Key Components of a Successful
Telephone Triage System
The Experience at an Integrated
Wellness Center
Rachel Ossmo, RN, BSN, David deBoer, PhD,
Mona Dugo, LCSW and Teresa Carey, RN, BSN
Lakeshore Campus
(7.4 mi)
Water Tower Campus
(12.8 mi)
Health Sciences Campus
Loyola University Chicago
• Nation’s Largest Jesuit Catholic University
• Total Student Enrollment ~ 16,000
– Undergraduate ~9,800 - Graduate ~6,100
• Full time student s ~ 13,500
• Part time students ~ 2,500
– On-campus students ~ 10,300
– Commuter Students ~ 3,200
– All Freshman and Sophomore students are required to live
on campus unless given a special exemption to do
otherwise
LUC – Wellness Center
• Integrated Model
• Medical, Mental Health and Health Promotion
• Staff of 30 people
• Total of 23 FTE
• Myriad of student workers, student trainees &Wellness
Advocates
Hours of Operation
Academic Year Summer/Winter Break/Spring Break
8a – 6p Mon –Th.
8:00a – 4p Mon-Fri.
8a – 5p Fri.
Closed Sat and Sun.
8a – 12p Sat.
Insurance
• Coordinated and chosen through the Bursars
office
– Required by LUC for all full time students
– Students can waive out of University plan and get
coverage elsewhere if they choose.
• WC does not bill for or make claims to
insurance companies
Telephone Triage, Defined:
“An interactive process between nurse and
client that occurs over the telephone and
involves identifying the nature and urgency
of client health care needs and determining
the appropriate disposition.”
Telehealth Nursing Practice Core Course Syllabus AAACN.Org
Why Telephone Triage?
“There is considerable evidence that telehealth
interventions can decrease the cost of patient care
while maintaining or improving both the quality of
care and patient satisfaction. As issues of cost,
shortages of nurses, and inadequate patient access
continue to press, telehealth must be among the
approaches the nurse leader considers as she works
to construct viable current and future health care
options.”
Jean Sorrells-Jones, Poldi Tschirch, Marie Anne S. Liong, Nursing and telehealth: Opportunities for nurse leaders to shape the future,
Nurse Leader, Volume 4, Issue 5, October 2006, Pages 42-46,58, ISSN 1541-4612, 10.1016/j.mnl.2006.07.008.
Evolution of Dial-A-Nurse
Initial phone line staffed by an RN
• Walk-in only clinic
• Part time MDs and all RN staff
• RN saw all patients
• Block of time in am and in pm
Evolution
Opened line during all Clinic hours
• Walk-in and scheduled appts
• Front desk and RNs
• 1 part time NP in addition to part time MDs
• Designated RN answered calls but also saw
walk-in pts.
Evolution
Dedicated Telephone Triage Line:
Dial-A-Nurse
• All appts were scheduled - RNs only
• 3 FT NPs and 4 PT MDs
• Line opened during all clinic hours
• RN assigned to staff DAN w/o clinic
responsibilities
Desired Outcomes
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•
•
•
Immediate access to an RN
Increase utilization of Telephone Triage line
Refer to most appropriate provider
Decrease call volume at front desk
Steps for Implementation
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Developed telephone triage protocols
Installed a voice mail prompt
Staffed line with RN during all clinic hours
Medical staff completed triage re-training
session
• Posted advertising on Wellness Center website
• Evaluated and updated telephone triage
documentation forms (before EMR)
Adapting to Student’s Needs
Evolution of Making an Appointment
Walk-in
Only
Telephone
Triage &
Walk-in
Telephone
Triage
Only
Telephone
Triage,
and WebBooked
Dial-A-Nurse: What a difference a
decade makes
700
600
500
400
300
200
100
0
Aug
Sept
Oct
Nov
Dec
2002/2003
Jan
Feb
2011/2012
Mar
April
May
Awareness Drives Calls Up 70%
NCHA Data 2010
Proportion of college students who self reported being diagnosed or
treated by a professional for the following:
URI
Ortho
Asthma
Allergies
Anxiety
Depression
UTI
Migraine
Chronic Dx
STI
Nearly 50% of College Health Concerns
Addressed in Telephone Triage
URI
UTI
Rash
Vaginal
Complaints/
Annual GYN
Exams
Anxiety
Benefits
Contributing to Student Learning Outcomes
1. Students will demonstrate health literacy
2. Students will identify risk reducing
behaviors that promote a healthy community
3. Students will demonstrate self-care skills
that promote academic success.
Learning Outcome #1
• Students will demonstrate health literacy.
– Resource for follow-up questions
– Referrals and insurance issues
Learning Outcome #2
• Students will Identify risk reducing
behaviors that promote a healthy
community.
– Antibiotic education
– Sexual Health Issues
– Preventative Care
Learning Outcome #3
• Students will demonstrate self-care skills
that promote optimal health to enable
academic success.
– Access to knowledge
– Time friendly
Additional Benefits
• Identifying an emergent call
• Pt is triaged prior to appt
• Better Use of Services and Time
– Reduced Walk-in appointments
– Increases availability of same day appointments
– More efficient and effective use of office time
Benefits
• Encourages Autonomy
– Patient Education
– Self-care guidance
• Continuity of Care
– Better time management
• Increase Patient Compliance
Benefits
• Increased Patient Satisfaction
“The creation of a ‘telephone clinic’ which utilizes nurses and
house staff physicians trained and dedicated to telephone
communication directly with patients resulted in more
efficient management and greater satisfaction for patients.”
- Patient Educ Couns. 2010 Sep;80 (3): 351-3 Epub 2010 Aug 4
“If your visit today was preceded by a brief telephone call
with a Wellness Center nurse or counselor, did this call
help you know what to do next?”
LUC Wellness Center Student Satisfaction Survey
Challenges
• Staffing
• Access
• Potential for Error
• Missed Opportunities
Adapting
Using our EMR to provide written materials
• Teaching sheets
• Referrals
• Secure messages
Collaborating with MH
• RN has access to MH notes
– Can direct calls to appropriate provider in a timely
manner
– Can also alert MH provider if there is a specific
concern about a pt.
Collaborating Outside the Wellness
Center
• After hours RN Advice Line
– Phone # left on VM at close
– Next day report
• Other LUC departments
• Dean of Students
• Campus Safety
Collaborating Outside the University
Multi-tasking – what nurses do best
For the Future
of Triage
• Track how many appointments are made as a result of
triage calls
• Track the work that is being done in DAN but not
being accounted for now.
• Surveying all triage calls for satisfaction rather than
just those patients who were actually seen
Screening
Healthy Lifestyle Questionnaire
• Brief Past Medical History Survey
• Gives opportunity to check in with pt in other
areas: Nutritional, mental, sexual and social health.
• Can answer questions, make referrals and set up
appts in these other areas during the appt
PHQ - 2
Patient Health Questionnaire Depression Module
• Developed by Kroenke, Spitzer and Williams
• Brief measure of depression often used as
part of a past medical history questionnaire
• Two-item survey whose questions are
derived from symptoms for a DSM-IV
diagnosis of major depression
Medical Care. Vol. 41, Number 11, pp 1284-1292. 2003. Lippinott,Williams and Wilkins, Inc.
PHQ-2
• Research has demonstrated that over 82% of
patients with major depression score a three or
greater
• Initial counseling visit is always offered at WC
when patient scores a 3 or greater
Evolution toward Mental Health Telephone Triage
• Traditional Intake Model
• Day-time coverage hours
Benefits of Old System
• 60 minutes, thorough assessment
• In person; facilitated rapport, easier to assess
nuances
• Clinical intervention along with assessment
Challenges of Intake Model
• Up to 10-day lag time between initial call and
first contact
• Flip side of rapport--face-to-face contact at
times made it more difficult to refer out;
referral to another internal therapist could be
frustrating for clients
• Paperwork burden
• Higher no-show rate
What we hoped to achieve
•
•
•
•
•
•
•
Improved efficiency, reduce waitlist
Reduce paperwork burden e.g. intakes referred out
Advance the time of first patient contact
Improve responsiveness to campus partners
Increase/expedite referrals to the community
Shift burden from nurse triage line and MH coverage
phone
Avoid intakes on ADHD issues
Rollout Process
• Administrative planning
• Helpful guiding resource: Rockland-Miller, H.S. &
Eells, G.T. (2006). The implementation of mental
health clinical triage systems in university health
services. Journal of College Student Psychotherapy,
20(4), 39-51.
• Consultation
• Staff Discussion, input, planning
• Implemented Fall 2010 on pilot basis
What We Implemented
Time
phone triage
intake appointments
phone coverage
sample schedule
8:00
phone coverage
8:30
2 hours
9:00
9:30
10:00
phone triage: 30 min
10:30
phone triage: 30 min
11:00
phone triage: 30 min
11:30
phone triage: 30 min
12:00
lunch
12:30
1:00
intake: 1 hour
1:30
2:00
therapy client: 1 hour
2:30
3:00
therapy client: 1 hour
3:30
4:00
paperwork: 1hour
4:30
5:00
therapy client: 1 hour
5:30
6:00
Gone for day
Booking a triage appointment
•
•
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Web based booking
Dial a nurse
Front desk staff
Mental health coverage worker
Phone triage template
Disposition from Triage
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Referred for therapy at Wellness Center
Refer out for therapy
Waitlist
Routine appointment
Priority appointment
Urgent appointment
Emergency appointment
Psychiatry appointment
Group referral
Referring out:
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•
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Database of community providers
Long term/chronic conditions
Not in acute distress
Previous experience with therapy
Demonstrates good insight and high degree of
motivation for long term therapy
• Has insurance or financial means for care
• Wait list
Likely to be scheduled at WC
•
•
•
•
•
•
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First experience of therapy
Acute state of distress
Cultural barriers to therapy
Lack of family support
Short term treatment appropriate
Referred by campus partner
Financial barriers
Eating Disorder
Case Management into Community
Services
When referring out from therapy or triage:
• Therapist calls insurance provider to determine
benefits
• Follow up appointments to ensure success of
referral
• Use triage appointments to follow up on case
management/referrals
Screening: PHQ-9, SRQ
PHQ-9 Results
PHQ-9
score
Provisional Diagnosis Treatment
Recommendatio
ns
5-9
Minimal symptoms
Support, educate to call if
worse; return in 1 month
10-14
•Minor depression
•Dysthymia
•Major depression, mild
•Support, watchful waiting
•Antidepressant or
psychotherapy
•Antidepressant or
psychotherapy
15-19
Major Depression,
Moderately severe
Antidepressant or
psychotherapy
> 20
Major Depression,
Severe
Antidepressant and
psychotherapy (especially
if not improved on
monotherapy)
Challenges
• Increased volume for case management
• Assessment more difficult over phone, more difficult to
assess/read affect
• Therapist tension between assessing and intervening
• Quality of cell phone connection
• ESL issues
• More difficult to refer to groups
• Trust issues for some
• Access to private phone for some
• Harder with less verbal students
Benefits
• Reduced wait for first contact with patient
• Allows staff to attend to intervene early and avert potential
crisis situations
• Opportunity to match patient with therapist prior to
first visit
• Reduced redundancy for patient
• Increases contact for socially anxious patients/opportunity to
do motivational interviewing
• For some, appears to be less threatening or ease
disclosure of sensitive information
• Facilitates/expedites community referral if needed
• Reduction in no shows for initial therapy visits
• Some therapists like the different mode/change of pace
Thank You
For Questions of Comments:
Rachel Ossmo, RN-BSN
Loyola University Chicago
Rossmo@luc.edu
773-508-2530