Telephone conversations provide education

Follow-up important to ensure understanding

About 9,000 patients at Marshfield (WI) Clinic learn self-care and disease management over the telephone from registered nurses. There are three telephonic care management programs that include the anticoagulation service, heart failure care management, and dyslipidemia care management.

Education can be very effective over the telephone, says Melissa Mikelson, RN, manager of care management at Marshfield Clinic. Because patient contact can be more frequent than office visits, information can be covered more than once to ensure understanding.

However, to be effective it must be done right, she adds. While there may be more time to discuss issues with patients on the telephone than in the office, nurses try to focus on one topic during their conversation, so they don't overwhelm patients with information.

With the aid of an education module, information is clear, consistent, repeated, and followed up on to ensure the patient understands. Written materials are usually mailed to a patient after a telephone conversation, and once the patient has had time to receive the material, the nurse calls the patient again to review it.

Scripts are available from a computer-based care management software program. The scripts are primarily written by Marshfield Clinic staff. Scripts guide the conversation and are required for nurses new to telephonic care management. On average, a nurse working in this area has 17 years of experience and has worked with patients face-to-face.

The scripts prompt questions and give examples in order to help patients set and meet goals. For example, if a heart failure patient is struggling to reduce salt in his or her diet, the script would direct the nurse to say, "I understand that you are looking at ways to decrease your salt intake. These are a few ways that we may help you reach that goal." The nurse then would give the patient the options from the script, such as eliminating a food that is high in salt from his or her diet, or not adding salt to foods on certain days of the week.

Scripts are used by all nurses during difficult situations, such as discussions about end-of-life issues with heart failure patients in stage four of the disease. They always ask permission before discussing sensitive issues with patients.

Patients in heart failure care management speak to the same nurse each time they are called. The frequency of calls depends upon the patient. All patients are contacted within 24 to 48 hours of discharge from the hospital, once care management staff are made aware of the discharge.

Once patients are in the program, contact depends on their symptoms, but can be weekly, every other week, monthly, or every three months. All calls are scheduled with the patient, so he or she is expecting to have the conversation, says Mikelson.

The focus of the phone calls in the heart failure care management program is management of symptoms, diet, and activity. The focus of the calls in the anticoagulation service and the dyslipidemia care management program is medication management, therapeutic lifestyle changes, and symptoms related to adverse events. Patients are called minimally on a monthly basis following lab tests. They are not always contacted by the same nurse.

"We do use policies and procedures, and our information is very structured; so the patient does not really hear anything different from nurse to nurse," says Mikelson.

Although nurses call patients according to a schedule, those enrolled in the programs can call whenever they have a question.

Perfecting telephone techniques

The cornerstone of telephonic care management is motivational interviewing, says Mikelson. This involves the use of open-ended questions that require more than a "yes" or "no" answer and active listening.

"Our nurses are experts in picking up cues over the phone, understanding what silence means, and what fear sounds like," says Mikelson.

Nurses meet the patient where he or she is and try to assist the patient in setting goals. They are the patient's coach.

To improve teaching techniques, conversations are frequently taped, so nurses can listen to them and provide feedback for one another. Nurses in care management also do a lot of role-playing with motivational interviewing to improve their presentation.

Motivational interviewing is a technique used to talk to patients at their own level in order to motivate them to change behavior, explains Mikelson. Patients often have a long list of things they want to change, so nurses help them set goals. During the conversation, the nurse helps them narrow the list, beginning with small steps and then celebrating achievements over the phone. Motivational interviewing challenges the status quo, says Mikelson.

Marshfield Clinic uses electronic medical records, so nurses in the care management programs know what was discussed at the physician's office, what recommendations were made, and any changes in medication. Also, the physician can see the interaction patients had with nurses in the care management program. In this way, the patient is treated as a whole, says Mikelson.

The telephonic care management program increases contact with patients and makes it possible to intervene quickly. Nurses communicate with the physicians on behalf of patients and can help direct patients in their health care. They can support the physician's instructions and make sure the patient is following through, says Mikelson.

"We can verify where the patient is at in regard to the education they have received, and we talk to patients about many different things. We go where the patient goes in those conversations, and we feel that has been very successful for us," she explains.

Conversations can last anywhere from 10 minutes to an hour. It depends on what the patient needs and how many questions he or she has.

One of the roles the nurse plays in all three management groups is telephone triage. Nurses talk to patients about their symptoms and help them decide whether they need to be seen by their physician. Patients enrolled in the care management programs have access to Marshfield Clinic's 24 Hour Nurse Line.

"We can make sure patients are seen in a timely manner when it really warrants it. Also, we can help patients avoid unnecessary office visits or emergency department visits by helping them sort things out at home first," says Mikelson.


For more information about the telephonic care management programs at Marshfield Clinic, contact:

• Melissa Mikelson, RN, Manager of Care Management, Marshfield Clinic, Marshfield, WI. Telephone: (715) 389-7508. E-mail: