Utilization management techniques that are based on tightly defined Appropriate Use Criteria are migrating to the ambulatory care setting. To effectively manage cost, there is a need to appropriately control the use of expensive acute resources and increasingly scarce primary care resources. One new and effective way to do that is to implement a more structured and clinically rigorous approach to managing access to utilization of primary care resources.
Nurse triage tools that are built on robust, algorithm-driven utilization management techniques will allow patients to be directed to the appropriate level of care whether it is the ER, an appointment with a primary care provider, or homecare. And patients view nurse triage as an improvement to the care they receive rather than a barrier.
Mayo Clinic is an early adopter of rules-based utilization management tools in their nurse triage call centers. They have built more than 150 algorithms with branching logic that ensures effective use regardless of who the end user is. The algorithms also ensure that ensures that each question is presented whereas less structured protocols depend upon the individual nurse's effective use of the checklist or guideline.
These algorithms are packaged within a state-of-the-art front-end tool that is easy-to-use, fast, efficient, and functionally accurate. The tool allows for dynamic questioning and only presents necessary and relevant questions to ask. It is also powerful because the entire encounter is documented, stored and transferred to the EMR without requiring any rework by the nurse. This saves the nurses time and can help provider organizations to effectively manage risk.
The results Mayo Clinic has achieved to this point leveraging algorithm-based utilization management techniques in their nurse triage call center show that it is possible to improve outcomes while reducing cost without sacrificing patient satisfaction. Here is a sampling of the results Mayo Clinic has achieved:
o 10% increase in patient access for those who need appointments
o 45% of patients redirected to a lower level of care than they initially sought (from ED to doctor; doctor to home care; ED to home care)
o 20% of patients redirected from the office or urgent care to homecare
o 97% of patients report increased satisfaction
o lower cost per call on the nurse triage line
o Reducing variation may reduce litigation risk due to symptom triage service consistency
The bottom line is that it is possible to improve access and quality of outcomes while reducing cost using algorithm-based nurse triage solutions.
Chief Medical Officer
As Chief Medical Officer of Applied Pathways and over the course of his career, Dr. Woodburn has focused on providing strategic guidance to accelerate quality improvement and consumer-centered systems change. Dr. Woodburn previously held the position of Vice President of Clinical Initiatives for United Healthcare and Optum Health, where he was a leader of the TeleMedicine ConnectedCare enterprise. He has served as an Entrepreneur-in-Residence for Lemhi Ventures and as Chief Medical Officer for MinuteClinic, where he helped to lead the national expansion of retail clinics and acquisition by CVS Pharmacy. Dr. Woodburn also spent more than a decade at Blue Cross Blue Shield of Minnesota, where he was a founder and leader of the Blue Cross Blue Shield Association’s Medical Management Forum. He is a residency and fellowship trained Emergency Medicine physician and holds two engineering degrees from the University of Wisconsin-Madison.
Sunday, April 23
5:15 PM – 5:30 PM