Nurses often say to their patients, “We’re here for you if you need us.” While they mean every word, nurses also recognize that the clinic phone goes to voicemail after hours and that hospital shifts don’t last 24 hours. They also know that many patients are too overwhelmed to refill medications or schedule follow-up appointments.

Nurses become nurses to help people, and they quickly realize that it takes a team. This is even more true now that Medicare and other payers are tying reimbursement to how well health care providers can coordinate care, improve patient outcomes, and reduce unnecessary and costly emergency department (ED) visits and hospital readmissions. Today, nurses not only have to ensure their patients are getting the right care in the right way at the right time, but also that the care is delivered in the most clinically appropriate setting.

Retail health clinics and web-based telemedicine services have received a lot of attention as new consumer-oriented care approaches. But more cost-effective approaches include telehealth and care management services. These services engage, triage, support, and/or coach patients in a wide variety of settings, from telephonic to in-person to online.

Widely adopted by health plans and government payers, telephonic and locally-delivered in-person care management services give members direct and immediate access to experienced nurses and care managers. These care managers help members with a wide range of health-related issues, from coaching a mother on how to care for a baby with a fever to helping a member locate transportation to his doctor appointment. The best of these services have high member satisfaction rates, are a clinically effective way to prevent unnecessary ED visits, and coordinate care for members to improve their health and satisfaction.

From the nurse’s perspective, telephonic nursing is a rewarding and flexible career path. Many of the nurses in these positions work from home, which helps them maintain a healthy life-work balance. Every shift, the nurses get to interact one-on-one with members, and they find it very fulfilling to make a difference in these people’s lives and health status.

Sometimes Advice Is All Members Need  

It could be 2 a.m. or 2 p.m. It could be the weekend, a weekday, or a holiday. When members have access to a nurse advice line, they can reach out by phone or electronic chat with any type of health question, and a registered nurse (RN) will answer immediately. Thanks to telecom advances, members are seamlessly connected to RNs licensed to practice in that member’s state.

The nurses use computerized algorithms, or sets of prompts, to assess the member’s condition and make appropriate recommendations. When the situation warrants it, the nurse will advise the member to go to the ED. In non-emergencies, the nurse recommends specific self-care actions to take, pointing the member to helpful online resources. The nurse might also advise the member to follow up with a primary care provider or go to urgent care.

In the best telephonic nursing services, the algorithms are developed and maintained by clinical staff based on treatment protocols, reviews of medical literature, and recommendations from physician advisors. However, the algorithms are not scripts. Rather, the system guides the nurses, who rely on their clinical experience and judgement, to ask appropriate questions and give on-target advice.

For example, the algorithm might tell the nurse to consider meningitis when the mother of a toddler with a headache calls. It would be impossible for the child to describe her symptoms like an adult could. In this case, the nurse might assess whether the child has neck stiffness by telling the mother, “Have your daughter look at her belly button. Does her chin touch her chest?” The answer to this question, tailored for the age of patient, gives the nurse information needed to make an appropriate recommendation.

A study of one highly rated service showed that the advice given by on-call physicians agreed with the advice given by their nurses greater than 99% of the time.

When Patient Needs Get Complex

While nurse advice lines are useful and welcome services, they are more reactive than proactive in terms of helping members. That’s why many health plans are also enlisting teams of care managers to preemptively work with high-risk members before their health deteriorates to the point where they need to go the ED or hospital.

Typically, insurance claims data – and in some cases, additional lab, pharmacy, biometric, and consumer data – are analyzed to identify members who would benefit from care management services. Sophisticated analytics can be used to sort through the available data and identify those members who have one or more health conditions. That list of members can be further prioritized by looking at which of those members frequently visit the ED or were recently discharged from the hospital.

Care managers then reach out to these high-risk members to see how they can help them follow through on their health care provider’s recommendations. The care manager will zero in on the most vital issues contributing to the member’s poor health until a clear solution can be identified that bridges that issue. For instance, a care manager might ask a member, “How can I help you keep your physician appointments? Is the office too far away or are the hours inconvenient? Or do you not think the appointments are important?”

In this type of care management, nurses still use the telephone as a tool to communicate with members. But the best services also have nurse care managers available to visit members in their homes or accompany members to doctor appointments. This is particularly important in situations where members have mental health or cognitive issues.

For instance, one nurse care manager was assigned to a member with multiple comorbidities, including diabetes, congestive heart failure, anxiety, and depression. The member was not compliant with medications and had skipped physician visits. As a result, the member was winding up back in the ED over and over.

When the care manager became involved, she recognized that the member’s mental health issues were the crux of the problem. The nurse accompanied the member to physician visits and partnered with office staff to reduce their frustration. The nurse also arranged to have the member’s medications delivered because he had trouble moving around physically and getting to the pharmacy. The end result: By taking medications regularly and following up with physicians, this member was able to manage his conditions at home and reduce his ED visits.

A Rewarding Career 

As population health management takes hold, the need for telephonic nurses and care managers will only increase. Nurses looking for a flexible, rewarding position may want to consider this career.

Because nurse care managers need to be able to think on their feet and provide specific advice on an extensive array of health issues, they often have solid and broad clinical experience. A nurse who worked for three or more years on a hospital medical-surgical unit, in an ED, or at a busy pediatric practice is typically a good fit for these positions. Excellent communications skills and an ability to put people at ease are also needed. At the core, this work is about drawing patients out and helping them help themselves.

Mary Jane Konstantin, RN

Mary Jane Konstantin, RN

Mary Jane Konstantin, RN, is senior vice president of clinical operations at AxisPoint Health.
Mary Jane Konstantin, RN

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