ED Utilization by Uninsured and Medicaid Patients after Availability of Telephone Triage

Abstract

It was interesting to read Howell's article regarding innovation that decreases low acuity and non-resource patients who present to the emergency department by implementing a telephone triage system (2016). The system described by Howell address issues with patients who are uninsured or underinsured on Medicaid, who present to the ED in lieu of their primary care provider (2016). Howell discusses the advantages of implementing a telephone triage system in order to decrease ED overcrowding by providing advice on other care options to patients with low acuity health conditions. Howell points out several reasons why this is beneficial to the aforementioned patient population, since 31% of primary care physicians in the state of Texas are no longer accepting Medicaid (2016).[1]Howell, T. (2016). ED utilization by uninsured and Medicaid patients after availability of telephone triage Journal of Emergency Nursing. 42 (2).Google Scholar As a middle manager in faith-based community hospital I have concerns about my role in facilitating this type of innovation. My first concern is where they refer the patients that the telephone triage nurse speaks to. Do they have arrangements or partnerships with community clinics that provide care for the uninsured or underinsured patients? How does this system work for faith-based hospital or hospital systems that make it part of their mission to care for all patients regardless of resource availability? In the case of my organization, Houston Methodist West, we refer our uninsured or underinsured patients that we see to community sponsored organizations such as Christ Clinic of Katy or Spring Branch Clinic. Houston Methodist West is also invested in a partnership with these clinics and others to make it a top priority to ensure that this population of patients in this community has a place to receive quality care. My other question is have the organizations examined any evidence-based processes to decrease overcrowding prior to implementing telephone triage? DeLia and Cantor indicate that overcrowding may often be related to inefficiencies in the flow of patients through different patient care units due to shortage of staffed beds (2009, p.15).[2]DeLia, D. and Cantor, J. (2009). Research synthesis report NO. 17. Emergency department Utilization and capacity. Retrieved from: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf43566/subassets/rwjf43566_1Google Scholar In my experience as a manager in the emergency department I have had the opportunity to be involved in developing metrics for our patient flow and then guiding our team in development and implementation of process improvement projects that have resulted in a decrease of all metrics on our dashboard. Consequently, the process improvement projects have served in improving staff engagement and have resulted in increased and sustained patient satisfaction scores from Press-Ganey and HCHAPS to superior status. We still maintain improved door to triage and door to bed times for over a year now, which has resulted in ED overcrowding. Dent and Armstead indicate that like the process improvement projects I described telephone triage has also helped to improve emergency department metrics including door to doctor time, length of stay (LOS) and fewer patients who leave without being seen. Consequently, it has produced higher patient satisfactions scores as well. However, I pose the question, have they tried anything else first?[3]Dent R Armstead C Telephone nurse triage system reduces use of emergencydepartment by non-urgent patients, reducing wait times, length of stay, and patientwalkouts. Agency for Healthcare Research and Quality, Health Care Innovations Exchange2015https://innovations.ahrq.gov/profiles/telephone-nurse-triage-system-reduces-use-emergency-department-nonurgent-patients-reducingGoogle Scholar As a nursing leader in the ED, it is important to examine the financial perspective. In doing so looking at whether there are reimbursement incentives to improve patient flow and reduce ED overcrowding is also important. DeLia & Cantor mention that current reimbursement incentives may produce barriers in improving patient flow efficiency and may also cause an inability to move admitted patients from the ED to an inpatient beds (2009, p.14). Even though the innovative concept of telephone triage sounds like a great alternative, the cost of planning and implementing may cost more than examining evidence-based practice in improving existing processes. ED Utilization by Uninsured and Medicaid Patients after Availability of Telephone TriageJournal of Emergency NursingVol. 42Issue 2PreviewFor emergency departments experiencing crowding and a high percentage of patients leaving without being seen, a telephone triage service can provide other care options for low-acuity patients. Full-Text PDF ResponseJournal of Emergency NursingVol. 43Issue 2PreviewI appreciate your investigation into ED care for the underinsured. It is good to know someone has read and considered my work as a potential application to their practice. Full-Text PDF ResponseJournal of Emergency NursingVol. 43Issue 1PreviewI appreciate your investigation into ED care for the underinsured. It is good to know someone has read and considered my work as a potential application to their practice. Full-Text PDF