Management Principles Essey5

Best Practice Intervention Package
Home Telehealth Simply Summer Series
HHQI National Campaign
Teletriage
Home Health
HHQIOSC
Quality Insights
Quality Improvement Organization Support Center
This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization Support Center for Home Health, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number 8SOW-PA-HHQ07.448 App. 5/03/07.
The Home Health Quality Improvement Organization Support Center (HHQIOSC) would like to thank everyone who contributed to the Best Practice Intervention Package Teletriage. We would also like to acknowledge the following individuals and organizations for their contributions as our Technical Expert Panel. Denise Davignon, MN, ARNP Quality Management Specialist, Highline Home Health and Hospice Tukwila,WA Sandra Fragleasso, RN, MS Clinical Support Specialist and OBQI Coordinator,Bayada Nurses Lisa A. Gorski, MS, APRN, BC, CRNI, FAAN Clinical Nurse Specialist, Wheaton Franciscan Home Health & Hospice Senior Associate Consultant, OASIS Answers, Inc. Carol Higgins, BS, OTL (retired), CPHQ Home Health Clinical Consultant, Qualis Health Washington Melinda Huffman, BSN, MSN, CCNS Principal, Outcomes/Disease Management Specialist Miller & Huffman Outcome Architects, LLC Christine Kocjancic, RN QI Coordinator, McKean County VNA and Hospice Bradford, PA Judy Lentz, RN, MSN, NHA Executive Director, Hospice and Palliative Nurses Association Terri Lindsey, RNC, BSN Project Manager, Virginia Health Quality Center Colleen Miller, RN, BS Outcomes/Disease Management Specialist Miller & Huffman Outcome Architects, LLC Ben Peirce, RN, CWOCN National Director, Clinical Practice Gentiva Services Carol Rutenberg, RNC-BC, MNSc Telephone Triage Consulting Laurie Salmons, RN, BSN Disease Management, Outcomes Improvement Specialist Suzan K. Sayres, RN, BSN Director, Davis HomePlus Elkins, WV Carol Siebert, MS, OTR/L, FAOTA Representative, American Occupational Therapy Association Rebecca Skrine, CCC-SLP, CHCE, COS-C Home Health Representative, American Speech-Language-Hearing Association Karen Vance, OTR/L Representative, American Occupational Therapy Association Linda Wankel, RN Director of Nursing, McKean County VNA and Hospice Bradford, PA
Acknowledgements
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HHQI Physician Advisor Members

Eric Coleman, MD, MPH University of Colorado Health Sciences Center Care Transitions Program Jay A. Gold, MD, JD, MPH Principal Clinical Coordinator and HCQIP Director, MetaStar, Inc.; Clinical faculty, Medical College of Wisconsin; Adjunct faculty, Marquette Law School Timothy Robert Gutshall, MD ER Staff Physician, Iowa Methodist Medical Center and Iowa Lutheran Hospital; Clinical Coordinator -Iowa Foundation for Medical Care Thomas F. Kline, MD, PhD, CMD Home Based Geriatric and Rehabilitation Medicine Canton, MA John N. Lewis, MD, MPH Medical Director, Health Care Excel of Kentucky; Internist/Epidemiologist; Greater Louisville Medical Society; Kentucky Medical Association Dennis Manning MD FACP FACC Director, Quality and Patient Safety Department of Medicine, Mayo Clinic Rochester Joseph G. Ouslander, MD Professor of Medicine and Nursing; Director, Division of Geriatric Medicine and Gerontology Chief Medical Officer, Wesley Woods Center of Emory University; Director, Emory Center for Health in Aging; Research Scientist, Birmingham/Atlanta GRECC Jane C. Pederson, MD, MS Minnesota Medical Association; Minnesota Medical Directors Association; Minnesota Gerontologic Society Stephen Winbery, PhD, MD Medical Director QSource (TN Quality Improvement Organization); ACP, ACMT Steven L. Yount, DO Medical Director Bastrop Nursing Center, Lifeway Home Health and A-Med Hospice; Clinical Assistant Professor, Department of Family Practice, University of North Texas; Texas Medical Foundation, State Review Program Committee
Editor
HHQIOSC Team
Misty Kevech, RN, MS, COSC, Communications/Training Manager
Contributing Home Health QIOSC Staff
Marian Essey, RN, BSN, Director, Health Care Quality Improvement, HHQIOSC Donna Anderson, RN, PhD, Subject Matter Expert Christine Bernes, RN, Project Coordinator Eve Esslinger, RN, MS, Project Manager Bonnie Kerns, RN, BSN, Community of Practice Manager Lee Krumenacker, RN, BS, Subject Matter Expert David Wenner, DO, Medical Director
Communications Staff
Shanen Wright, Communications Manager Russell Hartman, Communications Specialist Bethany Knowles, Communications Specialist
Communications QIOSC Staff
Tinabeth Burton, Public Relations Consultant to the Communications QIOSC Jennifer Willey, Communications Specialist
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Table of Contents
Acknowledgements..................................................................................................2 Table of Contents .....................................................................................................4 Leadership Section ..................................................................................................5 Implementation Tools: How to Use ..................................................................................34 Patient & Family Connection ............................................................................................... 35 Physician & Hospital Connection .......................................................................................36 Hospice & Palliative Connection......................................................................................... 37 Nurse Track ........................................................................................................... 41 Therapy Track ....................................................................................................... 51 Medical Social Worker Track .................................................................................63 Home Health Aide Track........................................................................................ 71
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Best Practice: Teletriage
Leadership Section
8SOW-PA-HHQ07.448 App. 6/25/07
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Leadership Section Objectives

Objectives
After completing the activities included in the Leadership Section of this Best Practice Intervention Package Teletriage, the leader will be able to: 1. Define teletriage. 2. Evaluate the agencys current use of teletriage. 3. Identify how structured teletriage can be implemented and/or improved. 4. Describe two leadership applications for teletriage.
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Teletriage: Leadership Track

The Foundation The first two Best Practice Intervention Packages, Hospitalization Risk Assessment and Emergency Care Planning, are foundational interventions that are key to building a successful plan to reduce avoidable acute care hospitalizations. The first two interventions complement each other as a hospitalization risk assessment helps agencies and clinicians identify which patients are at risk for hospitalization and emergency care planning helps patients understand who, what, where, when, why and how to respond to changes in health status. Effectively identifying patients at-risk for hospitalization and coaching patients to notify the agency with early changes in health status will assist with establishing the agencys foundation for an effective plan to reduce avoidable hospitalizations. Building Upon the Foundation: Next Steps Once you are comfortable that your foundation for identifying your patients at risk for hospitalization is sound enough to sustain itself over time, there are other best practice interventions that may be implemented that can support your efforts to reduce avoidable acute care hospitalization. Best Practice Intervention Packages for Medication Management and Phone Monitoring /Frontloading have been introduced so far with 7 more to come. All Best Practice Intervention Packages are available on the HHQI Web site:
The fifth best practice package, Teletriage, is part of the Simply Summer Series that focuses on telehealth. Teletriage is a component of both phone monitoring and telemonitoring.
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How to Use this Package

Pick & Choose ANY of the pieces from ANY of the tracks
Leadership Track (pages 5 41) Education on topic Leadership SelfAssessment, Action Items & Action Plan Connection pages Poster(s) Tools & Resources Nurse, Therapy, MSW & HH Aide Tracks (begin on page 41) Guide to Practical Application Podcasts (Audio Recordings) WebEx Post-test
Example # 1
Read, discuss and complete the Leadership Track (Leadership Section, SelfAssessment, Tools, Connection pages) at managers meeting Select 1 2 action items to implement within the month Provide the Physician and Hospital Connection to intake staff Provide SN, Therapy & MSW Tracks at next staff meeting o Listen to audio together & review selected tool(s) o Complete the remaining discipline tracks within the next week Utilize the HH Aide Track at monthly education meeting
Example # 2
QI lead reviews Leadership Track Display the monthly poster on the HHQI bulletin board Provide SN, Therapy and MSW Tracks as self-study to individual staff and ask staff to return post-tests for competency documentation
Example # 3
QI lead reviews Leadership Track Keep package as a resource and for new hire orientation Distribute the Fast Track to staff
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July June Teletriage Phone Monitoring & Frontloading Visits
August
Telemonitoring
The Simply Summer Series (June-August) focuses on telehealth. The series continues with this package-Teletriage. The Schedule for the Home Telehealth Simply Summer Series is as follows: June 2007: Phone Monitoring and Frontloading Visits
July 2007:
August 2007:
Teletriage
Telemonitoring
Teletriage supports the other telehealth interventions:

Teletriage occurs at all home health agenciesevery time a patient or caregiver contacts the agency. Twenty-four hours a day! Consistent teletriage processes support phone monitoring and telemonitoring.
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Teletriage
Exactly what is teletriage?
As it relates to home telehealth, teletriage is the unscheduled, appropriate disposition of health-related problems by skilled clinicians via telephone or electronic information processing technologies that have been initiated by the patient/caregiver. (Home Telehealth Reference 2005)
Simply stated, teletriage is what occurs when a patient calls the agency for health-related advice. This is usually initiated by the patient and/or caregiver, but can occur in response to phone monitoring or telemonitoring encounters.
Unscheduled distinguishes teletriage from phone monitoring, which is scheduled phone encounters.
Appropriate disposition is the outcome of a teletriage encounter.
Teletriage occurs when information is received by a skilled clinician, either by phone or a telemonitoring encounter.
Teletriage is initiated by the patient/caregiver, unlike phone monitoring and telemonitoring, which are communications initiated by the home health care provider.
Value of teletriage Utilizes a mechanism that home health agencies can employ to increase the value/effectiveness of services to patients, caregivers and referral sources Increases access to skilled, empathetic and effective clinical service providers delivered via telecommunications technology Promotes the appropriate use of services and resources and supports the reduction of avoidable hospitalizations - 10 -
Teletriage
Teletriage Considerations for Leadership
Operational considerations Teletriage is not optional It occurs daily as part of normal operations The organization and the professionals within the organization determine the success of teletriage. Who triages? Agency nurses triage patient information over the phone to determine the best course of action. When does teletriage begin? When a patient or caregiver contacts the home health agency with a clinical problem or question The actual process of teletriage begins as soon as the nurse picks up the phone. When telemonitoring data are received When telemonitoring data falls out of pre-established parameters Prior to teletriage Identify potential interventions that may be approved by a physician in advance of an emergent situation Obtain acceptable clinical parameters from the physician Establish home care goals with the patient and family Become proactive to decrease risk for an urgent teletriage encounter Ensure past medical history, current medications and allergy information are readily accessible by the nurses accepting triage calls Teletriage safeguards Recognize risk management principles associated with teletriage Assure operational procedures are examined for potential risks Determine if professionals understand the scope of their practice and regulatory issues Key: A structured teletriage program with defined standards, processes and polices will minimize risk.
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Teletriage
Organizational assessment Assess the current status of your agencys teletriage process Review Home Health Telehealth Protocol for Teletriage (page 14) Key: Use Leadership Self-Assessment and Action Items (on pages 15 - 16) to improve teletriage processes.
Orientation and ongoing evaluation Ensure patient calls are answered promptly and appropriately by all staff Evaluate nursing staffs teletriage skills Include teletriage component in orientation process Develop teletriage annual competencies for nurses
Teletriage professional characteristics: Excellent assessment skills Dynamic communication skills Systematic documentation capability Understanding of home health regulations and community resources Appreciation of the role of other disciplines Ability to collaborate Ability to work under pressure Ability to prioritize
Key: Professional staff must be adequately trained for the teletriage process and understand agency policies, procedures, decision support tools and/or protocols to reduce liability issues and support effective teletriage.
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Teletriage
Effective teletriage Promote an expectation of quality teletriage Include teletriage in staff education program Provide training to clerical support in routing of calls Provide teletriage education to professionals who respond to calls Develop a process to evaluate teletriage for effectiveness Key: Teletriage is not optionalthe organization and the professionals within the organization determine how well it is accomplished! Decision support tools Assure staff have clinical resources for symptom management to promote consistent and effective teletriage Consider utilization of symptom-specific references and documentation tools to support consistent and appropriate teletriage assessment and intervention Assure that teletriage documentation provides accurate information for other health care providers that make contact with a patient after the phone call ends Key: Teletriage documentation must include patient-specific information, include problem-specific information, utilize standards of care, and address risk management elements.
Dont recreate the wheelutilize the Home Telehealth References for forms and guidelines.
Available on MedQIC - Home Telehealth Reference 2006/2007 and Home Telehealth Reference 2005 or go to www.homehealthquality.org: For Home Health Agencies, Resources Includes teletriage: Safeguards Orientation Ongoing evaluation Effective teletriage encounters Decision support tools Includes teletriage: Description and general information Policies and procedures
For a reference on Teletriage Standards: Telehealth Nursing Practice Administration and Practice Standards (American Academy of Ambulatory Care Nursing 2007) www.aaacn.org - 13 -
Home Telehealth PROTOCOL For Teletriage

Purpose:
To provide guidelines for teletriage within homecare agencies
Policy:
Agency leadership will establish teletriage guidelines and support tools for patient-initiated phone calls, phone monitoring and telemonitoring. Clinicians providing treatment advice to patients/caregivers will follow agency guidelines and policies. Agency Leadership will: Review and provide clinical practice standards Orient clinicians and provide access to teletriage standards, policy and procedures Keep clinicians apprised of updates and/or changes in teletriage standards of clinical practice Consider using decision support tools as references and/or documentation tools
Procedure:
Clinicians will: Assess, evaluate and treat per the teletriage standards of clinical practice Utilize the nursing process in all teletriage encounters Instruct patients in self-monitoring and recording of health status information Use self-monitoring and/or telemonitoring data to assess, evaluate and treat Documentation of teletriage encounters will occur per agency guidelines Evaluation of teletriage encounters will occur periodically Are teletriage encounters documented per agency guidelines? Was the timeliness of the encounter within agency parameters? Was the disposition of the encounter validated by decision support tools or agency policy? Are there specific areas identified that need additional education? - 14 -
Leadership Self-Assessment Teletriage

Two Paths
The Leadership Path is for the leader that has limited or no formal teletriage processes. The Leadership Highway (next page) is for those leaders that have implemented a formalized teletriage process. Choose one track based upon your answer to this question:
Does your agency have guidelines for teletriage?

Leadership Path Does your agency have specific professional personnel who handle incoming patient calls? Do agency policies and procedures designate who is responsible at the agency for handling patient/caregiver calls? Does staff understand how to identify and handle an urgent patient call? How are patient calls directed through my agency? Are calls answered promptly? (By clerical staff or others) Are calls transferred quickly and efficiently? (By clerical staff or others) Is there a potential for calls being lost? Are patient/caregiver calls forwarded to clinicians voicemail? Are the calls handled consistently OR does advice/patient outcome vary depending on nurse attending to the call? What type of clinical practice references does the nurse have when giving advice to the patient? How are the calls documented? Is there a way to track outcomes for calls? Are after hours calls handled differently than business hour calls? Are all staff familiar with the term teletriage? Including therapists, medical social workers, clerical staff and aides? Does patient satisfaction include a question to evaluate responsiveness/expertise to phone calls to the agency?
If NO
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Choose one track based upon your answer to this question:

Leadership Highway How are calls directed through my agency? Are calls answered promptly? (By clerical staff or others) Are calls transferred quickly and efficiently? (By clerical staff or others) Is there a potential for calls being lost? Are patient/caregiver calls forwarded to clinicians voicemail? Is there a way to track outcomes for calls? Who is trained on phone assessment/ teletriage? All nurses? Only nurse managers/supervisors? Is teletriage included in nurses orientation? Are there protocols or decision support tools to assist with making decisions with patient calls? Are there protocols for decisions related to teletriage? What tools and/or resources does our staff utilize? Are all nurses consistently using the same tools and/or resources? Is there verification of the patients (or callers) comfort with plan? Do nurses assess and document the callers reassurance that the plan addresses their concerns? Is there a system for sharing call information with other members of the health care team? Are other team members made aware of information in a reasonable time? Does documentation reflect notification of other team members? Is there standardization for teletriage within the organization? Are nurses consistent with their teletriage assessments, documentation, plans, and follow-up? Are after hours calls handled differently than business hour calls? Are there annual competency evaluations for nurses performing teletriage? Is teletriage included as part of the patient satisfaction survey?
If YES
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Sample Decision Support & Documentation Tools

Teletriage Support Tools
There are 18 Teletriage Reference Tools, three Decision Support Tools and 21 accompanying Teletriage Documentation Tools. Additionally there is an initial encounter and follow up teletriage documentation tool available. These are located in the Home Telehealth Reference 2006/2007 available at www.medqic.org or by accessing a link from the www.homehealthquality.org Web site.
Teletriage Reference Tools provide symptom specific assessment questions, additional considerations and potential interventions. Reputable resources validate each and are documented on the tools. Decision Support Tools (developed by OASIS Answers, Inc.) for Heart Failure,
Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus were selected as high-risk diagnoses for symptom exacerbations that contribute to repeated hospitalizations.
Teletriage Documentation Tools:

(1) Expand on the references to support consistent triage and disposition (2) Are categorized into levels of assessment and urgency risk: Urgent (high-risk) Likely urgent: Emergency care likely (moderate-high-risk) Potentially urgent: Same day onsite visit required (Low-moderate-risk) Non-Urgent: Informational (low-risk) Non-Urgent: Routine Care (low-risk) The following page contains a complete list of all teletriage reference tools, decision support tools and teletriage documentation tools.
Best Practice Intervention Package Teletriage

Selected tools included in this package will help contribute to the HHQI National Campaign focus of reducing avoidable hospitalizations. Home health agencies may want to add to these tools based on patient population characteristics. Additionally, a Routing of phone calls tool is included to assist agencies examine potential issues within their organization with answering and routing of patient phone calls. Included in this package are: Teletriage reference: Breathing difficulty Teletriage documentation tool: Breathing difficulty Teletriage reference: Falls/Other Injury Teletriage documentation tool: Falls/Other Injury Teletriage reference: Wound drainage/infection Teletriage documentation tool: Wound drainage/infection Routing of phone calls
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Teletriage Support Tools

Teletriage Reference Tools Adverse drug reaction Anxiety Bleeding Breathing difficulty Confusion Constipation Depression Falls & injuries Feeding tube problems Fever Gastro-intestinal difficulty/nausea & vomiting Hyperglycemia Hypoglycemia Lightheadedness/dizziness Pain Urinary catheter problems Urination difficulty Wound drainage/infection Teletriage Documentation Tools Adverse drug reaction Anxiety Bleeding Breathing difficulty Confusion Constipation COPD Depression Falls & injuries Feeding tube problems Fever Gastro-intestinal difficulty/nausea & vomiting Heart failure Hyperglycemia Hypoglycemia Lightheadedness/dizziness Pain Urinary catheter problems Urination difficulty Wound drainage/infection
Decision Support Tools Heart failure COPD Diabetes
These tools are available at www.medqic.org in Home Health Reference 2006/2007
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TELETRIAGE TOOLS
Teletriage Reference: Breathing Difficulty. Difficulty breathing is usually a result of a medical condition or problem and should not be considered a normal process of aging.
Assessment Questions
Is the patient having any of the following S&S along with breathing difficulty? o Pleuritic chest pain with restlessness/apprehension, tachypnea? o Changes in leg pain/new onset of leg pain? o Excessive shaking, chills, sweating? o Productive cough with purulent sputum? o Severe SOB w/ wheezing? o Sudden chest pain/pressure? o Irregular heart rate/pulse? o Other pain? Is the patient experiencing any of the following signs or symptoms? o Fever o SOB that increases when laying flat o Swelling in feet/ankles o Persistent cough with small amount of hemoptosis o Fatigue / pale o Change in breathing pattern when sleeping o Flu / cold symptoms o Anxiety o Sleep disturbance History of asthma? Home O2, CPAP, inhalants?
Additional Considerations
Sudden onset of severe shortness of breath Possible airway obstruction Possible pulmonary embolism Consider recent surgery, decreased mobility, prior history of blood clot, presence of venous access device, diagnosis of cancer Sudden fever of 100 degrees w/ or w/o a cough = possible lung abscess Possible acute asthma attack Possible MI, collapsed lung or blood clot in lung Call 911 Call 911
Intervention
Call 911 Call 911 Call 911
Cleaning agents, pesticides, fertilizers Possible infection/pneumonia Possible CHF Possible lung inflammation or pneumonia Possible anemia 15-60 sec periods of no breathing = possible sleep apnea Possible bronchitis Determine if taking anxiety-producing medications Determine recent tobacco or alcohol withdrawal/substance abuse Exacerbation. Asthma action plan; Use of rescue/reliever medications
Call 911 Notify the physician Notify the physician Notify the physician Notify the physician Notify the physician See physician if S&S last greater than 48 hours Nursing visit
Same day nursing visit
References:
1. American Academy of Family Physicians. 1996. Shortness of Breath Algorithm. http://www.familydoctor.org.
2. The American Geriatric Society Foundation for Health in Aging. 2004. Eldercare at Home Breathing Problems. http://www.healthinaging.org. 3. Registered Nurses Association of Ontario Asthma Guideline. http://www.RNAO.org.
Decision support tools are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. 8SOW-PA-HHQ06.156
Teletriage Documentation Tool

Patient: Caller: MR #: Date: Clinician Signature: Time:
Teletriage: Breathing Difficulty

Assessment (check all that apply)

Interventions (check all that apply)

Follow-up/Evaluation (check all that apply)
Risk Level: URGENT

Shortness of breath and:
Excessive shaking, chills, sweating Pain Hemoptysis Productive cough with purulent sputum Severe SOB with wheezing Sudden chest pain, pressure Irregular heart rate Other (describe):
Immediate Intervention Required

911 Called Support provided via phone until 911 personnel arrived Notified emergency contact person if applicable Patient was not transported to ER; nursing visit scheduled within the next 24 hours. Physician Contacted: Time: Physician: Other (describe): Received report from 911 personnel after their evaluation Patient was transported to (add facility name): Follow-up call provided to hospital ER Patient was not transported to ER; nursing visit scheduled within the next 24 hours. Other (describe):
Risk Level: POTENTIALLY URGENT

Shortness of breath and:
Fever Orthopnea Swelling in feet and ankles Persistent cough with small amount of hemoptysis Other (describe):
Nursing Visit Required within 24 Hours

Physician Contacted*: Time: Physician: Nursing visit scheduled same day Nursing visit scheduled within the next 24 hours Other (describe): Physician Contacted (at visit): Time: Physician: Additional nursing visit scheduled for (date):
Other (describe):


Assessment (check all that apply)

Interventions (check all that apply)
Teletriage: Breathing Difficulty Followup/Evaluation (check all that apply)
Risk Level: NON-URGENT

Occasional shortness of breath and:
Fatigue/Pale Flu/cold symptoms Other (describe):
Routine Care Assessment

Coordinate care with primary nurse. Schedule onsite visit for next day. Physician: Physician Contacted (at visit): Time:

Questions: Patient called to clarify instructions regarding change in medication and potential side effects (describe):
Informational
Answer question(s): Instructed clinical staff scheduled for next onsite visit to discuss question or concern.
Give instructions:
Comments/Additional Notes:
Patient/CT understood and agreed to plan
TELETRIAGE REFERENCE: FALLS/OTHER INJURY

Predisposing risk factors for falls: Over 65 years of age, previous fall, problems with balance/gait, upper/lower body weakness, cognitive impairment, history of stroke/other cardiac problems, vision disturbances, incontinence, more than one chronic condition, up at night to void, takes four or more medicines, postural hypotension, use of illfitting shoes, takes any one medication that might contribute to falls.
Assessment Questions Unresponsive? Not breathing? Bleeding severely? Unable to move? In severe pain? Patient experienced other severe injury? Fever? Fall with injury: o What type of injury have you sustained? o What caused you to fall? Fall without obvious injury: o Does anything hurt? o Did you hit your head? o Did you feel dizzy before you fell? o What caused you to fall? Minimal to moderate injury, without a fall: o What type of injury have you sustained? o What caused the injury? Any change in cognition that contributed to incident/injury? Have you had recent medication changes? Are you taking medications as prescribed? Additional Considerations Intervention If yes, call 911 Provide support until EMS arrives.
LOC/orientation, pain, balance/mobility Diabetic with foot or leg trauma? LOC/orientation, pain, balance/mobility
Notify physician May result in emergent care at physician office or ER Probable same day nursing visit Notify physician Nursing visit within 24 hours Evaluate for medical social worker or rehab services Notify physician Nursing visit within 24 hours
LOC/orientation Possible adverse drug reaction Currently taking meds that increase risk of falls/injury? (Hypnotic/sedative, OTC sleep aid, tranquilizer, anti-psychotic, diuretics, beta-blockers)
If new, inform physician of findings Notify physician Coordinate with pharmacist as needed

Post-Fall: o Evaluate contributing factors, history of falls o Precipitating factors o Home hazards assessment o Medication regime o Cognition o Functional abilities need for rehab services References: 1. Guideline for the prevention of falls in older persons. 2001. Journal of American Geriatrics Society, 49:664-672. 2. Falls among older adults. 2005. National Center for Injury Prevention and Control. http://www.cdc.gov/ncipc/factsheets/falls.htm. 3. National Collaborating Centre for Nursing and Supportive Care. 2004. Clinical practice guideline for the assessment and prevention of falls in older people. London: National Institute for Clinical Excellence (NICE). http://www.guideline.gov. 4. Health Care Association of New Jersey. 2005. Fall management guidelines. http://www.guideline.gov. 5. American Academy of Family Physicians. 2000. What causes falls in the elderly? http://www.aafp.org/afp20000401/2173ph.html.
FALLS/OTHER INJURY
Patient: Caller: Assessment (check all that apply) MR #: Date: Interventions (check all that apply) Clinician Signature: Time: Follow-up/Evaluation (check all that apply)
Risk Level: URGENT

Family/caregiver reports unresponsiveness or patient is not breathing Reports serious injury Reports patient is unable to move post fall/injury Reports fall/injury with severe pain Reports inability to move post fall/injury Other (describe):
Immediate Intervention Required

911 Called Support provided via phone until 911 personnel arrived Provided report to 911 personnel Follow-up call provided to hospital ER Physician Contacted: Time: Physician: Other (describe): Other (describe): Patient was not transported to ER; nursing visit scheduled within the next 24 hours. Received report from 911 personnel after their evaluation Patient was transported to (add facility name):
Risk Level: LIKEY URGENT
Immediate Physician Contact Required

Physician Contacted: Time: Physician: Same day nursing visit Other (describe): Patient was transported to (add facility name): Follow-up call provided to hospital ER Patient was not transported to ER; nursing visit scheduled within the next 24 hours, preferably same day Other (describe):
Reports fall with obvious injury Reports fall without obvious injury associated with brief LOC, orientation problems, pain, mobility problems
FALLS/OTHER INJURY

Reports fall without injury Reports injury without significant pain and/or associated pain Other (describe):

Physician Contacted*: Time: Physician: Notified emergency contact person if applicable Nursing visit scheduled within the next 24 hours, preferably same day Other (describe): Physician Contacted (at visit): Time: Physician: Additional nursing visit scheduled for (date): Other (describe):

Reports balance problems Reports intermittent dizziness Reports feeling weak Other (describe):

Note Risk Assessment Findings as related to specific fall incident.
TELETRIAGE REFERENCE: WOUND DRAINAGE/INFECTION

The clinician taking calls should have access to current wound care orders. There are many types of wounds and many more treatments. If a call is received about a wound, it probably requires immediate attention. Home environment and social support must be evaluated and addressed for successful home wound management. Assessment Questions
Has your wound care treatment been changed recently? Pressure Ulcers/Venous stasis ulcer/wounds of lower extremity: When did symptoms start? Have you noticed: o A foul odor? o Thick yellow or green pus? o Redness or warmth around the wound? o Swelling around the wound? o Tenderness around the wound? o Fever? Is the patient incontinent of urine or stool that is penetrating wound?
Additional Considerations
Intervention
May requires nursing visit within 24 hours to assess
Fever or chills Mental confusion or difficulty concentrating Rapid heartbeat Weakness = advanced infection/possible sepsis
If sepsis is suspected notify physician immediately. Possible hospitalization. Notify physician of suspected wound infection
Is your wound draining more than usual without signs of infection?
Apply moisture barrier cream or ointment Rule out fungal infection; if presenttreatment as ordered with appropriate topical antifungal ointment or powder Consider pursuing physician order for sustained-release antimicrobial dressing
Institute bowel/bladder program Insert foley catheter as ordered by physician Provide patient caregiver education: o Cleansing and drying skin after each incontinent episode Provide patient/caregiver education: o Wound cleansing and dressing o Use dressings that provide moist wound environment and moisture retentive o Pressure relief mattress/ wheelchair cushions o Turn at least every two hours o Reduce friction/shear o Adequate nutrition/fluids Notify physician/surgeon immediately Notify physician/surgeon immediately Notify physician Provide patient/caregiver education: o Wound cleansing and dressing as ordered
Surgical Incisions: Has your incision opened anywhere? Do you have a fever, localized pain or tenderness at the surgery site? Have you noticed: o Purulent drainage? o Pain, tenderness around incision? o Localized swelling, redness or heat at the incision site?
Yes Possible dehiscence Yes Possible abscess Possible superficial incision infection
References:
1. 2. 3. Odom-Forren, J. 2006. Preventing Surgical Site Infections. http://www.nursingcenter.com. National Guideline Clearinghouse. 2003. Guideline for prevention and management of pressure ulcers. http://www.guidelines.gov. American Academy of Family Physicians. 2005. Pressure Ulcers. http://www.familydoctor.org.
WOUND DRAINAGE/INFECTION
Patient: Caller: Assessment (check all that apply) MR #: Date: Interventions (check all that apply) Clinician Signature: Time: Follow-up/Evaluation (check all that apply)
Risk Level: LIKELY URGENT
Immediate Physician Contact Required

Physician Contacted: Time: Physician: Note: Inability to reach MD may be strong indicator to call 911 Other (describe): Patient was transported to (add facility name):
Report of fever/chills accompanied by mental confusion or difficulty concentrating Reports of wound drainage and rapid heart rate, weakness Surgical incision opened (explain):
Follow-up call provided to hospital ER Patient was not transported to ER; nursing visit scheduled within the next 24 hours. Other (describe):

Reports drainage with foul odor Reports thick yellow or green pus Reports redness or warmth around wound Reports increase in drainage with foul odor Describe:

Physician Contacted*: Time: Physician: Nursing visit scheduled within the next 24 hours, preferably same day Other (describe): Physician Contacted (at visit): Time: Physician: Additional nursing visit scheduled for (date): Other (describe):
WOUND DRAINAGE/INFECTION

Reports increased drainage Reports tenderness around wound Describe:

Routing of Phone Calls

Incoming Call
Automated Menu
Live Response
Are options clear and appropriate? Does patient know call wait time? Does agency know average wait time? Waiting message assures caller their call will be answered Option of voicemail rather than waiting for nurse, with clear directions to not leave message if condition is emergent Patient understands when call will be returned and to call agency back if message not returned by specified wait time Caller has option for immediate live assistance
Receptionist receives and transfers call appropriately Caller placed on hold during transfer Is patient informed of call wait time? Does agency know average wait time? Waiting message assures caller their call will be answered Option of voicemail rather than waiting for nurse, with clear directions to not leave message if condition is emergent Patient understands when call will be returned and to call agency back if message not returned by specified wait time Caller has option for immediate live assistance
Call received by nurse who does triage Nurse answers call and uses agency approved forms and/or decision support tools. Assesses medical record information according to policy Appropriate disposition of call Caller verbalizes understanding, expresses intent to comply, comfort with plan and understands to call back if condition worsens or has further concerns
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Leadership Action Items Teletriage

Choose one track (Leadership Path, this page and Leadership Highway, next page) based upon your answer. Check all the action items you may want to execute at your agency.

If NO Leadership Path Develop team of leadership and staff to review how incoming patient phone calls are handled? (Use Routing of Phone Calls) Select both nurses that are currently doing teletriage and those who are not. Processes: Team will develop list of needs to improve teletriage practices. List may include: Improve Process for Routing of Patient Calls Implement Teletriage Support Tools and/or teletriage documentation tool* Develop/Implement a teletriage call log Complete staff education for teletriage (Nursing, Therapy, MSW, HHA Tracks) Include teletriage as a component to orientation Develop teletriage competency for nurses who perform teletriage Include an evaluation of teletriage (patient phone calls) in patient satisfaction survey Develop evaluation tool to evaluate random teletriage encounters (for nurse consistency, patient outcome) Review teletriage call log, patient satisfaction survey, and evaluation tools for nurse interventions and patient outcomes. Summarize findings. Share evaluation results with staff and management. Identify areas of nurse consistency and inconsistency with teletriage. Share examples of effective and ineffective teletriage Develop timeline for teletriage improvement process Staff education and involvement: Explain that additional on-call visits may need to be provided to improve patient care and to attempt to keep the patient at home. Utilize champion nurses to be the primary providers initially to begin the pilot of teletriage support tools (if applicable) Recognize and reward nurse(s)/team(s) when hospitalization is avoided with skillful teletriage
* Sample forms for most of the suggested teletriage processes are available in the Home Telehealth Reference 2006/2007. Cues to prompt staff to make an onsite visit: Patient/Caregiver calls the agency a second time related to their problem or issue. High-risk patient calls with s/s of exacerbation related to their disease or medical condition.
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Choose one track based upon your answer. Check all the action items you may want to execute at your agency.

If YES Leadership Highway Processes: Review current processes for teletriage. Do current processes include: Well defined process for routing of patient calls Teletriage support tools and/or teletriage documentation tool* Staff education and involvement: Utilize the Nursing, Therapy, MSW and HHA tracks to provide education and increase understanding of the value of teletriage Provide instruction to clerical staff in routing of patient phone calls Explain that additional on-call visits may need to be provided to improve patient care and to attempt to keep the patient at home Add teletriage component to agency orientation Develop annual nurse competencies for teletriage Offer in-services for instruction on the use of teletriage support tools and better documentation practices for teletriage Evaluation: Develop/implement a teletriage call log Develop evaluation tool to evaluate random teletriage encounters (for nurse consistency, patient outcome) Evaluate nurse interventions and patient outcomes through review of teletriage call log, patient satisfaction survey, and evaluation tool. Summarize the findings. Include an evaluation of teletriage (patient phone calls) in patient satisfaction survey Share evaluation results with management and staff. Identify areas of nurse consistency and inconsistency with teletriage. Share examples of effective and ineffective teletriage Care Coordination: Do nurses performing teletriage communicate patient calls/outcomes with staff who are seeing patients? Do clinicians have easy access to patient schedules? Is recent documentation available to all staff, so they can review patient communications, interventions?
* Sample forms for most of the suggested teletriage processes are available
in the Home Telehealth Reference 2006/2007.
Cues to prompt staff to make an onsite visit: Patient/Caregiver calls the agency a second time related to their problem or issue. High-risk patient calls with s/s of exacerbation related to their disease or medical condition.
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Suggestions for Leadership Involvement:
Home health administrators can:

Establish policies and directives for teletriage Review recruitment and hiring practices to include assessment of teletriage skills Utilize professional nurses in teletriage positions
Clinical managers can:

Incorporate teletriage as a component of orientation and as a nurse competency Assure agency processes allow for consistent handling of patient calls Model good teletriage skills Allow nurses time to conduct effective teletriage
Quality improvement leadership can:

Educate all staff regarding teletriage and professional nurses on teletriage skills Monitor/evaluate to determine if effective teletriage is actually occurring Share patients case studies and/or success stories that describe how effective teletriage prevented hospitalizations
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Leadership Action Plan Teletriage

Using the Leadership Action Items (previous three pages), request that your leadership team members select and prioritize two to four items that they want to implement or modify. Remember, you will have four weeks to review, plan, and implement some key action items. Another important best practice intervention will be released at the beginning of the following month. You may choose to add more action items after accomplishing your priority action items.
Date Action Implement specific Teletriage Decision Support Tools as a reference and documentation for staff performing teletriage Review care discipline tracks to determine what portions of this Best Practice Package Teletriage that you choose to use and how you want to utilize them. By Whom Status
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Implementation Tools: How to Use Teletriage

Patient & Family Connection Discuss concept of patient/caregiver self-management at staff meeting Brainstorm with staff: how well does staff promote patient/caregiver selfmanagement? Identify solutions to promote patient/caregiver selfmanagement Physician & Hospital Connection Utilize this information with your intake staff, on-call staff and clinical managers so that urgent patient issues will be managed in the appropriate setting Hospice & Palliative Connection Learn from the hospice and palliative community and transfer that knowledge into homecare process/system change Share with staff the knowledge gained by hospice staff in teletriage processes Encourage hospice and home health staff to confer about teletriage processes in a staff meeting (if your agency has a hospice program) HHQI Teletriage Posters Use poster as a visual reminder of the importance of teletriage to reduce avoidable hospitalizations Success Stories Read at staff meetings, distribute in mail boxes, post on bulletin boards Encourage staff to share anecdotal teletriage success stories of their own
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Patient & Family Connection

(Self-Management) Teletriage
The ultimate goal of every home health episode is the successful transfer of health management to the patient/ caregiver. Emergency care planning is the first step toward self-management as the agency provides the patient with guidance on how to recognize and respond to health changes. Teletriage is the agencys response to the patient/caregivers implementation of the emergency care plan. When the patient recognizes a problem and contacts the agency, the purpose of teletriage is to confirm the problem and begin problem resolution. Teletriage can identify and manage a situation that might otherwise result in an acute care hospitalization. Teletriage is also an opportunity to gauge the patients understanding of the emergency plan, to reinforce self-monitoring, and to teach problem solving to promote patient/caregiver self-management. All staff must understand that teletriage is not simply a response to a specific problem or event. Help clinicians connect the dots so they link teletriage to the emergency plan and self-management. Start of Care
AGENCY
Emergency Care Planning
Teac h
PATIENT/CAREGIVER
Self-Monitoring/ Problem Recognition
Teletriage
Ass Seek
istanc
Ad Reinfo dress Prob le r Teach ce Self-Mon m it Proble m-Sol oring ving

Self-Management Discharge
ce peten e Com ence Mor nfid Co
Improved Self-Monitoring Problem Solving
As the patient acquires skills and knowledge to self-monitor, and they begin to recognize and solve problems, competence and confidence increases. As the episode progresses, the patient/caregiver becomes less dependent on the agency to manage care and resolve problems. Successful partnerships between home health agencies and patient/caregivers produce effective self-managers.
Developed by Carol Siebert, MS, OTR/L, FAOTA, American Occupational Therapy Association and Karen Vance, OTR/L, BKD Healthcare Group and American Occupational Therapy Association
Physician & Hospital Connection

Teletriage
Enhance Teletriage Effectiveness Through Connections Between Health Care Settings BEGIN WITH EMERGENCY CARE PLANNING:
Effective emergency care planning can assist with improving teletriage processes. A patient who knows who and when to call will expedite the opportunity for a better outcome. Begin Emergency Care Planning as soon as patient referral is received! A call to the patient before home care admission can initiate instruction in emergency care planning. (Give agency number, on-call information, etc.)
WHEN URGENT CARE IS NECESSARY:

Collaborate with the physician; an office visit may be an alternative to an emergency room visits. Develop a working partnership with the emergency room staff. Emergency care may be necessary and collaborating with the emergency room staff with a plan for follow up care may prevent a hospitalization.
Sometimes urgent patient situations can be handled by the primary care physician in the physician office. This may avoid an ER visit and hospitalization. Dennis Manning, MD, FACP, FACC
FOLLOW THROUGH:
Communicate with primary physician when patient receives emergency care and/or is hospitalized. Facilitate care transition to other settingscommunicate with the emergency room, hospital and physician the disposition of the patient.
Thomas F. Kline, MD, PhD
Receiving a phone call from a patient can be difficult--having a nurse on the scene is extremely helpful in determining what may be the problem
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Hospice & Palliative Connection Teletriage

One of the key components of hospice nursing is effective Teletriage whether it occurs during office hours, on-call or on weekends. This is also true for home care and is instrumental in reducing acute care hospitalizations.
Teletriage Critical Key Points
Staff promptly returns calls
Basic patient medical information available
Clinicians skilled with symptom management
Proactive with high-risk patients
Teletriage tools or scripts
Return call to patients within 15 minutes, especially if acute s/s are being reported
Need at a minimum, diagnosis, comorbidities, & current problems. Can be paper or computer based
Learn to identify urgency risk level, prioritize and determine appropriate interventions
Be aware of patients at highrisk for hospitalization and proactively utilize interventions
Assist new or less seasoned clinicians with teletriage to obtain better assessment & identify problems
Information was provided by Margaretta Dorey, RN, BSN, Project Coordinator, Quality Insights of Delaware, Delaware Quality Improvement Organization. Margaretta has 14 years of hospice experience.
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Teletriage
Hello. Im calling about my mother. Your nurses come to see her.
We can help you. I just need some more information
Teletriage occurs every time a patient calls the agency with a health-related problem. Teletriage includes determining the urgency risk level of a call, then intervening as needed. Effective teletriage helps ensure that the patient receives the right care every time.
Home Health
HHQIOSC
Quality Insights
Quality Improvement Organization Support Center
This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization Support Center for Home Health, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number 8SOW-PA-HHQ07.509 App. 6/07/07.
Post-Test Answer Keys Teletriage

Each track of the Best Practice Intervention Package has a post-test that providers may choose to complete after reviewing the track and completing the activities. For the Teletriage package, the post-tests are found on the following pages: Nurse Track page 49 Therapy Track page 61 Medical Social Work Track page 70 Home Health Aide Track page 79 Use the answer keys below to score the post-tests included with the Best Practice Intervention Package - Teletriage. Nursing post-test answers: 1. D 2. A 3. E 4. D 5. E Therapy post-test answers: 1. D 2. A 3. E 4. F 5. D
Medical Social Worker post-test answers: 1. A 2. C 3. B 4. D 5. D Home Health Aide post-test answers: 1. A 2. C 3. B 4. C 5. E - 39 -
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Nurse Track
Nurse
8SOW-PA-HHQ07.448 App. 6/25/07
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Nurse Track
Nurse
This best practice intervention package is designed to introduce nurses to teletriage and to demonstrate how to apply effective teletriage principles to support reducing avoidable hospitalizations.
Objectives
After completing the activities included in the Nurse Track of this Best Practice Intervention Package Teletriage, the learner will be able to: 1. Define teletriage and how it can be executed effectively. 2. Explain how decision support tools may be used to support sound clinical assessments and interventions. 3. Describe two nursing actions or applications that enhance teletriage. Complete the following activities: Activity Read the Nurses Guide to Practical Application Listen to the Podcast (audio recording): Teletriage - The Good, the Bad, the Ugly for Clinicians View Teletriage WebEx Read the success story RNs: Complete the nursing evaluation and post-test online for free CNEs LPNs: Complete the nursing post-test Total time for completion Location Page 43 Page 46 Page 46 Page 47 See link below Page 49 Estimated Time 5 minutes 15 minutes 60 minutes 10 minutes 10 minutes (10 minutes) 100 minutes
FREE CNEs for Registered Nurses RNs may apply for free 1.7 CNEs for completing all of the nursing track activities (see above table) from this Best Practice Intervention Package Teletriage
Complete above activities & complete evaluation/post-test online at http://www.zoomerang.com/survey.zgi?p=WEB226N3AB59PJ
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Nurse
Nurses Guide to Practical Application Teletriage

Purpose: To assist nurses with understanding and applying effective teletriage principles to support reducing avoidable hospitalizations Definition: Teletriage is what occurs when a patient calls the agency for health-related advice. This is usually initiated by the patient and/or caregiver, but can occur in response to phone monitoring or telemonitoring encounters. Practical Application: Become familiar with agency policies, procedures and/or decision support tools and protocols to reduce liability issues. When triaging a call, promptly assess urgency risk level then intervene and follow-up as appropriate. Evaluate patients acceptance and understanding of the plan. Decision support tools should be used with flexibility, intuition, critical thinking skills and professional nursing judgment. Communication via a teletriage phone encounter requires active listening. Be alert for cues to unspoken problems; be patient and address the patient at his/her level. Documentation of calls initiated by the patient/caregiver includes the specific problem, phone assessment findings and disposition including instruction provided, and follow-up that may be needed. Ensure that other members of the health care team who will be making an onsite visit or phone encounter are aware of patient/caregiver calls to support follow-up as needed. Include patients/caregivers that are frequently calling the agency with health related problems in interdisciplinary communication and case conferencing. Clinicians must have knowledge of psychosocial needs of the patients and their families to determine appropriate interventions. It is also essential to communicate to the patient and family in a reassuring, calm and knowledgeable manner.
Simply stated, teletriage is what occurs whenever the patient calls the agency with a healthrelated problem.
Key: Teletriage is not optional. It occurs every time a
Margaretta Dorey, RN, BSN Project Coordinator Quality Insights of Delaware, Delaware Quality Improvement Organization
patient/caregiver calls the agency. Effective teletriage helps ensure that the patient receives the right care, every time.
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Teletriage at a Glance
A teletriage encounter begins with recognition of a problem followed by the determination of urgency risk level. The nurse must use clinical judgment to identify appropriate interventions. The encounter concludes with evaluation of patients understanding and acceptance of plan and follow/up as needed. Assessment Urgent 911 paramedic transport necessary Patient condition may be life threatening Likely Urgent: Emergent care likely Minimally, an immediate contact to physician is necessary Consider 911 paramedic transportation Assessment High Risk Level Interventions Teletriage clinician instructs patient/caretaker to immediately seek 911 paramedic transport May require additional patient care instructions until 911 transport arrives Teletriage clinician provides instruction and support to maintain the patient until the physician can be reached Inability to reach the physician may be a strong indicator for 911 paramedic transport Evaluation/ Follow-up Teletriage clinician provides support until 911 transport arrives Care is coordinated with physician May result in an onsite visit that day May result in emergent care at the physician office or emergency department
Moderateto-High
Risk Level
Interventions Teletriage clinician provides instruction and support to maintain the patient until the nurse arrives onsite Onsite nursing visit is scheduled for that day Care is coordinated with primary nurse Teletriage encounter is documented in the medical record In the event that a nursing visit cannot be made that day, the patient may require emergent care
Evaluation/ Follow-up May result in physician contact May result in adjusted physician orders or care plan
Potentially Urgent: Same day onsite visit required Patient condition requires the skills of the homecare provider onsite that day either for assessment or for hands-on interventions
Low-toModerate
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Assessment
Risk Level
Interventions Teletriage clinician answers the question and/or gives instructions Care is coordinated with other agency staff as needed Teletriage encounter is documented in the medical record Teletriage clinician provides instruction Care is coordinated with primary nurse Onsite visit scheduled for the next day Teletriage encounter is documented in the medical record
Evaluation/ Follow-up No additional follow-up needed immediately after teletriage encounter Clinical staff visiting patient discuss question or concern at next onsite visit Nurse visiting patient at onsite visit the next day addresses problem May result in physician contact May result in adjusted physician orders or care plan
Non-Urgent: Informational Patient/caregiver calls with a clinical question
Low
Non-Urgent: Routine care Patient/caregiver calls with a question or problem that requires clinical interventions of the agency
Low
Simonsen-Anderson, S. 2002. Safe and sound: telephone triage and homecare recommendations save lives and money, Nursing management, June: pp 41-43.
Teletriage Scenario:
Background: Mr. J. is being seen monthly for Foley catheter changes. He has a history of asthma and frequent bronchitis. He was seen two weeks ago. The daughter calls the agency at noon on the weekend to report a change. The receptionist that takes all calls recognizes this is a health status call and transfers to the on-call nurse. Daughter: My father feels a little warm and he is coughing more than usual today. Nurse on-call: Accesses patient records and quickly familiarizes herself with patients medical history, medication regimen and plan of care. There are no orders for skilled assessment beyond Foley catheter issues. The nurse gathers pertinent information from daughter including when symptoms started, how patient has been taking his medications and color of sputum. The nurse explains that she would like to contact the physician. The daughter agrees that would be a good idea. The nurse has the daughter take her fathers temperature. The nurse has determined that this is not life-threatening, but that it could develop into an emergent care situation unless action is taken. Enough information has been gathered to contact the physician. A call is placed to the physician using the SBAR technique* to provide phone assessment findings and significant past medical history. The results include orders to make a PRN visit to assess patients status and to call physician back with findings. An expectorant and antibiotic is ordered and a potential hospitalization
is avoided. * For more information about SBAR go to www.medqic.org. SBAR will be addressed in the October 2007 Best Practice Intervention Package.
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Teletriage Multi-Media Activities Podcast* (Audio Recording)

Nurse
Teletriage Audio Instructions: Listen to the Podcast (audio recording) to learn more about reducing avoidable acute care hospitalizations with the use of teletriage. Title Teletriage - The Good, the Bad, the Ugly for Clinicians Description A 15-minute audio recording related to teletriage Link The audio link is located at www.homehealthquality.org/interve ntionpackages/teletriage.aspx
There are several ways to listen to the Podcast (audio recording): Visit the link above and listen directly through the Web site. Download the Podcast (audio recording) by right-clicking on the audio file and selecting Save Target As.... This will save the file to your hard drive. Once you have saved the file, you can listen to it on your computer or you can burn the audio file to a CD to listen to in your car or stereo. *A Podcast is a digital media file, often an audio recording, placed on by the Internet and made available to the listener on their home computer or personal digital recording device for convenience. There is no change from previous references to audio recordings except the name. You may continue to download and listen to recordings as you have in previous months.
Teletriage WebEx:
Title Home Telehealth WebEx (Part 4 of 4)-Teletriage Description A 60-minute WebEx related to teletriage Link This link is located at www.homehealthquality.org/interve ntionpackages/teletriage.aspx
View on your personal computer or download to use as a presentation: a. Download the PowerPoint handouts (PDF) b. View presentation from individual computer i. Click on the WebEx link to the file c. View presentation using the WebEx file with projector for in-service i. Download the WebEx file onto your laptop computer or save the WebEx file on a CD ii. Open file and test your audio volume (may need to use a microphone to project the audio in your room) iii. Click play
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Success Stories
Nurse
Pennsylvania Home Health Agency Implements Teletriage Process, Reduces Patient Emergency Room Visits During After Hours and Improves Customer Service Neighborhood Health Agency (NHA) in West Chester, Pennsylvania came across a thought provoking resource (Home Telehealth Reference, 2006-2007) from their state Quality Improvement Organization (QIO), Quality Insights of Pennsylvania. After reading the packet, which outlined the benefits of a structured teletriage system, they took a close look at how they were managing their patient phone calls and organized a teletriage committee. The teletriage committee was formed in October 2006. Participants included two on-call nurses, office employees and frontline staff members. By including various levels of employees and disciplines, the team received buy-in throughout the agency. The committee took approximately a month to sort through the information and delve into other resources, then select the activities and process they wished to implement. The decision was made to start the process development by focusing on the agencys after hours call program. Carol Conrad is the Quality Improvement Manager at Neighborhood Health Agency. Together with Beth Fuller, Staff Development Coordinator, they researched call logs in order to understand when and why patients were calling the agency and found most calls were taking place in the morning. Patients were calling to tell us that they went to the emergency room or called 911 the previous night. It seemed that patients and home care didnt understand that we had after hours staff to assist them. We wanted to change that, shared Carol. Its really about customer service. We compared the process to checking into a hotel once you get to your room, the front staff calls to check in on the customers satisfaction. We thought, Why cant we apply the same principles? The teletriage team developed tools for staff to use, like call scripts with targeted questions encouraging yes or no answers in order to keep calls informative, yet concise. Protocol was written to help staff understand the purpose and goals of the program, along with an outline of the procedure to be implemented. Staff orientation began in November 2006 and then the process was initiated the next month. After the agency admits a new patient, staff conducts an orientation with them. This happens during normal business hours. With Neighborhood Health Agencys new process, an on-call nurse follows up with the patient later that day, after office hours. The nurse follows the script, asks questions about how the patient is feeling and if they have any questions, and then concludes the call by sharing that there is someone at Neighborhood Health Agency 24-hours a day to answer any questions.
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Neighborhood Health Agency not only implemented this with new patients, but also called current patients to inform them of the after hours service. Overall, patients have been delighted some even surprised that they have this option. Due to the number of backlog patients to call, internal monitoring did not begin until April 2007. However, based on Home Health Compare and Outcome-Based Quality Improvement statistics things have already improved. Neighborhood Health Agencys Acute Care Hospitalization rate dropped 3.5% in the last calendar year, placing them 1% above the national average. Of course, the most telling improvement is evident from the patient satisfaction survey. One particular question in the survey asks if the patient knows how to contact the agency. Prior to the agency implementing a solid after hours call program, roughly 80-90% of patients on average agreed. While that is certainly not poor, now the number totals close to 100%. Evaluating staff is key. Beth Fuller, Staff Development Coordinator for Neighborhood Health Agency, shares, We watch very closely how staff handles their patient calls, including documentation of when calls were placed and where patients are referred for assistance. We look at logs on a daily basis and then help train any staff that has concerns. The next step for NHA is to implement a new staff position a Teletriage Coordinator who will support implementing further teletriage processes. The responsibilities of this position will include receiving patient calls that voice a clinical concern during scheduled work hours and making appropriate recommendations. The Coordinator will also initiate telephone calls for the after hours phone call program through follow up to the patient within 24 to 48 hours of admission. This position will ultimately be responsible for making patient visits in response to an identified problem during the telephone calls. The after hours call program is just one piece, but its been very important to Neighborhood Health Agency and extremely valuable to their patients. Data in this article was provided by Carol Conrad of Neighborhood Health Agency.
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Clinician name:
________________________________
Nursing Post-Test
Nurse
Teletriage
RNs May apply for 1.7 FREE CNEs by following directions on page 41
Date: _____________
Directions: Choose the ONE BEST response to the following questions. Circle your answer that identifies the ONE BEST response. 1. Teletriage includes all of the following except: A. Receiving an unscheduled call from a patient/caregiver related to a health-related problem B. Receiving telemonitoring results that are outside of acceptable parameters for the patient C. Determining appropriate disposition of health-related problems by skilled clinicians D. Sending all patients to the emergency department (ED) because staff is not available to see patient 2. Teletriage is not an option, all agencies are performing teletriage every time a patient/caregiver contacts the agency office or specific agency staff or telemonitoring data is submitted. It is essential to have policies and procedures to guide staff. Documentation and communication to the interdisciplinary team regarding the disposition/outcome of the encounter is crucial for quality patient care. A. True B. False 3. Which of the following statements about Decision Support Tools are true: A. Assist clinician in obtaining an accurate phone assessment of the patient B. Guide the clinician in determining urgency risk level C. Require application of the nurses clinical judgment and critical thinking skills D. Assist with making clinically sound decisions on determining the appropriate level of care or intervention E. All of the above 4. Teletriage scenario: Mr. M. calls the on-call nurse and reports increased shortness of breath today. Patient is audibly short of breath over the phone with a respiration rate of 28-30. Patients medical record notes a diagnosis of CHF & COPD. How would your classify this patients urgency risk level using the Teletriage at a Glance? A. Urgent, likely urgent B. Potentially urgent C. Non-urgent D. Possibly A or B, additional assessment is required E. None of the above
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5. Teletriage scenario continued from question #4. The nurse continues to assess Mr. M. over the phone and discovers that the patient: 1) had not been using his oxygen as ordered, 2) did not have his air conditioning on (air alert action day with high humidity and high heat index); and 3) had not utilized his rescue inhaler at this point in time. The nurse determines that the patient is at a potential urgent level and would most likely plan any of the following interventions, except: A. Instruct patient on correct use of oxygen and inhalers and to initiate use immediately B. Instruct on signs and symptoms to report to the nurse/agency C. Schedule a follow-up visit for the next day to: 1) perform a physical assessment, 2) assess for any financial, knowledge deficits or nonmedical reasons the patient is was not adhering to plan of care, 3) instruct and/or reinforce on identified areas of knowledge deficits D. Schedule a phone encounter with the patient in an hour to re-assess status E. Send patient to the emergency department immediately F. Contact a family member to check in on patient and reinforce how to contact the agency if status does not improve.
Answers to Post-Test are located in the Leadership Section.
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Therapy Track
Therapist
8SOW-PA-HHQ07.448 App. 6/25/07
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Therapy Track
Therapist
This best practice package is designed to introduce home care physical and occupational therapists as well as speech language pathologists to effective teletriage as an intervention to assist in reducing avoidable acute care hospitalizations. Objectives After completing the activities in the Therapy Track of this Best Practice Intervention Package Teletriage, the learner will be able to: 1. Define teletriage. 2. Describe the value of interdisciplinary communication in relation to patient/caregiver initiated calls. 3. Portray the role of therapy to support effective teletriage. Complete the following activities: Activity Read the Teletriage Therapists Guide to Practical Application Review the Teletriage Reference and Documentation Tool for Falls/Other Injury* Listen to the Podcast (audio recording): Teletriage-The Good, the Bad, the Ugly for Clinicians Read the teletriage success stories Complete the therapy post-test Total Time Location Page 53 Page 54 Page 58 Page 59 Page 61 Estimated Time 5 minutes 15 minutes 15 minutes 15 minutes 10 minutes 60 minutes
* Teletriage is primarily the responsibility of skilled nursing. The Teletriage Reference and Documentation Tools for Falls/Other Injury have been included in the therapy track as examples of teletriage decision support tools to demonstrate to therapists the teletriage process of assess urgency level, intervene and follow-up on a topic to which they can relate.
FREE Certificate of Participation for 1.0 hours of continuing education

PTs, OTs & STs completing all of the therapy track activities (see above table) from this Best Practice Intervention Package Teletriage can apply for a certificate of attendance that may be accepted by your state or national association as continuing education hours. A PDF file is posted on www.homehealthquality.org if you need to submit additional documentation.
Complete above activities & complete evaluation/post-test online at
http://www.zoomerang.com/survey.zgi?p=WEB226N3AH59T7 - 52 -
Therapist
Therapists Guide to Practical Application Teletriage
Purpose: To assist therapists with understanding effective teletriage as an intervention to support reducing avoidable hospitalizations Definition: Teletriage is what occurs when a patient calls the agency for healthrelated advice. This is usually initiated by the patient and/or caregiver, but can occur in response to phone monitoring or telemonitoring encounters.
Key Points:
Teletriage is a daily aspect of home health practice. It occurs every time a patient/caregiver calls the agency with a health-related problem. Be familiar with the teletriage process in your agency and know how to route calls that do not fall within your professional scope.
Simply stated, teletriage is what occurs whenever the patient calls the agency with a health-related problem.
There may be times when a patient/caregiver reports a problem or a change in status during a call initiated by the therapist. This is also a teletriage situation. Triage of a call includes assessing urgency risk-level, intervening as appropriate then follow-up and documentation. Your agency may use decision support tools to standardize this process. Support teletriage by reminding patients to follow their emergency care plan and to call the agency with health related concerns. Review documentation of calls initiated by the patient/caregiver; it should include the specific problem, phone assessment findings and disposition including instruction provided and follow-up that may be needed. Recognize when a patient/caregiver is calling the agency with health-related problems and then contribute to follow-up when appropriate. This may include referrals to other disciplines if needed. Patients/caregivers that are frequently calling the agency with health related problems should be closely tracked through interdisciplinary communication and case conferencing. Education to other disciplines involved with teletriage related to problem solving and/or resources for orthotic or equipment issues. Key: Therapists need to be observant for problems or changes, respond to those that are within their scope of practice, and report those outside disciplinary scope to the appropriate clinical staff for early interventions. Keep the interdisciplinary team informed of patient status changes.
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Predisposing risk factors for falls: Over 65 years of age, previous fall, problems with balance/gait, upper/lower body weakness, cognitive impairment, history of stroke/other cardiac problems, vision disturbances, incontinence, more than one chronic condition, up at night to void, takes four or more medicines, postural hypotension, use of illfitting shoes, takes any one medication that might contribute to falls.
Assessment Questions Unresponsive? Not breathing? Bleeding severely? Unable to move? In severe pain? Patient experienced other severe injury? Fever? Fall with injury: o What type of injury have you sustained? o What caused you to fall? Fall without obvious injury: o Does anything hurt? o Did you hit your head? o Did you feel dizzy before you fell? o What caused you to fall? Minimal to moderate injury, without a fall: o What type of injury have you sustained? o What caused the injury? Any change in cognition that contributed to incident/injury? Have you had recent medication changes? Are you taking medications as prescribed? Additional Considerations Intervention If yes, call 911 Provide support until EMS arrives.
LOC/orientation, pain, balance/mobility Diabetic with foot or leg trauma? LOC/orientation, pain, balance/mobility
Notify physician May result in emergent care at physician office or ER Probable same day nursing visit Notify physician Nursing visit within 24 hours Evaluate for medical social worker or rehab services Notify physician Nursing visit within 24 hours
LOC/orientation Possible adverse drug reaction Currently taking meds that increase risk of falls/injury? (Hypnotic/sedative, OTC sleep aid, tranquilizer, anti-psychotic, diuretics, beta-blockers)
If new, inform physician of findings Notify physician Coordinate with pharmacist as needed

Post-Fall: o Evaluate contributing factors, history of falls o Precipitating factors o Home hazards assessment o Medication regime o Cognition o Functional abilities need for rehab services References: 1. Guideline for the prevention of falls in older persons. 2001. Journal of American Geriatrics Society, 49:664-672. 2. Falls among older adults. 2005. National Center for Injury Prevention and Control. http://www.cdc.gov/ncipc/factsheets/falls.htm. 3. National Collaborating Centre for Nursing and Supportive Care. 2004. Clinical practice guideline for the assessment and prevention of falls in older people. London: National Institute for Clinical Excellence (NICE). http://www.guideline.gov. 4. Health Care Association of New Jersey. 2005. Fall management guidelines. http://www.guideline.gov. 5. American Academy of Family Physicians. 2000. What causes falls in the elderly? http://www.aafp.org/afp20000401/2173ph.html.
Podcast * (Audio Recording)

Therapist
Teletriage Audio Instructions: Listen to the Podcast (audio recording) to learn more about reducing avoidable acute care hospitalizations with the use of teletriage. Title Teletriage - The Good, the Bad, the Ugly for Clinicians Description A 15-minute audio recording related to teletriage Link The audio link is located at www.homehealthquality.org/interve ntionpackages/teletriage.aspx
There are several ways to listen to the audio recording (Podcast): Visit the link above and listen directly through the Web site. Download the audio recording (Podcast) by right-clicking on the audio file and selecting Save Target As.... This will save the file to your hard drive. Once you have saved the file, you can listen to it on your computer or you can burn the audio file to a CD to listen to in your car or stereo. *A Podcast is a digital media file, often an audio recording, placed on by the Internet and made available to the listener on their home computer or personal digital recording device for convenience. There is no change from previous references to audio recordings except the name. You may continue to download and listen to recordings as you have in previous months.
Clinicians must have knowledge of psychosocial needs of the patients and their families to determine appropriate interventions. It is also essential to communicate to the patient and family in a reassuring, calm and knowledgeable manner.
Margaretta Dorey, RN, BSN Project Coordinator, Quality Insights of Delaware, Delaware Quality Improvement Organization
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Success Stories
Therapist
Pennsylvania Home Health Agency Implements Teletriage Process, Reduces Patient Emergency Room Visits During After Hours and Improves Customer Service Neighborhood Health Agency (NHA) in West Chester, Pennsylvania came across a thought provoking resource (Home Telehealth Reference, 2006-2007) from their state Quality Improvement Organization (QIO), Quality Insights of Pennsylvania. After reading the packet, which outlined the benefits of a structured teletriage system, they took a close look at how they were managing their patient phone calls and organized a teletriage committee. The teletriage committee was formed in October 2006. Participants included two on-call nurses, office employees and frontline staff members. By including various levels of employees and disciplines, the team received buy-in throughout the agency. The committee took approximately a month to sort through the information and delve into other resources, then select the activities and process they wished to implement. The decision was made to start the process development by focusing on the agencys after hours call program. Carol Conrad is the Quality Improvement Manager at Neighborhood Health Agency. Together with Beth Fuller, Staff Development Coordinator, they researched call logs in order to understand when and why patients were calling the agency and found most calls were taking place in the morning. Patients were calling to tell us that they went to the emergency room or called 911 the previous night. It seemed that patients and home care didnt understand that we had after hours staff to assist them. We wanted to change that, shared Carol. Its really about customer service. We compared the process to checking into a hotel once you get to your room, the front staff calls to check in on the customers satisfaction. We thought, Why cant we apply the same principles? The teletriage team developed tools for staff to use, like call scripts with targeted questions encouraging yes or no answers in order to keep calls informative, yet concise. Protocol was written to help staff understand the purpose and goals of the program, along with an outline of the procedure to be implemented. Staff orientation began in November 2006 and then the process was initiated the next month. After the agency admits a new patient, staff conducts an orientation with them. This happens during normal business hours. With Neighborhood Health Agencys new process, an on-call nurse follows up with the patient later that day, after office hours. The nurse follows the script, asks questions about how the patient is feeling and if they have any questions, and then concludes the call by sharing that there is someone at Neighborhood Health Agency 24-hours a day to answer any questions.
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Neighborhood Health Agency not only implemented this with new patients, but also called current patients to inform them of the after hours service. Overall, Therapist patients have been delighted some even surprised that they have this option. Due to the number of backlog patients to call, internal monitoring did not begin until April 2007. However, based on Home Health Compare and Outcome-Based Quality Improvement statistics things have already improved. Neighborhood Health Agencys Acute Care Hospitalization rate dropped 3.5% in the last calendar year, placing them 1% above the national average. Of course, the most telling improvement is evident from the patient satisfaction survey. One particular question in the survey asks if the patient knows how to contact the agency. Prior to the agency implementing a solid after hours call program, roughly 80-90% of patients on average agreed. While that is certainly not poor, now the number totals close to 100%. Evaluating staff is key. Beth Fuller, Staff Development Coordinator for Neighborhood Health Agency, shares, We watch very closely how staff handles their patient calls, including documentation of when calls were placed and where patients are referred for assistance. We look at logs on a daily basis and then help train any staff that has concerns. The next step for NHA is to implement a new staff position a Teletriage Coordinator who will support implementing further teletriage processes. The responsibilities of this position will include receiving patient calls that voice a clinical concern during scheduled work hours and making appropriate recommendations. The Coordinator will also initiate telephone calls for the after hours phone call program through follow up to the patient within 24 to 48 hours of admission. This position will ultimately be responsible for making patient visits in response to an identified problem during the telephone calls. The after hours call program is just one piece, but its been very important to Neighborhood Health Agency and extremely valuable to their patients. Data in this article was provided by Carol Conrad of Neighborhood Health Agency.
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Success Stories
Therapist
Teletriage: Reflections of a Hospice Nurse Teletriage is a necessary and important part of the home care continuum. It can also be an effective tool for reducing acute care hospitalizations when teletriage nurses are armed with the right information and understand the goals of good teletriage. Margaretta Dorey, Home Health Project Coordinator for Quality Insights of Delaware, the Medicare Quality Improvement Organization (QIO), was a hospice nurse for 14 years before coming to the QIO to work on home health quality improvement. She sees opportunities for the home health field to learn from hospice when it comes to teletriage. The [Medicare] reimbursement process is different in hospice than in homecare, says Dorey. When patients elect hospice, it is assumed they will not be returning to the hospital since aggressive care is no longer required. Dorey observes that hospice on-call nurses are charged with providing effective teletriage, and therefore use their clinical skills to do everything they can to make sure patients are able to stay at home while managing their condition with minimal discomfort. Effective Teletriage: The Components Teletriage is largely about information, education and reassurance, says Dorey. Nurses need to have all pertinent medical information about the patient so when they get a call, they can quickly and effectively assess the patients needs. A diagnosis is not enough. Medical history is important, but they also need to know if a patient is having an exacerbation that may progress during the night. Promptly returning phone calls (within 15-30 minutes) is key to averting emergency care. Teletriage nurses should also understand the physical and psychosocial issues patients and caregivers are facing especially at night. The education component of teletriage provides an opportunity for the teletriage nurse to reinforce protocols, promote patient self-management which includes reminding them how to comply with medications and multiple prescriptions. Education is especially important if there is a recent change in the care plan. Reassurance is also incorporated in the education piece. It more than just saying, Youll be OK its about patient/family centered education so they know they are OK. Reassurance goes both ways. Patients are reassured that someone is aware of their condition, and the on-call nurses can be reassured that they are less likely to receive middle of the night calls or have patients visit the ER unnecessarily. Teletriage: Paradigm Shift Dorey finds that advanced hospice and home health facilities are shifting to a new paradigm as they move from teletriage to a system of phone monitoring making proactive calls. In this model, on-call nurses reach at-risk patients early in the - 59 -
Therapist
evening, where they conduct patient/caregiver education and assess any new developments in the condition. Then the nurse may call the doctor proactively if the patients condition has deteriorated. A doctor might make changes in medications based on the teletriage nurses assessment. Patients and caregivers are receptive to this model. They are reassured that someone who was on call is aware and updated and is monitoring their condition, Dorey says. Teletriage: Creating a System Dorey recommends that an agency creates a system with standardized, evidencebased protocols for teletriage. Risk assessments should be incorporated so the teletriage nurses are aware of the patients most at risk for readmission. Then the agency needs to educate the nurses; scripts can help remind nurses of the elements of good teletriage symptom management, patient education, reassurance, not jumping to conclusions, reviewing all medications taken and medications available to the patient, assessing anxiety level. Teletriage: Flexibility Teletriage requires the agency to be flexible in their approaches and responses, sometimes by reassuring that a care worker will visit sooner, or by recognizing that something may need to be done differently based upon new information the caller provides about the patient condition. Tell the patient you will call them back in a few hours, suggests Dorey. If you ask the patient to call you back, then they are more likely to call 911 because they feel they have already called the nurse. You accomplish two things by calling back: you get an update and youre telling the patient that you believe they will improve. Also, patients may be embarrassed to call you back again. They call 911 because they think they have no other choice. A Vital Resource Dorey concludes that communications and reassurance are among the most important elements of successful teletriage, and are effective means for keeping patients out of the hospital. For more information, she recommends home health agencies use the QIOSC-developed Home Telehealth Reference available at www.medqic.org. Data in this article provided by Margaretta Dorey of Quality Insights of Delaware.
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Clinician name:
________________________________
Therapist
Therapy Post-Test Teletriage
Date: _____________
Therapists May apply for a FREE Certificate of Participation (1.0 contact hours) that may be used towards educational hours by following directions on page 51
Directions: Choose the ONE BEST response to the following questions. Circle your answer that identifies the ONE BEST response. 1. Teletriage includes all of the following except: A. Receiving an unscheduled call from a patient/caregiver related to a health-related problem B. Receiving telemonitoring results that are outside acceptable parameters for the patient C. Determining appropriate disposition of health-related problems by skilled clinicians D. Sending all patients to the emergency department (ED) because staff is not available to see patient 2. Teletriage is not an option, all agencies are performing teletriage every time a patient/care giver contacts the agency office or specific agency staff or telemonitoring data is submitted. It is essential to have policies and procedures to guide staff. Documentation and communication to the interdisciplinary team regarding the disposition/outcome of the encounter is crucial for quality patient care. A. True B. False 3. Which of the following statements about Decision Support Tools are true: A. Assist clinician in obtaining an accurate phone assessment of the patient B. Guide the clinician in determining urgency risk level C. Require advocates application of the nurses clinical judgment and critical thinking skills D. Assist with making clinically sound decisions on determining the appropriate level of care or intervention E. All of the above 4. Teletriage Scenario: Mrs. C. is a patient with a new onset CVA patient that was admitted after a short stay in a rehabilitative facility. Patient was evaluated and identified with residual weakness right side, mild swallowing difficulties, unsteady balance and gait and is utilizing a standard walker for 25 30 feet. The physician has ordered SN related to Coumadin therapy, and PT, OT & ST for appropriate rehab treatment and management. Patients husband calls the agency during regular office hours and reports that the patient had fallen in the bathroom. The
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clinician utilizes the Falls/Other Injury Teletriage Documentation Tool (on page XX in the Therapy Track) to teletriage the patient. What questions would you ask the patients husband? (Use the Falls/Other Injury Teletriage Documentation Tool to answer this question and question 5.) A. Is or was the patient unresponsive or not breathing? B. Has the patients orientation or mental status changed since the fall? C. Is the patient able to move after the fall? D. Does the patient have severe pain? Location? E. Is the patient able to walk? F. All of the above 5. Teletriage scenario continued from question #4. After asking the husband many questions, the clinician learns that the patient tripped while walking on a throw rug with her walker. Mrs. C. did not lose consciousness and the only injury was a skin tear on her left elbow, and a pain level of 3 out of 10 to left shoulder and wrist. She is able to move all joints. The clinician decided that the patient call was a risk level of Non - Urgent and interventions could include any of the following, except: A. Schedule a nursing visit to assess skin tear B. Schedule a physical therapy visit within the next 24 hours to assess and instruct on ambulation safety C. Call physician after completing physical assessment to report fall and obtain any necessary orders D. Send patient to the emergency department immediately Answers to Post-Test are located in the Leadership Section.
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Medical Social Worker Track

MSW
8SOW-PA-HHQ07.448 App. 6/25/07
- 63 -
Medical Social Worker Track

MSW
This best practice package is designed to introduce medical social workers to effective teletriage as an intervention to assist in reducing avoidable acute care hospitalizations. Objectives After completing the activities in the Medical Social Worker (MSW) Track of this Best Practice Intervention Package Teletriage, the learner will be able to: 1. Define teletriage. 2. Describe the value of interdisciplinary communication in relation to patient/caregiver initiated calls. 3. Recognize the role of medical social worker to support effective teletriage. 4. Recognize basic telehealth terms. Complete the following activities: Activity Read the Teletriage MSW Guide to Practical Application Complete the MSW Home Telehealth Crossword Puzzle Read the teletriage success story Complete the MSW post-test Total Time Location Page 65 Page 66 Page 68 Page 70 Estimated Time 5 minutes 15 minutes 10 minutes 10 minutes 40 minutes
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MSW
Medical Social Workers Guide to Practical Application Teletriage

Purpose: To assist the medical social worker with understanding effective teletriage principles to support reducing avoidable hospitalizations Definition: Teletriage is what occurs when a patient calls the agency for healthrelated advice. This is usually initiated by the patient and/or caregiver, but can occur in response to phone monitoring or telemonitoring encounters.
Key Points:
o Teletriage is not optional. It occurs every time a patient/caregiver calls the agency with a health-related problem. Teletriage is primarily a nursing responsibility; however, social workers should be aware of teletriage processes and the routing of calls within their organization.
Simply stated, teletriage is what occurs whenever the patient calls the agency with a health-related problem.
Triage of a call includes assessing urgency risk-level, intervening as appropriate then follow-up and documentation. Your agency may use decision support tools to standardize this process. Social workers can support teletriage by reminding patients to follow their patient emergency plan and to call the agency with health related concerns. Review documentation of calls initiated by the patient/caregiver; it should include the specific problem, phone assessment findings and disposition including instruction provided and follow-up that may be needed. Social workers are informed when a patient/caregiver is calling the agency with health-related problems and contribute to follow-up when appropriate. Interdisciplinary communication and case conferencing should include patients/caregivers that are frequently calling the agency with health related problems.
Key: Effective teletriage helps reduce avoidable hospitalizations by ensuring that the patient receives the right care, every time.
- 65 -
Home Telehealth for Social Workers

1 3 4 2
6 7 8
10
www.CrosswordWeaver.com
ACROSS 5 Determining urgency level when a patient calls the agency with a health issue 7 Chronic condition that may be supported by use of telehealth 8 Risk factor for hospitalization 9 Home Health Quality Improvement 10 Most basic type of telehealth (2 words)
DOWN 1 Necessary sense for effective phone monitoring 2 Example would be taking his/her own blood pressure (hyphen in 5th space) 3 Providing more visits early in the episode 4 Collecting and sending vital signs electronically 6 Monitoring the patient while not actually being in the patient's home
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Home Telehealth for Medical Social Workers Puzzle Solution
H E T A E R T E L E T R I A G E N M G T C O P D E N F A L L I E T H O E R A I L P H O N E M O N I T G H
F R O E N T L O S A D H Q I N G O R I
S E L F M O N I T O R I N N G
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Success Story
MSW
Teletriage: Reflections of a Hospice Nurse Teletriage is a necessary and important part of the home care continuum. It can also be an effective tool for reducing acute care hospitalizations when teletriage nurses are armed with the right information and understand the goals of good teletriage. Margaretta Dorey, Home Health Project Coordinator for Quality Insights of Delaware, the Medicare Quality Improvement Organization (QIO), was a hospice nurse for 14 years before coming to the QIO to work on home health quality improvement. She sees opportunities for the home health field to learn from hospice when it comes to teletriage. The [Medicare] reimbursement process is different in hospice than in homecare, says Dorey. When patients elect hospice, it is assumed they will not be returning to the hospital since aggressive care is no longer required. Dorey observes that hospice on-call nurses are charged with providing effective teletriage, and therefore use their clinical skills to do everything they can to make sure patients are able to stay at home while managing their condition with minimal discomfort. Effective Teletriage: The Components Teletriage is largely about information, education and reassurance, says Dorey. Nurses need to have all pertinent medical information about the patient so when they get a call, they can quickly and effectively assess the patients needs. A diagnosis is not enough. Medical history is important, but they also need to know if a patient is having an exacerbation that may progress during the night. Promptly returning phone calls (within 15-30 minutes) is key to averting emergency care. Teletriage nurses should also understand the physical and psychosocial issues patients and caregivers are facing especially at night. The education component of teletriage provides an opportunity for the teletriage nurse to reinforce protocols, promote patient self-management which includes reminding them how to comply with medications and multiple prescriptions. Education is especially important if there is a recent change in the care plan. Reassurance is also incorporated in the education piece. It more than just saying, Youll be OK its about patient/family centered education so they know they are OK. Reassurance goes both ways. Patients are reassured that someone is aware of their condition, and the on-call nurses can be reassured that they are less likely to receive middle of the night calls or have patients visit the ER unnecessarily. Teletriage: Paradigm Shift Dorey finds that advanced hospice and home health facilities are shifting to a new paradigm as they move from teletriage to a system of phone monitoring making
- 68 -
proactive calls. In this model, on-call nurses reach at-risk patients early in the evening, where they conduct patient/caregiver education and assess any new developments in the condition. Then the nurse may call the doctor proactively if the patients condition has deteriorated. A doctor might make changes in medications based on the teletriage nurses assessment. Patients and caregivers are receptive to this model. They are reassured that someone who was on call is aware and updated and is monitoring their condition, Dorey says. Teletriage: Creating a System Dorey recommends that an agency creates a system with standardized, evidencebased protocols for teletriage. Risk assessments should be incorporated so the teletriage nurses are aware of the patients most at risk for readmission. Then the agency needs to educate the nurses; scripts can help remind nurses of the elements of good teletriage symptom management, patient education, reassurance, not jumping to conclusions, reviewing all medications taken and medications available to the patient, assessing anxiety level. Teletriage: Flexibility Teletriage requires the agency to be flexible in their approaches and responses, sometimes by reassuring that a care worker will visit sooner, or by recognizing that something may need to be done differently based upon new information the caller provides about the patient condition. Tell the patient you will call them back in a few hours, suggests Dorey. If you ask the patient to call you back, then they are more likely to call 911 because they feel they have already called the nurse. You accomplish two things by calling back: you get an update and youre telling the patient that you believe they will improve. Also, patients may be embarrassed to call you back again. They call 911 because they think they have no other choice. A Vital Resource Dorey concludes that communications and reassurance are among the most important elements of successful teletriage, and are effective means for keeping patients out of the hospital. For more information, she recommends home health agencies use the QIOSC-developed Home Telehealth Reference available at www.medqic.org. Data in this article provided by Margaretta Dorey of Quality Insights of Delaware.
- 69 -
Clinician name:
________________________________
MSW
Medical Social Worker Post-Test Teletriage
Date: _____________
Directions: Choose the ONE BEST response to the following questions. Circle your answer that identifies the ONE BEST response. 1. Telehealth is the general term for monitoring the patient while not actually being in the patient home. A. True B. False 2. The most basic form of telehealth is ____________. It provides a structured opportunity to assess the patient in between scheduled visits. This type of telehealth occurs when the agency initiates the process. A. Telemonitoring B. Teletriage C. Phone Monitoring D. Telerehab 3. Teletriage is only for on-call nurses. A. True B. False 4. Teletriage includes all of the following except: A. Receiving an unscheduled call from a patient/caregiver related to a health-related problem B. Receiving telemonitoring results that are outside of acceptable parameters for the patient C. Determining appropriate disposition of health-related problems by skilled clinicians D. Sending patients to the emergency department (ED) when staff is not available to see patient 5. Medical Social Workers can support teletriage by: A. Reinforcing the patient emergency plan B. Communicating effectively to all disciplines and to the office related to potential and actual patient issues that may effect patients health care or status C. Participating in case conferences related to patient issues and needs D. All of the above Answers to Post-Test are located in the Leadership Section.
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Home Health Aide Track

HHA
8SOW-PA-HHQ07.448 App. 6/25/07
- 71 -
Home Health Aide Track

HHA
This best practice package is designed to introduce the home health aide to teletriage to assist in reducing avoidable acute care hospitalizations Objectives After completing the activities in the Home Health Aide track of this Best Practice Intervention Package Teletriage, the learner will be able to: 1. Define teletriage 2. Describe the role of the home health aide to support effective teletriage 3. Recognize basic telehealth terms Complete the following: Activity Read the HHAs Guide to Practical Application Complete the HHA Telehealth Crossword Puzzle Listen to the Podcast (audio recording) Teletriage for Home Health Aides Read the success story Complete the home health aide post-test and give it to your manager Total Time Location Page 73 Page 74 Page 76 Page 77 Page 79 Estimated Time 10 minutes 15 minutes 15 minutes 5 minutes 15 minutes 60 minutes
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HHA
Home Health Aides Guide to Practical Application Teletriage

Purpose: To assist home health aides with understanding teletriage as an intervention to support reducing avoidable hospitalizations Definition: Teletriage is what occurs whenever the patient or caregiver calls the agency with a health-related problem. It involves deciding if a call is urgent or nonurgent and then intervening as needed. Key Points: Teletriage is not optional. It occurs every time a patient/caregiver calls the agency with a health-related problem. Teletriage is a nursing responsibility; however, home health aides should be aware of teletriage processes and how calls are handled within their agency. When the nurse triages a call from a patient or caregiver, the interventions can be anything from calling 911 to scheduling a visit to simply listening to the caller and perhaps giving advice. Home health aides can support teletriage by reminding patients to follow their emergency care plan and to call the agency with health related concerns. Case conferences should include patients that are frequently calling the agency with problems. Home health aides may assist with follow-up as a result of a patient call to the agency. For example, a caregiver called the agency during the night because the Foley bag is leaking. This is a non-urgent call. The aide may be asked to take a new bag on their visit the next day.
Key: Effective teletriage helps reduce avoidable hospitalizations by ensuring that the patient receives the right care, every time.
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Home Telehealth For Aides
1 3
9
www.CrosswordWeaver.com
ACROSS DOWN 1 A risk factor for hospitalization 3 Telemonitoring activity an aide may perform (rhymes with 'caregiver') 4 Collecting and sending vital signs electronically 6 A chronic condition that may be supported by use of telehealth 7 A necessary sense for effective phone monitoring 8 Home Health Quality Improvement 9 Example would be patient taking her own blood pressure (hyphen in 5th space) 1 Providing more visits early in the episode 2 Most basic type of telehealth (2 words) 4 Determining urgency level when a patient calls the agency with a health issue 5 Monitoring a patient while not actually being in the patient's home
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Home Telehealth for Aides Puzzle Solution
F A L L S P D E L I V E R H O O T E L E M O N I T O R I N G E T E E L L L M E O E O T A H N R C O P D E I I I A T A N L O G G T R H E A R I N G H H Q I I N S E L F - M O N I T O R I N G
- 75 -
Podcast* (Audio Recording)

HHA
Teletriage Audio Instructions: Listen to the Podcast (audio recording) to learn more about reducing avoidable acute care hospitalizations with the use of teletriage. Title Teletriage for Home Health Aides Description A 15-minute audio recording related to teletriage Link The audio link is located at www.homehealthquality.org/interve ntionpackages/teletriage.aspx
There are several ways to listen to the Podcast(audio recording): Visit the link above and listen directly through the Web site. Download the Podcast(audio recording) by right-clicking on the audio file and selecting Save Target As.... This will save the file to your hard drive. Once you have saved the file, you can listen to it on your computer or you can burn the audio file to a CD to listen to in your car or stereo. *A Podcast is a digital media file, often an audio recording, placed on by the Internet and made available to the listener on their home computer or personal digital recording device for convenience. There is no change from previous references to audio recordings except the name. You may continue to download and listen to recordings as you have in previous months. HHA Team Exercise: Use these following points in a discussion as an exercise together: As a group, discuss several patient scenarios and suggest steps that could improve the teletriage process for these patients. As a group, identify key process improvement steps your agency could add to help improve the agencys teletriage process and outcomes. Identify ways in which team members can be quickly notified when you identify possible gaps in the process and possible ways to improve the teletriage process awareness for home health aides. Provide recommendations to your quality improvement team for improvement! Take an active role in supporting teletriage and reminding your patients about their emergency contact plan and how to use it!
- 76 -
Success Story
HHA
Pennsylvania Home Health Agency Implements Teletriage Process, Reduces Patient Emergency Room Visits During After Hours and Improves Customer Service Neighborhood Health Agency (NHA) in West Chester, Pennsylvania decided to take a close look at how they were managing their patient phone calls. They began by reviewing a telehealth manual, Home Telehealth Reference 2006/2007, and organizing a teletriage committee. The teletriage committee was formed in October 2006. Participants included two on-call nurses, office employees and frontline staff members. By including various levels of employees and disciplines, the team received buy-in throughout the agency. The committee took approximately a month to sort through the information and delve into other resources, then select the activities and process they wished to implement. The decision was made to begin changes by reviewing the agencys after hours call program. Carol Conrad is the Quality Improvement Manager at Neighborhood Health Agency. Together with Beth Fuller, Staff Development Coordinator, they researched call logs in order to understand when and why patients were calling the agency and found most calls were taking place in the morning. Patients were calling to tell us that they went to the emergency room or called 911 the previous night. It seemed that patients and home care didnt understand that we had after hours staff to assist them. We wanted to change that, shared Carol. Its really about customer service. We compared the process to checking into a hotel once you get to your room, the front staff calls to check in on the customers satisfaction. We thought, Why cant we apply the same principles? The teletriage team developed tools for nurses to use, like call scripts with targeted questions encouraging yes or no answers in order to keep calls informative, yet concise. A new policy was written to help staff understand the purpose and goals of the program, along with an outline of the procedure to be implemented. Staff orientation began in November 2006 and then the process was initiated the next month. After the agency admits a new patient, staff conducts an orientation with them. This happens during normal business hours. With Neighborhood Health Agencys new process, an on-call nurse follows up with the patient later that day, after office hours. The nurse follows the script, asks questions about how the patient is feeling and if they have any questions, and then concludes the call by sharing that there is someone at Neighborhood Health Agency 24-hours a day to answer any questions. Neighborhood Health Agency not only implemented this with new patients, but also called current patients to inform them of the after hours service. Overall, patients have been delighted some even surprised that they have this option.
- 77 -
Due to the number of backlog patients to call, internal monitoring did not begin until April 2007. However, based on Home Health Compare and Outcome-Based Quality Improvement statistics things have already improved. Neighborhood Health Agencys Acute Care Hospitalization rate dropped 3.5% in the last calendar year, placing them 1% above the national average. Of course, the most telling improvement is evident from the patient satisfaction survey. One particular question in the survey asks if the patient knows how to contact the agency. Prior to the agency implementing a solid after hours call program, roughly 80-90% of patients on average agreed. While that is certainly not poor, now the number totals close to 100%. Evaluating staff is key. Beth Fuller, Staff Development Coordinator for Neighborhood Health Agency, shares, We watch very closely how staff handles their patient calls, including documentation of when calls were placed and where patients are referred for assistance. We look at logs on a daily basis and then help train any staff that has concerns. The next step for NHA is to implement a new staff position a Teletriage Coordinator who will support implementing further teletriage processes. The responsibilities of this position will include receiving patient calls that voice a clinical concern during scheduled work hours and making appropriate recommendations. The Coordinator will also initiate telephone calls for the after hours phone call program through follow up to the patient within 24 to 48 hours of admission. This new position will eventually be responsible for making patient visits in response to an identified problem during the telephone calls. The after hours call program is just one piece, but its been very important to Neighborhood Health Agency and extremely valuable to their patients. Data in this article provided by Carol Conrad of Neighborhood Health Agency.
- 78 -
Clinician name:
________________________________
HHA
Home Health Aide Post-Test Teletriage
Date: _____________
Directions: Choose the ONE BEST response to the following questions. Circle your answer that identifies the ONE BEST response. 1. Telehealth is the general term for monitoring a patient while not actually being in the patients home. A. True B. False 2. The most basic form of telehealth is ____________. It provides a structured opportunity to assess the patient in between scheduled visits. This type of telehealth occurs when the agency initiates the process. A. Telemonitoring B. Teletriage C. Phone Monitoring D. Telerehab 3. Teletriage is only for on-call nurses. A. True B. False 4. Teletriage includes all of the following except: A. Staff listening carefully to patient and/or caregiver B. Staff asking appropriate questions to get a clear picture of what is occurring with the patient C. Staff always sending the patient to the emergency department as soon as the patient calls D. Staff deciding if the call is urgent or non-urgent 5. Home Health Aides can support teletriage by: A. Reinforcing the patient emergency plan B. Communicating to all disciplines and to the office related to potential and actual patient issues that may effect patients health care or status C. Participating in case conferences related to patient issues and needs D. Providing a follow-up visit the following day, if necessary as directed by clinicians (e.g. taking out a Foley catheter bag) E. All of the above Answers to Post-Test are located in the Leadership Section.
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Best Practice Intervention Package

Home Telehealth Simply Summer Series

HHQI National Campaign

HHQI Physician Advisor Members

Misty Kevech, RN, MS, COSC, Communications/Training Manager

Contributing Home Health QIOSC Staff

Communications QIOSC Staff

Best Practice: Teletriage

8SOW-PA-HHQ07.448 App. 6/25/07

Leadership Section Objectives

Teletriage: Leadership Track

How to Use this Package

July June Teletriage Phone Monitoring & Frontloading Visits

Teletriage supports the other telehealth interventions:

Appropriate disposition is the outcome of a teletriage encounter.

Home Telehealth PROTOCOL For Teletriage

Leadership Self-Assessment Teletriage

Does your agency have guidelines for teletriage?

Choose one track based upon your answer to this question:

Does your agency have guidelines for teletriage?

Sample Decision Support & Documentation Tools

Teletriage Documentation Tools:

Best Practice Intervention Package Teletriage

Teletriage Support Tools

Decision Support Tools Heart failure COPD Diabetes

These tools are available at www.medqic.org in Home Health Reference 2006/2007

Call 911 Call 911 Call 911

Same day nursing visit

Teletriage Documentation Tool

Teletriage: Breathing Difficulty

Teletriage: Breathing Difficulty

Teletriage: Breathing Difficulty

Risk Level: URGENT

Immediate Intervention Required

Risk Level: POTENTIALLY URGENT

Nursing Visit Required within 24 Hours

Teletriage Documentation Tool

Teletriage: Breathing Difficulty

Teletriage: Breathing Difficulty

Teletriage: Breathing Difficulty Followup/Evaluation (check all that apply)

Risk Level: NON-URGENT

Routine Care Assessment

Risk Level: NON-URGENT

Patient/CT understood and agreed to plan

TELETRIAGE REFERENCE: FALLS/OTHER INJURY

TELETRIAGE REFERENCE: FALLS/OTHER INJURY

Teletriage Documentation Tool

Risk Level: URGENT

Immediate Intervention Required

Risk Level: LIKEY URGENT

Immediate Physician Contact Required

Teletriage Documentation Tool

Risk Level: POTENTIALLY URGENT

Nursing Visit Required within 24 Hours

Risk Level: NON-URGENT

Routine Care Assessment

Patient/CT understood and agreed to plan

Note Risk Assessment Findings as related to specific fall incident.

TELETRIAGE REFERENCE: WOUND DRAINAGE/INFECTION

Is your wound draining more than usual without signs of infection?

Teletriage Documentation Tool

Risk Level: LIKELY URGENT

Immediate Physician Contact Required