Another Kind of Tele-Home Health: Medical Call Centers

Robert M. Johnston, M.D., Richard L. Nevins, M.D., and Michael L. Weaver, M.D.

The authors are co-founders of FONEMED, LLC, a medical call center service based in Kansas City, MO. 816/968-1300; www.fonemed.com.

Patients today are increasingly proactive about seeking health information and participating in decisions about their medical care. Much of healthcare, perhaps 40%, consists of the simple exchange of information between experts (physicians and nurses) and patients. Until recently, the surest way to assure this exchange was to see a physician in their office. This can be a time consuming, expensive, highly inefficient way to accomplish many of those interactions that don’t require hands-on, face-to-face assessment. This is especially true in the after-hours setting, when what would have been a simple office visit during the day becomes a very expensive emergency room visit at night or on the weekend.

There is a simple, inexpensive way for patients to "see" a qualified healthcare worker after hours – for reassurance, for advice, for education, or for triage to a care center as necessary. That is by establishing a "medical call center" staffed by trained nurses. A study published in 1993 (see Reference) reported on the 4-year experience of a call center that took after-hours phone calls for 56 pediatric practices in the Denver metropolitan area. During the study period over 100,000 calls were managed without any adverse clinical outcomes. Just over half the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to a care facility be seen after hours, 78% were determined to have a condition necessitating after-hours care. Satisfaction among subscribing pediatricians was 100%, and among parents was greater than 96%. Our experience with a wide complete range of patients (not just pediatric) confirms that these findings apply also to adults.

Role in managed care

Increasingly, medical call centers are seen as a way of short-circuiting the expensive, doleful process that sends so many anxious patients to the emergency room late at night for what turns out to be a trivial or "delayable" condition. Call centers, coupled with other low-tech approaches to patient education, has evolved into what is called "personal healthcare management." This is becoming an important way for managed-care entities to reduce the cost of covering lives while maintaining or improving quality of care. Personal Health Management Programs, an umbrella term that includes medical call centers as a key constituent, covered about 8 million outsourced lives/year in 1994. Currently, call centers respond to almost 100 million calls/year from about 35 million covered lives in the U.S., with virtually no incidence of litigation. At current growth rates they could cover 100 million lives by 2000. (Source: Merrill Lynch & Co.) (See Chart)

What happens when the patient dials the call center

Medical Call Centers connect patients by phone, 24 hours/day and 365 days/year, to the health information they seek. When patients in need of medical assistance call a Medical Call Center, they will typically hear a custom greeting, designed for the organization to which they belong. The caller will have the option of being connected to the audio health library, or speaking immediately with a Registered Nurse. If the caller selects to talk to a nurse, the nurse works through the patient's symptoms and recommends an appropriate course of action. In our system, 90% of all calls are answered by a nurse within 20 seconds of going into the call queue. With proprietary software, the triage nurses have at their fingertips the patient’s recent call history and their doctor and coverage information. Members will know immediately if their visit to a provider will be covered by their insurance, because callers are matched against the system’s knowledge base of health plan requirements. Member satisfaction is increased, and claims adjudication costs decreased, because the approval process for many visits will occur up front.

For the actual triage process, the nurse uses medical algorithms that as a guide for appropriate management for the situation at hand. This could mean telling the patient to go to the Emergency Room immediately, helping the patient in self-care, or recommending an appointment with the appropriate medical provider. If the patient is told to go to the Emergency Room, a record of the patient’s call is immediately sent to the ER to expedite the emergency care given. If a doctor’s visit is suggested, the nurse tells the patient how soon to see the doctor, and the patient’s call record is transferred directly to the doctor’s office

Other Medical Call Center services include 24-hour access to audio text health libraries for patient self-education. The system we use consists of over 1,500 topics. These reduce the amount of time nurses need to spend giving out basic health information, and allow the calls that are subsequently transferred back to the nurses to be handled more efficiently, as the members are now more educated about their topic of concern.

Cost and savings frankophyl@aol.com

The cost of enrolling each patient in a medical call center service varies depending on the size of the contracting insurer and other factors. Services vary from basic library and advice to risk assessment, health events counseling, compliance monitoring, outcomes measurement and disease management; and they may involve both inbound and outbound calling. The cost/ year for a family of four for basic medical call center coverage ranges from $15 to $107.40. For a typical managed care contract with 50,000 covered lives, the approximate yearly cost of covering each member amounts to about $4.40-$7.75. A recent study from the Center for Corporate Health showed that for every $1 dollar invested in a telephone-based health management system, $4.75 was saved through better self-selection and use of resources.

We believe that a Medical Call Center is the single best strategy to deliver the right care at the right time in the right setting with the right resources. Medical Call Center activities are measurable, manageable and actionable, and can form the core of a highly efficient health care structure with very high patient and practitioner acceptance.

Reference

Poole SR, Schmitt B, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics 92:670-9, 1993