Effective telemanagement: Developing a solid game plan keeps calls on track
Effective telemanagement: Developing a solid game plan keeps calls on track
Here’s how to get the data you need in 20 minutes or less
Telemanagement is a cost-effective tool for monitoring the health of chronically ill patients and avoiding preventable complications that land patients in the hospital or emergency department. Unfortunately, many case managers find that it’s difficult to keep patients on track during televisits.
Lorraine Deschaine, RN, LSW, case manager with Northern Maine Medical Center in Ft. Kent, ME, works a 30-hour week as case manager for a community outreach program that targets congestive heart failure (CHF) patients and others in need of disease management in the outpatient setting. "I have about 50 patients I’m working with at this point. I need to keep my telephone visits to no more than 15 or 20 minutes, or I’ll never be able to keep up with my caseload."
Deschaine and Donna Zazworsky, MS, RN, CCM, director of home health and outreach for St. Elizabeth of Hungary Clinic in Tucson, AZ, and principal of Case Manager Solutions, an independent case management company with offices in Tucson and New York City, say the key to controlling televisits is to have a game plan that includes the following:
1. Set the ground rules.
Deschaine begins educating patients while they are still hospital inpatients, or through the mail for patients who are referred to her through their physician’s office. "I cover the important things they need to know about their diagnoses and call them the day after discharge to review their medications and the signs and symptoms of complications, as well as preventive measures," she says. "I also provide them with written materials, checklists, weight logs, or glucose logs — whatever information I need them to track in order for me to help them manage their particular disease."
In addition to providing patients with written materials, Deschaine uses a yellow highlighter to emphasize issues of particular importance to specific patients. "I highlight issues I want patients to pay special attention to, and I draw their attention to those highlighted areas during televisits," she says. "So when I call, they are prepared and that’s a big factor in keeping the calls on track."
2. Schedule the televisit.
Organization must be a high priority for any case manager developing a telemanagement program, Deschaine stresses. One way to stay on track is always to schedule your televisits with the patient, suggest Zazworsky and Deschaine. "I schedule six calls a day," Deschaine says. "And I start in the morning with the most acute patients. In that way, if there is a crisis, I can allow extra time for the call and reschedule calls with more stable patients for the next day. I never want to overschedule and risk rushing a patient in crisis," she adds. "It’s important that you build some flexibility into your schedule."
It’s also important to schedule calls at the best time for your patient, Deschaine notes. For example, some people are late risers and shouldn’t be scheduled for early morning meetings. "They won’t be ready for you, and you’ll waste time while they look for the folder with the materials you want to cover." She suggests that case managers tell patients what day they plan to call and allow the patients to select the time of day that works best for them. "This way when you call, they have their documentation ready, and the call progresses smoothly."
3. Avoid open-ended questions.
"The telemanagement program I worked with was for seniors with congestive heart failure. The nurses who asked open-ended questions quickly ran into trouble, because seniors want to talk," she notes. "Don’t ask, What did you eat yesterday?’ or they will begin to recite everything they had from the moment they got out of bed. Instead, ask what they had for dinner."
4. Set up a documentation system.
No case management program can survive without evidence that its interventions improve clinical and financial outcomes, Zazworsky cautions. "You must have objective data that can be collected and reported if you want to prove your program works and ensure that funding for it is continued."
Deschaine works with a quality improvement staff member at Northern Maine Medical Center to track the progress of patients in her program. For each patient, Deschaine collects utilization data for the six months immediately prior to case management and the six months after initiation of case management. For the 18 patients who have been enrolled in the telemanagement program the longest, the results look very promising, she notes. These include:
• Total number of hospital admissions for the 18 patients decreased from 33 hospitalizations in the six months prior to case management to 18 admissions in the six months after beginning case management.
• Total number of hospital inpatient days decreased from 146 days in the six months prior to case management to 84 days in the six months after beginning case management.
• Total number of emergency room visits decreased from 19 in the six months prior to case management to eight in the six months after beginning case management.
5. Listen carefully.
Naturally, televisits have some limitations, but even those can be overcome with practice, Deschaine notes. "I can’t read body language over the phone. However, I really listen to each patient’s voice and familiarize myself with their normal tone."
If a CHF patient appears short of breath, Deschaine often "measures" the degree of breathlessness by sending the patient into another room. "I may have a patient tell me he’s short of breath, but it’s no big deal.’ To assess whether or not the shortness of breath is an issue of concern, I may ask the patient to go weigh himself. I know the bathroom is down the hall and that to weigh himself, the patient will have to walk down the hall to the bathroom and back. When he returns, I listen to his breathing."
And just because you don’t work with your patients "face to face" doesn’t mean you won’t develop a relationship with them, says Deschaine. She recalls one patient who had been referred through his doctor’s office. "We had never met, but I sent him literature in the mail and conducted regular televisits with him." About six months after he had been admitted to case management, the patient was hospitalized for an acute CHF exacerbation.
"When we finally met in the hospital, the minute he realized who I was, he turned to the person visiting him and said, Oh, this is my nurse.’" Deschaine adds that in the six months prior to case management the patient had been admitted almost monthly.
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