The Effect of Telephone Nurse Triage on the Appropriate Use of the Emergency Department

Exploring the Value Proposition of Primary Care for Safety-Net Patients Who Utilize Emergency Departments to Address Unmet Needs

Background: An underlying assumption of strategies intended to promote appropriate primary care over emergency department (ED) use for ongoing health care needs is that patients will understand the “value proposition” of primary care: that they will receive specific benefits from primary care providers over and above what they receive from EDs. However, there is evidence that this value proposition may be unclear to safety-net patients. The goals of this study are to describe factors motivating ED use for low-acuity conditions; describe similarities and differences in usual source of care (USOC) experiences, by ED versus non-ED setting; and assess awareness and perceptions of the patient-centered medical home (PCMH) concept among safety-net patients. Methods: We conducted a cross-sectional descriptive study of adult patients (n = 329) at 3 safety-net hospitals in the Southwest. Results: Key reasons for ED use were perceived urgency, lack of awareness about other options for care, payment flexibility, and perceived quality and convenience. Approximately half of participants indicated they would seek treatment in non-ED settings, if available, but agreement differed by group (non-ED USOC, 60.2%; ED USOC, 50.7%; no USOC, 45.3%; P = .025). Agreement that providers coordinated access to needed medical services was significantly higher among patients with non-ED USOCs; agreement that providers coordinated non-medical services that facilitate access to care was similar (approximately 45%) for patients with ED and non-ED USOCs. Approximately 70% of participants in both groups agreed that every person should have a medical home. Conclusions: Perceived experiences of care in ED and non-ED USOC settings suggest challenges and opportunities for increasing the value proposition of primary care for safety-net patients. Although patients are receptive to the PCMH concept, effective strategies to better highlight the value of primary care in coordinating both medical and related nonmedical services and other PCMH benefits warrant further investigation.

ED Utilization by Uninsured and Medicaid Patients after Availability of Telephone Triage

PROBLEM

For emergency departments experiencing crowding and a high percentage of patients leaving without being seen, a telephone triage service can provide other care options for low-acuity patients.

METHODS

A nonexperimental pre- and postintervention comparative design was used to measure ED visit volumes from Medicaid and uninsured patients presenting with a low-acuity health care problem. Visit volumes for the 12 months before and 12 months after the initiation of telephone triage were compared.

RESULTS

The overall low-acuity visit volume increased in the first 12 months of telephone triage availability. However, the proportion of low-acuity Medicaid and uninsured patients seeking ED care decreased. For the first 12 months of operation, telephone triage received 10,055 calls. Sixty percent of the calls (N = 6086) were from uninsured and Medicaid patients. More than 43% of the calls resulted in a self-care decision.

IMPLICATIONS FOR PRACTICE

A telephone triage service may help decrease ED crowding by communicating other care options to patients with low-acuity health problems.

An economic analysis of a nurse-led telephone triage service

Telephone nurse lines help callers to select the most appropriate site and level of care for acute conditions. We examined whether compliance with nurse recommendations was associated with lower average health care expenditure, and identified the employer characteristics associated with higher than average savings. Telephone calls to a nurse-led help line made by commercial health plan members who worked for large employers were identified. The callers' intention before calling and the nurse recommendation regarding site/level of care were recorded. Compliance was determined using medical claims during a 30-day post-call observation period and was based on adherence to nurse recommendations. A total of 132,509 calls during 2012 were identified for the study. Nurse recommendations were that 31% of the callers seek a higher level of care than mentioned at the start of the call, 25% use a lower level of care and 44% pursue their originally intended level of care. After regression-based adjustment, the average medical expenditures were compared between compliers and non-compliers. Overall, 57% of callers were compliant with nurse recommendations. The average expenditures were $328 lower among compliant callers. A logistic regression analysis identified employer characteristics positively associated with achieving higher than average savings. These were having a low employee-to-dependent ratio, a headquarters in the Western region of the US, a low prospective health risk score, and participation by the employer in a targeted communication campaign. Compliance with the triage recommendations resulted in lower average health care expenditures, and several characteristics were positively associated with achieving higher savings.