This article is brought to you by IntellaTriage. The article is based on an interview that took place during a virtual panel discussion with Carla Davis, Senior VP of Hospice Operations at LHC Group, Barbara Knott, VP of Continuing Care Services, Lisa Schmitz, Regional VP of Operations at CommonSpirit Health at Home, and Bernadette Smith, VP of Marketing at IntellaTriage. The panel took place virtually on March 22, 2022 during the Hospice News Staffing Summit. This is an excerpt from the session, which has been edited for length and clarity.
Bernadette Smith: Good afternoon and thank you for joining us for this exploration into several common models of post-acute after-hours triage staffing. On-call nurses help fill in the gaps, but many organizations struggle with how to efficiently and effectively manage calls that come in after-hours and lack the data to help to improve their processes. The three most common models are non-clinical answering service, internal nurse team, and external nurse team. We will hear from providers who use these models in their organizations. We’ll discuss the pros and cons for each and even hear from a provider who’s in the middle of a transition to a new model.
There are some key trade-offs to these different models. That’s the second part that we’ll be discussing today; when you’re deciding how to plan out and strategize your model for post-acute. When you think about it, 75% of the week is actually after-hours.
When was the last time you called into your own after-hours team and experienced it from a patient or a family member’s point of view? That’s what we’re hoping you think about today as you start to understand the different models available. Ask yourself, “Have I been thinking about this from the best angle? Do I have the best model in place for my patients, my caregivers, and my nurses?” We’ll discuss the metrics of where the impacts lie and what to consider.
Before we get started, I want to call attention to the makeup of today’s expert panel. It’s composed of all women, leaders in their fields and successful in their organizations. In our organization, IntellaTriage is working to drive change in multiple areas, including diversity and inclusion. To that aim, we were intentional in our panelist selection.
With us today are Carla Davis of the LHC Group, Barbara Knott of University of North Carolina Health, and Lisa Schmitz of CommonSpirit Health at Home. I’m proud to moderate this panel today and thank you all for joining us.
Carla Davis: Thanks, Bernadette, and thanks for inviting my esteemed colleagues and I to have this discussion. I’ve learned a lot just in the practice sessions about the models and thinking about how we should think about it differently. I’m representing LHC Hospice today. I think most people know that LHC bought Heart of Hospice last year. I’m going to talk about the Heart of Hospice model and where we are in the context of the overall LHC organization. We are going to take some aspects of that and take it across the country.
We’re studying which after-hours triage aspects we want to do now. We had a bifurcated model, where calls for patients on service go one direction and calls for potential patients’ referrals go in a different direction. I just wanted to mention that high level. I’m going to be addressing the calls for the patients that are on service today because I think that’s what we’re talking about, but I think it is interesting to note that you might want a different structure for patients who you’re caring for and patients who you are not yet caring for.
For the patients that we’re caring for, our model is first, a contracted, non-clinical answering service. Then number two, we have a centralized internal nurse triage team. Then at the agency level, we have, obviously, the clinical team on call. That model varies by the size of the agency. This centralized model was put in place for about 1,700 patients in 16 different locations across 5 states.
Smith: Thank you so very much. Lisa, what about your internal nurse team?
Lisa Schmitz: Our internal call structure is supported by a non-clinical team. They are not contracted, they are our employees. We call that the star center. Then we do not have an internal or a consolidated nurse triage group. The external nurses, they sit at the branch level, then work the calls after the star center fills those calls. Unlike Carla, it’s one pipeline, referrals, calls, patients we’re caring for. It’s a lot coming into one spot.
Smith: Thank you. How about Barbara? Tell us about your model, please.
Barbara Knott: We use an outsourced company for our after-hours calls, Monday through Friday, and weekends as well. What our on-call services do is answer the phone as though they’re UNC. Not just hospice, but home health and our home infusion nursing program are also attached to this same company as an outsourced service. The company will answer the phone based on where the call is coming from.
They will say UNC Home Health, UNC Hospice, UNC Home Infusion Nursing, depending on where it’s coming from. It’s a registered nurse that answers the phone and triages and troubleshoots any of the calls that come in. The protocols are set up when we first contract with the service so that they are speaking and functioning the same as if it were one of our nurses that were answering the phone.
Smith: That’s wonderful. Thank you very much, Barbara. As we talk a little bit further about these different staffing models, some of the things we hear is about when escalation needs to occur, who is doing that in each of your models? Someone has answered the phone and it is determined that that person who has answered the phone cannot handle the situation at that time. What happens next?
Knott: With the outsourced service, the nurse, as I said earlier, will try to handle any call that comes in. We set up, in our protocols, what an escalation would look like. If a patient calls twice, you automatically call the nurse either in hospice, home health, or home infusion. We do still have a nurse that’s on-call from our agency, but it’s only for answering escalations. It’s not for answering any of the other calls that come in.
Schmitz: So, Barbara reminded me that when our calls come in as well, they will press one for hospice, one for home health. The hospice goes to the top because we’re a home health and hospice company. Again, it goes to a non-clinical individual. If it is patient-related, then it is sent to the nurse at the individual branch. There’s some struggle to connect there at times because of the volume of calls that we’re answering in the star center, and then there’s a wait time for that nurse to get back to that patient or that patient’s family.
Smith: How long can that take, Lisa? Can that take quite a long time then?
Schmitz: Sure, it can. Anywhere from our average wait times on the original call is 51 seconds up to 9 minutes, depending on the volume, depending on the time of day. Of course, after-hours and weekends are what we’re talking about, right? We also have staff calling that number every once in a while, just to have something changed in the EMR. Yes, the wait times can be long– 51 seconds, 2 minutes, 3 minutes doesn’t sound like a lot, but when you’re talking about a hospice patient or a family member that’s uncomfortable, just extend that time in your head because that’s what it feels like to them.
Smith: We say that a lot. We talk about three minutes can feel like three years when you’re really in the middle of something with a family member or a loved one who is making a new sound that you’re not familiar with, or their pain is escalated to such an extent that length of time really does change how you feel- significantly. How about you, Carla? Can you tell us a little bit about how you handle escalations?
Davis: Sure. Well, on the length of time part, I think too, we realize that they don’t call until it’s gotten to the point where they felt like they had to. They’ve been in anxious way before they actually picked up the phone, so I agree with that. In our model, the non-clinical answering service (that’s external) passes on every patient-care issue, so not if it’s an employee having a question.
The centralized triage staff are staffed according to the day and the call volume that we historically have experienced, and there may be two or three nurses on call. Their role is to try to handle it if it can be handled well over the phone, or to get something started with the patient’s family while the nurse on the ground is hitting the road in transit to the patient’s family.
There are a lot of calls that they are able to handle. The only time the nurse on the ground gets called from triage is if the centralized triage could not handle it well and they need to have somebody in person. We also have standards around when visits need to be made so that we are consistently handling that across all the triage nurses. They escalate it to the nurse on the ground.
I say “nurse,” but I think another part of our model that might be a little bit unique is that we have psychosocial on call, we have a manager on call, I have a salesperson on call, and I have aides in most of our locations on call because the calls don’t always need to be handled by the nurse. I think in today’s day with the nursing shortage, anything that could be handled with a non-nurse will be.
If the issue is really the anxiety of the daughter, then that would be better handled with a social work visit. If the issue is the patient soiled themselves and the caregiver can’t change them, then that issue would be better handled by the aide. If the person on the ground, usually the nurse, isn’t able to resolve the issue or, for some reason, we can’t contact them or they refuse to go or something like that, then it is accelerated. Triage knows to accelerate it. We have certain time frames for getting those things to the manager on call.
Knott: Bernadette, I just wanted to follow up to add to the answer time. With the company that we use, the average time to answer is 35 seconds, which has been wonderful. We have had people say they’ve never had anybody answer the phone as fast as they do in after-hours.
We do get staff calling in to call out sick and we do have patients calling in to ask, “What time is my nurse coming tomorrow?” The triage nurse handles all of that. None of that gets escalated. As Carla said, you’ll have people call just to call sometimes. They do take care of that. Our average talk time for the nurse to resolve an issue is less than three and a half minutes and we don’t see those calls. We’ve been pretty satisfied.
This excerpt has been edited for length and clarity. To watch the full discussion on video, please visit:
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