key components of a successful telephone triage system the experience at an integrated wellness...

Key Components of a Successful Telephone Triage System

The Experience at an Integrated Wellness Center

Rachel Ossmo, RN, BSN, David deBoer, PhD,

Mona Dugo, LCSW and Teresa Carey, RN, BSN

Lakeshore Campus

Water Tower Campus

Health Sciences Campus

(12.8 mi)

(7.4 mi)

Loyola University Chicago

• Nation’s Largest Jesuit Catholic University

• Total Student Enrollment ~ 16,000– Undergraduate ~9,800 - Graduate ~6,100

• Full time student s ~ 13,500

• Part time students ~ 2,500

– On-campus students ~ 10,300

– Commuter Students ~ 3,200

– All Freshman and Sophomore students are required to live on campus unless given a special exemption to do otherwise

LUC – Wellness Center

• Integrated Model• Medical, Mental Health and Health Promotion

• Staff of 30 people• Total of 23 FTE

• Myriad of student workers, student trainees &Wellness Advocates

Hours of Operation

Academic Year Summer/Winter Break/Spring Break

8a – 6p Mon –Th. 8:00a – 4p Mon-Fri.

8a – 5p Fri. Closed Sat and Sun.

8a – 12p Sat.

Insurance

• Coordinated and chosen through the Bursars office– Required by LUC for all full time students– Students can waive out of University plan and get

coverage elsewhere if they choose.

• WC does not bill for or make claims to insurance companies

Telephone Triage, Defined:

“An interactive process between nurse and client that occurs over the telephone and involves identifying the nature and urgency of client health care needs and determining the appropriate disposition.”

Telehealth Nursing Practice Core Course Syllabus AAACN.Org

Why Telephone Triage?

“There is considerable evidence that telehealth interventions can decrease the cost of patient care while maintaining or improving both the quality of care and patient satisfaction. As issues of cost, shortages of nurses, and inadequate patient access continue to press, telehealth must be among the approaches the nurse leader considers as she works to construct viable current and future health care options.”

Jean Sorrells-Jones, Poldi Tschirch, Marie Anne S. Liong, Nursing and telehealth: Opportunities for nurse leaders to shape the future, Nurse Leader, Volume 4, Issue 5, October 2006, Pages 42-46,58, ISSN 1541-4612, 10.1016/j.mnl.2006.07.008.

Evolution of Dial-A-Nurse

Evolution

Evolution

Desired Outcomes

• Immediate access to an RN

• Increase utilization of Telephone Triage line

• Refer to most appropriate provider

• Decrease call volume at front desk

Steps for Implementation

• Developed telephone triage protocols

• Installed a voice mail prompt

• Staffed line with RN during all clinic hours

• Medical staff completed triage re-training session

• Posted advertising on Wellness Center website

• Evaluated and updated telephone triage documentation forms (before EMR)

Adapting to Student’s NeedsEvolution of Making an Appointment

Dial-A-Nurse: What a difference a decade makes

0

100

200

300

400

500

600

700

Aug Sept Oct Nov Dec Jan Feb Mar April May

2002/2003 2011/2012

Awareness Drives Calls Up 70%

NCHA Data 2010 Proportion of college students who self reported being diagnosed or

treated by a professional for the following:

Nearly 50% of College Health Concerns Addressed in Telephone Triage

Benefits

Contributing to Student Learning Outcomes

1. Students will demonstrate health literacy

2. Students will identify risk reducing behaviors that promote a healthy community

3. Students will demonstrate self-care skills that promote academic success.

Learning Outcome #1

• Students will demonstrate health literacy.

– Resource for follow-up questions

– Referrals and insurance issues

Learning Outcome #2

• Students will Identify risk reducing behaviors that promote a healthy community.

– Antibiotic education

– Sexual Health Issues

– Preventative Care

Learning Outcome #3

• Students will demonstrate self-care skills that promote optimal health to enable academic success.

– Access to knowledge

– Time friendly

Additional Benefits• Identifying an emergent call

• Pt is triaged prior to appt

• Better Use of Services and Time– Reduced Walk-in appointments– Increases availability of same day appointments– More efficient and effective use of office time

Benefits

• Encourages Autonomy– Patient Education– Self-care guidance

• Continuity of Care– Better time management

• Increase Patient Compliance

Benefits• Increased Patient Satisfaction

“The creation of a ‘telephone clinic’ which utilizes nurses and house staff physicians trained and dedicated to telephone communication directly with patients resulted in more efficient management and greater satisfaction for patients.” - Patient Educ Couns. 2010 Sep;80 (3): 351-3 Epub 2010 Aug 4

“If your visit today was preceded by a brief telephone call with a Wellness Center nurse or counselor, did this call help you know what to do next?”

LUC Wellness Center Student Satisfaction Survey

Challenges

• Staffing

• Access

• Potential for Error

• Missed Opportunities

Adapting

Using our EMR to provide written materials

• Teaching sheets

• Referrals

• Secure messages

Collaborating with MH

• RN has access to MH notes

– Can direct calls to appropriate provider in a timely manner

– Can also alert MH provider if there is a specific concern about a pt.

Collaborating Outside the Wellness Center

• After hours RN Advice Line– Phone # left on VM at close– Next day report

• Other LUC departments• Dean of Students• Campus Safety

Collaborating Outside the University

Multi-tasking – what nurses do best

For the Futureof Triage

• Track how many appointments are made as a result of triage calls

• Track the work that is being done in DAN but not being accounted for now.

• Surveying all triage calls for satisfaction rather than just those patients who were actually seen

Screening

Healthy Lifestyle Questionnaire

• Brief Past Medical History Survey

• Gives opportunity to check in with pt in other areas: Nutritional, mental, sexual and social health.

• Can answer questions, make referrals and set up appts in these other areas during the appt

PHQ - 2

Patient Health Questionnaire Depression Module

• Developed by Kroenke, Spitzer and Williams

• Brief measure of depression often used as part of a past medical history questionnaire

• Two-item survey whose questions are derived from symptoms for a DSM-IV diagnosis of major depression

Medical Care. Vol. 41, Number 11, pp 1284-1292. 2003. Lippinott,Williams and Wilkins, Inc.

PHQ-2

• Research has demonstrated that over 82% of patients with major depression score a three or greater

• Initial counseling visit is always offered at WC when patient scores a 3 or greater

Evolution toward Mental Health Telephone Triage

• Traditional Intake Model

• Day-time coverage hours

Benefits of Old System

• 60 minutes, thorough assessment

• In person; facilitated rapport, easier to assess nuances

• Clinical intervention along with assessment

Challenges of Intake Model

• Up to 10-day lag time between initial call and first contact

• Flip side of rapport--face-to-face contact at times made it more difficult to refer out; referral to another internal therapist could be frustrating for clients

• Paperwork burden

• Higher no-show rate

What we hoped to achieve

• Improved efficiency, reduce waitlist

• Reduce paperwork burden e.g. intakes referred out

• Advance the time of first patient contact

• Improve responsiveness to campus partners

• Increase/expedite referrals to the community

• Shift burden from nurse triage line and MH coverage phone

• Avoid intakes on ADHD issues

Rollout Process

• Administrative planning• Helpful guiding resource: Rockland-Miller, H.S. &

Eells, G.T. (2006). The implementation of mental health clinical triage systems in university health services. Journal of College Student Psychotherapy, 20(4), 39-51.

• Consultation• Staff Discussion, input, planning• Implemented Fall 2010 on pilot basis

What We ImplementedTime phone triage intake appointments phone coverage sample schedule

8:00       phone coverage

8:30       2 hours

9:00        

9:30        

10:00       phone triage: 30 min

10:30       phone triage: 30 min

11:00       phone triage: 30 min

11:30       phone triage: 30 min

12:00       lunch

12:30        

1:00       intake: 1 hour

1:30        

2:00       therapy client: 1 hour

2:30        

3:00       therapy client: 1 hour

3:30        

4:00       paperwork: 1hour

4:30        

5:00       therapy client: 1 hour

5:30        

6:00       Gone for day

Booking a triage appointment

• Web based booking

• Dial a nurse

• Front desk staff

• Mental health coverage worker

Phone triage template

Disposition from Triage

• Referred for therapy at Wellness Center• Refer out for therapy• Waitlist• Routine appointment• Priority appointment• Urgent appointment• Emergency appointment• Psychiatry appointment• Group referral

Referring out:

• Database of community providers• Long term/chronic conditions• Not in acute distress• Previous experience with therapy• Demonstrates good insight and high degree of

motivation for long term therapy• Has insurance or financial means for care• Wait list

Likely to be scheduled at WC

• First experience of therapy• Acute state of distress• Cultural barriers to therapy • Lack of family support• Short term treatment appropriate• Referred by campus partner• Financial barriers • Eating Disorder

Case Management into Community Services

When referring out from therapy or triage:

• Therapist calls insurance provider to determine benefits

• Follow up appointments to ensure success of referral

• Use triage appointments to follow up on case management/referrals

Screening: PHQ-9, SRQ

PHQ-9 Results PHQ-9 score

Provisional Diagnosis Treatment Recommendations

5-9 Minimal symptoms Support, educate to call if worse; return in 1 month

10-14 •Minor depression•Dysthymia•Major depression, mild

•Support, watchful waiting•Antidepressant or psychotherapy•Antidepressant or psychotherapy

15-19 Major Depression,

Moderately severe

Antidepressant or psychotherapy

> 20 Major Depression,

Severe

Antidepressant and psychotherapy (especially if not improved on monotherapy)

Challenges• Increased volume for case management

• Assessment more difficult over phone, more difficult to assess/read affect

• Therapist tension between assessing and intervening

• Quality of cell phone connection

• ESL issues

• More difficult to refer to groups

• Trust issues for some

• Access to private phone for some

• Harder with less verbal students

Benefits• Reduced wait for first contact with patient

• Allows staff to attend to intervene early and avert potential crisis situations

• Opportunity to match patient with therapist prior to first visit

• Reduced redundancy for patient

• Increases contact for socially anxious patients/opportunity to do motivational interviewing

• For some, appears to be less threatening or ease disclosure of sensitive information

• Facilitates/expedites community referral if needed

• Reduction in no shows for initial therapy visits

• Some therapists like the different mode/change of pace

Thank YouFor Questions of Comments:

Rachel Ossmo, RN-BSN

Loyola University Chicago

Rossmo@luc.edu

773-508-2530