stretch of beach with her two sisters, as they enjoyed their annual trip to the Atlantic. One of them had accidentally left her carry-on bag in an airport restroom while traveling, and had not realized it until arriving at her destination. She was not initially concerned when thinking about the magazines and snacks that were in the bag, but began to panic when she realized all of her medications had also been in that bag.

Unsure what to do, she called her daughter at home and explained the situation. The daughter had a very active role in her mother’s health care provision, and knew that her Primary Care Physician (PCP) had a 24/7 nurse line that they had utilized in the past with other dire issues. It was well after her mother’s PCP office had closed, but with one call to the nurse line, a friendly voice on the other end assured them an RN was available at that moment to assist them.

For senior citizens, immediate access to medications is often a vital necessity. Not having that access can be the basis for potential disaster, especially when the individual is nowhere near their PCP office. For the elderly vacationer, it had become a frightening reality. However, this problem was one of many a triage nurse is specifically accustomed to solving. She alleviated the woman’s anxiety and reassured her that the situation was under control. The nurse directed the woman to a store one block from the beach and provided enough of her prescription to get her through the entire vacation. The woman and daughter thanked the triage nurse for her help–and then the nurse reminded her to be sure to wear sunscreen while walking along the beach!

One evening as I sat looking at the ocean and listening to the waves, I was interrupted by the familiar sound of a siren approaching. Looking down the road, I noticed an ambulance pulling in to the driveway of a beach house just down the road from ours. In any setting, that picture is cause for alarm, but it is even worse when you are away from home. A short time later we saw the ambulance head back up the road, most likely to a local hospital or other healthcare facility. The next day while visiting with some neighbors, we learned that a 54 year-old man had been sitting on his deck watching sunset with his wife (just as I had been doing) when he began experiencing chest pain. His wife knew he needed medical care, but had no idea what to do or where to go. She remembered seeing a magnet on the refrigerator door with a phone number to call for medical emergencies. The emergency service was staffed by community triage nurses and available to anyone in need. The skilled nurse directed the woman to have her husband lie down and remain on the line while she contacted EMS for assistance. The nurse offered support and reassurance to the wife, and was even able to speak to the husband. Once the emergency responders arrived, the triage nurse hung up and let them take over.

The chest pain ultimately ended up being cardiac in nature and potentially life threatening. Once the local Emergency Department stabilized the man, he was transferred to the nearest major medical center. The wife called the rental company and thanked them for placing the magnet on the refrigerator. She said that the ‘wonderful’ triage nurse helped her and her husband through one of the worst experiences of their lives.

Although I did not know that nurse, I was so proud of her and wished that she could have heard their heartfelt compliment.

I heard one final story while sitting in the airport. As we waited for our flight home, I noticed a toddler with a bright red sunburn on her face and arms. That is an unusual sight these days, since many parents I know cover their children from head to toe with the highest SPF, water-proof lotions available. The child’s mother must have noticed me looking at her daughter with concern. She said, “You should have seen her yesterday.”

She went on to explain that a family friend had offered to put sunscreen on the toddler prior to a family outing. The mother assured me she always uses a high quality, high SPF sunscreen approved by her daughter’s pediatrician. In this case, the family friend unknowingly applied a SPF 8 tanning lotion instead of the mom’s sunscreen. After walking in the sun for only 20 minutes, the toddler’s cheeks and forearms began to turn red and blotchy. They decided to get out of the sun and assess the child’s condition. While her arms and face were warm to the touch, the young girl was happy and interacting with her family as normal.

Regardless, the mother was very concerned about any present or future harm the sunburn may cause to her daughter. She decided to call Mary Jo, the triage nurse at her pediatrician’s office, as she does whenever she has health concerns for her daughter. Mary Jo asked some specific questions about the symptoms related to the sunburn and assured the mother that it appeared the little girl was going to be fine. She suggested some basic home care instructions, which included giving her daughter a lukewarm oatmeal bath, moisturizing the area while the skin is still moist and administering a dose of an OTC analgesic if her daughter was uncomfortable.

The mother expressed to me her complete trust in the advice she receives when calling her nurse help line. She especially appreciates the respect and understanding she receives when calling, never being made to feel that her question is foolish or that she is overreacting. That is very important to any concerned parent who only wishes to make sure their child is going to be okay.

There is no denying the fact that a call to a trained triage nurse is often the first step taken whenever a need for medical advice or instruction arises. Having this type of access to definitive health care is both comforting and effective. I was very proud to hear these heartfelt stories from three separate strangers during my vacation. It further confirmed to me the value of a service that I have felt to be invaluable for decades. Nurse Triage – Don’t leave home without it.

Gina Tabone, MSN, RNCGina Tabone MSN, RNC
Vice President, Strategic Clinical Solutions
TeamHealth Medical Call Center

By |May 26, 2016|Customer Service|Comments Off on Nurse Triage – Don’t Leave Home Without It

Risk Stratification Necessitates Nursing Coordination

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 health care world, the familiar saying, “the right hand doesn’t know what the left hand is doing” often rings 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 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 home.

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 when her response was, “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 25 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 fact explained 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 very 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% of the population. The alarming fact is that while only 15% of patients are stratified as high-risk, their care consumes more than 80% 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 RN’s to be accessible 24/7 is not always feasible. Many organizations are challenged with having enough bed-side 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 RN’s available if and when 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 an 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 absolutely necessary, and end up having to incur expensive co-pay costs. Health care 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. When all is said and done, it is easy to see that care coordination is the best option for both patient and 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. A reform effort such as risk stratification is a great example of an initiative designed to improve patient outcomes without compromising practices that positively impact 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 partnering 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, RNCGina Tabone, MSN, RNC-TNP, is Director of 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. Under her direction, ED utilization declined, continuous care coordination improved, performance metric targets dropped from 33% ABD to less than 5%, URAC accreditation was achieved, and the call center grew from covering 350 physicians to the integration of more than 1,500 employed and affiliated providers.

By |February 11, 2016|Quality Improvement|Comments Off on Risk Stratification Necessitates Nursing Coordination

Texas Children’s Pediatrics Increases Efficiency with System Interface

For nearly a decade, Texas Children’s Pediatrics (TCP) has entrusted TeamHealth Medical Call Center (THMCC) with providing quality after-hours triage and clinical advice to its patient base of nearly 500,000. During that time, THMCC has performed more than 500,000 encounters that were documented and communicated back to TCP via fax. Those generated documents required TCP personnel to manually retrieve, sort, prioritize, and ultimately file those documents within each patient’s medical record—creating numerous hours of work that in turn generated additional labor costs for TCP.

When TCP began looking for an electronic medical record system, it became apparent to TCP and THMCC that there was an opportunity to save valuable clinical resources and simplify physician review of after hours triage encounters by leveraging the workflow capabilities of their new system. After TCP implemented EPIC throughout their organization, TCP and THMCC collaborated to develop an interface that enabled the two organizations to exchange data and documentation. Using Health Level 7 Standards (HL7), TCP can now sends specific patient information, including a medical record number (MRN) to THMCC, who then uses this patient information to create triage encounter documentation when the parent of a TCP patient calls and requests after hours services. By using existing TCP data, THMCC can send the encounter information back to TCP in a format that is recognizable to TCP’s EMR system.

When a telephone triage occurs, THMCC creates a PDF document of the patient encounter as well as an accompanying index file in .txt format. Index file data ties patients to their EPIC EMR, their physicians’ practice, and the triage documentation. Upon completion of the triage event, these documents are transferred to a pick-up location using File Transfer Protocol (FTP).

TCP collects patients’ documents from THMCC at regular intervals using OnBase, their enterprise content management (ECM) system, and using the data in the index file, OnBase distributes the documents into the EPIC workflow process that validates the data and subsequently routes the triage encounter to practice-specific work queues. Medical personnel responsible for these work queues review the documents, follow up with the patients, and escalate patient review and care to physicians as needed,

The electronic documentation generation and interface between THMCC and TCP’s EPIC system has sped up getting needed information to patients’ physicians faster so that patient care and safety are improved. An additional benefit of the TCP and THMCC collaboration effort has been a reduction in TCP’s costs associated with the time required for personnel to retrieve, sort, prioritize, and file printed documentation and the elimination of a cumbersome, paper-dependent process.


By |October 5, 2015|Case Study|Comments Off on Texas Children’s Pediatrics Increases Efficiency with System Interface