During a pandemic like COVID-19, a telephonic triage service can be helpful in reducing fear, and anxiety among patients and healthcare providers as well as ensuring that the people who need immediate or urgent care are navigated to the providers for further interventions in a timely manner, points out Ramesh Gopalan, President – Global Healthcare and Head of India Business, HGS in an interview with Raelene Kambli. In the last 30 years, HGS has been helping hospital systems and medical organisations to manage early assessments and direct patients to the relevant level of care. HGS has over 1,200 nurses around the globe supporting business-critical functions ranging from care management, nurse advice and triage line, prior authorisation and retrospective clinical reviews, high dollar clinical reviews for claims payment integrity, and personal nurse concierge careline. Here, he explains the significance of such services in times of COVID and his experience and key learnings from implementing this system in India
What is the significance of a telephone triage and advice services (TTAS)?
The TTAS scope includes nurse advice as well as general practitioner assessment. The HGS Nurse Triage and Advice Services use clinically-experienced nurses. These services are provided via telephonic and online channels, and do not make treatment recommendations, but rather provide clinically-appropriate self-care and optimal care setting recommendations based on clinical guidelines. The nurse triage services typically are operated 24/7/365 days and augment support to clients’ internal resources, especially when the physician offices are understaffed such as during weekend and evening hours.
Is there enough body of evidence that proves its effectiveness in such times?
Yes, there are several peer-reviewed articles that evaluate TTAS across several intended outcome parameters. These parameters span across timeliness, access to care, quality and cost of care, and patient satisfaction.
The healthcare system is strained, especially in times of emergencies and crisis. During a pandemic like COVID-19 and others, the telephonic triage services are very helpful in reducing fear and anxiety as well as ensuring that the people with the need for the most immediate or urgent care are navigated to the providers for further interventions in a timely manner. Hence, the nurse triage services are also found to positively impact patient/customer experience.
What is the scope, consistency and generalisability of findings in relation to the governance, safety and quality of TTAS?
The scope of the nurse triage line is an assurance to safely navigate the caller to the right level of care and provide clinically appropriate self-care guidelines. The nurse triage lines are administered using evidence-based clinical guidelines that are evaluated by a panel of medical experts from the various specialities, every six months. In the United States, where a majority of HGS’ healthcare clients are based, there is an accrediting body that audits the accuracy of the dispositions. In addition to this, a well-governed program also conducts calibration of its algorithms against service providers of similar speciality.
However, the generalisability of the guidelines depends on the healthcare delivery structure. For example, there may not be urgent care in certain countries, and hence, the guidelines that direct a patient to an urgent care may have to be modified to the appropriate level of care in that country. In addition, the recommendation for non-emergent cases, especially of public health concern, may require additional customisation to each regional requirement.
From the Indian context’s point of view, how effectively do you think this system can be implemented? What has been your experience, key learnings from implementing this system in India?
HGS doesn’t operate in the Indian domestic market currently. However, we leveraged our experience of running TTAS lines for the US clients to recently partner with the Karnataka State Health Department to set up Apthamitra, a 12-hour telemedicine helpline manned by over 50 volunteer nurses and doctors. This TTAS line is a critical helpline initiative that uses HGS’ delivery site and technology infrastructure in Bengaluru (and not its clinical algorithms or content) and aims to help our community in their fight against COVID-19. The system is proving to be very helpful to users by counselling them on general COVID-19 health queries, thereby reducing the rush at the state hospitals.
How many people have responded to this system, and what is your evidence of TTAS performance?
Let me answer this in two parts. For the Apthamitra helpline that we started in April-end, the team has clocked over 6,500 hours and attended more than 22,000 calls, including both inbound and outbound (to follow up with callers). The initiative is helping the government provide the right information to the concerned citizens in a very stressful time. It’s an ongoing effort.
From our experience in the US, we see an adoption of anywhere between three to five per cent of membership if the sponsor is a health plan. If it is a self-funded employer group, with sufficient incentive to use the nurse line, the adoption can go higher than eight to ten per cent. For example, in a programme where we have a high adoption of services, we have delivered ROI of 2:1, as evidenced by an 82 per cent reduction in unwanted use of emergency services.
As per literature available, the current evidence does not provide definitive answers to questions about the quality of care provided, access and equity of the service, its costs and outcomes. How would you justify or give us a better understanding of these aspects through your business model?
The focus of the Nurse Triage and Advice line is on avoidance of inappropriate under and over utilisation of emergency services.
From our experience, we redirect more than 80 per cent of callers away from emergency room services to a more appropriate care setting and the guidance on the level of care given by our nurses have an over 99 per cent agreement from the physicians. Another advantage of the nurse triage services is the impact on positive member/patient experience resulting from timely support and advice, which has unfortunately not been the traditional focus of healthcare delivery. Lastly, using digital channels to improve member engagement during high volume calls can optimise the ROI from these services.
From your experience, what are the interactional factors (e.g., relationship with other health service providers) which can impact on measures of performance of such a system?
Providing options for the nurse triage services to refer patients to a telehealth provider, wherever appropriate, can be beneficial in circumstances where the travel times or access issues are widely impacting care.
Alignment to the providers’ objectives for the TTAS is important in order to drive brand value as well as meet cost and outcome objectives. For example, during downtimes, the nurse helpline services can also provide outbound campaigns to the hospital’s community healthcare events such as blood pressure screening or osteoporosis screening.
An added advantage of the TTAS line is the marketing value from patient-engagement services. Hence, working with the Chief Marketing Officers is important to help define programme objectives.
How differently do you ensure that partners in this model align well in order to get better outcomes?
The outcome must be clearly defined by the stakeholders. TTAS can deliver value in many ways.
For the timeliness of care, TTAS can be a filtering channel for the emergency rooms or public health systems where waiting times are a concern for patient experience management.
To mitigate cost issues, TTAS can provide value through redirection or navigation to correct level of care as well as retain patient within the health systems’ network thereby optimising resources at the various points of services.
To improve brand value, TTAS can work with the hospitals or health systems and provide an engagement plan that can positively impact brand value to the community
What are the key lessons that people opting for such systems can learn from you?
Two points that I would call out as critical are: firstly, the cost of servicing a nurse triage line can be offset with decoupled workflows and digital channels that can handle callers with varied queries that may not need clinically trained staff. Secondly, stakeholder sponsorship is key to increase the adoption of the TTAS line.