Key Components of a Successful Telephone Triage System

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Key Components of a Successful Telephone Triage
System

• The Experience at an Integrated Wellness Center
• Rachel Ossmo, RN, BSN, David deBoer, PhD,
• Mona Dugo, LCSW and Teresa Carey, RN, BSN

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Lakeshore Campus
(7.4 mi)
Water Tower Campus
(12.8 mi)
Health Sciences Campus
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Loyola University Chicago

• Nations Largest Jesuit Catholic University
• Total Student Enrollment 16,000
• Undergraduate 9,800 - Graduate 6,100
• Full time student s 13,500
• Part time students 2,500
• On-campus students 10,300
• Commuter Students 3,200
• All Freshman and Sophomore students are required
  to live on campus unless given a special
  exemption to do otherwise

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LUC Wellness Center

• Integrated Model
• Medical, Mental Health and Health Promotion
• Staff of 30 people
• Total of 23 FTE
• Myriad of student workers, student trainees
  Wellness Advocates
• Hours of Operation
  
  
• Academic Year Summer/Winter Break/Spring
  Break
• 8a 6p Mon Th. 800a 4p
  Mon-Fri.
• 8a 5p Fri. Closed Sat
  and Sun.
• 8a 12p Sat.

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Insurance

• Coordinated and chosen through the Bursars office
• Required by LUC for all full time students
• Students can waive out of University plan and get
  coverage elsewhere if they choose.
• WC does not bill for or make claims to insurance
  companies

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Telephone Triage, Defined

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

Telehealth Nursing Practice Core Course Syllabus
AAACN.Org
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Why Telephone Triage?

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

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

• Immediate access to an RN
• Increase utilization of Telephone Triage line
• Refer to most appropriate provider
• Decrease call volume at front desk

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Steps for Implementation

• Developed telephone triage protocols
• Installed a voice mail prompt
• Staffed line with RN during all clinic hours
• Medical staff completed triage re-training
  session
• Posted advertising on Wellness Center website
• Evaluated and updated telephone triage
  documentation forms (before EMR)

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Adapting to Students NeedsEvolution of Making
an Appointment
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Dial-A-Nurse What a difference a decade makes
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Awareness Drives Calls Up 70
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NCHA Data 2010 Proportion of college students
who self reported being diagnosed or treated by a
professional for the following
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Nearly 50 of College Health Concerns Addressed
in Telephone Triage
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Benefits

• Contributing to Student Learning Outcomes
• 1. Students will demonstrate health
  literacy2. Students will identify risk reducing
  behaviors that promote a healthy community3.
  Students will demonstrate self-care skills that
  promote academic success.

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Learning Outcome 1

• Students will demonstrate health literacy.
• Resource for follow-up questions
• Referrals and insurance issues

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Learning Outcome 2

• Students will Identify risk reducing behaviors
  that promote a healthy community.
• Antibiotic education
• Sexual Health Issues
• Preventative Care

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Learning Outcome 3

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

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Additional Benefits

• Identifying an emergent call
• Pt is triaged prior to appt
• Better Use of Services and Time
• Reduced Walk-in appointments
• Increases availability of same day appointments
• More efficient and effective use of office time

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Benefits

• Encourages Autonomy
• Patient Education
• Self-care guidance
• Continuity of Care
• Better time management
• Increase Patient Compliance

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Benefits

• Increased Patient Satisfaction
• The creation of a telephone clinic which
  utilizes nurses and house staff physicians
  trained and dedicated to telephone communication
  directly with patients resulted in more efficient
  management and greater satisfaction for
  patients. - Patient Educ Couns. 2010 Sep80
  (3) 351-3 Epub 2010 Aug 4
• If your visit today was preceded by a brief
  telephone call with a Wellness Center nurse or
  counselor, did this call help you know what to do
  next?
• LUC Wellness Center Student Satisfaction
  Survey

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Challenges

• Staffing
• Access
• Potential for Error
• Missed Opportunities

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Adapting

• Using our EMR to provide written materials
• Teaching sheets
• Referrals
• Secure messages

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Collaborating with MH

• RN has access to MH notes
• Can direct calls to appropriate provider in a
  timely manner
• Can also alert MH provider if there is a specific
  concern about a pt.

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Collaborating Outside the Wellness Center

• After hours RN Advice Line
• Phone left on VM at close
• Next day report
• Other LUC departments
• Dean of Students
• Campus Safety

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Collaborating Outside the University

• Multi-tasking what nurses do best

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For the Futureof Triage

• Track how many appointments are made as a result
  of triage calls
• Track the work that is being done in DAN but not
  being accounted for now.
• Surveying all triage calls for satisfaction
  rather than just those patients who were actually
  seen

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Screening

• Healthy Lifestyle Questionnaire
• Brief Past Medical History Survey
• Gives opportunity to check in with pt in other
  areas Nutritional, mental, sexual and social
  health.
• Can answer questions, make referrals and set up
  appts in these other areas during the appt

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PHQ - 2

• Patient Health Questionnaire Depression Module
• Developed by Kroenke, Spitzer and Williams
• Brief measure of depression often used as part
  of a past medical history questionnaire
• Two-item survey whose questions are derived from
  symptoms for a DSM-IV diagnosis of major
  depression

Medical Care. Vol. 41, Number 11, pp 1284-1292.
2003. Lippinott,Williams and Wilkins, Inc.
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PHQ-2

• Research has demonstrated that over 82 of
  patients with major depression score a three or
  greater
• Initial counseling visit is always offered at WC
  when patient scores a 3 or greater

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Evolution toward Mental Health Telephone Triage

• Traditional Intake Model
• Day-time coverage hours

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Benefits of Old System

• 60 minutes, thorough assessment
• In person facilitated rapport, easier to assess
  nuances
• Clinical intervention along with assessment

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Challenges of Intake Model

• Up to 10-day lag time between initial call and
  first contact
• Flip side of rapport--face-to-face contact at
  times made it more difficult to refer out
  referral to another internal therapist could be
  frustrating for clients
• Paperwork burden
• Higher no-show rate

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What we hoped to achieve

• Improved efficiency, reduce waitlist
• Reduce paperwork burden e.g. intakes referred
  out
• Advance the time of first patient contact
• Improve responsiveness to campus partners
• Increase/expedite referrals to the community
• Shift burden from nurse triage line and MH
  coverage phone
• Avoid intakes on ADHD issues

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Rollout Process

• Administrative planning
• Helpful guiding resource Rockland-Miller, H.S.
  Eells, G.T. (2006). The implementation of
  mental health clinical triage systems in
  university health services. Journal of College
  Student Psychotherapy, 20(4), 39-51.
• Consultation
• Staff Discussion, input, planning
• Implemented Fall 2010 on pilot basis

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What We Implemented
Time phone triage intake appointments phone coverage sample schedule
800       phone coverage
830       2 hours
900        
930        
1000       phone triage 30 min
1030       phone triage 30 min
1100       phone triage 30 min
1130       phone triage 30 min
1200       lunch
1230        
100       intake 1 hour
130        
200       therapy client 1 hour
230        
300       therapy client 1 hour
330        
400       paperwork 1hour
430        
500       therapy client 1 hour
530        
600       Gone for day
         
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Booking a triage appointment

• Web based booking
• Dial a nurse
• Front desk staff
• Mental health coverage worker

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Phone triage template
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Disposition from Triage

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

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Referring out

• Database of community providers
• Long term/chronic conditions
• Not in acute distress
• Previous experience with therapy
• Demonstrates good insight and high degree of
  motivation for long term therapy
• Has insurance or financial means for care
• Wait list

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Likely to be scheduled at WC

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

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Case Management into Community Services

• When referring out from therapy or triage
• Therapist calls insurance provider to determine
  benefits
• Follow up appointments to ensure success of
  referral
• Use triage appointments to follow up on case
  management/referrals

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Screening PHQ-9, SRQ
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PHQ-9 Results
PHQ-9 score Provisional Diagnosis Treatment Recommendations
5-9 Minimal symptoms Support, educate to call if worse return in 1 month
10-14 Minor depression Dysthymia Major depression, mild Support, watchful waiting Antidepressant or psychotherapy Antidepressant or psychotherapy
15-19 Major Depression, Moderately severe Antidepressant or psychotherapy
gt 20 Major Depression, Severe Antidepressant and psychotherapy (especially if not improved on monotherapy)
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Challenges

• Increased volume for case management
• Assessment more difficult over phone, more
  difficult to assess/read affect
• Therapist tension between assessing and
  intervening
• Quality of cell phone connection
• ESL issues
• More difficult to refer to groups
• Trust issues for some
• Access to private phone for some
• Harder with less verbal students

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Benefits

• Reduced wait for first contact with patient
• Allows staff to attend to intervene early and
  avert potential crisis situations
• Opportunity to match patient with therapist prior
  to first visit
• Reduced redundancy for patient
• Increases contact for socially anxious
  patients/opportunity to do motivational
  interviewing
• For some, appears to be less threatening or ease
  disclosure of sensitive information
• Facilitates/expedites community referral if
  needed
• Reduction in no shows for initial therapy visits
• Some therapists like the different mode/change of
  pace

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Thank You

• For Questions of Comments
• Rachel Ossmo, RN-BSN
• Loyola University Chicago
• Rossmo_at_luc.edu
• 773-508-2530