HLBCPhysicianTriagePilotProject

ProvincialHealthServicesAuthority(PHSA)VancouverCoastalHealthAuthority(VCH)ProvidenceHealthCare(PHC)HealthLinkBC(HLBC)SpecialistServices Committee(SSC)

CHEOSWIPJune1st,2016

EricGrafsteinMDFrankScheuermeyer MDRobStenstromMDRiyad Abulaban MD

Agenda• Background• Studymethodology• Results- Interimanalysis• EconomicBenefitsanalysis• NextSteps– Businesscaseforbridgefundingandsustainment

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Background

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HealthLink BCNurseServices• Launchedin2001andrebrandedtoincludethe8-1-1numberin2008

• Nursetriage24/7x365• Generalandspecifichealthinformation+dietician,pharmacy,andpalliativecareaccess.

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WhatHappensto8-1-1CallsinVCH-PHC?

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N=36,000calls

MANY ED REFERRALSFROM8-1-1SEEMUNNECESSARY

Anectodally...

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WeMadeittotheStartingLine….• SSCoftheDoctorsofBCFunded• >250projectssubmitted• 22tentativelyaccepted• 14fundedatthistime

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ObjectivesPrimary• DoestheintroductionofanMDintothe8-1-1triagealgorithmdecreasethe“red”callsthatendupgoingtotheED.

Secondary• Satisfaction(QualitativeAnalysis)– Howisthenewservicereceived?o Safety(QuantitativeAnalysis)o NumberofBouncebackstoEDwithin7days/Mortalitywithin30days.

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Methodology- I• Before-afterstudydesign.• Inclusions:

o Allcallerso Anyageo 8:00– 24:00o ResidentsofVancouverCoastalHealth–ProvidenceHealthCare(VCH-PHC)

o “Red”calltriage(seekcarenow).• Exclusions:

o Callersrequiringatranslator

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Methodology- II• HLBCNursesworkthroughacomplaintbasedalgorithm

• Callerswhoaretriagedas“red”aretransferredtotheco-locatedphysicianforfurtherassessment.

• Physiciansmaketheirtriagedecisionsbasedonpersonaljudgmentandclinicalexperience.

• ThereisdocumentationofclinicaldetailsintheHLBCelectronicrecord.(KDR)

• Afollowupcallismadetoeachphysician-triagedcallertogatherpatientstatusanddisposition.

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TriageProcess• Redcalls– definedas“SeekCareNow”• Canbetoeitheraprimarycarephysician/FamilyDoctorortotheED.

• Allaresupposedtogotothe8-1-1TriageMDfordisposition.

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Methodology– III• LinkagebetweenHLBCandVCHDecisionSupportusingPHNwillvalidatecallerdispositionandEDvisitdetails.

• TheprimaryoutcomeisthenumberofHLBCnursedesignatedredcallsthatdonotendupgoingtotheEDbecauseofthephysicianintervention.

• Comparisonwithhistoricalcontrolgroupoverthesameperiodoftime1yearearlierbothwithVCH-PHC.

• FraserHealthredcalldispositionswillserveasaconcurrentcontrol.

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ProjectGo-LiveSummary• Go-liveApril5,2016• 34EDphysiciansinvolvedfrombothVCHandFHA• ExcellenttrainingandsupportfromHLBCteam• Dataqualityseemshigh• Someissueswithdataquantity• Excellentpatientfeedback.• Nocomplaintstodate.• Analysisforthefirst7weeksoftheproject

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Results– IDemographics• 891EncounterssenttotheMDQueue• 850HandledbyanMD

– 4.6%AbortRate• 796Encounterscompletedfollow-ups

– 94%successrate• 647Encountersincludedintheinterimdispositionanalysis

SummaryData– PhysicianDisposition

Encounter Disposition EncountersHandled byMD

EmergencyDepartment 163 25%

PrimaryCare 336 52%

JustHomeTreatment 136 21%

Other(naturopath, chiropractor) 12 2%

Total 647 100%

• 25%ofallredcallsthatthephysicianhandlesarebeingdirectedtotheED

SummaryData– WhoGoestotheED?EncounterDispositions RN-MD/HCP RN-ED Total

EmergencyDepartment 65 21% 98 29% 163 25%

PrimaryCare 167 54% 169 50% 336 52%JustHomeTreatment 69 22% 67 20% 136 21%

Other 6 2% 6 2% 12 2%

Total 307 100% 340 100% 647 100%• TheRNswouldhavereferred53%ofcallers(340)totheED.• TheMDsactuallyreferred25%(163),52%relativereductioninEDreferrals.• Overthecourseof1year,about25%of13,000patientswouldavoidEDuse.

• SummaryData– Follow-Up

ConditionatFollow-Up NumberofEncounters Percentage

SymptomsResolved/Resolving 609 77%

SymptomsRemainUnchanged 148 19%

SymptomsWorse 30 4%

MissingData 9 1%

Total 796 100%

• MDsaredoingagoodjobsortingoutpatientproblems.Mostdogetbetterbythetimefollowupismade.

OutcomeatFollow-Up

Outcome NumberofEncounters Percentage

WenttoED 151 31%NoFollowUp 159 31%WentToFP/GP 89 15%

WenttoRavenSong 7 1%WenttoWIC 56 11%

Other 50 9%MissingData 21 3%

Total 796 100%• Anincidentalbenefit isthatasignificantnumberofcallerstriagedbytheRNas

redcallsendeduprequiring nofollowup– atruecostavoidance.• Thisneedstobevalidatedagainsthistoricaldata.

ClientSatisfactionatFollow-Up

Satisfaction NumberofEncounters Percentage

Extremelysatisfied 581 73%

Verysatisfied 161 20%

Satisfied 37 5%

Unsatisfied 2 0%

Missing Data 15 2%

Total 796 100%

• Averagescore4.6/5• Removing themissingdata,95%ratedExtremelySatisfiedorVerySatisfied

GPAccessvsAttachment• Mostcallershaveafamilydoctor• Mostcallerscannotaccesstheirfamilydoctor

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SampleClientComments• “IwasprettyblownawaybythefactthatIcouldtalktoadoctor.”

• “SohappytogettheanswerIneededwithoutwaitingatED.Itoldallmyfriendsaboutitbecausewe'reallnewmoms.”

• “Verysatisfiedwiththecall.Hadbeenveryanxiousandwasreassured.”

• “Reallylikedtheideaofthispilotandwouldloveitifthedoctorswereincorporatedintothe811call.”

DataQualityIssues• Nurseredcallreferrals– notallbeingsenttoMD

o catchmentareao uncertaintyofprocess

• DatacapturebynursesandMDs

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EconomicAnalysis• WhatisthecostofanEDvisit?

o EDusage(RN,staff,facility)o EDphysicianbilling

• Needforadditionalstaff?o Averagephysiciansees~2800patients/yearo Howmanynursesandunitclerksarerequiredtostaffanextra14,000patients/year?

• ValueofincreasedsafetyintheED,patientsatisfaction?

• AvoidanceofGPvisits?

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BRIDGINGOPTIONSNextSteps

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FY2015/16TimeofDayDistributionof“RED”ClientEncounters

0%

1%

2%

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4%

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6%

7%

8%

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Combined

VCH

FHA

PotentialDemandAfterIncludingFHAFY2015/16 AveragePerDay

Hour Combined VCH FHA Combined VCH FHA

00:00 1,121 465 656 3 1 201:00 801 330 471 2 1 102:00 708 307 401 2 1 103:00 611 255 356 2 1 104:00 467 206 261 1 1 105:00 483 187 296 1 1 106:00 658 247 411 2 1 107:00 1,028 428 600 3 1 208:00 1,525 585 940 4 2 309:00 1,631 627 1,004 4 2 310:00 1,658 620 1,038 5 2 311:00 1,630 645 985 4 2 312:00 1,635 582 1,053 4 2 313:00 1,572 621 951 4 2 314:00 1,559 569 990 4 2 315:00 1,781 682 1,099 5 2 316:00 1,939 712 1,227 5 2 317:00 2,345 867 1,478 6 2 418:00 2,594 989 1,605 7 3 419:00 2,756 1,020 1,736 8 3 520:00 2,734 1,008 1,726 7 3 521:00 2,502 968 1,534 7 3 422:00 2,181 845 1,336 6 2 423:00 1,557 615 942 4 2 3

SummaryofFHA+VCHData• Continuingdoing8-1-1MDtriageforVCHwillyield36redcalls/dayonaverage(8:00– 24:00).

• AddingFHAandshrinkingandoverlappingthehoursofcoveragetobefrom14:00– 24:00yields59redcalls/day

• AddingFHAandathirdoverlapping8hourshifttocreatecoveragefrom8:00to24:00yields84calls/day.

• TherearelikelytobemoreRN-EDtriagesafterhoursandonweekendsbecausetherearelessoptionslikeFamilyPracticeorWICs.

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Summary• Rigorousstudyofoperationalprocessesarechallenging(randomizedtrialsarehard)

• Positiveoperationalsuccesso Staffsatisfactiono Patientsatisfactiono Positiveoutcome?

• Datachallengesexist• Economicimpactassessmentiscriticaltofuturefunding.

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APPENDIX

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ProvincialStatisticsRedDispositionCallsPerHour

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RedDispositionCallsPerHour

Time VancouverCoastal

VancouverCoastalandFraser

VancouverCoastal,FraserandIsland

VancouverCoastal,Fraser, Islandand

Interior

AllHealthAuthorities Unknown

0:00 1.1 2.7 3.4 3.9 4.2 0.81:00 0.8 1.9 2.4 2.9 3.1 0.62:00 0.7 1.7 2.1 2.4 2.6 0.53:00 0.6 1.5 1.8 2.1 2.3 0.44:00 0.5 1.1 1.4 1.7 1.8 0.35:00 0.4 1.1 1.5 1.7 1.8 0.46:00 0.6 1.6 2.0 2.5 2.7 0.47:00 1.0 2.4 3.2 4.0 4.4 0.58:00 1.4 3.6 4.8 5.9 6.4 0.79:00 1.5 3.9 5.1 6.4 7.0 0.810:00 1.5 3.9 5.2 6.4 7.0 0.811:00 1.5 3.9 5.0 6.3 6.8 0.812:00 1.4 3.9 5.1 6.3 6.9 0.713:00 1.5 3.7 5.0 6.1 6.6 0.814:00 1.4 3.7 4.9 5.8 6.4 0.915:00 1.6 4.2 5.5 6.7 7.3 0.816:00 1.7 4.6 6.1 7.3 8.0 0.817:00 2.1 5.6 7.3 8.9 9.6 1.118:00 2.4 6.2 7.9 9.6 10.5 1.319:00 2.4 6.6 8.5 10.4 11.3 1.420:00 2.4 6.5 8.4 10.1 11.0 1.421:00 2.3 5.9 7.6 9.0 9.8 1.222:00 2.0 5.2 6.6 7.7 8.4 1.1

23:00 1.5 3.7 4.8 5.5 6.0 0.9

SecondaryMeasuresofSuccess1)Satisfaction –QualitativeAnalysis–Howisthenewservicereceived?• Callers aresatisfiedwiththeservice.Measure:Nextdayfollowupcallandsurveyofcallerstoratetheservicetheyreceived.• Numberofpatientcomplaintsaroundthephysicianservice.• Nurses aresatisfiedwiththeservice.Measure: SurveyofHLBCnursestoratethequalityofthenewservice.• Physicians aresatisfiedwiththeservice.Measure: Surveyofparticipatingphysicianstoratethequalityofthenewservice.

2)CostAvoidance– Quantitative- Arewesavingmoneyorresources?• Measure: CostperavoidedEDreferral (totalphysiciancompensationdividedbythenumberofsuccessfullyredirectedredpatients

awayfromanEDvisit)comparedtotheestimatedcostofseeingthesepatientintheED.

3)Workflow –QuantitativeAnalysis– Doestheprocesswork?• Measures: Droppedcalls/numberofcallshandled/daybyphysician(Telephony)

4)Safety - QuantitativeAnalysis–Doesanyonehaveanadverse outcome?• Measures:NumberofBouncebackstoEDwithin7days/Mortalitywithin30days.

5)DescriptiveDataAnalysis – Whatarekeytrendsin8-1-1usage?• EDreferralavoidancebyagegroup• EDreferralavoidancebytimeofday• EDreferralavoidancebydayofweek• EDreferralavoidancebypresentingcomplaint

6)Efficiency – QuantitativeAnalysis–Dopatientsfollowadvice?• Measure: PatienttoldNOTtogototheEDbutdo.• Measure: PatientstoldtogototheEDbutdoNOT.• Measure: PatientsreferredtoRavensong andwhoshowupforappointment.

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