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Top Factors for Successful Management of After-Hours Calls
On-call rotations are stressful for most clinicians. Taking on-calls for the nursing home (NH) population presents many challenges for covering clinicians, who may not be familiar with geriatrics practices and patient presentations. Information related to the patient condition may be communicated adequately from the nursing staff, but the clinician may not be familiar with NH capabilities of care and other mitigating circumstances. Liability and the ability to assess the best place of care based on patient changes in condition can make for difficult decision-making.
The Evercare Model
Evercare is one of the nation’s largest care coordination programs for people that have long-term or advanced illness and disability. The Evercare model using the nurse practitioner/physician assistant (NP/PA) as the center of an integrated team (includes the physician, patient and family, and NH) detects changes of condition earlier and provides more proactive care management. NH patients can be treated in place more readily, thereby avoiding costly and debilitating trips to the Emergency Department (ED).1
Evercare is part of Ovations, which is a division of United Health Group. At the Evercare New England site, NP/PAs, physicians, and care managers serve residents in NHs and persons who live independently in their home. Evercare is a model that Robert Kane looked at in a study published in the October 2003 issue of the Journal of the American Geriatrics Society, in which hospitalizations were reduced by 45% with no change in mortality. Kane also found reduced ED visits and decreased acute episodes in the NH setting. Kane reported that the Evercare model, which focuses on holistic care and early intervention, was directly responsible for the positive results.2,3
Another source that did not participate in a study about Evercare estimated that 55% of ED visits are not medically necessary.4 It is reported that physicians who have patient panels at skilled nursing facilities receive an average of 49.5 calls per patient per year.5 Evercare New England, which includes Massachusetts (MA) and Rhode Island (RI), has an on-call system to complement the high-touch care provided by the collaborative primary care teams in the NH. The on-call program provides service to Evercare members in approximately 169 NHs in MA and RI from 5:00 PM to 8:00 AM, and 24 hours on weekends and holidays. Our on-call staff includes telecommuters and rotated NP/PAs who work collaboratively in teams with physicians as back-ups to provide the on-call service. Our average metrics are 37 calls made or received from 5:00 PM to 8:00 AM and 113 calls from 8:00 AM to 5:00 PM made or received on weekends and holidays.
We estimate that we avoid unnecessary hospital transfers without loss of quality for two to four members per shift. The avoidance of unnecessary acute transfer has proven to be cost-effective. The savings from avoidance of unnecessary transfers is over 100% of the cost of the on-call program. Our goal is to provide continuity of care and to ensure that care is delivered in the appropriate setting. In order to manage these calls effectively and efficiently, the system is structured to have teams of NP/PAs on call. The on-call staff consists of clinicians whose full-time job is to take calls along with NP/PAs who care for patients from 8:00 AM to 5 PM who volunteer for rotation into the on-call shifts. The full-time on-call staff works a combination of 5:00 PM to 8:00 AM and weekend shifts each week. The rotated staff works as the structure changes with review of metrics and can be adjusted to enable the on-call clinician to be successful in the delivery of high-touch telephonic care in the appropriate setting.
All on-call clinicians attend a seminar and have a mentoring period with a seasoned on-call clinician. Our team uses as resources collaborative practice guidelines and algorithms to provide the on-call service, along with an electronic medical record (EMR). The clinician has access to the primary care physician or designee (through his/her usual on-call practices) and/or the Evercare medical director when collaboration is required. The Evercare medical director and the primary care physician or designee do not take the first call but are to be available for consultation. The primary care physicians have been educated about their expectations of our on-call program for collaboration by the Evercare medical directors. Based on our eight years of experience, following are the top factors for successfully managing after-hours care efficiently and effectively:
1. Communication
Communication of medical plans for acute residents in the NH with laboratory results pending is critical for our system to work. Our system uses a modified version of the SBAR (Situation, Background, Assessment, Recommendation) form to communicate member plans.6,7 The purpose is to reduce miscues as NP/PAs transfer telephonic care to the next shift. The elements in the communication form include: Situation: Describe the situation in a few words; get someone’s attention. Background: Provide enough information to give the clinician some context for the problem. Assessment: Give your assessment of the overall condition. Recommendation: Give your specific recommendation and plan of care. In addition, our EMR contains notes, diagnosis, medications, and advance directives available to the on-call staff. Our teams also communicate with families/healthcare proxy when there is significant change in condition for input to the care. Our site also educates NH staff on communication of medical changes in patients’ conditions. The goal of the education is not only improved communication around the change in condition of patients to the primary care team and on-call teams, but also improved assessment to determine the change in medical status for early intervention.8
2. Metric Management
In order to have the on-call teams be successful, we monitor volume of calls, time of calls, complexity of calls, and seasonal spikes to ensure the level of communication necessary to provide appropriate care. The program will make adjustments based on the metrics. The on-call program began in RI this year and, to date, the system has demonstrated a decreased need for after-hours transfers to the ED.
3. Guidelines and References
We have onsite training for all who participate in the on-call program, which provides practice guidelines and algorithms for reference. The algorithms were developed by the site. This is critical for safe and effective telephonic care. We have suggested questions for review of international normalized ratio and dosing for warfarin, as this is one of the most difficult calls and most documented areas of possible concern in the literature.9 We encourage all of our primary care staff to follow up on day routine labs and problems as much as is feasible prior to 5:00 PM.10 (See box for helpful guidelines and references.11-13)
4. Collaboration With the Primary Care Physician or Designee or Evercare Medical Director When Indicated
We have a specific practice guideline for physician collaboration. In addition, if the on-call team needs to review a particular situation, we encourage that communication and have physician back-up if the primary care physician or designee is not available. This collaboration can be essential to assist in medical management in the NH setting.
5. Full-Time On-Call Clinicians
Our system has four NP/PAs who are dedicated to work in the on-call program. We also have other NP/PAs who rotate into the on-call system. By having a core dedicated on-call staff we have a base level of expertise and consistent telephonic relationships with our NH partners.
6. Know the Call System at At-Risk NHs
Our level of communication enables the on-call clinician to be aware of NHs that may be experiencing certain illness spikes or other areas of concern. At times our NH partners may benefit from ongoing education that is provided onsite at the NH on various topics that not only benefit the on-call system, but the daily management of Evercare members. The education consists of continuing education programs provided by NPs on subjects such as, but not limited to, dehydration, cardiac care, and change in condition. In addition, the on-call team may periodically make proactive calls to certain NHs to review a patient’s status or to review any new at-risk patients. The NHs are educated to use our call system for Evercare members.The physician call systems that the NHs may use are instructed to redirect the NHs to the Evercare call system.
7. Collaboration With the ED
When a member is transferred to the ED, collaboration with the ED physician is essential. The on-call clinician has the ability to review the EMR, advance directives, abilities of the NH to provide follow-up care, and any conversations with the families/physicians to help work with the ED team to provide the best outcome for the patient.
Summary
A NH on-call program can be successfully managed by knowing a facility’s population needs and structuring an efficient on-call system to support the patients’ and clinicians’ effective management of calls.
The author reports no relevant financial relationships.
Acknowledgements Ms. Tepper would like to thank the NP/PAs in Massachusetts and Rhode Island who participated in the after-hours call program, and mentors Mark Ostrem, MD, Caritas Carney Hospital, and Alan Abrams, MD, Medical Director, Evercare. Ms. Tepper is Clinical Services Manager, Evercare New England, Waltham, MA.
References
1. Evercare survey finds long-term illness along with religion and politics ranks high on list of “taboo” subjects. Business Wire. October 11, 2007. Accessed June 8, 2010.
2. Kappas-Larson P. The Evercare story: Reshaping the health care model, revolutionizing long-term care. J Nurs Practitioners 2008;4(2):132-136. Published Online: February 9, 2008.
3. Kane RL, Keckhafer G, Flood S, et al. The effect of Evercare on hospital use. J Am Geriatr Soc 2003;51(10):1247-1434.
4. Goldsmith C. Telephone triage: Help is just a call away. Nursing Spectrum 2006:18-20.
5. Whitson HE, Hastings SN, Lekan DA, et al. A quality improvement program to enhance after hours telephone communication between nurses and physicians in a long-term care facility. J Am Geriatr Soc 2008;56(6):1080-1086. Published Online: April 11, 2008.
6. Landro L. Hospital combat error ‘at the hand off.’ The Wall Street Journal, June 28, 2006.
7. Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006;32:167-175.
8. Berry J. A nurse practitioner/patient communication styles in clinical practice. J Nurs Practitioners 2009;5(7):508-514.
9. Coll PP. Medical malpractice and the primary care provider. Clinical Geriatrics 2008;16(9):27-30.
10. Schneiderman H. 100 Precepts for my house staff: Part 2. ConsultantLive 2009;49(6):361-365.
11. Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips. 11th ed. New York: American Geriatrics Society; 2009.
12. Marshall S, Ruedt J, Gillies JH. On Call: Principles and Protocols. 3rd ed. Philadelphia, PA: WB Saunders Company; 2000.
13. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2006. Updated February 2006.
