Urgent Care Best Practices
One of the quality improvement efforts that IBD Qorus focused on was identifying and testing practice changes designed to reduce the high rates of unplanned emergency department (ED) visits and hospitalizations that occur within the IBD patient population. The resulting positive impact these practice changes had on patient outcomes was the impetus for the creation of this toolkit.
There is significant variation in the care of adults with Crohn’s disease and ulcerative colitis, collectively known as inflammatory bowel disease (IBD), suggesting a need to standardize and improve the quality of care delivered to this population. Reducing unwanted variation and improving health outcomes for those living with IBD is difficult without a mechanism for designing new approaches to care delivery and for testing these approaches in real world patient care.
Background
IBD Qorus is a network of IBD care centers from across the United States that collectively engage in quality improvement efforts to transform care delivery and improve patient outcomes. This first-ever adult learning health system focuses on improving how care is delivered to patients by tracking care performance and outcomes using patient-centered metrics.
To address this, the Crohn’s & Colitis Foundation established IBD Qorus.
1 Create a High-risk List page 2 2 High-riskManageProactivelyyourList page 6 3 AppointmentsUrgentOfferCare page 12 4 PatientsEducateAboutWhenandHowtoAccessUrgentCare page 17 Emergency Department Utilization Relative Decrease 22% Opiate RelativeUtilizationDecrease 50% Corticosteroid Utilization Relative Decrease 50% RelativeHospitalizationDecrease 21%
Because of the intermittent nature of inflammatory bowel diseases (IBD), patients often need to access urgent and unplanned healthcare services, where they may undergo testing and receive treatments that can interfere with their long-term disease management plan. Through the collective efforts of IBD Qorus sites, we were able to identify and implement specific interventions in various clinic settings that helped us pinpoint those patients at increased risk and intervene before an unplanned visit to the emergency department. After applying these interventions in practice and analyzing the data, improvement was noted across multiple measures, including a reduction in the need for emergency department visits, hospitalizations, corticosteroids, and opioids among patients participating in the program (reference):
The most common interventions that sites used to achieve these results were: high-risk patient lists, proactive calls to high-risk patients, reserved urgent care appointments, and patient education materials about when and how to seek urgent care. Upon further analysis, it was also discovered that implementation of these interven tions (thereby reducing unplanned healthcare utilization) was associated with an annual cost savings of $2,500 per patient (reference). To help you reduce unplanned healthcare utilization at your clinic, we have created this Urgent Care Best Practices Toolkit. The Toolkit reviews these interventions and contains helpful tips and resources for implementing these interventions in practice.
Introduction
Crohn’s & Colitis Foundation Urgent Care Best Practices Toolkit | 1
tip 2 A medical doctor doesn’t have to be the only staff member allowed to decide which patients get added to the high-risk list. Many clinics allowed all IBD providers—medical doctors and advanced practice providers—to make this decision.
“Any provider, which in our practice is defined as a medical doctor or an advanced practice provider, can determine which patients get added to the high-risk list. We set up a system in our electronic medical records where the provider can flag a high-risk patient. This information then goes to the nurses and the nurses put that patient on the high-risk list. In our clinic, the nurses are the ones physically managing who comes on and off the list.”
Example 1: The Oregon Clinic Gastroenterology South
tip 3 Choose whichever workflow, process, or system that works best for your clinic, whether that is establishing a formal identification process within your Electronic Health Record (EHR) system or simply sending an email to your point-person. It’s not important how you get the high-risk patient on the list, it’s that you get the patient on the list.
1: Create a workflow/process for adding patients to the high-risk list. To eliminate uncertainty, create a streamlined process that clearly indicates how a patient gets added to the high-risk list as well as who can decide whether a patient is considered high-risk.
Establish a mechanism to identify those patients at greatest risk of being hospitalized or going to the emergency room (i.e., a high-risk list), in an attempt to intervene before they do so.
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tip 1 Assign a point-person to be manager of the high-risk list and have a back-up in case that person is out of the office. This person will receive the names of high-risk patients from other providers and be responsible for adding patients to the list. Most sites assigned a nurse (ex. RN, Nurse Navigator, Infusion Nurse, or NP) to this role.
“In our clinic, a medical doctor identifies a high-risk patient and sends a note to our clinical nurses saying, for example, ‘This patient is high-risk and starting a new medication. Let’s place them on the high-risk list and follow up via phone in 3-6 weeks, with our nurse coordinator or our pharmacist, to see how they are doing.”
Example 2: UC San Diego best practice
Create a high-risk list
• Frequently calling or visiting the office
• Experiencing psychosocial issues (ex. depression/anxiety)
• Not adhering to the treatment plan (ex. non-adherence to medication)
tip 3 If the inclusion criteria are not adequately capturing the highest risk patients, use your intuition and ask yourself: “Which patients are keeping me up at night? Which patients am I most worried about? For which patients can I make the most difference?” Then, work with those patients. “My criteria are based on how the patient has done in the recent past, such as recent hospitalizations, complications, new diagnosis of severe disease, etc. There were people who had medically severe dis ease but weren’t on the high-risk list because they didn’t need much handholding from us. For example, some people are very in-control even though they have severe disease—and I know that they will be proactive in reaching out to me. So, I give those patients the responsibility of reaching out to me and say, ‘Hey, reach out to me in two weeks and let me know how things are.’ The patients who are more overwhelmed are the patients that I will send to my nurses for further follow-up.”
Example 1: Spectrum Health “We found it helpful to break the high-risk group into three categories: 1. high-risk active disease, 2. high-risk psychosocial, and 3. high-risk chronic pain. A high-risk list with hundreds of patients on it is not helpful because you cannot possibly have heightened surveillance on hundreds of patients on a weekly or bi-weekly basis. We felt that these patients needed different interventions. Therefore, we felt that reaching out to patients who fell into the uncontrolled, active disease category with our urgent care interventions would be more meaningful and helpful. So, while we were certainly offering services to those patients with psychosocial and chronic pain issues, we were not putting them on our high-risk list for urgent care intervention.”
Example 2: University of Utah
Crohn’s & Colitis Foundation Urgent Care Best Practices Toolkit | 3 best practice 2: Define inclusion criteria. Defining inclusion criteria can help you identify those patients at highest risk of being hospitalized or going to the emergency room. tip 1 Select the inclusion criteria that you feel adequately captures those patients at highest risk. The most common criteria that clinics used included those patients who were: • Actively flaring • Recently hospitalized or visited the emergency room • On corticosteroids
• Starting a biologic
• Pregnant tip 2 If the chosen inclusion criteria are capturing too many patients for you to effectively manage, re-examine and remove some criteria. Several clinics chose to do this along the way.
• Not confident in their ability to manage their symptoms
tip 1 Start off small. While the number of high-risk patients each clinic could manage successfully varied, the majority had the greatest success when they kept the high-risk list between 5 to 10 patients.
“In the beginning, we tried to be more structured (with our high-risk inclusion criteria). For example, starting a new biologic or those patients we see in high volume. Ultimately, it came down to, ‘Who am I worried about, and who keeps me up at night?’ It could be someone going to the hospital, someone that is actively flaring and has poor follow-up, or somebody with depression or anxiety issues.”
“Limiting the high-risk list to 10 patients was the most manageable choice for us. We wanted to specify the highest of the high-risk patients and focus our resources on them.”
“We review the high-risk list to contain it to a reasonable number, with a goal of keeping it below 25 patients. Our high-risk list was usually between 15 to 25 patients. It was necessary to contain the list so that we could focus our efforts and resources on the patients that needed it the most. Even going through the list of high-risk patients takes time during our meetings. For example, we cannot go through a list of 50 patients at each meeting—so, you have to call it somewhere. Unfortunately, we have limited time and resources.”
Example 2: Spectrum Health
Example 3: Cedars-Sinai Medical Center best practice
tip 2 Monitor the number of patients on your high-risk list regularly and adjust accordingly. Routinely check-in with the person managing the high-risk list to ensure you are successfully managing your high-risk patients. If you find that you do not have enough resources, reduce the number of patients on the high-risk list and focus on those at highest risk. If you have enough resources, increase the number.
“We found that having a big list was not practical. We wanted to identify the patients that we were most worried about, in terms of ending up in the emergency room or requiring urgent care. Therefore, we selected a ‘Top 5-7 List.’ Specifically, these were patients who: were flaring and on steroids, had recently been in the hospital or emergency room, or recently started a biologic. Our medium-risk list were patients teetering on the edge, but not enough to be on the ‘Top List.’ For example, these were patients who had problems with insurance, getting rides, understanding the importance of not missing their medications, etc. We thought it would be helpful to keep track of these medium-risk patients, and follow-up with them every few months, rather than weekly, like we would with the Top List.”
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Example 1: Gastroenterology Associates, Inc.
In an ideal world with unlimited resources, we could offer urgent care services to every high-risk patient. However, most clinics do not have the capacity to provide heightened surveillance to everyone. Therefore, it is important that you establish a maximum number of high-risk patients that your clinic staff can manage successfully—otherwise you may be setting yourself, your colleagues, and your patients up for disappointment.
Example 3: NYU Langone
3: Set a manageable number of high-risk patients.
tip 3 Create a workflow/process for removing patients from the high-risk list, including who is responsi ble for making the decision to remove someone as well as who is responsible for physically remov ing them. For most clinics, the nurse responsible for physically adding patients to the high-risk list was also the person responsible for physically removing them.
“Patients will be removed from the list by the nurse navigator after resolution of issues/tasks and confir mation from the IBD provider who placed the patient on the list. The nurses do the heavy lifting — they are the ones who monitor the list and reach out to the patient. When we put people on the list, we identify tasks that we should be working on. The nurse navigator works on those tasks, so next time we look at the list the nurse can say, ‘I’ve done all four tasks. Can we take the patient off the high-risk list?’ It was purposefully set up as a task-oriented process so that patients don’t wind up on the list forever.”
tip 1 Work with your colleagues to establish removal criteria that everyone is comfortable with. tip 2 Be flexible. Not every patient’s reason for being on the high-risk is the same. Therefore, you may need to have different removal criteria for different situations.
Example 1: MedStar Health
Resources: High-risk List in Excel • Sample #1 • Sample #2 Creating a high-risk list in Epic
Example 3: University of Colorado “They stay on the high-risk list until their next visit. Upon their next visit, we use the same questions and physician assessment. If the physician marks them as no longer high-risk, then the nurse takes them off the list.”
“Some people were on the high-risk list because they were non-adherent — and, when they started coming in regularly to get their treatments, they would come off the list. If the patient was coming in for a lot of emergency room or urgent care visits — once their disease was in remission, they would come off the list. It was dependent on why they were on the list in the first place. On the high-risk list we did have a column labeled, ‘reason for high-risk.’ Having the reasons listed was important for getting someone off the list.”
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Example 2: Regional Gastroenterology best practice 4: Define removal criteria. Without defining criteria for removing patients from the high-risk list, your list may start accumulating names and growing exponentially. Several clinics sought to avoid this situation by designing removal crite ria they felt were most appropriate for them as well as their high-risk patients.
tip 5 Set the huddle up for success. Put one person in charge of running through the high-risk list during the huddle. This person decides when it is time to move onto the next patient (to keep the huddle running on time) and the one who delegates tasks to other team members. Put one person in charge of taking notes on what tasks were agreed upon and who is responsible for completing the tasks. These persons may or may not be the same team member.
Example 1: Baylor College of Medicine
The huddle represents an opportunity for the team to review and update the high-risk list as well as create action items for the week ahead. Most clinics felt that a brief, weekly, 15-to-30-minute huddle was critical to keep the team engaged, stay organized, and maintain momentum.
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tip 3 Make it easy for everyone to attend. Some clinics sent huddle reminders or held virtual huddles so team members could participate from wherever they are.
tip 2 Establish a set day and time. Most clinics stressed the importance of scheduling the huddle at a specific day and time each week to ensure that it takes place. Make a specific team member responsible for scheduling the meeting and adding it to everyone’s calendar.
tip 4 Squeeze it into an existing meeting if you can. Some clinics found it easier to carve out 15 minutes of an existing meeting to discuss the high-risk list or add an additional 15 minutes onto an existing meeting where the necessary team members were already present.
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tip 1 Ensure appropriate and necessary team members are present. The team usually includes: the provider(s) who treat(s) the high-risk patients as well as those team member(s) responsible for managing the high-risk list and reaching out to the high-risk patients.
best practice 1: Convene a regular team huddle to discuss the high-risk list.
Establish a mechanism to track high-risk patients and reach out to them more frequently.
Proactively manage your high-risk list
tip 6 Make it a priority. If it is not made a priority, then it will never happen. “We conducted weekly 15-to-20-minute huddles, bundled with research meetings. We usually met with the team on Thursdays at noon. The most important thing is the huddle. If you do not have the huddles, you do not keep people engaged and you cannot track what you are doing. It is easy for things to fall away if it is not constantly in your face.”
Example 3: Gastroenterology Associates, Inc.
Example 2: University of Colorado best practice
“Me and the nurse met each week to go over the high-risk list—whether it was making sure the patient had a follow-up scheduled for next week, got on a specific medication, or, if it was a patient with severe anxiety and depression, that we checked-in with them once a month to make sure they are doing OK. During the huddle, we would make sure to run through the list as well as the action items for each patient.”
“It would take five minutes to run through the list at the weekly huddles with the nurse navigator and say, ‘Can you please check in on this patient, this patient, and this patient.’ The nurse would then checkin on the ones that needed to be checked-in on. I thought that was SUPER helpful. The weekly huddles allow for organization, reflection, and a chance to review stats and data. They are helpful for creating action items for the upcoming week, as well as in maintaining an up-to-date high-risk list.”
tip 2 At a minimum, make sure that each high-risk patient has a follow-up appointment scheduled. If not, it should be first priority.
2: Define next steps (i.e., create an “urgent care plan”) for each high-risk patient. Meet with your team to create actionable next steps that are specifically tailored for each high-risk patient’s unique need(s). tip 1 Make the next steps clear, task-oriented, and time-bound to eliminate uncertainty.
Example 1: NYU Langone
Example 2: Cedars-Sinai Medical Center
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“One of the students or residents would manage the high-risk list and we would go over it together during the huddle. Every Thursday at 6:00 pm we have our team meeting virtually by Zoom, and we go through the ‘Hot List.’ Because there are several team members on board, we will alternate—one person pulls up a patient for discussion, and while discussing, the other staff member is pulling up the second patient. In this way, there is no downtime while reviewing. We can usually run through the list in 5 to 10 minutes. In the beginning it was hard to meet on a regular basis because we tried to meet in-person. What solved it was Covid—because we went to virtual meetings. The virtual meetings have been good because most people can attend, and we can change it on the fly. Meeting weekly keeps you focused on the projects. It is really critical.”
“My advice would be to make it clear who is responsible for it and have realistic expectations. For example, have discrete tasks for patients on the high-risk list so you are not confused as to why the patient is on the list and it is clear what you are supposed to be doing with that patient. Accountability is also important. How we hold people accountable is by having a weekly meeting and reviewing the list, so it is clear when something (a task) hasn’t been done. For example, ‘Did you check to see if the patient got their infliximab scheduled? Did you call them after they were discharged to ensure they were tapering prednisone?”
Most clinics assigned a nurse (ex. RN, Nurse Navigator, Case Manager, Infusion Nurse, or Nurse Practitioner) to reach out to high-risk patients.
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tip 1 Make a specific team member responsible for each next step or task to ensure it gets completed.
tip 2 Tailor the mode of communication to the patient and the issue. If the patient likes (or prefers) to use the electronic medical record portal for communication, use the portal. If the patient prefers the telephone, use the telephone. Although the mode of communication varied by clinic and patient, most clinics reached out to their high-risk patients via telephone.
tip 3 Tailor the frequency of communication to the issue. Some issues require more frequent follow-up. Although the frequency of outreach to high-risk patients varied, most clinics chose to reach out to their high-risk patients every week or every other week until the patient was no longer considered high-risk.
tip 6 If the patient is not following up with your messages, have their medical doctor (gastroenterologist) give them a call. Some sites felt that by doing so it increased the likelihood that the patient would call back and made the team members responsible for reaching out to the patients feel supported. “Our RN proactively manages the highest risk patients by calling them as often as needed. For example, it might be daily if a patient is rapidly declining or very anxious, weekly, bi-weekly, or monthly. This is determined on a case-by-case basis by the RN. We would often make a plan with the patient in terms of how frequently they would like to be contacted. As a result, patients felt more involved in their care and had less concerns. Follow up would be by phone and office visits. We would set a time and date with the patient for contacting them (ex. ‘What day and time works for you?’). Therefore, the patient would expect the call.”
Once next steps are identified, reach out to the patient on a consistent basis to assess how they are doing, answer any questions they may have, or schedule follow-up appointments as necessary. Reaching out more frequently (and/or scheduling appointments to see your high-risk patients more consistently) will help address issues before they potentially result in a trip to the hospital or emergency room.
tip 4 Let the high-risk patient know that a team member will be reaching out regularly, as well as which team member will be reaching out and how often. Some clinics found it helpful to prepare the highrisk patient for more frequent communication so that the patient would expect it and, therefore, be more likely to respond.
3: Reach out to each high-risk patient on a regular basis.
Example 1: Saratoga Schenectady Gastroenterology Associates
tip 5 If possible, have the same staff person reach out to the same high-risk patient. Some clinics indicated that keeping the staff member consistent helped the patients be more open and feel more comfortable discussing their issues.
“The nurses do a good job setting expectations with the patients by telling them that they are going to call them every week. What has helped is when the physician gives the patient a bit of a heads up, ‘We are going to have our nurse follow up with you for a few weeks to make sure your symptoms are doing OK, etc.’ This sets the nurse up for success. So, when the nurse calls, the patient knows why they are calling and is expecting it. The script I usually give as a provider is, ‘I am really worried about you. I am going to have one of my nurses who is well trained in IBD call you because I know I won’t be able to see you every week. Please use them as a resource to move your care forward.’ Most of the patients are relieved that they are going to have someone helping them navigate the system.”
“Once a patient is identified as high-risk, we have two dedicated RNs (also infusion nurses), who serve as nurse care coordinators, call the patient. Patients are called weekly to every other week depending on clinical issues. As they continue to improve, we will increase it to every 3 to 4 weeks, and hopefully get them off the list at that point. We also made it a point that the patient has an office visit within 2 months of being added onto the high-risk list. We are contacting high-risk patients predominantly through phone calls. Phone calls can be a bit of an issue because there is some phone tag. But there aren’t too many patients that do not respond.”
Example 6: The Oregon Clinic Gastroenterology East
“Our nurse calls our ‘High 5 List’ weekly or bi-weekly. What works well is that the patients get extensive, repeated education about how they should manage their current symptoms and issues. What also works well is that the patients receive very good, purposeful listening as well as good disease management therapy from our nurse. Time is often something we don’t have with our patients. So, the patient gets more time to be listened to, on a level they have not experienced before and are not accustomed to. It allows them to better manage and utilize the health resources that are available to them.”
Example 3: The Oregon Clinic Gastroenterology South
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Example 5: Regional Gastroenterology
“Our RN is calling these patients regularly and documenting answers to a list of preplanned questions. They are then relaying the answers back to the provider. It has helped our site to have a template of questions that we ask high-risk patients when we reach out to them so that there is consistency, irrespective of the nurse that is managing the list and making outbound calls. The answers to these questions are what we as physicians need to use.”
Example 2: The Oregon Clinic Gastroenterology East
Example 4: The Oregon Clinic Gastroenterology South
“We learned that patients would say they feel most comfortable talking to the same person or the same few people about their IBD. The patients felt that the nurses knew them. So, usually it is the same nurse reaching out.”
tip 1 Use the tracking system that works best for your clinic and team. To track high-risk patients, most clinics used their electronic medical record system or an Excel spreadsheet. Clinics cited pros and cons of both systems, so choose the one that best fits into your workflow.
tip 2 Try to make the tracking system accessible to everyone on your team (or as many persons on your team as possible). By expanding access to the tracking system, it gives all team members the ability to easily edit the tracker. Only allowing the team member responsible for managing the list to have access can create a problem if that team member is ever out of the office.
tip 3 If using a system outside of the electronic medical record, be sure you are taking the necessary steps to protect the patients’ personal health information. For example, implement various layers of password protection when necessary. “We are using an excel spreadsheet that is managed by the Nurse Navigator. It is a good tool because everything is there on one sheet: their chart number, what the big concerns are, whether they are on steroids, if they are pregnant, etc. It is easier this way rather than having to sift through the electronic medical record. It is quick and helpful to use even when a patient calls us.”
10 | Urgent Care Best Practices Toolkit Crohn’s & Colitis Foundation best practice 4: Implement a tracking system. To stay organized, most clinics found it helpful to track the patients on their high-risk list. Some clinics also chose to track additional pieces of information for each high-risk patient, such as: medical record number, reason for being on the high-risk list, next steps, when and how often the clinic reached out, etc.
“We created a shared drive with an Excel sheet that we can update with high-risk patients. Maybe inputting it into the EHR would be better. But, getting anything implemented into the EHR is difficult. It would be nice to have some of it a little bit more automated. However, I think overall our Excel method worked for our team. One of the keys about the list is having it be easily accessible. I would recommend finding a user-friendly, easily accessible, HIPAA-compliant shared drive, or something that works for your team.”
Example 3: MedStar Health
Example 2: Cedars-Sinai Medical Center
Example 1: Gastro One
“We originally created a high-risk Excel sheet to review every week, which listed the high-risk patients as well as the reason the patient was on the list. But that process changed. We went from Excel to Epic. Having a separate program (like Excel) on your screen is hard. The benefit of Epic is that it’s available wherever you are. However, we did lose something with the transition to Epic. In Excel, we were tracking certain things, such as why the patient was on the high-risk list, the patient’s outcomes, etc. With Epic, we lost the ability to track. The only thing that Epic allowed us to do was to have an accurate, available, up-to-date list at all times. To implement this tracking in Epic would require a lot of customization.”
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Example 5: University of Colorado “Everyone had their own method. Some nurses use pen and paper while other nurses use a spreadsheet. It was difficult to find a methodology that worked for all three triage nurses. So, we just had each triage nurse use the method that worked best for them. The nurses meet twice a week to discuss what is going on with their high-risk patients. The spreadsheet includes: patient name/phone number, provider initials, date of last contact call, date of next office visit, and a check box for the reason they are highrisk (ex. started prednisone or ER visit).”
“We created a high-risk list in EPIC for task-directed case management. IBD providers and/or RNs will identify patients to be added to the list. High-risk tasks (also known as a “short-term plan”) will be identified for each patient and added to the list. Case managers will review the list each week and ensure issues/tasks are addressed. Tasks for the short-term plan are documented on the “Specialty” portion of the “Snapshot” page of Epic. Calls with patients are documented as a triage note in the electronic medical record and providers are updated. We have one big Patient List, but it is divided by provider. Our nurse case managers monitor the list. We all have weekly meetings with our case managers and run the lists. The pros are that we are all very familiar/comfortable with Epic. It is easy to pull-up. When I do my meeting with my nurse, we just pull the list up quickly in Epic. On our high-risk list we have several columns: name, medical record number, currently admitted, and specialty comments. The specialty comments tab is the first thing you see when you pull up a patient’s chart. We keep the Task List in the specialty comments—so it goes into the patient’s chart. However, it is not part of their medical record, so it is not discoverable. On our high-risk list, in the “Patient List” function, we have the specialty comments as a column. We have the provider’s name and the date the patient went onto the high-risk list listed at the top so that we can easily sort the high-risk list by provider. I would recommend this methodology and Patient List functionality for other sites who use Epic. The benefits are that it is all in one place and everyone can see it and find it. For example, the nurse navigators that are cross-covering can easily find it—it is not living in a silo somewhere.”
“I had an Excel spreadsheet for a while, but then we just built it into Epic on a shared ‘Patient List.’ We switched because Epic is easier—it can be shared by everyone, you know you are always looking at the most updated version, you can easily access the patient chart, and it is not outside of the EHR.” 4: Dartmouth-Hitchcock Medical Center
Example 6: Saratoga Schenectady Gastroenterology Associates
Resources: High-risk List in Excel • Sample #1 • Sample #2 Creating a high-risk list in Epic
Example
• How urgent calls/messages are responded to. For example, does your clinic have a standard operating procedure to ensure that all urgent calls/messages are reviewed and responded to within a specified timeframe. Most clinics sought to respond to all urgent messages within 1 to 4 hours.
• Which team member collects the information from the patient. Most clinics felt it was important to have a team member with clinical training to collect information from the patient.
Offer urgent appointmentscare
tip 1 Ensure each step along the intake and triage pathway is mapped out. An effective workflow will adequately address:
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• How urgent calls/messages are received. For example, what phone number should patients be using for urgent issues? Who is answering the phone? Who should be answering the phone (i.e., should it be someone with clinical expertise or knowledge of inflammatory bowel disease)?
best practice 1: Create an effective intake and phone triage system for urgent issues. To ensure urgent calls get addressed in an appropriate timeframe, it is important to create a defined intake and phone triage workflow for your clinic.
• What information needs to be collected from the patient to accurately determine how urgent their needs are. Some clinics used a standardized intake questionnaire to help them make this determination. This is especially important if the team member answering the phone is not responsible (or clinically trained) for deciding whether a patient is experiencing an urgent or emergent issue and is simply responsible for collecting the information and passing it onto a different team member who can make that determination.
• Which team member schedules urgent appointments.
Establish a mechanism for offering an urgent care appointment within 48 to 72 hours of a patient calling your clinic.
• Which team member(s) can make the decision as to whether the patient should go to the emergency room or be scheduled for an urgent care appointment. Most clinics felt that an IBD provider should make this decision.
tip 2 Train your schedulers on IBD and how to handle urgent IBD calls. Some clinics found it helpful to hold IBD-specific trainings for staff who are responsible for answering phones and/or scheduling office visits (especially if they are not clinically trained) to ensure understanding of the inflammatory bowel disease population and why they may need access to urgent services.
Example 5: The Oregon Clinic Gastroenterology South
Example 3: Regional Gastroenterology
Example 4: Gastroenterology Associates, Inc.
“We have a central phone number, and our nurse navigators carry pagers. So, for an urgent call, the nurse navigator can be reached by page at all times during office hours. This is particularly effective when our patients are trying to get through to our central number. Our voicemail states, ‘If this is very urgent and you would need a call by the end of the day, please page the nurse navigator.’ The patients have given us great feedback on knowing they can always reach someone. Surprisingly though, we have found that the pagers are not used much and not abused.”
“We have a templated phone interaction for all triage nurses to use across the practice. The template allows us to get a more systematic and qualitative assessment over the phone of how sick someone is and whether they need to go to the emergency room or not. A lot of these decisions are made by a nurse because the medical doctors aren’t immediately available.”
“We implemented a red-flag for support staff to alert providers that an IBD patient has called with an urgent issue. The criteria for an urgent issue = 1. New, severe abdominal pain, 2. New, severe anal pain, 3. Fever greater than 101 degrees F, and 4. Unremitting emesis = vomiting that does not stop. Patient calls that met any of these criteria were highlighted by support staff with a ‘red jellybean’, an oval cue at the top-right corner of eClinicalWorks’ interface. Whereupon clicking the red jellybean, additional details of the phone call is made available for clinical review in a text box labeled ‘IBD Urgent.’ A gastro enterologist at the office is expected to respond within four hours and provide medical advice directly to the patient or a nurse (who will in turn contact the patient). The red jellybean is inserted by the secretary when they talk to the patient on the phone. The secretary will of course transfer them to an appropriate staff person if they know that person is available, but otherwise they use the jellybean. The red jellybean simply flags the messages as ‘urgent.’ For example, you may be looking through all of your messages, but when you see that red jellybean, you know to check those messages first.”
Example 2: Penn State Health
“Our phone tree is set up with two options: 1. If you are symptomatic, press this button and it will take you to the nursing line and 2. All other calls go to the medical assistant line. The nursing line will ring until someone picks up, but there is an option to leave a voicemail. The voicemail gets checked several times throughout the hour. So, the patient should get a call back within one to two hours.”
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“We have a general number that patients can call. However, there is an option on the phone to get through to a nurse. Our phone triage nurses start the process. They get a good assessment of what the issues/problems are and then route that information to the treating physician or another physician.”
Example 1: The Oregon Clinic Gastroenterology East
tip 4 Try using telehealth. Many clinics found great success in using telehealth as a means of providing urgent care services rather than strictly using in-person urgent care slots.
tip 6 Develop a policy for when you can convert an urgent care slot to a regular clinic slot/appointment. There may be times when the urgent care slot(s) go unused, therefore, some clinics found it helpful to adopt a policy whereby if the urgent care slot was not being used the day before (or a few days before), the scheduler was allowed to convert it into a regular clinic slot/appointment.
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tip 7 Train staff responsible for scheduling urgent care appointments on why it is important for keeping urgent care slots open and when an urgent care slot can be converted into a regular clinic slot/ appointment.
Example Regional Gastroenterology best practice 2: Offer urgent care services to your patients. To prevent unnecessary visits to the emergency room, it is important to have a mechanism in place so that inflammatory bowel disease (IBD) patients with urgent issues can be scheduled to see and/or speak with a provider quickly (within 48 to 72 hours). Most clinics chose to reserve urgent care slots. Although the number of urgent care slots offered varied (depending on preference as well as the number of IBD providers and volume of IBD patients), most clinics chose to reserve at least one urgent care slot in one IBD provider’s schedule per week.
6:
tip 1 So long as you can see a patient with urgent issues within 48 to 72 hours, use whatever urgent care mechanism that works for your clinic—whether it is reserving urgent care slots or simply overbooking a provider’s schedule. Every clinic is different—so work with what you have.
tip 2 Test different days and times to find the time slot(s) that works best for your clinic and your patients. Most clinics found greatest success holding urgent care slots in the middle of the week and in the late morning or early afternoon. Holding urgent care slots later in the day gives your team time to return urgent phone calls/messages and schedule urgent appointments.
“We hold an IBD-specific presentation for staff who are responsible for scheduling office visits to ensure understanding of the care/scheduling the IBD population needs and to answer any questions. Most staff found it helpful and gained a better understanding of why these patients are fit into the schedule differently. Most of the people who initially answer the phone, are not nurses. We train them about why the scheduling and phone system is unique for our inflammatory bowel disease patients.”
tip 3 It doesn’t have to be a medical doctor who sees patients with urgent issues. Make sure that you are utilizing each team member and that everyone on your team is working up to their license. Several clinics had their advanced practice providers (i.e., Nurse Practitioners or Physician Assistants) be responsible for holding urgent care slots or seeing patients with urgent issues.
tip 5 If possible, try to get labs done before having someone come in for an urgent care slot. By doing so, you may prevent the patient from having to come in at all.
Crohn’s & Colitis Foundation Urgent Care Best Practices Toolkit | 15 tip 8 Do your best to convince administration on the importance of holding urgent care slots open for IBD patients experiencing urgent issues. Many clinics found it extremely challenging to keep urgent care slots open—especially if they go unused (i.e., do not generate revenue). Some clinics had success convincing administration by presenting: the reasons why it is important to have this urgent care mechanism for the IBD population, how you intend on measuring usage of the urgent care slots over time, and a plan for releasing urgent care slots before they go unused.
Example 4: Cedars-Sinai Medical Center
“When it comes to urgent care, we do have a nurse practitioner. We have intentionally kept her schedule with open spaces on Tuesdays and Thursdays so that she can see urgent patients. We were finding that on Mondays, slots were not being filled. Thursdays allow us to schedule a necessary procedure (ex. colorectal surgery, imaging, etc.) the next day (i.e., Friday).”
Example 2: Penn State Health
Example 1: The Oregon Clinic Gastroenterology East
“We started with a half-day on Monday. We picked Monday intentionally because if we happened to handle a semi-urgent call over the weekend, we could potentially avoid a hospital admission. However, we realized that if someone called on a Tuesday, they would have to wait a whole week. Therefore, we added another one on Thursday. Then we realized that the rapid access clinic was not being fully used. So, we evolved our system. Since our nurse practitioner has availability in her schedule to see patients nearly every day, it does not require us to have a dedicated urgent care slot available. I think urgent care slots are the better solution if you are very resource-constrained.”
“We trialed 2 slots per day for six months. The first slot was being used 100% of the time, and the second slot was used only 30-40% of the time so we transitioned back to one urgent care slot. The practice has always pushed back on the IBD team saying, ‘Well we want to fill that slot with a non-urgent IBD patient if possible.’ We had two, and they weren’t being used 100% of the time, so we compromised and went back down to one. It is a trade-off you do with your managing partner.”
Example 3: Spectrum Health
Example 5: MedStar Health
“Initially, we had the urgent care slot earlier in the day, and that did not work well because you often needed that morning to contact/get-in-touch-with that person. Therefore, later in the afternoon worked better; and sometimes after 1:00 pm works even better. If the patient is trying to avoid the emergency room over the weekend, they will likely call at some point on Monday. Therefore, having the appointment on Tuesday works well because you can just schedule them for the next day.”
“I don’t know if there is a magic number of urgent care slots necessarily, it is something that is rather fluid. I think it is reasonable to start off with a handful of slots per provider per week, and then go from there. I have 6 to 9 urgent care slots available over my Tuesday/Wednesday clinic.”
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“Since Covid happened, we have been able to use tele-medicine. As a result, I have added what I call a tele-medicine noon slot. It is amazing how it reassures the patient and allows us to do triaging as well. Tele-medicine can be billed now. If I only have a morning clinic scheduled, and I add a 1:00 pm appoint ment, within the system it looks like I opened an afternoon clinic with one spot and the rest are empty. So, scheduling the tele-health visit at noon prevents it from looking like I opened an afternoon clinic. This has worked particularly well. There are disadvantages to telemedicine—no physical exam, we can miss things, there are some things that could be lost in translation. But it has been a game-changer. It is pretty much filled every single week. I have some patients who come from 2.5 hours away…so they are loving this. Noon slots work well because patients can have an appointment with us during lunch and disrupt their workday less.” Penn State Health
Example 6:
Resources: Urgent care intake questionnaire or triage samples: • Sample #1 • Sample #2 • Sample #3 • Sample #4 The following presentation can be used to help convince your administration of the merits of implementing urgent care interventions and/or urgent care appointments at your clinic: • Sample PowerPoint
tip 2 Use simple, clear, patient-friendly language that describes which symptoms are considered urgent.
Establish a mechanism for educating patients on when to seek urgent care and how to access urgent care services at your clinic.
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tip 3 Be clear on how to get in touch with your clinic when the patient is experiencing an urgent issue.
tip 4 Have several patients review the resource you create to ensure that it is easily understood and addresses all patient concerns. “Our educational materials include: symptoms that are considered urgent vs. emergent and what to do in those circumstances. The educational materials have been well received, with a lot of positive feedback from both patients and staff. We feel that by providing our patients with education, contact information, and explaining the difference between urgent vs. non-urgent we have been able to decrease the number of patients seeking the emergency room inappropriately.”
“We did a look to see which patients were going to the emergency room and mapped out the narrative of what happened. We found that a lot of patients that went to the emergency room were not contacting us before-hand and just showing up at the emergency room. So, we created the patient education document, which contains information on what to do if you have urgent symptoms, how to call/message us, and describes what is urgent and not urgent.”
Educate patients about when and how to access urgent care
1: Create an educational resource for patients. To intervene before a patient takes an unnecessary trip to the emergency room, it is important to educate them on what symptoms are considered urgent and how they can get in touch with your team if they experience those symptoms. Most clinics adopted and adapted the patient education resource template that appears in the Resources listed at the end of this section.
Example 2: Northwestern University
best practice
tip 1 Be clear with your IBD patients that you would like them to contact you (if possible) before going to the emergency room.
Example 1: Gastro One
tip 2 Patients often get a lot of information thrown at them, so be sure to specifically highlight this resource, as well as its importance, with the patient. Most sites found it helpful to provide this education during the first visit and repeat it upon subsequent visits.
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Example 3: University of Chicago “Prior to Qorus, patients didn’t know which method of contact to use for what they needed. Patients were following up with urgent issues via MyChart, which of course wasn’t the best method to get urgent care. So, we created a form for patients on how to follow-up with us, which included:
• make sure you register for MyChart
Example 2: Gastroenterology Associates, Inc.
2:
“We include the patient education resource in our Welcome Packet. I will talk to the patient about it when they are a new patient. We will tell them that, ‘This is the hospital that we use, and call us before you to go to the ER.’ It is a one-page sheet. However, a lot of patients just take a picture of it on their Smart Phone so that they will always have it.”
• send non-urgent requests through MyChart
tip 3 Periodically evaluate the distribution system with patients to ensure that it is working and that patients are receiving the information in the way that they would like to receive it. “We were first putting it in the After Visit Summary, and it got printed with their discharge papers. However, we found that it was not useful because patients do not read everything that they are given. So, then we started talking about it to specific patients who we thought needed it. We then decided to make it into a business card (a laminated trifold). The card contained reasons to call. It even had specific names. For example, ‘Ask for so-and-so.’ It was still in the After Visit Summary, but we also started handing it out. We saw an uptick of use after this.”
• for urgent issues, first try calling the nurse’s direct line and leave a message for the nurse and if after-hours call the on-call fellow Implementing the form did help quite a bit.”
Example 1: Baylor College of Medicine
Determine how and when you will provide the educational resource to patients. Most clinics chose to either distribute a hard copy of their patient education resource as a brochure or flyer, include it in their After Visit Summary, and/or provide it through their electronic medical record system.
• if contacting us for an appointment, direct them to the scheduling number
• if contacting for a routine clinical question, direct them to the nurse
tip 1 Implement a system for distributing your patient education resource that works best for your clinic and your patients.
“The educational resources are included in the new patient packets and in After Visit Summaries. A paper packet is given to folks we see in person and a dot phrase for others.”
Example 5: Gastro One
Resources: Patient
Example 3: University of Utah education samples:
• Business card • Wallet card trifold • Wallet card four-fold • Brochure-size card • One-page flyer Patient education template
“We started giving our patients these cards about a year and a half ago. They are given to every patient as they are coming in for a follow-up visit. We are working to digitize the hard copy of the card so that we can send it through MyChart.”
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Example 4: Northwestern University “I personally give it to any new biologic patients in the infusion center, or I give it to anyone that I think may be at high-risk. Providers would also hand them out to their patients. It is a physical hard copy. We do not provide it via the electronic medical record.”
Gil Y.
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Advisory Committee
Saurabh Kapur, MD Kauffman,
Donald Lum,
Erin Forster, MD, Carolina SC
Charleston,
MD, FACG Director, Inflammatory Bowel Disease The Oregon Clinic Gastroenterology East Portland, OR
MD Spectrum Health Grand Rapids, MI
MPH Assistant Professor College of Medicine Medical University of South
Assistant UniversityProfessorofKansas Medical Center Kansas City, KS Lia
Melmed, MD, MS, FACG Professor of Medicine Cedars-Sinai Medical Center Los Angeles, CA Carrie Mize, LPN Manager, Clinical Services Gastro Germantown,One TN
The Crohn’s & Colitis Foundation is the leading non-profit organization focused on both research and patient support for inflammatory bowel disease (IBD). The Foundation’s mission is to cure Crohn’s disease and ulcerative colitis, and to improve the quality of life for the millions of Americans living with IBD. Our work is dramatically accelerating the research process through our investment initiatives; we also provide extensive educational resources for patients and their families, medical professionals, and the public. a grant from The Leona M. and Harry B. Helmsley Charitable Trust.
www.crohnscolitisfoundation.org 73305/2022Third Avenue Suite 510 New York, NY This800-932-242310017projectissupported by