AN INDEPENDENT VOICE FOR NURSING
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“Just a Telephone Call Away”: Transforming the Nursing Profession With Telecare and Telephone Nursing Triage Edtrina L. Moss, MSN, RN-BC, NE-BC Edtrina L. Moss, MSN, RN-BC, NE-BC, is PhD Nursing Science Student, Texas Woman’s University, Houston, TX. Keywords Accreditation, best practice, quality, telephone nursing practice, Veterans Health Administration Correspondence Edtrina L. Moss, MSN, RN-BC, NE-BC, Texas Woman’s University, Houston, TX E-mail: [email protected]
PURPOSE. The purpose of this article is to examine the Institute of Medicine’s recommendations, the National Prevention Council Action Plan, the medical home model, and the nursing standards that drive quality for telephone nursing triage. FINDINGS. These guidelines require reconceptualizing nursing roles, a commitment to lifelong learning, continued competence, and transformational leadership as demonstrated in a best practice case study. CONCLUSION. Given the changing climate of the healthcare system, telephone nurses are capable of improving healthcare delivery in the twenty-first century.
There is no funding support or conflict of interest for this manuscript.
Moss
Telehealth allows healthcare delivery over a distance as an alternative to face-to-face encounters. A subcategory of telehealth is telephone triage. In telephone triage, nurses are considered primary caregivers who provide health advice, emotional support, consultation, resource identification, and counseling. The literature documents the advantages and disadvantages of implementing telephone triage programs (American College of Physicians-American Society of Internal Medicine, 2000; Kevin, 2002; Qureshi, 2010; Richards et al., 2002). Table 1 summarizes the pros and cons of these programs from the patient and nurse perspectives. Telephone triage services are usually performed in health call centers. These call centers routinely operate
in hospitals, managed care organizations, clinics, or other health organizations (McGonigle & Mastrian, 2009). Nurses use evidence-based, computer-accessed decision support algorithms, clinical expertise, and critical thinking skills to provide medical advice regarding the level of care needed (Cariello, 2003). The patient retains autonomy in the process and makes the final choice about seeking care (Nauright, Moneyham, & Williamson, 1999). The American Academy of Ambulatory Care Nursing (AAACN) defined telephone nursing (TN) as all nursing care and services delivered over the telephone (AAACN, 2007). TN provides an avenue for addressing the healthcare needs of chronically and acutely ill patients, regardless of age and geographical 233
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Just a Telephone Call Away
Table 1. Advantages and Disadvantages of Telephone Triage Services Advantages
Disadvantages
Reduction in unnecessary office visits Immediate access to healthcare professionals
Absence of visual cues
Minimizes patient out-of-pocket costs Patient satisfaction with convenience, flexibility, and advice provided Patient and nurse empowerment Centralized service that overcomes geographical barriers Patient remains in comfort of own home Reduction in workload in emergency departments
Increased liability related to improper documentation Increased liability related to incorrect evaluation of urgency of situation Possibly long hold times No reduction in costs of patient management for requests of same-day appointments Possible increase in surgery consultations Inability to use touch as a communication aid Relative patient anonymity
location. TN empowers patients and creates an autonomous environment for self-management of chronic illness, enhances continuity of care, and increases access to healthcare services (Greenberg, 2009). Information technology and computeraccessed decision support algorithms allow the nurse to turn traditional clinician-observable signs into questions whereby the patient becomes the observer and provides answers to signs and symptoms (Pols, 2010). Greenberg (2009) proposed a theoretical model of TN based on the results of a qualitative study aimed to identify the process that nurses used to deliver telephone care (Figure 1). The model describes the process of TN as dynamic and goal-oriented with three phases: gathering information, cognitive processing, and output. The phases are simultaneous or recurring based on the callers’ needs. Interpreting is the central focus in the model that links the actions within the process. The Institute of Medicine (IOM, 2001) published recommendations for implementing information technology infrastructures that could potentially transform healthcare delivery. Due to the expanding demand and implementation of telephone care programs, numerous opportunities exist for nurses to change 234 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
E. L. Moss nursing practice by leading and diffusing collaborative efforts related to improving access to care, outcomes, and patient satisfaction. Recommendations by the IOM’s release of The Future of Nursing: Leading Change, Advancing Health (2011) identified the need to reconceptualize nurses’ roles as health coaches for health promotion and coordination of care. Healthcare reform created the National Prevention Council to focus on disease management and patient education initiatives to improve health. The medical home model (Clarke, 2011) is an emerging best practice aimed to improve care coordination and access. The implementation of health call center standards through accrediting bodies has increased awareness of the need for quality improvement metrics and initiatives related to telephone care and access. Recognition and implementation of ambulatory and telehealth nursing standards demonstrate the continued use of the nursing process in telephone care. The purpose of this article is to explore these recommended best practices jointly as a foundation for improving access, care coordination, quality, and health promotion with TN practice, and identify one best practice case study that has embraced these shifting roles in nursing.
IOM Recommendations on the Future of Nursing The IOM (2011) report identified opportunities for the nursing profession to redesign the healthcare system through reconceptualized roles that would assist in meeting the increased demand for health services. The report identified nurse health coaches as one of those roles. As a health coach, a registered nurse (RN) would provide care coordination among multiple providers, and provide education to families and other caregivers to meet patient needs. Telephone RN health coaches are able to assist with navigating the healthcare system, and address the physical, psychosocial, and environmental factors that may promote or interfere with health maintenance (IOM, 2011). The TN health coach role relies on patientfocused interactions between the nurse and the patient. These interactions integrate self-efficacy, emphasize behavioral lifestyle changes, and utilize motivation as key drivers in collaborating with patients to improve health outcomes (Schenk & Hartley, 2002). The IOM supports the use of telehealth services that not only provide treatment but also include follow-up, health promotion, and increased access to medically underserved communities.
E. L. Moss
Just a Telephone Call Away
Figure 1. The Model of the Process of Telephone Nursing (Greenberg, 2009) Reproduced by permission of Blackwell Publishing Ltd.
The nursing profession depends on knowledge acquisition of its practitioners. According to the IOM (2011), this knowledge acquisition requires a continuous commitment to lifelong learning and continuing
competence. Specialty certification is an example of this commitment. The American Nurses Association’s Congress on Nursing Practice and Economics drafted the criteria for recognizing nursing specialty practice. 235
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Just a Telephone Call Away Specialty certification solidifies nursing’s commitment to lifelong learning and continued competence, and prepares clinicians to meet diverse patient needs, advance the science of the profession, and function as leaders. Specialty certification in ambulatory nursing encompasses TN practice. TN clinicians are able to lead the design of new models of care. These designs include health coaching, health promotion, and patient engagement initiatives that are patientcentered and outcomes-driven. Creating these models of care may create environments for autonomous selfmanagement of chronic illness and care coordination. The National Prevention Council Action Plan The National Prevention Council (2010) was created to focus on national health improvement and prevention strategies. The action plan identified seven strategic priorities designed to improve health and wellness, and provide evidence-based recommendations that have the greatest potential to reduce the leading causes of major illness and preventable death. These priorities are tobacco-free living, healthy eating, preventing drug and alcohol abuse, avoiding sedentary lifestyles, injury- and violence-free living, mental and emotional well-being, and reproductive and sexual health. The council designed these priorities to increase the number of Americans who are healthy at every stage of life. TNs are able to educate about tobacco cessation programs, coach patients and families on healthy eating habits, promote personalized physical activity recommendations, and identify social and environmental resources that may improve mental and emotional well-being. The Medical Home Model The patient-centered medical home model (PCMH) has emerged as a central model of primary care design that provides accessible, coordinated, and patientcentered care as a means to improve quality and potentially reduce healthcare costs (Clarke, 2011; Scholle, Saunders, Tirodkar, Torda, & Pawlson, 2011). The hallmarks of the PCMH include access to care, patient engagement, clinical information systems to measure and track outcomes, team care, patient feedback, and care coordination (Clarke, 2011). TNs are able to serve as key members of the PCMH team. They are able to augment the PCMH goals by providing coaching, counseling, monitoring, chronic care man236 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
E. L. Moss agement, health promotion, care coordination, and health risk appraisals. This care is often provided by health call centers that operate 24 hr a day. Nursing Standards That Drive Quality The AAACN is the professional nursing association that serves as a voice for ambulatory care nurses, identifies care practices as an essential component to access, and sets practice standards for ambulatory and telehealth nursing practice (AAACN, 2012). The AAACN defined telehealth nursing practice as “the delivery, management, and coordination of care and services provided via telecommunications technology within the domain of ambulatory care nursing” (Espensen, 2009, p. 5). RNs perform care using evidence-based information that promotes wellness, assists in the management of illness, and improves patient outcomes (AAACN, 2012). Due to increased use of telehealth and telephone care programs, the AAACN published the fifth edition of the Scope and Standards of Practice for Professional Telehealth Nursing in 2011. These standards support and recognize the RN as the appropriate provider of telehealth nursing care by utilizing the nursing process when providing patient care via the telephone. The American Nurses Credentialing Center (ANCC) is a subsidiary of the American Nurses Association. The ANCC promotes nursing excellence and leadership globally through credentialing programs, such as the Magnet Recognition Program®. Consumers rely on Magnet recognition and designation as the ultimate credential for quality, excellence, and innovations in professional nursing practice (ANCC, 2012). TNs who provide services in Magnet-recognized organizations could be change agents for telephone care. Welldefined shared governance structures allow nurses to improve processes and performance, and advocate for resources that improve outcomes. A study by Armstrong, Laschinger, and Wong (2009) suggests that RNs employed by Magnet-accredited organizations have greater access to empowerment structures and supportive environments that significantly influence a climate of safety for patient care. Health Call Center Quality The Utilization Review Accreditation Commission (URAC) describes health call centers as places that provide triage and health information services to the
Just a Telephone Call Away
E. L. Moss public by telephone, web site, or other electronic means (URAC, 2012). Managed care organizations, clinics, and hospitals typically implement call center services to provide access to healthcare advice after hours, manage care demands, and reduce the number of unnecessary visits to emergency departments (Bunn, Byrne, & Kendall, 2009). Quality drivers distinct to health call centers ensure confidential, up-todate, and evidence-based advice, as well as timely access for consumers. Continuous monitoring of these metrics is necessary to maintain and improve program outcomes. Many organizations have turned to accreditation processes to ensure ongoing quality measures. Accreditation is a process by which an impartial thirdparty organization reviews health call center standards to ensure that the performance metrics of the call center consistently meet national standards (URAC, 2012). The URAC is one such organization that accredits health call centers. These standards assure the public that RNs, pharmacists, and physicians provide timely access and evidence-based advice to consumers. TNs are able to advocate for processes that improve access and reduce cost. Integration of web chats, automated workforce management solutions for real-time scheduling and forecasting, and automated quality management solutions for customer satisfaction metrics are examples (North American Quitline Consortium, 2010). Results from several studies report that more than half of patients would use telephone triage services again and were satisfied with the advice or outcome during their interactions (Bunn et al., 2009; Williams, Warren, McKim, & Janzen, 2012). Best Practice Case Study One organization has managed to glean national recommendations from the IOM, the National Prevention Action Plan, and quality standards that together create an environment conducive to the shifting nursing roles necessary for TN. The Veterans Health Administration (VHA) implemented a telephone care policy in 1994. The policy had several goals that include around-the-clock access to healthcare advice, telephone service integrated with primary care, alternatives to face-to-face visits for optimal utilization of services, and enhance veterans’ ability to problemsolve and self-manage their care (Department of Veterans Affairs, 2009). The VHA established a national initiative for its regional and Veterans Integrated Service Network (VISN) call centers to achieve national accreditation in telephone care through the
URAC (Department of Veterans Affairs, 2010). The VHA policy for telephone care uses benchmark studies from Kaiser Permanente California call centers, URAC, and the Federal Consortium Benchmark Study Report: “Best Practices in Telephone Service” published in 1995 (Department of Veterans Affairs, 2010). To date, there are nine accredited VISN and regional health call centers (URAC, 2012). The VHA health call center in Houston, Texas, received its first URAC accreditation in 2003. The program continues to maintain full accreditation status. As outlined in the National Prevention Council Action Plan, the VHA is one of the 17 federal departments working to move the healthcare system from an illness-based model to wellness and prevention. The model of care for the VHA emphasizes outpatient care, community clinics, and prevention. This model makes use of information technology and coordination of care practices that may be more efficient than any other healthcare system in the country (Longman, 2012). TNs are able to effectively coordinate care with information technologies, and create efficient processes that decrease unnecessary emergency room visits, increase access to medical care, and provide evidence-based medical advice. The VHA was also an early adopter of the PCMH model, the model officially launched as Patient Aligned Care Teams (PACT) in April 2010 (Fortney, Kaboli, & Eisen, 2011). The VA has implemented PACT with expanded roles for RNs as care managers. One of the roles of the care manager includes daily patient contact via telephone for follow-up, education, and appointment verification. Nursing leadership in VHA shows its commitment to excellence in nursing through the Magnet Recognition Program®. There are currently four VHA Magnet-recognized facilities in the United States (ANCC, 2012). The VHA Medical Center in Houston, Texas, was the second in the nation to achieve this recognition. The style of nursing leadership that flows from the point of care to the boardroom supports the transformational leadership needed for Magnet designation and innovative practices in TN care and access (IOM, 2011). Implications for Nursing Practice The last decade has seen tremendous expansion in telehealth services that include remote monitoring, follow-up with computerized reminders, care coordination, health promotion, and telephone triage. TNs 237
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Just a Telephone Call Away create an autonomous environment for selfmanagement of chronic illness and increased access to healthcare services. This specialty area of nursing creates an ideal environment for clinicians to restructure nursing practice. TNs are able to lead changes through new and innovative roles, such as health coaches. This role would prove beneficial in providing care coordination, patient education, health promotion through behavior change models, and improved access for patients 24 hr a day. Recommendations for future nursing research include testing theoretical frameworks and assumptions specific to the role of TNs as health coaches. Testing the effectiveness of evidence-based health coaching curriculums provided to TNs may also prove noteworthy in supporting this reconceptualized role. Telephone RNs are able to lead in systems redesign, implementation, and evaluation of ongoing reforms that highlight health promotion and disease prevention initiatives. Their leadership efforts are important to providing quality care and ensuring patient engagement related to access. These clinicians are uniquely positioned to create new models of nursing care that are patient-centered and outcomes-driven. Executive nursing leaders are able to impact organizational leadership efforts through advocating for and driving telephone care initiatives empirically proven to improve care coordination, patient satisfaction, and access. Nursing leadership in the boardroom is necessary for TN to achieve the goals of improved patient engagement, operational efficiency, quality care, and client satisfaction. TNs are able to maintain the necessary human interaction and use information technology infrastructures that may effectively transform healthcare delivery. Conclusion The future of TN practice is boundless. Technology and innovations in communications allows for realtime healthcare delivery while maintaining a caring human interaction. Effectiveness intervention studies related to TN practice have the potential to highlight the need to expand TN strategies that focus on improving healthcare delivery and translating research into practice in the twenty-first century. References American Academy of Ambulatory Care Nursing. (2007). Telehealth nursing practice administration and practice standards (4th ed.). Pitman, NJ: Author. 238 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
E. L. Moss American Academy of Ambulatory Care Nursing. (2012). About AAACN. Retrieved from http://www.aaacn.org/ about-aaacn American College of Physicians-American Society of Internal Medicine. (2000). Telephone triage. Retrieved from http://www.acponline.org/acp_policy/policies/telephone _triage_diagnostic_techniques_procedures_2000.pdf American Nurses Credentialing Center. (2012). Magnet Program overview. Retrieved from http://www .nursecredentialing.org/Magnet/ProgramOverview Armstrong, K., Laschinger, H., & Wong, C. (2009). Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate. Journal of Nursing Care Quality, 24(1), 55–62. Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/19641435 Bunn, F., Byrne, B., & Kendall, S. (2009). Telephone consultation and triage: Effects on health care use and patient satisfaction. Cochrane Database of Systematic Reviews, Issue 3. Article no. CD004180. doi:10.1002/14651858 .CD004180.pub2 Cariello, F. (2003). Computerized telephone nurse triage: An evaluation of service quality and cost. Journal of Ambulatory Care Management, 26(2), 124–137. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12698927 Clarke, J. L. (2011). Seeking patient-centered solutions to a national epidemic. Population Health Management, 14(Suppl. 2), S-3–S-16. doi:10.1089/pop.2011.1482 Department of Veterans Affairs. (2009). DeBakey VA ReDesignated Magnet Hospital by American Nurse Credentialing Center. Retrieved from http://www.houston.va.gov/ pressreleases/News_20090114b.asp Department of Veterans Affairs. (2010). Primary Care Program Office: Telephone care. Retrieved from http://www.va.gov/ PrimaryCare/tc/ Espensen, M. (2009). Telehealth nursing practice essentials. Pitman, NJ: American Academy of Ambulatory Care Nursing. Fortney, J., Kaboli, P., & Eisen, S. (2011). Improving access to VA care. Journal of Internal Medicine, 26(Suppl. 2), 621–622. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3191216/pdf/11606_2011_Article _1850.pdf Greenberg, M. (2009). A comprehensive model of the process of telephone nursing. Journal of Advanced Nursing, 65(12), 2621–2629. doi:10.1111/j.1365-2648.2009 .05132.x Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy of Sciences. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Kevin, J. (2002). An evaluation of telephone triage in mental health nursing. Australian e-Journal for the Advancement of Mental Health, 1(1), 1–12. Retrieved from http://www.medibankhealth.com.au/files/editor _upload/File/publications/MH_03_evaluation_mental _health_triage.pdf Longman, P. (2012). Best care anywhere: Why VA health care would work better for everyone. San Francisco: Berrett-Koehler.
E. L. Moss McGonigle, D., & Mastrian, K. (2009). Nursing informatics and the foundation of knowledge. Mississauga, ON: Jones and Bartlett. National Prevention Council. (2010, June 1). National Prevention Council Action Plan: Implementing the national prevention strategy. Retrieved from http://www .surgeongeneral.gov/initiatives/prevention/2012-npc -action-plan.pdf Nauright, L., Moneyham, L., & Williamson, J. (1999). Telephone triage and consultation: An emerging role for nurses. Nursing Outlook, 47(2), 219–226. Retrieved from http://download.journals.elsevierhealth.com/pdfs/ journals/0029-6554/PIIS0029655499900544.pdf North American Quitline Consortium. (2010). Call center metrics: Fundamentals of call center staffing and technologies. Retrieved from http://c.ymcdn.com/sites/www .naquitline.org/resource/resmgr/issue_papers/ callcentermetricspaperbestpr.pdf Pols, J. (2010). The heart of the matter. About good nursing and telecare. Health Care Analysis, 18, 374–388. doi:10.1007/s10728-009-0140-1 Qureshi, N. A. (2010). Triage systems: A review of the literature with reference to Saudi Arabia. Eastern Mediterranean Health Journal, 16(6), 690–698. Retrieved from http://applications.emro.who.int/emhj/V16/06/ 16_6_2010_0690_0698.pdf
Just a Telephone Call Away Richards, D., Meakins, J., Tawfik, J., Godfrey, L., Dutton, E., Richardson, G., & Russell, D. (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(23), 1–6. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC135495/pdf/1214.pd Schenk, S., & Hartley, K. (2002). Nurse coach: Healthcare resource for this millennium. Nursing Forum, 37(3), 14–20. doi: 10.1111/j.1744-6198.2002.tb01006.x Scholle, S., Saunders, R., Tirodkar, M., Torda, P., & Pawlson, L. (2011). Patient-centered medical homes in the United States. Journal of Ambulatory Care Management, 34(1), 20–32. Retrieved from http://ca3cx5qj7w.search.serials solutions.com/OpenURL_local?sid=Entrez:PubMed&id =pmid:21160349 Utilization Review Accreditation Commission. (2012). General questions about URAC accreditation. Retrieved from https://www.urac.org/healthcare/accreditation/ Williams, B., Warren, S., McKim, R., & Janzen, W. (2012). Caller self-care decisions following teletriage advice. Journal of Clinical Nursing, 21, 1041–1050. doi:10.1111/ j.1365-2702.2011.03986.x
239 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
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“Just a Telephone Call Away”: Transforming the Nursing Profession With Telecare and Telephone Nursing Triage Edtrina L. Moss, MSN, RN-BC, NE-BC Edtrina L. Moss, MSN, RN-BC, NE-BC, is PhD Nursing Science Student, Texas Woman’s University, Houston, TX. Keywords Accreditation, best practice, quality, telephone nursing practice, Veterans Health Administration Correspondence Edtrina L. Moss, MSN, RN-BC, NE-BC, Texas Woman’s University, Houston, TX E-mail: [email protected]
PURPOSE. The purpose of this article is to examine the Institute of Medicine’s recommendations, the National Prevention Council Action Plan, the medical home model, and the nursing standards that drive quality for telephone nursing triage. FINDINGS. These guidelines require reconceptualizing nursing roles, a commitment to lifelong learning, continued competence, and transformational leadership as demonstrated in a best practice case study. CONCLUSION. Given the changing climate of the healthcare system, telephone nurses are capable of improving healthcare delivery in the twenty-first century.
There is no funding support or conflict of interest for this manuscript.
Moss
Telehealth allows healthcare delivery over a distance as an alternative to face-to-face encounters. A subcategory of telehealth is telephone triage. In telephone triage, nurses are considered primary caregivers who provide health advice, emotional support, consultation, resource identification, and counseling. The literature documents the advantages and disadvantages of implementing telephone triage programs (American College of Physicians-American Society of Internal Medicine, 2000; Kevin, 2002; Qureshi, 2010; Richards et al., 2002). Table 1 summarizes the pros and cons of these programs from the patient and nurse perspectives. Telephone triage services are usually performed in health call centers. These call centers routinely operate
in hospitals, managed care organizations, clinics, or other health organizations (McGonigle & Mastrian, 2009). Nurses use evidence-based, computer-accessed decision support algorithms, clinical expertise, and critical thinking skills to provide medical advice regarding the level of care needed (Cariello, 2003). The patient retains autonomy in the process and makes the final choice about seeking care (Nauright, Moneyham, & Williamson, 1999). The American Academy of Ambulatory Care Nursing (AAACN) defined telephone nursing (TN) as all nursing care and services delivered over the telephone (AAACN, 2007). TN provides an avenue for addressing the healthcare needs of chronically and acutely ill patients, regardless of age and geographical 233
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Just a Telephone Call Away
Table 1. Advantages and Disadvantages of Telephone Triage Services Advantages
Disadvantages
Reduction in unnecessary office visits Immediate access to healthcare professionals
Absence of visual cues
Minimizes patient out-of-pocket costs Patient satisfaction with convenience, flexibility, and advice provided Patient and nurse empowerment Centralized service that overcomes geographical barriers Patient remains in comfort of own home Reduction in workload in emergency departments
Increased liability related to improper documentation Increased liability related to incorrect evaluation of urgency of situation Possibly long hold times No reduction in costs of patient management for requests of same-day appointments Possible increase in surgery consultations Inability to use touch as a communication aid Relative patient anonymity
location. TN empowers patients and creates an autonomous environment for self-management of chronic illness, enhances continuity of care, and increases access to healthcare services (Greenberg, 2009). Information technology and computeraccessed decision support algorithms allow the nurse to turn traditional clinician-observable signs into questions whereby the patient becomes the observer and provides answers to signs and symptoms (Pols, 2010). Greenberg (2009) proposed a theoretical model of TN based on the results of a qualitative study aimed to identify the process that nurses used to deliver telephone care (Figure 1). The model describes the process of TN as dynamic and goal-oriented with three phases: gathering information, cognitive processing, and output. The phases are simultaneous or recurring based on the callers’ needs. Interpreting is the central focus in the model that links the actions within the process. The Institute of Medicine (IOM, 2001) published recommendations for implementing information technology infrastructures that could potentially transform healthcare delivery. Due to the expanding demand and implementation of telephone care programs, numerous opportunities exist for nurses to change 234 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
E. L. Moss nursing practice by leading and diffusing collaborative efforts related to improving access to care, outcomes, and patient satisfaction. Recommendations by the IOM’s release of The Future of Nursing: Leading Change, Advancing Health (2011) identified the need to reconceptualize nurses’ roles as health coaches for health promotion and coordination of care. Healthcare reform created the National Prevention Council to focus on disease management and patient education initiatives to improve health. The medical home model (Clarke, 2011) is an emerging best practice aimed to improve care coordination and access. The implementation of health call center standards through accrediting bodies has increased awareness of the need for quality improvement metrics and initiatives related to telephone care and access. Recognition and implementation of ambulatory and telehealth nursing standards demonstrate the continued use of the nursing process in telephone care. The purpose of this article is to explore these recommended best practices jointly as a foundation for improving access, care coordination, quality, and health promotion with TN practice, and identify one best practice case study that has embraced these shifting roles in nursing.
IOM Recommendations on the Future of Nursing The IOM (2011) report identified opportunities for the nursing profession to redesign the healthcare system through reconceptualized roles that would assist in meeting the increased demand for health services. The report identified nurse health coaches as one of those roles. As a health coach, a registered nurse (RN) would provide care coordination among multiple providers, and provide education to families and other caregivers to meet patient needs. Telephone RN health coaches are able to assist with navigating the healthcare system, and address the physical, psychosocial, and environmental factors that may promote or interfere with health maintenance (IOM, 2011). The TN health coach role relies on patientfocused interactions between the nurse and the patient. These interactions integrate self-efficacy, emphasize behavioral lifestyle changes, and utilize motivation as key drivers in collaborating with patients to improve health outcomes (Schenk & Hartley, 2002). The IOM supports the use of telehealth services that not only provide treatment but also include follow-up, health promotion, and increased access to medically underserved communities.
E. L. Moss
Just a Telephone Call Away
Figure 1. The Model of the Process of Telephone Nursing (Greenberg, 2009) Reproduced by permission of Blackwell Publishing Ltd.
The nursing profession depends on knowledge acquisition of its practitioners. According to the IOM (2011), this knowledge acquisition requires a continuous commitment to lifelong learning and continuing
competence. Specialty certification is an example of this commitment. The American Nurses Association’s Congress on Nursing Practice and Economics drafted the criteria for recognizing nursing specialty practice. 235
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Just a Telephone Call Away Specialty certification solidifies nursing’s commitment to lifelong learning and continued competence, and prepares clinicians to meet diverse patient needs, advance the science of the profession, and function as leaders. Specialty certification in ambulatory nursing encompasses TN practice. TN clinicians are able to lead the design of new models of care. These designs include health coaching, health promotion, and patient engagement initiatives that are patientcentered and outcomes-driven. Creating these models of care may create environments for autonomous selfmanagement of chronic illness and care coordination. The National Prevention Council Action Plan The National Prevention Council (2010) was created to focus on national health improvement and prevention strategies. The action plan identified seven strategic priorities designed to improve health and wellness, and provide evidence-based recommendations that have the greatest potential to reduce the leading causes of major illness and preventable death. These priorities are tobacco-free living, healthy eating, preventing drug and alcohol abuse, avoiding sedentary lifestyles, injury- and violence-free living, mental and emotional well-being, and reproductive and sexual health. The council designed these priorities to increase the number of Americans who are healthy at every stage of life. TNs are able to educate about tobacco cessation programs, coach patients and families on healthy eating habits, promote personalized physical activity recommendations, and identify social and environmental resources that may improve mental and emotional well-being. The Medical Home Model The patient-centered medical home model (PCMH) has emerged as a central model of primary care design that provides accessible, coordinated, and patientcentered care as a means to improve quality and potentially reduce healthcare costs (Clarke, 2011; Scholle, Saunders, Tirodkar, Torda, & Pawlson, 2011). The hallmarks of the PCMH include access to care, patient engagement, clinical information systems to measure and track outcomes, team care, patient feedback, and care coordination (Clarke, 2011). TNs are able to serve as key members of the PCMH team. They are able to augment the PCMH goals by providing coaching, counseling, monitoring, chronic care man236 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
E. L. Moss agement, health promotion, care coordination, and health risk appraisals. This care is often provided by health call centers that operate 24 hr a day. Nursing Standards That Drive Quality The AAACN is the professional nursing association that serves as a voice for ambulatory care nurses, identifies care practices as an essential component to access, and sets practice standards for ambulatory and telehealth nursing practice (AAACN, 2012). The AAACN defined telehealth nursing practice as “the delivery, management, and coordination of care and services provided via telecommunications technology within the domain of ambulatory care nursing” (Espensen, 2009, p. 5). RNs perform care using evidence-based information that promotes wellness, assists in the management of illness, and improves patient outcomes (AAACN, 2012). Due to increased use of telehealth and telephone care programs, the AAACN published the fifth edition of the Scope and Standards of Practice for Professional Telehealth Nursing in 2011. These standards support and recognize the RN as the appropriate provider of telehealth nursing care by utilizing the nursing process when providing patient care via the telephone. The American Nurses Credentialing Center (ANCC) is a subsidiary of the American Nurses Association. The ANCC promotes nursing excellence and leadership globally through credentialing programs, such as the Magnet Recognition Program®. Consumers rely on Magnet recognition and designation as the ultimate credential for quality, excellence, and innovations in professional nursing practice (ANCC, 2012). TNs who provide services in Magnet-recognized organizations could be change agents for telephone care. Welldefined shared governance structures allow nurses to improve processes and performance, and advocate for resources that improve outcomes. A study by Armstrong, Laschinger, and Wong (2009) suggests that RNs employed by Magnet-accredited organizations have greater access to empowerment structures and supportive environments that significantly influence a climate of safety for patient care. Health Call Center Quality The Utilization Review Accreditation Commission (URAC) describes health call centers as places that provide triage and health information services to the
Just a Telephone Call Away
E. L. Moss public by telephone, web site, or other electronic means (URAC, 2012). Managed care organizations, clinics, and hospitals typically implement call center services to provide access to healthcare advice after hours, manage care demands, and reduce the number of unnecessary visits to emergency departments (Bunn, Byrne, & Kendall, 2009). Quality drivers distinct to health call centers ensure confidential, up-todate, and evidence-based advice, as well as timely access for consumers. Continuous monitoring of these metrics is necessary to maintain and improve program outcomes. Many organizations have turned to accreditation processes to ensure ongoing quality measures. Accreditation is a process by which an impartial thirdparty organization reviews health call center standards to ensure that the performance metrics of the call center consistently meet national standards (URAC, 2012). The URAC is one such organization that accredits health call centers. These standards assure the public that RNs, pharmacists, and physicians provide timely access and evidence-based advice to consumers. TNs are able to advocate for processes that improve access and reduce cost. Integration of web chats, automated workforce management solutions for real-time scheduling and forecasting, and automated quality management solutions for customer satisfaction metrics are examples (North American Quitline Consortium, 2010). Results from several studies report that more than half of patients would use telephone triage services again and were satisfied with the advice or outcome during their interactions (Bunn et al., 2009; Williams, Warren, McKim, & Janzen, 2012). Best Practice Case Study One organization has managed to glean national recommendations from the IOM, the National Prevention Action Plan, and quality standards that together create an environment conducive to the shifting nursing roles necessary for TN. The Veterans Health Administration (VHA) implemented a telephone care policy in 1994. The policy had several goals that include around-the-clock access to healthcare advice, telephone service integrated with primary care, alternatives to face-to-face visits for optimal utilization of services, and enhance veterans’ ability to problemsolve and self-manage their care (Department of Veterans Affairs, 2009). The VHA established a national initiative for its regional and Veterans Integrated Service Network (VISN) call centers to achieve national accreditation in telephone care through the
URAC (Department of Veterans Affairs, 2010). The VHA policy for telephone care uses benchmark studies from Kaiser Permanente California call centers, URAC, and the Federal Consortium Benchmark Study Report: “Best Practices in Telephone Service” published in 1995 (Department of Veterans Affairs, 2010). To date, there are nine accredited VISN and regional health call centers (URAC, 2012). The VHA health call center in Houston, Texas, received its first URAC accreditation in 2003. The program continues to maintain full accreditation status. As outlined in the National Prevention Council Action Plan, the VHA is one of the 17 federal departments working to move the healthcare system from an illness-based model to wellness and prevention. The model of care for the VHA emphasizes outpatient care, community clinics, and prevention. This model makes use of information technology and coordination of care practices that may be more efficient than any other healthcare system in the country (Longman, 2012). TNs are able to effectively coordinate care with information technologies, and create efficient processes that decrease unnecessary emergency room visits, increase access to medical care, and provide evidence-based medical advice. The VHA was also an early adopter of the PCMH model, the model officially launched as Patient Aligned Care Teams (PACT) in April 2010 (Fortney, Kaboli, & Eisen, 2011). The VA has implemented PACT with expanded roles for RNs as care managers. One of the roles of the care manager includes daily patient contact via telephone for follow-up, education, and appointment verification. Nursing leadership in VHA shows its commitment to excellence in nursing through the Magnet Recognition Program®. There are currently four VHA Magnet-recognized facilities in the United States (ANCC, 2012). The VHA Medical Center in Houston, Texas, was the second in the nation to achieve this recognition. The style of nursing leadership that flows from the point of care to the boardroom supports the transformational leadership needed for Magnet designation and innovative practices in TN care and access (IOM, 2011). Implications for Nursing Practice The last decade has seen tremendous expansion in telehealth services that include remote monitoring, follow-up with computerized reminders, care coordination, health promotion, and telephone triage. TNs 237
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Just a Telephone Call Away create an autonomous environment for selfmanagement of chronic illness and increased access to healthcare services. This specialty area of nursing creates an ideal environment for clinicians to restructure nursing practice. TNs are able to lead changes through new and innovative roles, such as health coaches. This role would prove beneficial in providing care coordination, patient education, health promotion through behavior change models, and improved access for patients 24 hr a day. Recommendations for future nursing research include testing theoretical frameworks and assumptions specific to the role of TNs as health coaches. Testing the effectiveness of evidence-based health coaching curriculums provided to TNs may also prove noteworthy in supporting this reconceptualized role. Telephone RNs are able to lead in systems redesign, implementation, and evaluation of ongoing reforms that highlight health promotion and disease prevention initiatives. Their leadership efforts are important to providing quality care and ensuring patient engagement related to access. These clinicians are uniquely positioned to create new models of nursing care that are patient-centered and outcomes-driven. Executive nursing leaders are able to impact organizational leadership efforts through advocating for and driving telephone care initiatives empirically proven to improve care coordination, patient satisfaction, and access. Nursing leadership in the boardroom is necessary for TN to achieve the goals of improved patient engagement, operational efficiency, quality care, and client satisfaction. TNs are able to maintain the necessary human interaction and use information technology infrastructures that may effectively transform healthcare delivery. Conclusion The future of TN practice is boundless. Technology and innovations in communications allows for realtime healthcare delivery while maintaining a caring human interaction. Effectiveness intervention studies related to TN practice have the potential to highlight the need to expand TN strategies that focus on improving healthcare delivery and translating research into practice in the twenty-first century. References American Academy of Ambulatory Care Nursing. (2007). Telehealth nursing practice administration and practice standards (4th ed.). Pitman, NJ: Author. 238 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
E. L. Moss American Academy of Ambulatory Care Nursing. (2012). About AAACN. Retrieved from http://www.aaacn.org/ about-aaacn American College of Physicians-American Society of Internal Medicine. (2000). Telephone triage. Retrieved from http://www.acponline.org/acp_policy/policies/telephone _triage_diagnostic_techniques_procedures_2000.pdf American Nurses Credentialing Center. (2012). Magnet Program overview. Retrieved from http://www .nursecredentialing.org/Magnet/ProgramOverview Armstrong, K., Laschinger, H., & Wong, C. (2009). Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate. Journal of Nursing Care Quality, 24(1), 55–62. Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/19641435 Bunn, F., Byrne, B., & Kendall, S. (2009). Telephone consultation and triage: Effects on health care use and patient satisfaction. Cochrane Database of Systematic Reviews, Issue 3. Article no. CD004180. doi:10.1002/14651858 .CD004180.pub2 Cariello, F. (2003). Computerized telephone nurse triage: An evaluation of service quality and cost. Journal of Ambulatory Care Management, 26(2), 124–137. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12698927 Clarke, J. L. (2011). Seeking patient-centered solutions to a national epidemic. Population Health Management, 14(Suppl. 2), S-3–S-16. doi:10.1089/pop.2011.1482 Department of Veterans Affairs. (2009). DeBakey VA ReDesignated Magnet Hospital by American Nurse Credentialing Center. Retrieved from http://www.houston.va.gov/ pressreleases/News_20090114b.asp Department of Veterans Affairs. (2010). Primary Care Program Office: Telephone care. Retrieved from http://www.va.gov/ PrimaryCare/tc/ Espensen, M. (2009). Telehealth nursing practice essentials. Pitman, NJ: American Academy of Ambulatory Care Nursing. Fortney, J., Kaboli, P., & Eisen, S. (2011). Improving access to VA care. Journal of Internal Medicine, 26(Suppl. 2), 621–622. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3191216/pdf/11606_2011_Article _1850.pdf Greenberg, M. (2009). A comprehensive model of the process of telephone nursing. Journal of Advanced Nursing, 65(12), 2621–2629. doi:10.1111/j.1365-2648.2009 .05132.x Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy of Sciences. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Kevin, J. (2002). An evaluation of telephone triage in mental health nursing. Australian e-Journal for the Advancement of Mental Health, 1(1), 1–12. Retrieved from http://www.medibankhealth.com.au/files/editor _upload/File/publications/MH_03_evaluation_mental _health_triage.pdf Longman, P. (2012). Best care anywhere: Why VA health care would work better for everyone. San Francisco: Berrett-Koehler.
E. L. Moss McGonigle, D., & Mastrian, K. (2009). Nursing informatics and the foundation of knowledge. Mississauga, ON: Jones and Bartlett. National Prevention Council. (2010, June 1). National Prevention Council Action Plan: Implementing the national prevention strategy. Retrieved from http://www .surgeongeneral.gov/initiatives/prevention/2012-npc -action-plan.pdf Nauright, L., Moneyham, L., & Williamson, J. (1999). Telephone triage and consultation: An emerging role for nurses. Nursing Outlook, 47(2), 219–226. Retrieved from http://download.journals.elsevierhealth.com/pdfs/ journals/0029-6554/PIIS0029655499900544.pdf North American Quitline Consortium. (2010). Call center metrics: Fundamentals of call center staffing and technologies. Retrieved from http://c.ymcdn.com/sites/www .naquitline.org/resource/resmgr/issue_papers/ callcentermetricspaperbestpr.pdf Pols, J. (2010). The heart of the matter. About good nursing and telecare. Health Care Analysis, 18, 374–388. doi:10.1007/s10728-009-0140-1 Qureshi, N. A. (2010). Triage systems: A review of the literature with reference to Saudi Arabia. Eastern Mediterranean Health Journal, 16(6), 690–698. Retrieved from http://applications.emro.who.int/emhj/V16/06/ 16_6_2010_0690_0698.pdf
Just a Telephone Call Away Richards, D., Meakins, J., Tawfik, J., Godfrey, L., Dutton, E., Richardson, G., & Russell, D. (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(23), 1–6. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC135495/pdf/1214.pd Schenk, S., & Hartley, K. (2002). Nurse coach: Healthcare resource for this millennium. Nursing Forum, 37(3), 14–20. doi: 10.1111/j.1744-6198.2002.tb01006.x Scholle, S., Saunders, R., Tirodkar, M., Torda, P., & Pawlson, L. (2011). Patient-centered medical homes in the United States. Journal of Ambulatory Care Management, 34(1), 20–32. Retrieved from http://ca3cx5qj7w.search.serials solutions.com/OpenURL_local?sid=Entrez:PubMed&id =pmid:21160349 Utilization Review Accreditation Commission. (2012). General questions about URAC accreditation. Retrieved from https://www.urac.org/healthcare/accreditation/ Williams, B., Warren, S., McKim, R., & Janzen, W. (2012). Caller self-care decisions following teletriage advice. Journal of Clinical Nursing, 21, 1041–1050. doi:10.1111/ j.1365-2702.2011.03986.x
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