In this interview we talk with Chris Phillips, RN, BSN, CCM, CPHQ and Lead Care Manager for Privia Health’s Care Advice Line. Chris has implemented ClearTriage within 2 large ACOs as part of their population health strategies. The first was a multi-hospital system; Privia Quality Network is more PCP-centric with close to 1600 physicians across the nation. In both locations ClearTriage is used with the ACO’s care management software and integrated into the providers’ EMR.
- Privia Health and the Triage Team
- Advice for Starting a Triage Service
- Finding and Training Triage Nurses
- Why ClearTriage?
Privia Health and the Triage Team
ClearTriage: Before we start talking about your triage line, what background can you share with our readers about Privia Health and yourself?
Chris: Privia Health is a physician practice management and population health technology company that partners with top doctors to keep people healthy, prevent disease, and better manage care in-between office visits. Our high-performance physician group, Privia Medical Group, and our accountable care organization (ACO) Privia Quality Network were built from the ground up to provide high-quality care in the new healthcare environment. We use cutting edge technology such as big data and advanced care models to achieve population health success.
My personal background includes close to 30 years of nursing from nursing homes to ICUs, home care to wellness. For the 4 years prior to my telephone triage roles, I did emergency room case management which was perfect for teeing me up to do triage in the population health world. I knew from working there what types of patients the ED would typically admit versus send home. During that time I also became certified in both hospital criteria sets, MCG-CM and InterQual.
ClearTriage: That sounds like a good fit for both of you. So how does Privia Health use telephone triage?
Chris: The original objective I was given was to significantly reduce unnecessary ER visits while maintaining high quality care across our physician networks. They knew this would involve nurse phone triage and probably other services such as rapid response home care nurses and telemedicine. However, they wanted to start with phone triage as the first step.
In today’s “on demand” world it made sense to also add real-time after hours care management to the triage call. Meaning we’re not just taking random calls and only addressing triage, but in the first 60 seconds of the call we’re reviewing the patient in our care management software, finding the best protocols and identifying health care gaps or important trends. We have all this rich integrated data at our fingertips, why not take a moment and synthesize those things?
So I like to say that our goal is not just 24/7 triage, but 24/7 care management. We’re able day and night to connect that patient to the very best resource in our system. And this gives us excellent population health management.
ClearTriage: Can you give us an idea of the size of your telephone triage group?
Chris: We’ve started by providing triage and after hours care management to the patients in our ACO, gradually rolling out to over 200,000 members. So far we’ve marketed our service to over 50,000 of those members and that has taken six nurses including myself. One nurse covers the line at all times with a backup nurse who can jump into the queue within 15 minutes during surge times. Surge times vary but tend to be 8am-9am and 5pm-7pm for us.
Our next step will be growing to 2 nurses on the line 7a-11pm with surge backup.
Advice for Starting a Triage Service
ClearTriage: What would you like to share with an organization wanting to start providing a telephone triage service?
Chris: Define ultimately what you’re trying to do, what your entire goal for patient care is. Think big, think beyond just the triage part. You can often accomplish comprehensive care management and maximize network utilization during these encounters.
It’s a new dawn for our services. ACOs and organizations taking full risk for patients’ lives changes the cost equation. It’s much easier now to justify your service, to prove return on investment. It’s not a perfect science but we are already tracking 1 to 2 calls a week that don’t go to the ER because of talking to us first and then quickly connecting to their PCP.
We also maximize the use of our integrated network for both quality and cost benefits. And the providers on all fronts have been impressed and thankful for the concise triage/care management note we leave in their EMR along with follow-up appointments we book ourselves. They used to be frustrated without this clear clinical communication, now they are more comfortable reducing their after hours load.
Finally, don’t be afraid to piecemeal your solution. Use what your provider network already has and don’t bring in another mini-EMR solution just for phone triage. Since our service is so integrated with the daytime Care Management staff it only makes sense to be on the same phone and data systems as them. A more elaborate triage system risks siloed information or data that is not available on the front lines.
Finding and Training Triage Nurses
ClearTriage: How do you find a good triage nurse for your group?
Chris: That’s been a big challenge, the hiring part. You really want that blend of both nursing experience and a love for technology. For technology I ask how often they search the Internet at home, do they bookmark sites, do they do online banking, what’s the difference between left and right-clicking, what’s the difference between copy/paste and cut/paste, how do you save an attachment and find it later? I know this can sound basic, but some very experienced nurses just aren’t that tech savvy and it can really slow them down and frustrate everyone.
For nursing, I know they’ll be using protocols but I want to start by understanding how they triage independently. I’ll do just a couple of short role-plays during the interview, like a vague symptom of chest heaviness when I breathe deeply, an moment of tingling on the right side of my face that is gone now, or a new rash on my leg. I’ll ask them what are you thinking in the back of your mind, what are you ruling out and what is your immediate next question?
Even though they will have the support of the protocols in ClearTriage during real calls, it helps to see what their baseline comfort is with big questions like these.
I also want to understand how comfortable they are with what happens in other care settings like urgent care or home health care. They need to not just have a “hospital” perspective, they need to have the proper respect and understanding for the wide variety of ways people can get care in today’s world.
ClearTriage: And how do you train a new nurse once you hire them?
Chris: The most important part of our training actually started with a simple suggestion from my project manager when he asked, “Why don’t you do some simulations?” I drew upon my ER experiences and created about 20 triage call simulations where I am the caller.
I start by sitting right next to the new nurse so I can see what they’re clicking. I talk calmly, professionally, not stressing them out. I found this was very important. I allow them to interrupt me rather than let them drown. I also frequently break character and coach them.
After 5 or 6 calls next to them, I’ll move to another room and call in as a real caller. I’ll throw all sorts of complications at them during the calls to mimic the worst actual calls I have taken. Every time I do simulations it seems “clunky” to both of us, but it definitely moves their confidence from a 3 to 9. Many nurses have thanked me afterwards for those times. I have found this critical even with highly trained nurses (MSNs, DNPs and CCMs). They still need the simulations to build this skill and their confidence.
A funny story is from a co-worker a couple cubicles down from me. She was originally so mad at me, she couldn’t understand why I would come to work when I was so sick! She complained to someone else nearby who told her I was just doing simulations. She then came by my cube laughing to share the story with me. I told her she was lucky she figured that out before I started my suicidal ideations.
ClearTriage: How do you use ClearTriage in your call process?
Chris: It’s the bedrock of any triage call that happens. We keep it up on our second screen at all times. The nurse will review the patient’s recent diagnoses, meds, encounters, labs, etc., while at the same time capturing information about their symptoms and selecting a triage protocol in ClearTriage. And in the end everything is stored back in our care management software and also pasted into the PCP’s EMR.
ClearTriage: Why did you select ClearTriage rather than an alternative solution?
Chris: One of the beauties of ClearTriage is that it’s simple and it really allows you to focus on other core functions. Telephone triage is a difficult task, one that is foreign to most nurses as they get started. And like most organizations we already have heavy technical demands as well. We already have an EMR. We already have a sophisticated phone system with tracking and reporting. We already have our population health software. The last thing we needed was another complex system or another standalone siloed system storing patient data. The vetting and integration and additional training would have added layers of complexity. For us simpler was not only better but safer and more affordable. I can’t imagine doing it any other way.
ClearTriage: Thanks Chris.
Chris: Thank you!