Journal of Pediatric Nursing (2015) 30, 915–923
Enhancing Care Coordination Through Patient- and Family-Initiated Telephone Encounters: A Quality Improvement Project Judith A. Vessey PhD, MBA, RN, FAAN a,b,⁎, Jennifer McCrave RN, BSN, CNRN c , Catherine Curro-Harrington RN, CPN c , Rachel L. DiFazio PhD, RN, FAAN c a
Medicine Patient Services, Boston Children's Hospital, Boston, MA Boston College, William F. Connell School of Nursing, Chestnut Hill, MA c Boston Children's Hospital, Boston, MA b
Received 17 November 2014; revised 22 May 2015; accepted 23 May 2015
Key words: Care coordination; Telephone triage; Pediatric chronic conditions; Quality improvement
Telehealth activities are often conducted by ambulatory nurses to assist with care coordination; these activities are especially important for children with complex, chronic conditions. This quality-improvement project examines specific components of nursing care delivered to children on the neurology and gastroenterology services through patient-initiated telephone encounters. Metrics and nurse-sensitive indicators explored include the type of services requested, the nurses' ability to resolve patients' concerns while eliminating otherwise unnecessary care, and associated costs with providing this care. The usefulness of a standardized instrument, the care coordination management tool, used in this project is discussed. © 2015 Elsevier Inc. All rights reserved.
WITH THE IMPLEMENTATION of the U.S. Patient Protection and Affordable Care Act (P.L. 111-148) and the emphasis on Accountable Care Organizations, increasing attention is focused on reducing fragmented care delivery systems, quality care issues, and unnecessary costs. Better care coordination is necessary to address these concerns. Care coordination (CC) refers to those patient- and family-centered activities conducted by a team that are designed to meet a family's needs and enhance their caregiving capabilities (Antonelli, McAllister, & Popp, 2009). Telehealth provides one avenue to help operationalize this objective and is consistent with the role of RNs working in ambulatory care (American Academy of Ambulatory Care Nursing, 2012). Selected telehealth strategies are especially important for families of children with chronic, complex conditions where
⁎ Corresponding author: Judith A. Vessey, PhD, MBA, RN, FAAN. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2015.05.012 0882-5963/© 2015 Elsevier Inc. All rights reserved.
care must be highly individualized and address age-related medical and developmental needs. Validated metrics of nurse-sensitive indicators are needed to ensure that the appropriate nursing activities needed for quality, seamless patient care are in place for these populations.
Background Knowledge The term ‘telehealth’ lacks a standardized definition but is broadly defined as the use of technology to deliver health care, health information, or health education at a distance. Telehealth covers a variety of audio and video modalities where content is delivered in real-time communications or ‘store-and-forward’, where information is captured electronically and shared at a later date (Sanmartin et al., 2008). Telehealth is a way of increasing the contact between the healthcare system and patients and their families and shows great potential in the management of complex chronic conditions (U.S. Department of Health and Human Services and Health Information Technology & Quality Improvement).
916 Telephone triage advice services (TTAS), the forerunner to the broader application of telehealth, and is widely used for patient interactions in ambulatory care (Bunn, Byrne, & Kendall, 2004, 2005; Peck, 2005). TTAS may be initiated by providers or patients and families. Provider-initiated calls are most common. They are used to assess patients' conditions following hospital discharge, monitor physiological indicators of worsening chronic conditions (i.e., weight gain and congestive heart disease), and assess patient satisfaction. Patient and family-initiated calls fall into two categories. The first are ‘hot lines’ where patients and families seek advice and clinical guidance on common health concerns. The second is patient or family-initiated telephone encounters (PiTEs) where they are seeking advice for the management of complex chronic conditions. Individuals answering the calls may be either professional nurses or adjunct personnel with specific training in call management. Computer decision support systems (CDSS) have been developed to help nursing and non-nurse personnel provide clinical guidance. These systems are designed to help standardize the processes employed when providing advice for common problems. CDSS have been met with mixed success but have not been used to provide clinical guidance in the management of complex, chronic conditions (Garg et al., 2005; Randell, Mitchell, Dowding, Cullum, & Thompson, 2007; Turnbull, Prichard, Halford, Pope, & Salisbury, 2012). Despite a robust literature on TTAS, its impact on consistently enhancing access, improving long-term clinical outcomes, or reducing costs has not been clearly demonstrated in published research studies or systematic reviews (Carrasquero, Olivereira, & Encarnacao, 2011; Jennette et al., 2003). In part, this is due to the diverse approaches used, lacking either a common definition or a core metric. Moreover, the majority of the current evidence focuses on providerinitiated calls or patient ‘hot lines’ for advice on acute problems. Information specifically examining the role PiTES play in managing ongoing care of complex chronic conditions by nurses in terms of quality and cost is not available. Evidence suggests, however, that patient calls handled by nurses may result in cost-shifting. While managing PiTES reduce overall condition-management expenditures they do consume greater nursing personnel resources (Bunn et al., 2005; Marklund et al., 2007; Richards et al., 2002).
Local Problem and Intended Improvement PiTEs, though heavily used in patient care management at our children's hospital, had not been comprehensively assessed. It was determined that an organized process of cataloging and analyzing calls was needed in order to assess PiTEs' effectiveness, contributions to care coordination, patient satisfaction, and utilization of resources. As an international tertiary care facility and referral center for children with complex pediatric conditions, many patients live outside of the hospital's immediate geographic area. These patients and their families still require extensive support between visits and ambulatory care nurses in
J.A. Vessey et al. specialty clinics use PiTEs to provide assistance to these families. The impressions of nurses who provided clinical guidance for specific issues from parents or patients with complex conditions are that these interactions were more likely to promote therapeutic adherence. When therapeutic adherence is improved, unnecessary costly care such as unwarranted clinic visits is prevented. Simultaneously patient and family satisfaction is improved. All of these are markers of better coordinated care (Antonelli et al., 2009; McAllister, Presler, & Cooley, 2007). No data were available, however, to support these assertions. Moreover, without initial data, benchmarking future care delivery or determining necessary nursing and other personnel resources was not possible. Thus, the aim of this evidence-based, quality improvement project is to examine PiTEs and how its implementation processes and outcomes improve coordinated care for complex pediatric patients. Information obtained could then shape improvements in the coordination of care for complex pediatric patients.
Project Questions Two primary project questions guided this quality improvement project: 1) what did nursing care delivered through PiTEs look like in terms of coordinated care as measured by the delivery of timely information/services, resolution of the patient/family concerns, and decreases in the number of unnecessary patient visits?; 2) what are the costs and cost-effectiveness of care delivered by RNs via PiTEs?
Methods Setting Two diverse ambulatory hospital-based clinics, neurology and gastroenterology, participated. These sites were chosen as they had distinctly different but equally complex patient populations, a high call volume, and an experienced nursing staff. In consultation with the hospital institutional review board, it was determined that this project was designed as a quality improvement project and thus exempt from IRB review.
Planning the Intervention and its Evaluation A team of five clinic nurses and two nurse scientists was formulated. The five clinic nurses were extremely experienced. All five clinic nurses held a BSN degree; one also held a doctor of nursing practice degree. All were nationally certified in pediatric nursing. They have worked in their respective subspecialty areas for between 6–26 years (M = 20 years), and all have worked as RNs for over 20 years. The two nurse scientists both hold PhD degrees and have conducted numerous clinical research projects. The collective experience of the team was instrumental in developing and implementing this project. For the purpose of this project, PiTEs were defined as the process where calls initiated from an established patient or family member are received, assessed, and managed by ambulatory care RNs through: 1) direct intervention; 2) in
Care Coordination Through Telephone Encounters Table 1
917
Key operational definitions.
Variable
Operational Definitions
Encounter Coordinated services Complexity level of patient
Total time spent on the telephone and additional activities needed to address issues (include multiple calls) Shares information and/or designation of tasks among family, school, payers, other agencies Level 1: Non-CSHCN 1, without complicating family or social issues Level 2: Non-CSHCN, with complicating family or social issues Level 3: CSHCN, without complicating family or social issues Level 4: CSHCN, with complicating family or social issues Checklist for determination of CSHCN: (checking yes to any of the following questions = CSHCN) • Does the patient have a physical, developmental, behavioral or emotional condition that has lasted or expected to last at least 12 months? • Is the patient at risk for having a physical, developmental, behavioral or emotional condition that is expected to last at least 12 months? • Does the patient require health and related services of a type or amount beyond that required by children generally? ○ Medicines prescribed by a doctor (other than vitamins) ○ Medical care ○ Mental health services ○ Educational services ○ Specialized therapies (PT, OT, speech) ○ Treatment or counseling for emotional, developmental or behavioral problems • Is the patient limited or prevented in any way in his/her ability to do things most children of the same age can do, due to a chronic medical, behavioral or other health condition? Complicating family or social issues may include: • Single parent without support • Language barrier • Divorce • Low socio-economic status • Drug/Alcohol abuse in home • Homelessness • Loss of job/insurance • Undocumented immigration status • Mental illness in home • Economic concerns • Foster child/ward of the state Complexity level of encounter 1: Minor: Test results within range for that child and no medication changes 2: Low complexity: reassurance, questions about condition with stable child 3: Moderate complexity: change in dosage of existing medications, explaining existing medication plan to parent, parent calling about unexpected symptoms/change in health 4: High complexity: one of the following: • Explaining unexpected abnormal test results with a follow up plan • Explaining a change in a medication plan which is not straightforward • Needing to take a full history from parent about present concern • Upset parent about a change in child's status • Arranging an ED visit or urgent care visit 5: Very high complexity: (at least two of the following) • Explaining unexpected abnormal test results with a follow up plan • Explaining a change in medication plan which is not straightforward • Needing to take a full history from parent about present concern • Upset parent about change in child's status • Arranging ED visit or urgent care 1 CSHCN: Children with special health care needs. The definition, as defined by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB) as “…those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” This definition was originally promulgated by McPherson and colleagues (Pediatrics, 1998:102;137–140. Information retrieved from: http://mchb.hrsa.gov/cshcn05/.
consultation with providers or another service; or 3) resulting in referral to another health, education, or human service professional or agency. All of these activities were conducted
within the nurses' scope of practice as explicated in the state's nurse practice act. This quality improvement project was reviewed and approved by nursing administration.
918 Table 2
J.A. Vessey et al. Characteristics of calls received.
Primary focus of call Clinical management Educational/Medical advice Other Secondary focus of call Clinical management Educational/Medical advice Growth/Nutrition Developmental/Behavioral Educational/School needs Patient needs Referral management Social services Mental health Legal/Judicial Care coordination Clinical management Education Reviewed lab results Make an appointment Follow up referrals Order prescriptions/supplies/services Reconcile discrepancies Coordination of services Transportation Financial barriers Socio-economic issues Result of call Advised on home management Referred to emergency department Scheduled an outpatient clinic visit Referred to primary care provider Referred for hospitalization Referred to laboratory Referred to radiology Referred to community agency Referred to therapy Prescriptions/supplies ordered Reconciled discrepancies Reviewed lab/test results Advocate for patient/family Written report Form process Confer with provider Patient focused research Developed/modified clinical plan Education/Anticipatory guidance Communicated with? Parent Patient Boston Children's Hospital specialist Inter-departmental Primary care provider Administrative staff Payer Non-Boston Children's Hospital provider Home care personnel
Neuro (n = 50)
GI (n = 50)
Combined (N = 100, %)
47 2 1
40 6 4
87 8 5
3 25 1 5 5
6 25 4 0 1
9 50 5 5 6
11 2 1 1
0 1 0 0
11 3 1 1
40 28 14 10 15 21 1 9 0 0 14
27 29 9 4 0 24 7 2 1 1 3
67 57 23 14 15 45 8 11 1 1 17
24 0 10 7 0 8 0 0 4 18 4 16 33 3 8 36 7 37 34
22 1 7 6 0 2 0 1 0 25 7 8 4 0 1 28 0 18 25
46 1 17 13 0 10 0 1 4 43 11 24 37 3 9 64 7 55 59
44 5 40 1 2 30 0 2 1
35 3 27 3 2 8 0 2 1
79 8 67 4 4 38 0 4 2
Care Coordination Through Telephone Encounters
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Table 2 (continued)
Inter-departmental Boston Children's Hospital Pharmacy School/Residential Social worker Department of children and families Radiology Lab Agency Other Type of communication Phone Meeting Interpreter Electronic medical record Other Email Letter Conference call Fax Children's Hospital Applications (maximizing) Patient Safety (CHAMPS) Was chart reviewed? Yes No Did family agree with plan? Yes No Not applicable What was prevented? Emergency department visit Specialist Medication error Labeling/Diagnostic tests Nothing Hospitalization Primary care provider MD call Special therapy Other Complexity of patient One Two Three Four Complexity of encounter One Two Three Four Five
Neuro (n = 50)
GI (n = 50)
Combined (N = 100, %)
0 9 3 0 2 2 0 1 7
1 20 2 1 0 0 3 2 6
1 29 5 1 2 1 3 3 13
46 0 0 0 0 45 15 0 8 7
40 0 1 18 2 28 1 1 12 14
86 0 1 18 2 73 16 1 20 21
50 0
50 0
100 100
46 2 2
39 0 11
85 2 13
3 3 3 0 10 0 1 30 2 5
9 7 6 0 18 1 1 7 0 5
12 10 9 0 28 1 2 37 2 10
0 0 27 23
10 5 22 13
10 5 49 36
2 5 21 18 4
10 11 10 9 10
12 16 31 27 14
This quality improvement project was developed based on evidence synthesized from the research and clinical literature and incorporating ‘best practices’ drawn from team members' extensive clinical experience. As part of this process, the team considered data collection schemes that would capture key
elements of PiTEs and selected the care coordination measurement tool (CCMT) developed by Dr, Richard Antonelli, to be used for this project (Antonelli & Antonelli, 2004; Antonelli, Stille, & Antonelli, 2008). The CCMT has been used successfully in ambulatory settings to gather
920 and quantify care coordination activities required by children with special healthcare needs. It allows for the collection of patient level data regarding needed care coordination services, the complexity of the patients' needs, outcomes resulting from the intervention, and time required by the provider to complete the encounter (Antonelli & Antonelli, 2004; Antonelli et al., 2008). The instrument is completed by the nurse who receives the call and takes approximately 5 minutes to complete. It contains seven separate domains: 1) patient demographics; 2) patient complexity level; 3) care coordination needs; 4) time involvement; 5) necessary provider competence level; 6) activities performed to address patient needs; and 7) outcomes. The tool is published in Pediatrics (Antonelli & Antonelli, 2004), available on the Boston Children's Hospital website, and by contacting the author, Dr. Richard Antonelli. Prior to implementing formal data collection, data collection procedures were codified. The team operationalized selected terms including ‘encounter’, ‘complexity level of patient’, and ‘complexity level of encounter’ which are used on the CCMT and redesigned the form's layout to promote easier and more accurate data collection (Table 1). Standardized procedures for logging calls, determining what constituted an encounter, and completing forms were developed. Often an encounter extended beyond a single call for a concern that could be immediately resolved. An encounter frequently included follow up calls, chart review and consultation with other healthcare providers. Before data collection commenced, the forms and processes were pilot-tested with a set of patient calls. Additional directions and several revisions in item wording on the form were made to improve accuracy. These processes helped ensure that the nurses had uniformed care processes for the patient. Data were collected by the clinic nurses manning the telephone lines on a predetermined staggered schedule. Twenty sequential calls were logged by each service each morning and afternoon for a 5-day period. This timeframe was established as the nurses' impressions were that the types of calls vary with the time of day and day of the week.
Analysis Data were collected for each of the fields listed on the CCMT (Table 2). The analytic plan used descriptive statistics, Spearman's Rho correlations, and t-tests to describe and compare the demographic and clinical characteristics of the entire sample and each of the two clinical subgroups. Baseline data on the costs of PiTEs were analyzed using a modification of micro-costing techniques (Kaplan & Porter, 2011). The total average cost per minute for each PiTE was calculated by first determining the expenses attributable to the nurse (employee compensation, etc.) divided by his or her availability. Availability was calculated by subtracting time (i.e., annual leave, lunch time, meetings & education, etc.) from a 40-hour work week when the nurse was not available to manage PiTEs.
J.A. Vessey et al.
Results Demographics of Calls A total of 100 incoming calls to the nursing call lines were recorded over a 1-week period with 50 calls to each of two ambulatory services.
Results for Study Question I The characteristics of calls received by the nurse are summarized and presented (Table 2). The primary focus of the majority of the calls was on clinical management (n = 87, 87%) followed by education/medical advice (n = 8, 8%). Across both clinics, 31 callers (31%) had additional needs besides the primary purpose for which they called. Occasionally these additional needs were immediately articulated by the caller. The vast majority of these additional needs were uncovered, however, when the nurse was assessing the patient's and family's presenting concern. Based on the assessment findings, the nurses frequently provided further education. The patient's chart was reviewed by the RN 100% of the time. Virtually all (97%) of the calls required their clinical expertise, that hybrid of experience, practical and theoretical knowledge where experienced RNs' use their intuitive abilities to efficiently make clinical decisions within the context of larger patient care situation (McHugh & Lake, 2010). The need for clinical expertise is supported by the complexity of the patient problem. Complexity scores ranged from 1–4 with a mean complexity level of 3.11 (mode = 3, SD = 0.898). The complexity level of the encounter ranged from 1–5 with a mean of 3.15 (mode = 3, SD = 1.209). In the vast majority of the encounters (n = 93, 93%) the primary focus of the call was resolved by the nurse. The majority of the parents (n = 84, 84%) agreed with the plan devised by the nurse during the encounter with only 2 patients (2%) not agreeing. Thirteen of the encounters were not with family members but with other healthcare providers, social service workers, and school personnel who were involved in the child's care. Each PiTE required 1–5 calls to resolve the initial question from the patient or family with an average of 1.85 calls per encounter (median = 2, SD = 0.957) (Table 3). Only one call was triaged to the physician due to a specific request from the primary care provider. Of the 54% of encounters not resolved
Table 3 Number of calls per encounter and time to complete encounters. Number of calls (length of time on call in minutes) (N = 100) Range Mean Mode SD Incoming telephone #1 (N = 100) 1–29 Additional call #2 (n = 54) 1–34 Additional call # 3 (n = 24) 1–16 Additional call # 4 (n = 6) 3–19 Additional call #5 (n = 1) 18 Total # of calls 1–5 Length of calls (in minutes) 1–70
10.4 7.1 6.2 8.5 18.0 1.9 16.2
6.0 4.0 3.0 3.0 18.0 13
6.8 5.8 3.7 5.8 – 1.0 11.3
Care Coordination Through Telephone Encounters during the initial incoming call, the most frequent consultations were with physician specialists (67%), administrative staff (38%), or pharmacists (29%). The total time for encounters ranged from 1 to 70 minutes with an average of 16.18 minutes (median = 14, SD = 11.33), with more complex encounters taking significantly longer. Results of the Spearman's Rank Order correlation demonstrated strong relationships between patient complexity (0.458) and encounter complexity (0.597) and patient complexity and the length of encounter that were statistically significant (p = 0.01 [2-tailed]). The greater the patient complexity, the longer the encounter lasted. Correlation coefficient = 0.458.
Results for Study Question II The costs per encounter ranged from $2.02 to $141.40, with a median cost of $28.28. Cost effective care is determined when the minimal expenditure of dollars, time, and other elements necessary to achieve a desired health outcome is expended. In this sample, 12 families revealed that they had planned on seeking emergent care before they spoke with the clinic nurse; chart reviews indicated that all of these visits were avoided. For two other patients, it was collaboratively determined through assessment data that an emergent clinic visit was necessary, despite their parents' initial desires to manage the issues at home. The costs of PiTEs as determined by comparing compensation rates when delivered by experience in RNs was approximately 66% of what it would be if attending physicians had managed the call. Moreover, CCMT data indicated that 37 calls to physicians were prevented resulting in further savings of the resources including time and compensation.
Discussion Improvements in Care Coordination PiTEs are highly useful in improving care coordination as measured by the delivery of timely information/services, resolution of the patient/family concerns, and decreases in the number of unnecessary patient visits. In this project, care delivered through PiTEs as measured by the CCMT demonstrated that specific patient and family concerns were addressed in a timely and efficient manner. The time to complete each PiTEs was approximately 17 minutes. This contrasts sharply with call times reported in other pediatric telephone triage studies. For example, one study of provider-initiated calls following emergency visits, the average call time was 70 seconds (Jones, Clark, Bradford, & Dougherty, 1988); this is compared to Kaminsky's study of Swedish telenurses answering parents' inquiries regarding acute pediatric problems (e.g., rashes, ear pain, sore throats, etc.) where the median call time for general calls was 4.4 minutes (Kaminsky, Carlsson, Höglund, & Holmström, 2010). The differences in the reported length of calls in these studies are due to more narrow foci of the calls. Moreover, only time on the telephone was calculated. Because nursing's goal was to help coordinate the care of complex patients while addressing PiTEs, the nurses' time was spent not only to
921 resolve the patient or family's primary concern but also to address other concerns that emerged. These differences underscore the importance of determining the goals and appropriate benchmarks for different types of TTAS activities used in managing different patient populations. The overwhelming majority of patient/family concerns that led to the PiTE were efficiently resolved by the RN, either directly or in consultation with other health professionals. Evidence from this project also indicates that PiTEs reduced the number of unnecessary visits for emergent care while facilitating visits for other patients for whom immediate care was necessary. This finding must be interpreted with caution as it is methodologically difficult to measure a non-event (Lohr, 1997). RN-led TTAS have repeatedly shown to reduce unnecessary care without adverse clinical effects (Jennette et al., 2003; Kaminsky et al., 2010). Since experienced ambulatory care RNs provide greater consistency than rotating house staff and are less expensive than attending physicians, they are often the best choice for managing PiTEs that address common concerns of parents caring for children with chronic conditions.
Costs and Cost-Effectiveness of Care Delivered by Registered Nurses (RNs) Via PiTEs This project calculated the monetary costs of PiTEs management by RNs. The median costs per PiTE were relatively modest. However, when there is a large volume of PiTEs managed by experienced nurses, the overall monetary cost for providing this service can become quite expensive, particularly as these services are not routinely reimbursable by private or public insurance schemes. Unfortunately, further explication of cost savings in this project could not be calculated. All types of cost analyses are difficult to conduct as they are confounded by the lack of data transparency (i.e., salary information), insufficient data granularity for direct and indirect costs, inconsistent definitions of terms (costs versus charges), and numerous other methodological issues (Drummond, O'Brien, Stoddart, Torrance, & Sculpher, 2005). This project only used highly experienced RNs to manage PiTEs. Although CDSS have been used to improve the cost-effectiveness of TTAS, they were not employed in this project due to patient complexity. CDSS algorithms lack the sophistication needed for the ongoing management of health problems (Garg et al., 2005; Randell et al., 2007; Turnbull et al., 2012). Moreover, research has demonstrated that RN-moderated telephone interventions provide additional social support to families which are important components of patient adherence and satisfaction (Bunik et al., 2007; Cameron, 1996; DiMatteo, 2004; Finfegeld-Connett, 2005). The use of non-clinicians to replace more expensive clinical staff to screen, manage, and triage calls requesting clinical guidance is becoming more common (Turnbull et al., 2012). These practices, however, may increase costs and wait time for complex patients known to clinic providers. There is a need for clinical agency leadership to clearly discriminate the type of patients receiving care and the appropriate staff mix needed to
922 render the most clinically efficacious and cost-effective care. Such information also would be useful in advancing evidence-based practice.
Nursing and Patient/Family Partnerships Three outcome measures—patient satisfaction, quality of care, and service usage—have been deemed important in evaluating patient-initiated calls to TTAS (Bunn et al., 2005; Valanis et al., 2003). Parents and patients in this quality improvement project reported high levels of agreement with the plans of care. This finding is not surprising. High levels of patient satisfaction and adherence to clinical care recommendations provided during a highly diverse group of TTAS studies have been reported (Blank et al., 2012; Bunik et al., 2007; Bunn et al., 2005). Both are further and positively influenced by the ease in reaching a provider and the interactive role and quality of communication between the caller and provider (Bunn et al., 2005; Purc-Stephenson & Thrasher, 2012). An important consideration for populations such as included in this project where virtually all of the families have long-standing relationships with the clinic nurses. The five clinic nurses were highly experienced and functioned with a great deal of autonomy when providing care to their respective patients during clinic visits or through PiTEs. The nurse–patient/family relationships often extended from the time of the child's diagnosis for a decade or more. It is possible that families and patients trusted the clinic nurses, and recognizing their competence and commitment, relied heavily on their counsel over the years.
Measuring Care Coordination There are a limited number of published instruments useful in designing organizational metrics around care coordination (Jennette et al., 2003; Schultz, Pineda, Lonhart, Davies, & McDonald, 2013). The CCMT provided information that was helpful in looking at the prevalence of various characteristics of PiTEs but did not help explain the trajectory of communications and activities, or their integration into other domains—clinic visits, hospital stays, and school and community programs—that are other essential components of care coordination. The results of this project offer direction for refining the CCMT in collecting essential data needed for addressing the complexity of care coordination. Other tools, such as case management checklists performed at the time of a clinic visit show promise in improving comprehensive service provision (Patel, 2014), but have limited use in coordinating care of complex patients. While such tools help ensure that critical elements of care are systematically addressed; they are not designed to capture individualization of care (Gwande, 2009). The CCMT is currently limited in its current paper-andpencil format. It can, however, be adapted to be included into a patient's electronic health record. Incorporating the CCMT into the electronic medical record would allow it to be linked to other types of patient care applications including the generation of automatic clinical updates, reminder systems,
J.A. Vessey et al. patient safety warning notices, patient satisfaction surveys, or messaging services. Without full integration of these functions, gaps and redundancies in documentation are likely to occur. The ideal tool for measuring the quality of interventions including PiTEs designed to improve care coordination by RNs in ambulatory settings would specifically track the nine dimensions of a care coordination model as proposed by the American Academy of Ambulatory Care Nursing (Haas, Swan, & Haynes, 2013). These include: 1) support for self-management; 2) education and engagement of patient and family; 3) cross setting communication and transition; 4) coaching and counseling of patients and families; 5) use of the nursing process; 6) teamwork and collaboration; 7) patient-centered care planning; 8) decision support and information systems; and 9) advocacy. The CCMT captures many of these elements, but would require refinement in order to fully align with the AACN standard and serve as a validated metric of nurse-sensitive indicators in ambulatory care.
Conclusions Ambulatory care nurses who participate in PiTEs play an important role in CC by improving the quality of patient care through providing clinical management and patient education, streamlining service provision, and helping eliminate unneeded care. The information garnered from this QI project has helped generate clinical, cost, and resource utilization data that are proving useful in determining quality care benchmarks for ambulatory nursing practice. The CCMT provides an initial approach for ambulatory nurses to begin documenting their contributions as it begins to pave the way for identifying key performance indicators that are useful in benchmarking both clinical care and professional services. Additional investigation on this and other instruments is needed in order to fully evaluate the impact that RNs who are managing PiTEs have on improving care coordination for children with complex conditions. Additionally, formal cost–benefit research will help to amplify the financial benefits of conducting PiTEs by RNs.
References American Academy of Ambulatory Care Nursing (2012). American Academy of Ambulatory Care Nursing Position Statement: The role of the registered nurse in ambulatory care. Nursing Economics, 30, 233–239. Antonelli, R. C., & Antonelli, D. M. (2004). Providing a medical home: The cost of care coordination services in a community-based, general pediatric practice. Pediatrics, 113, 1522–1528, http://dx.doi.org/10.1542/peds.113. 5.S1.1522. Antonelli, R. C., McAllister, J. W., & Popp, J. (2009). Making care coordination a critical component of the pediatric health system: A multidisciplinary framework. New York: The Commonwealth Fund (Retrieved from: http://www.lpfch.org/programs/cshcn/Care% 20Coordination%20A%20Multidisciplinary%20Framework.pdf). Antonelli, R. C., Stille, C. J., & Antonelli, D. M. (2008). Care coordination for children and youth with special health care needs: A descriptive, multisite study of activities, personnel costs, and outcomes. Pediatrics, 122, e209–e216, http://dx.doi.org/10.1542/peds.2007-2254. Blank, L., Coster, J., O’Cathain, A., Knowles, E., Tosh, J., Turner, J., et al. (2012). The appropriateness of, and compliance with, telephone triage decisions: A systematic review and narrative analysis. Journal of
Care Coordination Through Telephone Encounters Advanced Nursing, 68, 2610–2621, http://dx.doi.org/10.111/j.1365-2648. 2012.06052.x. Bunik, M., Glazner, J. E., Chandramouli, V., Emsermann, C. B., Hegarty, T., & Kempe, A. (2007). Pediatric telephone call centers: How do they affect health care use and costs? Pediatrics, 119, e305–e313, http://dx.doi.org/ 10.1542/peds.2006-1511. Bunn, F., Bryne, G., & Kendall, S. (2005). The effects of telephone consultation and triage on healthcare use and patient satisfaction: A systematic review. British Journal of General Practice, 55, 956–961. Bunn, R., Byrne, G., & Kendall (2004). Telephone consultation and triage: Effects on health care use and patient satisfaction. The Cochrane Collaboration, 3, http://dx.doi.org/10.1002/14651858.CD004180. pub2 (pages). Cameron, C. (1996). Patient compliance: Recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. Journal of Advanced Nursing, 24, 244–250, http://dx.doi.org/10.1046/j.13652648.1996.01993.x. Carrasquero, S., Olivereira, M., & Encarnacao, P. (2011). Evaluation of telephone triage and advice services: A systematic review on methods, metrics, and results. Studies in Health Technology and Informatics, 169, 407–411, http://dx.doi.org/10.3233/978-1-60750-806-9-407. DiMatteo, M. R. (2004). Social support and patient adherence to medical treatment: A meta-analysis. Health Psychology, 23, 207–218, http://dx. doi.org/10.1037/0278-6133.23.2.207. Drummond, M. F., O'Brien, B. S. G. L., Stoddart, G. L., Torrance, G. W., & Sculpher, M. J. (2005). Methods for the economic evaluation of health care programmes. New York: Oxford University Press. Finfegeld-Connett, D. (2005). Telephone social support or nursing preference: Analysis of a nursing intervention. Qualitative Health Research, 13, 19–21, http://dx.doi.org/10.1177/1049732304269852. Garg, A. X., Neill, K. J., Adhikari, K. J., McDonald, H., Rosas-Arellano, M. P., Devereaus, P. J., et al. (2005). Effects of computerized clinical decision support systems on practitioner performance and patient outcomes. A systematic review. Journal of the American Medical Association, 293, 1223–1238, http://dx.doi.org/10.1001/jama.293.10.1223. Gwande, A. (2009). The checklist manifesto. New York: Metropolitan Books. Haas, S., Swan, B. A., & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition management. Nursing Economics, 31, 44–49. Jennette, P. A., Affleck Hall, L., Hailey, D., Ohinmaa, A., Anderson, C., Thomas, R., et al. (2003). The socio-economic impact of telehealth: A systematic review. Journal of Telemedicine and Telecare, 9, 311–320. Jones, J., Clark, W., Bradford, J., & Dougherty, J. (1988). Efficacy of a telephone follow-up system in the emergency department. Journal of Emergency Medicine, 6, 249–254, http://dx.doi.org/10.1016/0736-4679(88)903336-8. Kaminsky, E., Carlsson, M., Höglund, A. T., & Holmström, I. (2010). Paediatric health calls to Swedish telenurses: A descriptive study of content and outcome. Journal of Telemedicine and Telecare, 16, 454–457. Kaplan, R. S., & Porter, M. E. (2011). How to solve the cost crisis in health care. Harvard Business Review, 1–18.
923 Lohr, K. N. (1997). Perspective: How do we measure quality? Health Affairs, 16, 22–25, http://dx.doi.org/10.1377/hlthaff.16.3.22. Marklund, B., Ström, M., Månsson, J., Borgquist, L., Baigi, A., & Fridlund, B. (2007). Computer-supported telephone nurse triage: An evaluation of medical quality and costs. Journal of Nursing Management, 15, 180–187. McAllister, J. W., Presler, E., & Cooley, C. (2007). Practice-based care coordination: A medical home essential. Pediatrics, 120, e723–e733. McHugh, M. D., & Lake, E. T. (2010). Understanding clinical expertise: Nurse education, experience, and the hospital context. Research in Nursing and Health, 33, 276–287, http://dx.doi.org/10.1002/nur.20388. Patel, A. D. (2014). A case series using a care management checklist to decrease emergency department visits and hospitalizations in children with epilepsy. Journal of Child Neurology, 29, 243–246, http://dx.doi. org/10.1177/0883073813500851. Peck, A. (2005). Changing the face of standard nursing practice through telehealth and telenursing. Nursing Administration Quarterly, 29, 339–343. Purc-Stephenson, R. J., & Thrasher, C. (2012). Patient compliance with telephone triage recommendations: A meta-analytic review. Patient Education and Counseling, 87, 135–142. Randell, R., Mitchell, N., Dowding, D., Cullum, N., & Thompson, C. (2007). Effects of computerized decision support systems on nursing performance and patient outcomes: A systematic review. Journal of Health Services Research and Policy, 12, 242–251, http://dx.doi.org/ 10.1258/135581907782101543. Richards, D. A., Meakins, J., Tawfik, J., Godfrey, L., Dutton, E., Richardson, G., et al. (2002). Nurse telephone triage for same day appointments in general practice: Multiple interrupted time series trial of effect on workload and costs. British Medical Journal, 325, http://dx. doi.org/10.1136/bmj.325.7374.1214 (Retrieved from: http://www.bmj. com/content/325/7374/1214.full.pdf+html). Sanmartin, C., Murphy, K. K., Choptain, N., Conner-Spady, B., Mclaren, L. , Bohm, E., et al. (2008). Appropriateness of healthcare interventions: Concepts and scoping of the published literature. International Journal of Technology Assessment in Health Care, 24, 342–349. Schultz, E. M., Pineda, M., Lonhart, J., Davies, S. M., & McDonald, K. M. (2013). A systematic review of the care coordination measurement landscape. BMC Health Services Research, 13, 1–12, http://dx.doi.org/ 10.1186/1472-6963-13-119 (Retrieved from: http://www. biomedcentral.com/content/pdf/1472-6963-13-119.pdf). Turnbull, J., Prichard, J., Halford, S., Pope, C., & Salisbury, C. (2012). Reconfiguring the emergency and urgent care workforce: Missed methods study of skills and the everyday work of non-clinical call-handlers in the NHS. Journal of Health Services Research and Policy, 17, 233–240. U.S. Department of Health and Human Services, & Health Information Technology and Quality Improvement ()). What is telehealth? Retrieved from: http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/ Telehealth/whatistelehealth.html Valanis, B., Izumi, S., Tanner, C., David, M., Moscato, S. R., Keyes, C., et al. (2003). A model for examining predictors of outcomes of telephone nursing advice. Journal of Nursing Administration, 33, 91–95.
Enhancing Care Coordination Through Patient- and Family-Initiated Telephone Encounters: A Quality Improvement Project Judith A. Vessey PhD, MBA, RN, FAAN a,b,⁎, Jennifer McCrave RN, BSN, CNRN c , Catherine Curro-Harrington RN, CPN c , Rachel L. DiFazio PhD, RN, FAAN c a
Medicine Patient Services, Boston Children's Hospital, Boston, MA Boston College, William F. Connell School of Nursing, Chestnut Hill, MA c Boston Children's Hospital, Boston, MA b
Received 17 November 2014; revised 22 May 2015; accepted 23 May 2015
Key words: Care coordination; Telephone triage; Pediatric chronic conditions; Quality improvement
Telehealth activities are often conducted by ambulatory nurses to assist with care coordination; these activities are especially important for children with complex, chronic conditions. This quality-improvement project examines specific components of nursing care delivered to children on the neurology and gastroenterology services through patient-initiated telephone encounters. Metrics and nurse-sensitive indicators explored include the type of services requested, the nurses' ability to resolve patients' concerns while eliminating otherwise unnecessary care, and associated costs with providing this care. The usefulness of a standardized instrument, the care coordination management tool, used in this project is discussed. © 2015 Elsevier Inc. All rights reserved.
WITH THE IMPLEMENTATION of the U.S. Patient Protection and Affordable Care Act (P.L. 111-148) and the emphasis on Accountable Care Organizations, increasing attention is focused on reducing fragmented care delivery systems, quality care issues, and unnecessary costs. Better care coordination is necessary to address these concerns. Care coordination (CC) refers to those patient- and family-centered activities conducted by a team that are designed to meet a family's needs and enhance their caregiving capabilities (Antonelli, McAllister, & Popp, 2009). Telehealth provides one avenue to help operationalize this objective and is consistent with the role of RNs working in ambulatory care (American Academy of Ambulatory Care Nursing, 2012). Selected telehealth strategies are especially important for families of children with chronic, complex conditions where
⁎ Corresponding author: Judith A. Vessey, PhD, MBA, RN, FAAN. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2015.05.012 0882-5963/© 2015 Elsevier Inc. All rights reserved.
care must be highly individualized and address age-related medical and developmental needs. Validated metrics of nurse-sensitive indicators are needed to ensure that the appropriate nursing activities needed for quality, seamless patient care are in place for these populations.
Background Knowledge The term ‘telehealth’ lacks a standardized definition but is broadly defined as the use of technology to deliver health care, health information, or health education at a distance. Telehealth covers a variety of audio and video modalities where content is delivered in real-time communications or ‘store-and-forward’, where information is captured electronically and shared at a later date (Sanmartin et al., 2008). Telehealth is a way of increasing the contact between the healthcare system and patients and their families and shows great potential in the management of complex chronic conditions (U.S. Department of Health and Human Services and Health Information Technology & Quality Improvement).
916 Telephone triage advice services (TTAS), the forerunner to the broader application of telehealth, and is widely used for patient interactions in ambulatory care (Bunn, Byrne, & Kendall, 2004, 2005; Peck, 2005). TTAS may be initiated by providers or patients and families. Provider-initiated calls are most common. They are used to assess patients' conditions following hospital discharge, monitor physiological indicators of worsening chronic conditions (i.e., weight gain and congestive heart disease), and assess patient satisfaction. Patient and family-initiated calls fall into two categories. The first are ‘hot lines’ where patients and families seek advice and clinical guidance on common health concerns. The second is patient or family-initiated telephone encounters (PiTEs) where they are seeking advice for the management of complex chronic conditions. Individuals answering the calls may be either professional nurses or adjunct personnel with specific training in call management. Computer decision support systems (CDSS) have been developed to help nursing and non-nurse personnel provide clinical guidance. These systems are designed to help standardize the processes employed when providing advice for common problems. CDSS have been met with mixed success but have not been used to provide clinical guidance in the management of complex, chronic conditions (Garg et al., 2005; Randell, Mitchell, Dowding, Cullum, & Thompson, 2007; Turnbull, Prichard, Halford, Pope, & Salisbury, 2012). Despite a robust literature on TTAS, its impact on consistently enhancing access, improving long-term clinical outcomes, or reducing costs has not been clearly demonstrated in published research studies or systematic reviews (Carrasquero, Olivereira, & Encarnacao, 2011; Jennette et al., 2003). In part, this is due to the diverse approaches used, lacking either a common definition or a core metric. Moreover, the majority of the current evidence focuses on providerinitiated calls or patient ‘hot lines’ for advice on acute problems. Information specifically examining the role PiTES play in managing ongoing care of complex chronic conditions by nurses in terms of quality and cost is not available. Evidence suggests, however, that patient calls handled by nurses may result in cost-shifting. While managing PiTES reduce overall condition-management expenditures they do consume greater nursing personnel resources (Bunn et al., 2005; Marklund et al., 2007; Richards et al., 2002).
Local Problem and Intended Improvement PiTEs, though heavily used in patient care management at our children's hospital, had not been comprehensively assessed. It was determined that an organized process of cataloging and analyzing calls was needed in order to assess PiTEs' effectiveness, contributions to care coordination, patient satisfaction, and utilization of resources. As an international tertiary care facility and referral center for children with complex pediatric conditions, many patients live outside of the hospital's immediate geographic area. These patients and their families still require extensive support between visits and ambulatory care nurses in
J.A. Vessey et al. specialty clinics use PiTEs to provide assistance to these families. The impressions of nurses who provided clinical guidance for specific issues from parents or patients with complex conditions are that these interactions were more likely to promote therapeutic adherence. When therapeutic adherence is improved, unnecessary costly care such as unwarranted clinic visits is prevented. Simultaneously patient and family satisfaction is improved. All of these are markers of better coordinated care (Antonelli et al., 2009; McAllister, Presler, & Cooley, 2007). No data were available, however, to support these assertions. Moreover, without initial data, benchmarking future care delivery or determining necessary nursing and other personnel resources was not possible. Thus, the aim of this evidence-based, quality improvement project is to examine PiTEs and how its implementation processes and outcomes improve coordinated care for complex pediatric patients. Information obtained could then shape improvements in the coordination of care for complex pediatric patients.
Project Questions Two primary project questions guided this quality improvement project: 1) what did nursing care delivered through PiTEs look like in terms of coordinated care as measured by the delivery of timely information/services, resolution of the patient/family concerns, and decreases in the number of unnecessary patient visits?; 2) what are the costs and cost-effectiveness of care delivered by RNs via PiTEs?
Methods Setting Two diverse ambulatory hospital-based clinics, neurology and gastroenterology, participated. These sites were chosen as they had distinctly different but equally complex patient populations, a high call volume, and an experienced nursing staff. In consultation with the hospital institutional review board, it was determined that this project was designed as a quality improvement project and thus exempt from IRB review.
Planning the Intervention and its Evaluation A team of five clinic nurses and two nurse scientists was formulated. The five clinic nurses were extremely experienced. All five clinic nurses held a BSN degree; one also held a doctor of nursing practice degree. All were nationally certified in pediatric nursing. They have worked in their respective subspecialty areas for between 6–26 years (M = 20 years), and all have worked as RNs for over 20 years. The two nurse scientists both hold PhD degrees and have conducted numerous clinical research projects. The collective experience of the team was instrumental in developing and implementing this project. For the purpose of this project, PiTEs were defined as the process where calls initiated from an established patient or family member are received, assessed, and managed by ambulatory care RNs through: 1) direct intervention; 2) in
Care Coordination Through Telephone Encounters Table 1
917
Key operational definitions.
Variable
Operational Definitions
Encounter Coordinated services Complexity level of patient
Total time spent on the telephone and additional activities needed to address issues (include multiple calls) Shares information and/or designation of tasks among family, school, payers, other agencies Level 1: Non-CSHCN 1, without complicating family or social issues Level 2: Non-CSHCN, with complicating family or social issues Level 3: CSHCN, without complicating family or social issues Level 4: CSHCN, with complicating family or social issues Checklist for determination of CSHCN: (checking yes to any of the following questions = CSHCN) • Does the patient have a physical, developmental, behavioral or emotional condition that has lasted or expected to last at least 12 months? • Is the patient at risk for having a physical, developmental, behavioral or emotional condition that is expected to last at least 12 months? • Does the patient require health and related services of a type or amount beyond that required by children generally? ○ Medicines prescribed by a doctor (other than vitamins) ○ Medical care ○ Mental health services ○ Educational services ○ Specialized therapies (PT, OT, speech) ○ Treatment or counseling for emotional, developmental or behavioral problems • Is the patient limited or prevented in any way in his/her ability to do things most children of the same age can do, due to a chronic medical, behavioral or other health condition? Complicating family or social issues may include: • Single parent without support • Language barrier • Divorce • Low socio-economic status • Drug/Alcohol abuse in home • Homelessness • Loss of job/insurance • Undocumented immigration status • Mental illness in home • Economic concerns • Foster child/ward of the state Complexity level of encounter 1: Minor: Test results within range for that child and no medication changes 2: Low complexity: reassurance, questions about condition with stable child 3: Moderate complexity: change in dosage of existing medications, explaining existing medication plan to parent, parent calling about unexpected symptoms/change in health 4: High complexity: one of the following: • Explaining unexpected abnormal test results with a follow up plan • Explaining a change in a medication plan which is not straightforward • Needing to take a full history from parent about present concern • Upset parent about a change in child's status • Arranging an ED visit or urgent care visit 5: Very high complexity: (at least two of the following) • Explaining unexpected abnormal test results with a follow up plan • Explaining a change in medication plan which is not straightforward • Needing to take a full history from parent about present concern • Upset parent about change in child's status • Arranging ED visit or urgent care 1 CSHCN: Children with special health care needs. The definition, as defined by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau (MCHB) as “…those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” This definition was originally promulgated by McPherson and colleagues (Pediatrics, 1998:102;137–140. Information retrieved from: http://mchb.hrsa.gov/cshcn05/.
consultation with providers or another service; or 3) resulting in referral to another health, education, or human service professional or agency. All of these activities were conducted
within the nurses' scope of practice as explicated in the state's nurse practice act. This quality improvement project was reviewed and approved by nursing administration.
918 Table 2
J.A. Vessey et al. Characteristics of calls received.
Primary focus of call Clinical management Educational/Medical advice Other Secondary focus of call Clinical management Educational/Medical advice Growth/Nutrition Developmental/Behavioral Educational/School needs Patient needs Referral management Social services Mental health Legal/Judicial Care coordination Clinical management Education Reviewed lab results Make an appointment Follow up referrals Order prescriptions/supplies/services Reconcile discrepancies Coordination of services Transportation Financial barriers Socio-economic issues Result of call Advised on home management Referred to emergency department Scheduled an outpatient clinic visit Referred to primary care provider Referred for hospitalization Referred to laboratory Referred to radiology Referred to community agency Referred to therapy Prescriptions/supplies ordered Reconciled discrepancies Reviewed lab/test results Advocate for patient/family Written report Form process Confer with provider Patient focused research Developed/modified clinical plan Education/Anticipatory guidance Communicated with? Parent Patient Boston Children's Hospital specialist Inter-departmental Primary care provider Administrative staff Payer Non-Boston Children's Hospital provider Home care personnel
Neuro (n = 50)
GI (n = 50)
Combined (N = 100, %)
47 2 1
40 6 4
87 8 5
3 25 1 5 5
6 25 4 0 1
9 50 5 5 6
11 2 1 1
0 1 0 0
11 3 1 1
40 28 14 10 15 21 1 9 0 0 14
27 29 9 4 0 24 7 2 1 1 3
67 57 23 14 15 45 8 11 1 1 17
24 0 10 7 0 8 0 0 4 18 4 16 33 3 8 36 7 37 34
22 1 7 6 0 2 0 1 0 25 7 8 4 0 1 28 0 18 25
46 1 17 13 0 10 0 1 4 43 11 24 37 3 9 64 7 55 59
44 5 40 1 2 30 0 2 1
35 3 27 3 2 8 0 2 1
79 8 67 4 4 38 0 4 2
Care Coordination Through Telephone Encounters
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Table 2 (continued)
Inter-departmental Boston Children's Hospital Pharmacy School/Residential Social worker Department of children and families Radiology Lab Agency Other Type of communication Phone Meeting Interpreter Electronic medical record Other Email Letter Conference call Fax Children's Hospital Applications (maximizing) Patient Safety (CHAMPS) Was chart reviewed? Yes No Did family agree with plan? Yes No Not applicable What was prevented? Emergency department visit Specialist Medication error Labeling/Diagnostic tests Nothing Hospitalization Primary care provider MD call Special therapy Other Complexity of patient One Two Three Four Complexity of encounter One Two Three Four Five
Neuro (n = 50)
GI (n = 50)
Combined (N = 100, %)
0 9 3 0 2 2 0 1 7
1 20 2 1 0 0 3 2 6
1 29 5 1 2 1 3 3 13
46 0 0 0 0 45 15 0 8 7
40 0 1 18 2 28 1 1 12 14
86 0 1 18 2 73 16 1 20 21
50 0
50 0
100 100
46 2 2
39 0 11
85 2 13
3 3 3 0 10 0 1 30 2 5
9 7 6 0 18 1 1 7 0 5
12 10 9 0 28 1 2 37 2 10
0 0 27 23
10 5 22 13
10 5 49 36
2 5 21 18 4
10 11 10 9 10
12 16 31 27 14
This quality improvement project was developed based on evidence synthesized from the research and clinical literature and incorporating ‘best practices’ drawn from team members' extensive clinical experience. As part of this process, the team considered data collection schemes that would capture key
elements of PiTEs and selected the care coordination measurement tool (CCMT) developed by Dr, Richard Antonelli, to be used for this project (Antonelli & Antonelli, 2004; Antonelli, Stille, & Antonelli, 2008). The CCMT has been used successfully in ambulatory settings to gather
920 and quantify care coordination activities required by children with special healthcare needs. It allows for the collection of patient level data regarding needed care coordination services, the complexity of the patients' needs, outcomes resulting from the intervention, and time required by the provider to complete the encounter (Antonelli & Antonelli, 2004; Antonelli et al., 2008). The instrument is completed by the nurse who receives the call and takes approximately 5 minutes to complete. It contains seven separate domains: 1) patient demographics; 2) patient complexity level; 3) care coordination needs; 4) time involvement; 5) necessary provider competence level; 6) activities performed to address patient needs; and 7) outcomes. The tool is published in Pediatrics (Antonelli & Antonelli, 2004), available on the Boston Children's Hospital website, and by contacting the author, Dr. Richard Antonelli. Prior to implementing formal data collection, data collection procedures were codified. The team operationalized selected terms including ‘encounter’, ‘complexity level of patient’, and ‘complexity level of encounter’ which are used on the CCMT and redesigned the form's layout to promote easier and more accurate data collection (Table 1). Standardized procedures for logging calls, determining what constituted an encounter, and completing forms were developed. Often an encounter extended beyond a single call for a concern that could be immediately resolved. An encounter frequently included follow up calls, chart review and consultation with other healthcare providers. Before data collection commenced, the forms and processes were pilot-tested with a set of patient calls. Additional directions and several revisions in item wording on the form were made to improve accuracy. These processes helped ensure that the nurses had uniformed care processes for the patient. Data were collected by the clinic nurses manning the telephone lines on a predetermined staggered schedule. Twenty sequential calls were logged by each service each morning and afternoon for a 5-day period. This timeframe was established as the nurses' impressions were that the types of calls vary with the time of day and day of the week.
Analysis Data were collected for each of the fields listed on the CCMT (Table 2). The analytic plan used descriptive statistics, Spearman's Rho correlations, and t-tests to describe and compare the demographic and clinical characteristics of the entire sample and each of the two clinical subgroups. Baseline data on the costs of PiTEs were analyzed using a modification of micro-costing techniques (Kaplan & Porter, 2011). The total average cost per minute for each PiTE was calculated by first determining the expenses attributable to the nurse (employee compensation, etc.) divided by his or her availability. Availability was calculated by subtracting time (i.e., annual leave, lunch time, meetings & education, etc.) from a 40-hour work week when the nurse was not available to manage PiTEs.
J.A. Vessey et al.
Results Demographics of Calls A total of 100 incoming calls to the nursing call lines were recorded over a 1-week period with 50 calls to each of two ambulatory services.
Results for Study Question I The characteristics of calls received by the nurse are summarized and presented (Table 2). The primary focus of the majority of the calls was on clinical management (n = 87, 87%) followed by education/medical advice (n = 8, 8%). Across both clinics, 31 callers (31%) had additional needs besides the primary purpose for which they called. Occasionally these additional needs were immediately articulated by the caller. The vast majority of these additional needs were uncovered, however, when the nurse was assessing the patient's and family's presenting concern. Based on the assessment findings, the nurses frequently provided further education. The patient's chart was reviewed by the RN 100% of the time. Virtually all (97%) of the calls required their clinical expertise, that hybrid of experience, practical and theoretical knowledge where experienced RNs' use their intuitive abilities to efficiently make clinical decisions within the context of larger patient care situation (McHugh & Lake, 2010). The need for clinical expertise is supported by the complexity of the patient problem. Complexity scores ranged from 1–4 with a mean complexity level of 3.11 (mode = 3, SD = 0.898). The complexity level of the encounter ranged from 1–5 with a mean of 3.15 (mode = 3, SD = 1.209). In the vast majority of the encounters (n = 93, 93%) the primary focus of the call was resolved by the nurse. The majority of the parents (n = 84, 84%) agreed with the plan devised by the nurse during the encounter with only 2 patients (2%) not agreeing. Thirteen of the encounters were not with family members but with other healthcare providers, social service workers, and school personnel who were involved in the child's care. Each PiTE required 1–5 calls to resolve the initial question from the patient or family with an average of 1.85 calls per encounter (median = 2, SD = 0.957) (Table 3). Only one call was triaged to the physician due to a specific request from the primary care provider. Of the 54% of encounters not resolved
Table 3 Number of calls per encounter and time to complete encounters. Number of calls (length of time on call in minutes) (N = 100) Range Mean Mode SD Incoming telephone #1 (N = 100) 1–29 Additional call #2 (n = 54) 1–34 Additional call # 3 (n = 24) 1–16 Additional call # 4 (n = 6) 3–19 Additional call #5 (n = 1) 18 Total # of calls 1–5 Length of calls (in minutes) 1–70
10.4 7.1 6.2 8.5 18.0 1.9 16.2
6.0 4.0 3.0 3.0 18.0 13
6.8 5.8 3.7 5.8 – 1.0 11.3
Care Coordination Through Telephone Encounters during the initial incoming call, the most frequent consultations were with physician specialists (67%), administrative staff (38%), or pharmacists (29%). The total time for encounters ranged from 1 to 70 minutes with an average of 16.18 minutes (median = 14, SD = 11.33), with more complex encounters taking significantly longer. Results of the Spearman's Rank Order correlation demonstrated strong relationships between patient complexity (0.458) and encounter complexity (0.597) and patient complexity and the length of encounter that were statistically significant (p = 0.01 [2-tailed]). The greater the patient complexity, the longer the encounter lasted. Correlation coefficient = 0.458.
Results for Study Question II The costs per encounter ranged from $2.02 to $141.40, with a median cost of $28.28. Cost effective care is determined when the minimal expenditure of dollars, time, and other elements necessary to achieve a desired health outcome is expended. In this sample, 12 families revealed that they had planned on seeking emergent care before they spoke with the clinic nurse; chart reviews indicated that all of these visits were avoided. For two other patients, it was collaboratively determined through assessment data that an emergent clinic visit was necessary, despite their parents' initial desires to manage the issues at home. The costs of PiTEs as determined by comparing compensation rates when delivered by experience in RNs was approximately 66% of what it would be if attending physicians had managed the call. Moreover, CCMT data indicated that 37 calls to physicians were prevented resulting in further savings of the resources including time and compensation.
Discussion Improvements in Care Coordination PiTEs are highly useful in improving care coordination as measured by the delivery of timely information/services, resolution of the patient/family concerns, and decreases in the number of unnecessary patient visits. In this project, care delivered through PiTEs as measured by the CCMT demonstrated that specific patient and family concerns were addressed in a timely and efficient manner. The time to complete each PiTEs was approximately 17 minutes. This contrasts sharply with call times reported in other pediatric telephone triage studies. For example, one study of provider-initiated calls following emergency visits, the average call time was 70 seconds (Jones, Clark, Bradford, & Dougherty, 1988); this is compared to Kaminsky's study of Swedish telenurses answering parents' inquiries regarding acute pediatric problems (e.g., rashes, ear pain, sore throats, etc.) where the median call time for general calls was 4.4 minutes (Kaminsky, Carlsson, Höglund, & Holmström, 2010). The differences in the reported length of calls in these studies are due to more narrow foci of the calls. Moreover, only time on the telephone was calculated. Because nursing's goal was to help coordinate the care of complex patients while addressing PiTEs, the nurses' time was spent not only to
921 resolve the patient or family's primary concern but also to address other concerns that emerged. These differences underscore the importance of determining the goals and appropriate benchmarks for different types of TTAS activities used in managing different patient populations. The overwhelming majority of patient/family concerns that led to the PiTE were efficiently resolved by the RN, either directly or in consultation with other health professionals. Evidence from this project also indicates that PiTEs reduced the number of unnecessary visits for emergent care while facilitating visits for other patients for whom immediate care was necessary. This finding must be interpreted with caution as it is methodologically difficult to measure a non-event (Lohr, 1997). RN-led TTAS have repeatedly shown to reduce unnecessary care without adverse clinical effects (Jennette et al., 2003; Kaminsky et al., 2010). Since experienced ambulatory care RNs provide greater consistency than rotating house staff and are less expensive than attending physicians, they are often the best choice for managing PiTEs that address common concerns of parents caring for children with chronic conditions.
Costs and Cost-Effectiveness of Care Delivered by Registered Nurses (RNs) Via PiTEs This project calculated the monetary costs of PiTEs management by RNs. The median costs per PiTE were relatively modest. However, when there is a large volume of PiTEs managed by experienced nurses, the overall monetary cost for providing this service can become quite expensive, particularly as these services are not routinely reimbursable by private or public insurance schemes. Unfortunately, further explication of cost savings in this project could not be calculated. All types of cost analyses are difficult to conduct as they are confounded by the lack of data transparency (i.e., salary information), insufficient data granularity for direct and indirect costs, inconsistent definitions of terms (costs versus charges), and numerous other methodological issues (Drummond, O'Brien, Stoddart, Torrance, & Sculpher, 2005). This project only used highly experienced RNs to manage PiTEs. Although CDSS have been used to improve the cost-effectiveness of TTAS, they were not employed in this project due to patient complexity. CDSS algorithms lack the sophistication needed for the ongoing management of health problems (Garg et al., 2005; Randell et al., 2007; Turnbull et al., 2012). Moreover, research has demonstrated that RN-moderated telephone interventions provide additional social support to families which are important components of patient adherence and satisfaction (Bunik et al., 2007; Cameron, 1996; DiMatteo, 2004; Finfegeld-Connett, 2005). The use of non-clinicians to replace more expensive clinical staff to screen, manage, and triage calls requesting clinical guidance is becoming more common (Turnbull et al., 2012). These practices, however, may increase costs and wait time for complex patients known to clinic providers. There is a need for clinical agency leadership to clearly discriminate the type of patients receiving care and the appropriate staff mix needed to
922 render the most clinically efficacious and cost-effective care. Such information also would be useful in advancing evidence-based practice.
Nursing and Patient/Family Partnerships Three outcome measures—patient satisfaction, quality of care, and service usage—have been deemed important in evaluating patient-initiated calls to TTAS (Bunn et al., 2005; Valanis et al., 2003). Parents and patients in this quality improvement project reported high levels of agreement with the plans of care. This finding is not surprising. High levels of patient satisfaction and adherence to clinical care recommendations provided during a highly diverse group of TTAS studies have been reported (Blank et al., 2012; Bunik et al., 2007; Bunn et al., 2005). Both are further and positively influenced by the ease in reaching a provider and the interactive role and quality of communication between the caller and provider (Bunn et al., 2005; Purc-Stephenson & Thrasher, 2012). An important consideration for populations such as included in this project where virtually all of the families have long-standing relationships with the clinic nurses. The five clinic nurses were highly experienced and functioned with a great deal of autonomy when providing care to their respective patients during clinic visits or through PiTEs. The nurse–patient/family relationships often extended from the time of the child's diagnosis for a decade or more. It is possible that families and patients trusted the clinic nurses, and recognizing their competence and commitment, relied heavily on their counsel over the years.
Measuring Care Coordination There are a limited number of published instruments useful in designing organizational metrics around care coordination (Jennette et al., 2003; Schultz, Pineda, Lonhart, Davies, & McDonald, 2013). The CCMT provided information that was helpful in looking at the prevalence of various characteristics of PiTEs but did not help explain the trajectory of communications and activities, or their integration into other domains—clinic visits, hospital stays, and school and community programs—that are other essential components of care coordination. The results of this project offer direction for refining the CCMT in collecting essential data needed for addressing the complexity of care coordination. Other tools, such as case management checklists performed at the time of a clinic visit show promise in improving comprehensive service provision (Patel, 2014), but have limited use in coordinating care of complex patients. While such tools help ensure that critical elements of care are systematically addressed; they are not designed to capture individualization of care (Gwande, 2009). The CCMT is currently limited in its current paper-andpencil format. It can, however, be adapted to be included into a patient's electronic health record. Incorporating the CCMT into the electronic medical record would allow it to be linked to other types of patient care applications including the generation of automatic clinical updates, reminder systems,
J.A. Vessey et al. patient safety warning notices, patient satisfaction surveys, or messaging services. Without full integration of these functions, gaps and redundancies in documentation are likely to occur. The ideal tool for measuring the quality of interventions including PiTEs designed to improve care coordination by RNs in ambulatory settings would specifically track the nine dimensions of a care coordination model as proposed by the American Academy of Ambulatory Care Nursing (Haas, Swan, & Haynes, 2013). These include: 1) support for self-management; 2) education and engagement of patient and family; 3) cross setting communication and transition; 4) coaching and counseling of patients and families; 5) use of the nursing process; 6) teamwork and collaboration; 7) patient-centered care planning; 8) decision support and information systems; and 9) advocacy. The CCMT captures many of these elements, but would require refinement in order to fully align with the AACN standard and serve as a validated metric of nurse-sensitive indicators in ambulatory care.
Conclusions Ambulatory care nurses who participate in PiTEs play an important role in CC by improving the quality of patient care through providing clinical management and patient education, streamlining service provision, and helping eliminate unneeded care. The information garnered from this QI project has helped generate clinical, cost, and resource utilization data that are proving useful in determining quality care benchmarks for ambulatory nursing practice. The CCMT provides an initial approach for ambulatory nurses to begin documenting their contributions as it begins to pave the way for identifying key performance indicators that are useful in benchmarking both clinical care and professional services. Additional investigation on this and other instruments is needed in order to fully evaluate the impact that RNs who are managing PiTEs have on improving care coordination for children with complex conditions. Additionally, formal cost–benefit research will help to amplify the financial benefits of conducting PiTEs by RNs.
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