Customer Interview – Forest Hills Pediatric Associates

We’d like to start introducing some of our customers and let them share their triage experiences. We hope these interviews will give you insight into different ways people manage telephone triage and provide ideas for improving your own triage. Our first interview in the series is with Claire Olgren, MD and Kathy Hickey, RN of Forest Hills Pediatric Associates.

To give you a sense of what we talked about, here are some of the topics we covered:

The Forest Hills Triage Team

ClearTriage: Could you tell me a little bit about Forest Hills Pediatric Associates and yourselves?

Kathy: Forest Hills is a private pediatric practice in a suburb of Grand Rapids, Michigan. We have one location with twelve physicians and I am the office manager. I’m a registered nurse and enjoy the business side of practice.

Claire: We’re a private practice owned by the physicians. Kathy’s our office manager. To help her run the practice, we have an executive committee made up of three physicians. I’m the go-to physician for the phone nurses.

ClearTriage: And how big is your triage team?

Kathy: We have six triage nurses with typically three or four working at one time. In the wintertime I can have five on for parts of some days. And we have care coordinators that sometimes help out with the triage as well.

ClearTriage: So people are rotating through the position?

Kathy: Yes, because I have a couple of nurses that work Monday-Tuesday, I have one that works four days a week, I have one nurse that just comes in two days a week from 9 am to 2 pm. So I have both part-time and full-time nurses.

ClearTriage: Why do you have that mix of the part-time and full-time?

Kathy: We’re very family-friendly here, so I would rather have good nurses who want to be moms most days of the week, but who are willing to come in. I have a couple of nurses who are grandmothers who watch kids on their days off – we try to do some flexible scheduling so we get good employees.

ClearTriage: It’s nice to be able to offer that to folks. Has that helped with your retention?

Kathy: Yes, we have good retention. We’ve had two nurses that have moved to other jobs in the past couple years, but we’ve been able to replace them with very solid nurses. I have some triage nurses that have been here ten to twelve years.

Protocols and Multiple Provider Opinions

ClearTriage: What were you using for protocols before you started with ClearTriage?

Kathy: We were using Dr. Barton Schmitt’s protocols, but some of the girls would say, “One doctor told me this, so I do that for him, and another physician told me this, so I do that for her.” And then we had some of our own protocols that we’d type up and put in a shared drive where people could pull it or make copies of it and put it in their cubicle area. That was a little hard. When somebody made a change to one, not everybody knew it, and different docs would want different things. One nice thing with ClearTriage is making changes that are seen by everyone.

ClearTriage: I would imagine your physicians still have their opinions, so how do you manage the different opinions of the different physicians?

Claire: One thing that I’ve noticed is that while we used the Barton Schmitt handbook for triage, close to twenty years ago we also printed our own handbook of childhood illnesses that we published and gave to our patients and have on our website. Sometimes the advice would be a little bit different between those two, or, as Kathy mentioned, if the nurse were to ask the doctor a question without necessarily reading what the advice would be in the book first, he or she might have their own answer. But with Dr. Schmitt’s advice right there on the computer, we’re finding that less questions are coming to the doctors. Less questions means less chance to answer differently.

Take stitches, for example. From when the cut happened, how long can the patient wait until they are stitched? People might have different ideas, but it’s right there in ClearTriage. The nurses a lot of times aren’t even asking a physician, they’re just using the protocol advice, and that’s made it much smoother for us. The physicians appreciate getting less questions, it’s really been helpful that way.

ClearTriage: So the physicians had different opinions if they were asked, but they are comfortable with the guidance from Dr. Schmitt?

Claire: Yes, going back to the laceration example, some physicians might reply they would stitch within an eight hour window, others would say twelve. The advice was similar, but the nurses might not be comfortable answering the patient’s question without asking their primary provider.

There haven’t been any significant complaints. We’ve had discussions about some of the protocols, but we were able to reach a consensus. We feel it’s too confusing for our patients to hear one thing from one physician and something different from somebody else. So we do work at that. I think that having it computerized has been helpful.

The Transition to ClearTriage

ClearTriage: Why else did you decide to start using ClearTriage?

Kathy: We knew we needed help with our triage. We wanted to make it easier for our staff and to standardize the triage.

Claire: We learned about you at the Office Practicum conference. Since you’re integrated into the program and we’ve used the Barton Schmitt book for years, it was kind of a no-brainer for us.

ClearTriage: Nice to hear! ClearTriage can be received differently sometimes by a nurse that’s a relatively new nurse in triage versus a nurse who’s been doing triage for ten or fifteen years. Did you experience that?

Kathy: I have a couple younger nurses and one nurse who worked at Mayo Clinic, in a call center, and they just picked it right up, no problems at all. It was our nurses who hadn’t used it, who had been nurses for a long time (15-30 years), who were not open to it at first. They do well on it now, but trying to sell that at first was not easy.

ClearTriage: How did you help with transition?

Kathy: We slowly did it. We gave them 3 or 4 types of calls that they had to try it with. It took some time, some encouraging, and then I just told them: this is what we’re doing. We got a little resistance, but after we had a couple people buy into it, then it was easy. The last nurse that came from Mayo Clinic, at her interview she asked me what type of triage we used. So she came in with a very positive attitude about it, and it has settled down from there. I think they all see the value in it now.

Claire: And you did help us, for a few months in the fall, to track our use. I’m kind of a data geek, so that was really helpful to me. You sent us numbers on how many topics each person read, and how many pastes they did, and we presented that to them at our nurse meetings. I think it got a little bit of a competition going to get those numbers up. Between the first report and the second we saw a nice big jump.

ClearTriage: I remember when you asked for those numbers – I wasn’t sure whether it would help move people along or whether some people would take offense at being measured.

Claire: All of us are competitive over here. [laughter] We have competitive doctors and nurses. It’s just getting over that initial jump. Once they saw that some of their colleagues were willing to do it, I think it moved everybody along.

Why Invest in Telephone Triage?

ClearTriage: You obviously invest a lot in telephone triage as a practice. Why? What’s important in it, both for you and for your patients and their parents?

Kathy: Well, we are designated as a patient centered medical home, so we want them to feel like they have call coverage and that they don’t have to run to the urgent care centers and the ED unnecessarily in the evening or weekend or holidays. We just think it’s important that we can give guidance, and most moms love talking to one of our nurses that they’ve talked to during the day, getting them on a Saturday. We have our computers at home, and they can pull up the child’s chart. We just think it’s good medical care for our families.

Claire: We try to do open scheduling, but it can get dicey in the summer with physicians on vacation and lots of sports physicals, and certainly during flu season. So if our patients call in and want a sick visit, we encourage them talk to one of our triage nurses before they’re scheduled for most things. We do offer a morning walk-in clinic where anybody who wants to be seen that day can just show up between 7:30 and 9:00 and be seen without calling first. But anybody who’s calling after 9:00 in the morning about Johnny with an earache, they talk to one of our triage nurses first to make sure they’ve tried all the home care things we’d recommend before we recommend they be seen.

I think families these days are so busy, especially with younger kids, that if they can get good advice on the phone and take care of it at home without having to invest the time to come in for an appointment, they appreciate it. And it keeps us available for the kids that we really have to see.

Kathy: And making sure that we’re not bringing someone in inappropriately, as well, like someone who needs to go to the emergency department. Making sure that we don’t have a kid who’s really having a respiratory issue being brought into our office. Even some lacerations that could not be repaired here. That’s where I think the registered nurse, having clinical decision-making skills, really helps out the whole practice.

High deductible plans as well – we have parents that can’t afford to come in regularly. I don’t like those angry parent calls when they say “but you didn’t do anything for me.” I don’t get many of those so that’s good business. Once in a while I get one of those at walk-in. But in that case they chose to come in.

Claire: Also our previous physician lead, who is now semi-retired but was here for 25 years, really pushed the practice to be on the edge of care coordination and medical home. So we are paid for participating in those kinds of programs, whether it be an uplift or more per member per month. We are reimbursed by several of our main insurers for care management, so if we have a phone call that goes over 5 minutes (as an example) we can bill for that. It’s not the same as an office visit, but there are other ways to bring in revenue while providing excellent and convenient care for children.

ClearTriage: That’s got to give you a lot of loyal families.

Kathy: You’re right, we’re fortunate that way.

Hiring and Training Triage Nurses

ClearTriage: You talked about bringing nurses in over the last couple years: how do you find a good triage nurse for your group?

Kathy: I’ll be honest with you, it’s a struggle. We’re near two big health systems, a third one that is medium sized, and it’s hard. I got very lucky with my Mayo Clinic nurse, things just lined up perfectly. She was a patient’s aunt who was moving back here from Minnesota. And the other ones, it’s kind of word of mouth. The last few I’ve hired have been from either a patient family here or someone our care coordinators worked closely with over the years. We just try to network. I have put ads out in different avenues, but word of mouth is always our best.

ClearTriage: And when you get a new nurse, how do you train them?

Kathy: I have one of our nurses who came a couple of years ago, and we had no training manual when she got here. So she’s been putting one together, and for the last nurse that came in, we made a manual for her. And then we have a headset that they can listen into calls, and we talk to them about the computer, get them started with OP. And then they spend half a day or a day listening to how the phone calls work and seeing where you navigate the screen.

One nice thing is that most of these nurses have had some background in triage, so they pick up pretty quick. Getting to know what doctors want, when do they work – that’s the hardest piece of it.

ClearTriage: That makes sense. So once they listen in for a while, do they then start taking some calls themselves?

Kathy: They’ll look at the call queue and start with what they felt comfortable with. So it might be just ears, or sore throat. And before they call, they look at ClearTriage – how do I navigate through here, where is the protocol that I’m going to follow? As they build up their confidence, they take more calls. I’ve been very fortunate to have nurses who have experience, so it didn’t take long for training.

ClearTriage: So they’re not taking the calls live?

Kathy: No, not at this time. The front desk answers the phones and they are not nurses. So they take Mom’s name or Dad’s name, whoever the caller is, a phone number, the child’s name, and then a brief description of what they’re calling for: vomiting, diarrhea, sore throat, whatever it is.

The nurses just work this call queue, it starts “unmarked” and when they’ve touched back with them, they mark it a green flag.

ClearTriage: ClearTriage has a partnership with Office Practicum (OP), so your nurses have a button within the OP message to launch ClearTriage. Has that been important to them?

Kathy: Yes it has. If they had to go to a different screen, or a different login, or whatever, it takes time. It’s much like our logins to the hospital. It takes time to log in, and it times out on you, and that kind of thing. I think they find it convenient–they’re in the patient’s message, they have their chart there, so just to be able to click one button and have ClearTriage come up is great.

ClearTriage: Do you have anything else that you’d share with a practice that was considering using ClearTriage?

Claire: I would say our biggest hurdle with our more seasoned nurses was that it seemed like there was a lot they had to do. Starting with the first page that gives background information about the condition, and the next page where they thought they had to ask every single question, from the most serious all the way down. And then for the care advice they thought they had to discuss every point because they wanted to be complete.

The biggest piece was getting them to realize: yes, there’s a lot of information there. You don’t have to read all of it. You don’t have to share all of it with the patient. You can talk about two or three things and then just send them the handout that has everything in it.

I encourage the nurses to take some time to sign in to ClearTriage from home and practice so that it doesn’t seem so overwhelming when you’re in the midst of trying to talk to a mom. We tell them we’ll pay for their time. There’s probably 10 or 15 protocols they’re going to use way more than everything else, and if they’ve taken time to read those when they’re not actually on a call, I think that would help them in the adjustment period.

ClearTriage: Perfect – thank you both for your time today!

Kathy and Claire: You’re welcome.

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