Telephone assessment and treatment Presenter: Dr Chris Fawcett Developed by Compass Health HCH Team
The first domain of the HCH Model
Why Telephone Assessment and Treatment? Patient choices Timely treatment Getting the right patients into face-to-face appointments Respect and value patients’ time Release capacity within the practice Enable clinicians to have more control over their day Telephone triage is acceptable to patients (Cochrane study 2004) Reduces need for face to face consultations (ESTEEM trial 2015)
What is Telephone Assessment and Treatment? • The process of determining the priority of patients' treatments based on the severity of their condition. • The purpose is to ensure the patient is referred to the appropriate team member for the appropriate level of care within an appropriate period of time
Who should Telephone Assessment and Treatment? • Clinicians who can diagnose and prescribe (ideally by the patient’s lead clinician) including: Ø GPs Ø Nurse Practitioners
Telephone Assessment and Treatment implementation process
Data collection
Adjustments
Planning discussion
Monitoring and evaluation
Promoting the service
Implementation
Data collection Key information: Acute demand profile Acute demand according to time of the day Acute demand phone and walk- ins Reason for walk- ins
Acute demand profile across the week and time of day
MEASURING DEMAND FOR SAME DAY APPOINMENT Responsible 1.
Clinician
Date
22/02/2017
Version No.
1.0
Record same-day appointment requests by phone over a two-week or four-week period into 2-3 hour time slots as per the attached tally sheets. Please total the number of requests each day
2.
Record walk-in over a two-week or fourweek period into 2-3 hour time slots as per the attached tally sheets. Please total the number of requests each day
3.
Scan or fax the tally sheets to your Compass HCH contact, who will convert the data to graphs
4.
Phone vs walk-in demand (average)
The data will help to identify the acute 90
population. (e.g: There are generally more requests on Mon-Tue-Fri) 5.
Some typical assumptions are: •
After clinical triage, 40% of the sameday appointment requests will be able to be managed another way instead of a face-to-face consultation
•
An experienced clinician can typically manage 3-5 clinical triage calls in a 15-minute slot
6.
Based on the identified demand profile, it is possible to work out how many GPs are needed to be rostered to do triage
7.
Appointment book templates changed to block out dedicated GP triage time
Number of appointments
demand profile for your practice
80.5
80 70 60 50
64.5
30
33
20 16
0
Mon
6 Tues
47
42.5
48.5
40
10
57
54.5
44.5
11.5
Wed
Thur s
Walk-in Total
35.5
9.5
Phone
12.5 Fri
Acute demand profile (average) across two weeks
Acute demand according to time (by phone) 8am-10am vs rest of the day
What is the data telling us? • Demand is highest on a Thursday with peak time being between 8-10am • Walk-in demand is very low • Telephone assessment and treatment (clinical triage) is a good solution for acute demand given most same acute appointment requests are made via phone
Tips for telephone assessment and treatment (clinical triage) [peak time] Number of Clinicians providing clinical assessment and treatment to meet demand: Assume: A clinician can triage 3 calls in 15 mins Therefore, 27 calls at your peak time would require: 4-5 Clinicians triaging for 30 minutes Number of acute appointments in template: Assume: Clinicians can triage 40% of patients away Therefore, 40% of 27 = 11 patients, would require 16 face-to-face appointment across 4 GPs (4 appointments per clinician)
Information from collected data
Telephone Assessment and Treatment is useful for acute appointment requests made via phone Suitable time of the day to do Telephone Assessment and Treatment (typically in the morning 8.30am – 10am) Peak days of the week
Planning discussion When to do Telephone Assessment and Treatment How long to do Telephone Assessment and Treatment for Identify clearly the role of staff during triage implementation (e.g. receptionist/call handler, clinicians‌) How to communicate it to patients
Getting started Different in each practice, depending on demand Phone system needs to be able to measure dropped calls, call volume and wait times Find what works best for the practice/ review/ PDSA Small steps Go live requirement
Front desk
01
02
03
04
Buy in
‘Sell’ Telephone Assessment and Treatment to patients
Front desk “spiel”
Peer review
Call handling management
Call handling management Script example Receptionist: [Name of practice], good morning / tena koe. Ko […] tena. Patient: Hi, its Bob, I’d like to see my doctor Receptionist: Hi Bob, when would you like to book an appointment Patient: Today please Receptionist: Okay well, I could get the doctor to give you a call in the next hour and see what the best plan is? It’s a new service we are offering where the doctor can help you on the phone. There will be a half price charge for this unless you need to come in or you need a script, then it’s the normal fee. Patient: Oh that sounds good Receptionist: Great, what is the best number to call you on please? Patient: My number is xxxxx Receptionist: Thanks Bob, the doctor will call you between 9 and 10. Patient: Thank you
What is Telephone Assessment and Treatment? • • • •
You will notice that if you phone for an appointment for the same day you will be told the call will be telephone triaged. This means that the doctor or nurse practitioner will phone you to assess the situation, usually within 10-20 minutes. It may be your problem can be solved over the telephone or by a prescription. If your problem is urgent and needs seen that day you will be. It might mean you will be seen quicker.
Why is the surgery doing this? •
The demand for appointments is on the increase and the range of services we wish to offer is increasing. We also want to be able to offer you different ways of communicating with us other than always needing a face to face consultation. This may be by telephone, email or eventually over the internet. We look forward to offering you this enhanced service.
Clinician checklist • Confirm patient identity
• Ask patient to recap the agreed plan
• Explain benefits of talking to GP or nurse now if necessary
• Safety net - “If your condition deteriorates or you develop XYZ (relevant to presenting complaint) please let us know, remember to call 111 in an emergency”
• Take a full history of presenting complaint • Review patient records, e.g. meds, warnings, classifications, etc • Consider need for physical examination to come to a diagnosis. Book face to face consult if necessary • Discuss options if confident you can manage patient without physical exam • Remember, patients can still request a face to face consult at any time
• “Do you have any further questions right now?” • Say goodbye and hang up • Fully document call in Advanced form. Consider sentence confirming patient happy with outcome. • Code the invoice outcome.
Example of HCH GP template
Let your patients know
Telephone assessment and treatment advanced form
Invoice coding for telephone assessment and treatment No fee charge: • TRC – Triage Call Telephone Triage and assessment phone call from patient, where advice has been given and no further action required. No fee is to be charged to the patient for this call Fees can be charged: • TRX – Triage prescription Telephone Triage and assessment phone call from patient, where a script has been given. It is envisaged that there be a fee charged to the patient for the prescription (to be determined by each practice as part of their fee structure set up) • TRM – Triage Management Telephone Triage and assessment phone call of patient, by a doctor or nurse where it has been determined that further clinical assessment or management is required virtually (other than a TRC and TRX). To be no more than half the normal consultation fee.
Telephone Assessment outcome Example report
•
Guideline outcomes About 30-40 calls/day for a practice of 10,000 patients
Resolution rate: 40% for GPs, 15% - 20% for nurses, 35% for nurse practitioners Call length on average: 3 minutes/call
Practice 1 Practice Profile
• Population:6,097 patients • 8 GPs • 90% high needs patients (Maori, Pacific or >Dep5 • Provider focused on caring for Maori, Pacific Island and Community Service Card holders
Story
• Able to create capacity for acute care • GPs have more control over the day • Huge Reduction in presentations to local A&M Direct line redirect patients to clinic • Reduction of inequalities, more high risk patients receiving on the day care
Examples of presentations to ED
ED after hours analysis at PUCHS
Changes in ED Attendance
Referred to Team medical Number
18
16
14
12
10
8
6
4
2
Median 0
7/8/2016 7/1/2016 6/24/2016 6/17/2016 6/10/2016 6/3/2016 5/29/2016 5/20/2016 5/13/2016 5/6/2016 4/29/2016 4/22/2016 4/15/2016 4/8/2016 4/1/2016 3/25/2016 3/18/2016 3/11/2016 3/4/2016 2/26/2016 2/19/2016 2/12/2016 2/5/2016 1/29/2016 1/22/2016 1/15/2016 1/8/2016 1/1/2016 9/3/2014 8/27/2014 8/20/2014 8/13/2014 8/6/2014 7/30/2014 7/23/2014 7/16/2014 7/9/2014 7/2/2014 6/25/2014 6/18/2014 6/11/2014 6/4/2014 5/28/2014 5/21/2014 5/14/2014 5/7/2014 4/30/2014 4/23/2014 4/16/2014 4/9/2014 4/2/2014 3/26/2014 3/19/2014 3/12/2014
Tips on introducing a telephone assessment and treatment system Experience is important Needs to be within clinician comfort It is important to link patients to their GP if possible Nurse triage vs GP triage No negative events Liked by patients Measure outcomes – are we changing anything? Little or no training required to use the form
Key principles of telephone assessment
The three following important aspects:
WHY should a
telephone assessment and treatment service be implemented?
HOW should
telephone assessment and treatment be implemented in general practices?
WHO at general
practices should do telephone assessment and treatment?
WHY? • Patients who request to be seen on the day with an assessment and treatment service by a clinician which may result in the patients needs being met in an alternative way to a face to face appointment. • Respect and value the patients time. Assessment is carried out for all patients requesting a same day appointment irrespective of whether the practice has empty appointments on the day. • Release capacity within the practice. • Enable clinicians to have more control over their day
WHO? • The telephone assessment and treatment service will be carried out by clinicians who can diagnose and prescribe (ideally by the patient’s lead clinician). • A clinician who can diagnose and prescribe could include the following: GP, Nurse Practitioner, or clinical pharmacist.
HOW? • The telephone assessment and treatment service should be available daily (Monday – Friday) to ensure consistency and continuity of service offered to patients. • Timing of the telephone assessment and treatment service being offered is based on the practice’s acute demand profile. • When patients make requests for a same day appointment, the call handler will direct calls to the telephone assessment and treatment service
ACTIVITY
For the practice to consider
Write your own spiel for the receptionists How will you change your appointment templates? Doctor time for triage, acute appointments, book on day, virtual consults, phone consults, nurse triage, doctor and nurse F2F How will you roll this out? e.g one doctor at a time or everyone at once? Who will be responsible for collecting the acute demand data? Charging guideline
THANK YOU