The Startling Impact of Appropriate Utilization


Today’s healthcare environment mandates the optimal utilization of all available resources. Every organization is scrambling to figure out how high quality care can be provided at a lower cost. Many organizations have hiring freezes, are suffering from decreased reimbursements and are relying on innovative administrative teams to work with budgets that are lower than previous years. Emergency Medicine Departments can be one of the most expensive venues for the provision of care and must come up with immediate solutions to the dilemma of unnecessary visits. Initiatives need to focus on offering patients the most appropriate level of care available that does not involve showing up at the ED. The safest, most cost effective, and easily implemented option is to provide nurse triage to potential patients, prior to them showing up.

The primary beneficiary of having a triage nurse available for advice is definitely the patient. Patient who leave their home and seek care in the ED, are often seeking a level of care that is not necessary for the degree of severity they are experiencing. Having an option to speak with a nurse trained in the specialty of telephone triage represents an access to care that most callers appreciate and end up complying with. They may be able to remain home, and either be referred to a provider in an office setting, or receive home care that will alleviate the current problem. Diverting Patients from the ED is not the goal. The goal is to direct patients to the most appropriate level of care for the symptoms they are experiencing, so that their treatment is continuous and aligned with their primary care providers. In addition to the health benefits of nurse triage there is also a copay savings that would occurs if care was provided in any setting other than the ED. Other stakeholders that would benefit from a pre-ED triage call include health plans, managed care plans, self-insured employers and organizations currently offering ACO’s. The National Hospital Ambulatory Medical Care Survey cites the additional cost of an ED visit vs a PCP office visit to be $580. There is significant opportunity for payer savings as well.

EDs are busy. They are over-crowded, understaffed, 24/7/365, and required by law to treat any patient who shows up. The Emergency Medical Treatment and Active Labor Act(EMTALA) is an act of Congress passed in 1986. It requires hospitals that accept payments from Medicare to provide emergency health care treatment to anyone who believes they need to be seen. There are no reimbursement provisions in the Act. The consequence of ED overuse is threatening the existence of hospital Emergency Departments across the country. The study of Avoidable Emergency Department Usage Analysis estimates that 76% of ED visits made by commercially insured patients are not medical emergencies and can be better treated with skilled and opportune outpatient care. In some states, Medicaid payments for certain ED diagnosis are no longer being reimbursed. Decreased payments, compounded with the fact that from 1991-2010 there was an 8% decline in the number of hospital ED’s in the United States poses a considerable threat to those that remain open. Integrating Telephone Triage is the solution to keeping those 76% of patients who don’t need to be there out of your ED waiting rooms. The specialty of Telephone Triage is practiced by registered nurses using years of experience, critical thinking skills, and evidence based decision support tools. Safe outcomes result from an adherence to the nursing process, a detailed assessment, analysis of symptom specific medical criteria and finally by providing the patient a recommendation to the most appropriate level of care. Offering patients this service provides high quality care at the lowest cost possible. Hospitals need to consider having telephone triage nurses as a component of their Emergency interdisciplinary teams.

AccessNurse is a nationally recognized, premier provider of remote patient care with enhanced outcomes for a variety of specialty departments including the ED. If you are interested in strategies that best utilize the resources of your organization, call 877-244-6312 to discover how the Telephone Triage Nurse Services at AccessNurse can provide an immediate solution.

Gina Tabone, MSN, RNC serves as the Vice President of Strategic Clinical Solutions for AccessNurse.

Prior to joining AccessNurse, she served as the Administrator of Cleveland Clinic’s NURSE on CALL 24/7 nurse triage program. Under her direction, ED utilization declined, continuous care coordination improved, performance metric targets dropped from 33% ABD to less than 5%, URAC accreditation was achieved, and the call center grew from covering 350 physicians to the integration of more than 1,500 employed and affiliated providers.


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