Healthline doing its share for primary care

Transcription

1 Healthline doing its share for primary care Lesley Clarke General Manager Ian St George Medical Director Janet Harp Senior Nurse Adviser McKesson New Zealand

2 Telephone triage our core business Assures consistent, quality advice and recommendations for patients with health concerns with the aim of directing the caller to the most appropriate health care provider

3 Healthline overview Nurse led service 24x7 nationwide Funded by Ministry of Health Incorporates the Well Child Telephone Advice service Provides free access for people seeking: Symptom assessment General health information Provider information Well Child advice

4 Care Enhance Call Centre software CeCC a clinically rigorous Triage System developed and owned by McKesson. The 413 guidelines in CeCC are evidence-based and peer reviewed with continued clinician feedback CeCC is designed to help the nurse prioritise multiple symptoms and select the appropriate guideline to complete the assessment The disposition is congruent with the presenting problem and the available services All calls are captured in CeCC as a unique call record and voice recorded for quality purposes

5 Utilisation Healthline and Well Child Utilisation (Annualised) January - March % 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Auckland BOP Cant C & C Counties-Man Hawkes Bay Hutt Lakes MidCentral HL/WC Regional Utilisation Nelson-Marlb Northland Otago Sth Cant Southland National Utililisation Tairawhiti Taranaki Waikato Wairarapa Waitemata West Coast Whanganui

6 Māori utilisation Maori Callers to Healthline and Well Child Advice Service January - March % 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Auckland Bay of Plenty Canterbury Capital & Coast Counties-Manukau Hawkes Bay Hutt Valley Lakes MidCentral Nelson-Marlborough Northland Otago Southland South Canterbury Tairawhiti Taranaki Waikato Wairarapa Waitemata West Coast Whanganui Maori % of pop (2006 Census) Maori % of HL/WC Callers National % of Maori pop (2006 Census)

7 Time of day Healthline Calls Offered by Time of Day, Day of Week January - March 2010 Number of Calls per Half Hour :00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 Noon 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 Time of Day MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Healthline and Well Child Call Distribution by Time of Day January - March 2010 Night Hours 8.0% Weekend Hours 30.5% Evening Hours 28.5% Business Hours 33.0% Business Hours Evening Hours Night Hours Weekend Hours

8 Call types Call Types: January - March 2010 Symptomatic 72.6% Non-Clinical 5.8% Negative Feedback (Complaint) 0.0% Cost/Access Issue 0.2% Health Education 9.0% Provider Referral 5.4% Well Child/Parenting Advice 6.9%

9 Outcomes of symptomatic calls Healthline and Well Child Triage Outcomes January - March 2010 Self/Home Care 34.3% Emergency 2.7% Urgent Care 16.9% Contact Provider (non-urg) 11.8% Contact Provider < 24 Hrs 34.2%

10 Most frequent symptomatic calls Guideline* % Vomiting (Paediatric) 4.0% Abdominal Pain / Discomfort 3.0% Seen Doctor/Health Care Provider 2.8% Fever (Paediatric) 2.8% Diarrhoea (Paediatric) 2.8% Medication Question Encounters 2.5% Rashes, Widespread, Cause Unknown (Paediatric) 2.5% Colds (Paediatric) 2.2% Seen Doctor/Health Care Provider Paediatric 1.7% Chest Pain / Discomfort 1.6% Nausea / Vomiting 1.6% Headache 1.6% Immunisation Reactions (Paediatric) 1.5% Cough (Paediatric) 1.5% Diarrhoea / Change in Bowel Habits 1.5% Trauma - Head (Paediatric) 1.4% Vaginal Bleeding (Premenopausal) -- Abnormal 1.4% Bites and Stings - Insects / Spiders 1.4% Poisoning - Ingestion (Paediatric) 1.2% Rash / Hives / Eruptions 1.1% Total Top 20 Accesses 40.2%

11 Most frequent symptomatic calls - pandemic Guideline* % Flu-Like Symptoms;Known/Suspected Influenza 6.0% Vomiting (Paediatric) 4.8% Cough (Paediatric) 3.4% Colds (Paediatric) 3.0% Diarrhoea (Paediatric) 2.8% Abdominal Pain / Discomfort 2.4% Fever (Paediatric) 2.3% Medication Question Encounters 2.2% Influenza (Paediatric) 2.1% Influenza [Swine] 1.9% Seen Doctor/Health Care Provider 1.8% Rashes, Widespread, Cause Unknown (Paediatric) 1.7% Seen Doctor/Health Care Provider Paediatric 1.7% Nausea / Vomiting 1.6% Chest Pain / Discomfort 1.5% Diarrhoea / Change in Bowel Habits 1.5% Headache 1.5% Cough - Adult 1.4% Upper Respiratory Tract Infections / Colds 1.3% Sore Throat / Hoarseness 1.3% Total Top 20 Accesses 46.2%

12 Most frequent information calls Most Frequently-Accessed HIL Topics: Healthline % Temperature Fever Self Care 7.5% Risk Of Lower Intent 4.2% Temperature Range And Thermometers 3.6% Chickenpox 3.3% Constipation Infants Toddlers 2.2% Hand Foot And Mouth Disease 1.9% Diarrhoea Selfcare 1.9% Vomiting Selfcare 1.6% Pregnancy Tests. 1.3% Emergency Contraception 1.3% School Exclusion 1.2% Tetanus. 1.1% Cough Flu Self Cares 1.0% Scabies. 1.0% Depo Provera 0.8% Giving Oral Medication 0.8% Colds 0.8% Herpes Zoster And Herpes Zoster In Pregnancy (Shingles) 0.8% Measles. 0.7% Combined Oral Contraceptive Pill 0.7% Top 20% of total 37.6%

13 Most frequent information calls - pandemic Most Frequently-Accessed HIL Topics: Healthline % Swine Flu H1N1 influenza 10.9% Temperature fever Self Care 8.5% Swine Flu in USA and Mexico Travellers Advice 7.1% Temperature Range and Thermometers 3.4% Tamiflu 3.2% Chickenpox 2.9% Risk of lower intent 2.7% Novel Influenza A H1N1 [Swine flu] 2.6% Constipation Infants Toddlers 2.1% Vomiting selfcare 2.1% Diarrhoea selfcare 1.9% Cough Flu Self Cares 1.9% Ministry of Education Swine Influenza Update 1.5% Colds 1.4% Pregnancy tests. 0.9% School Exclusion 0.9% Influenza A [H1N1] Advice for Health Professionals 0.9% Emergency Contraception 0.9% Croup 0.9% Scabies. 0.8% Top 20% of total 57.5%

14 Doing its share: H1N1 pandemic

15 H1N1 pandemic timeline 26 April News: 10 students returning from Mexico have tested positive for swine flu. 27 April Code Yellow: Ministry of Health begins containment activities. People who had travelled to Mexico or the US in the last fortnight advised to contact Healthline generating a 60% increase in calls. 30 April NZ has 16 confirmed cases, 104 suspected and 111 isolated. 13 June Two confirmed cases with no links to travel indicate community transmission. Containment strategies continued. General public advised to ring Healthline for information and health advice. 16 June Increasing number of school closures. People advised to stay at home if unwell and phone Healthline or General Practitioner. 19 June community transmission widespread in Auckland, Wellington and Christchurch. 4 July First 3 NZ deaths associated with swine flu. Calls to Healthline peak on 6 July with 3,622 calls offered. 31 August 17 deaths 30 September 18 deaths

16 GP consultations during the pandemic

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18 HL calls during the pandemic Influenza Like Illness Calls to Healthline Number of ILI Guidelines Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 Week 32 Week 33 Week 34 Week 35 Week 36 Week 37 Week 38 Week 39 Week 40 May June July August September

19 Press options: 1 No symptoms but seeking flu info Recorded message for public Press 0 for Wanganui call centre (case def; Q&A script) If symptomatic call back and press 2 (but if long delays, advise phone doctor ) 2 Any symptoms Healthline Answered by HL nurse: normal triage, or if no symptoms told to phone back and press 1 for flu info Not answered (overload) additional message: flu symptoms call back and press 1 to talk to an operator, or other symptoms queue for Healthline Calls to Healthline Telecom cloud 3 Well Child call (no symptoms) Well Child line or PlunketLine Default 4 If you are a health professional Recorded message for health profs (including DHB contact details) Press 0 for Operator Healthline 5 Workplace or school info Recorded message for workplaces and schools Press 0 for Operator Call flow

20 Call numbers Healthline and Well Child Calls Offered/Handled: 15 Month Trend Jan-Mar 09 Apr-Jun 09 Jul-Sep 09 Oct-Dec 09 Jan-Mar 10 Calls Offered Calls Handled

21 Doing its share: right care, right time, right place

22 People with symptoms may need advice on the right place and the right time to seek care: 100 callers intending (A) were triaged to ED Urgent GP Nonurgent care Selfcare ED Urgent GP Nonurgent care Selfcare A

23 Effect on an urban ED Transferring ED calls to Healthline did not decrease the number of presentations to Christchurch Emergency Department, but did decrease the number of phone callers seeking advice, to the extent that one fulltime nurse was freed for other duties -- Graber DJ, O Donovan P, Ardagh MW, St George IM. NZ Med.J (1177): ).

24 Effect on a rural practice Telephone triage reduced out-of-hours work for country doctors Fewer phone calls Probably fewer patients to see Safe and reliable -- St George IM, Cullen M, Branney M, Hogan M, Duncan L. NZ Family Physician, :

25 Do primary care doctors agree with our advice? Three primary care specialists examined 90 calls blind to HL endpoint Endpoints advised by the three doctors varied: crude percentage agreement between the highest and lowest was only 51% (Cohen s K 0.43) We compared the median doctor- advised endpoint for each case with the endpoints reached by the Healthline nurses: crude percentage agreement was 70% (Cohen s K = 0.78) Cohen s Kappa = Substantial Agreement -- St George IM, Cullen M. Branney M. Healthline: do primary care doctors agree with the advice? NZMedJ, 2005; 118 (1224).

26 Doing its share: improving access

27 Ethnicity NZ European 70.2%* (75.8) Maori 17.4% (11.8) Samoan 2.8% (1.8) Indian 2.1% (1.9) Chinese 1.0% (1.8) * = Healthline 2010 = National Primary Medical Care (NatMedCa) GP survey 2004

28 HL use by older people.1 Healthline and Well Child Advice Service: Patient/Caller Demographics (n= ) Over % 0-14 yrs 37.4% yrs 41.1% yrs 15.4%

29 HL use by older people.2 Fig.3: distribution of patient-initiated GP encounters (WaiMedCa ) and calls (Healthline) by age group WaiMedCa Healthline percent < age group

30 Deprivation levels Fig.1: Percent of callers to Healthline in each deprivation decile, compared with percent of the New Zealand population in each decile percent Healthline New Zealand decile -- St George IM, Cullen MJ, Branney M. The deprivation profile and ethnicity of Healthline callers. NZ Fam Phys 2006; 33 (6):

31 Cellphone callers Fig.1. Cellphone users as percent of all callers, May 2005 to February % 20% Percent 15% 10% Cellphone calls 5% 0% Months May 05 to Feb St George IM, Cullen MJ, Harp J. Cellphone callers to a triage and advice line may have high health needs. Submitted to Australian & NZ Journal of Public Health 2009.

32 Cellphone callers: 2 Fig.2: percent of cellphone callers (n = 132) in each NZDep06 decile of deprivation, compared with percent of landline callers (n = 873) in each decile Percent Cellphone users Landline users Deprivation index

33 Healthline s original aims: achieved Social equity: those who perceived barriers to seeking help would be able to do so: especially Māori, Tagata Pasifika, socioeconomically deprived, elders. Economic: resources would be saved by demand management: directing people to the right place at the right time.

34 Doing its share: Quality & safety

35 Transparency Comprehensive data collection Quarterly reports Frequent conference presentations Articles in popular health press Studies published in peer-reviewed literature

36 1. St George IM, Cullen MJ. The Healthline pilot: call centre triage in New Zealand. N Z Med J Sep 28;114(1140): St George IM. The holidays at Healthline. NZ Fam Phys 2002; 29: St George IM, Branney M, Horo-Gregory W, Duncan L, Cullen M. Maori callers to a telephone triage service. NZ Fam Phys, 2003; 30: St George IM, Cullen M. Crisis calls to Healthline. N Z Fam Phys, : Graber DJ, O Donovan P, Ardagh MW, St George IM. A telephone advice line does not decrease the number of presentations to Christchurch Emergency Department, but does decrease the number of phone callers seeking advice. NZ Med.J (1177): St George IM, Cullen M, Branney M, Hogan M, Duncan L. Telephone triage reduces out-of-hours work for country doctors. NZ Family Physician, : St George IM, Cullen M, Branney M. A primary care demand management pilot in New Zealand: telephone triage using symptom-based algorithms. Asia-Pacific Family Medicine 2003; 2 (3): St George IM. Cullen M, Branney M. How well does telephone triage meet the needs of older people? NZ Family Physician 2005; 32: St George IM, Cullen M. Branney M. Healthline: do primary care doctors agree with the advice? NZMedJ, 2005; 118 (1224): St George IM, Cullen MJ, Branney M. The deprivation profile and ethnicity of Healthline callers. NZ Fam Phys 2006; 33 (6): St George IM, Cullen M, Wilson A, Wilson F, Dolan B, McGeorge P. The Mental Health Line. NZ Family Physician, 2006; 33 (5): St George IM, Cullen MJ, Branney M. What part does a national health call centre play in an integrated primary care service? NZ Med J 2007; 120 (Feb). 13. St George IM, Matthew Cullen, Louise Gardiner, Georgia Karabatsos, Joseph Ng, Andrew Patterson, Andrew Wilson. Universal telenursing triage in Australia and New Zealand: a new primary health service. Australian Family Physician, 2007; Vol 37, (6) St George IM, Julie Baker, Georgia Karabatsos, Richard Brimble, Andrew Wilson, Matthew Cullen. How safe is telenursing from home? Collegian: Journal of the Royal College of Nursing Australia 2009; Vol. 16 (3): St George IM, Cullen MJ, Harp J. Cellphone callers to a triage and advice line may have high health needs. Submitted to Australian & NZ Journal of Public Health St George IM, Harp J. Telenursing in New Zealand. A chapter in Telenursing In press.

37 Clinical governance principles Clinical effectiveness - correct use of up to date protocols, algorithms, guidelines and procedures. Professional development continuing learning; employee satisfaction; credentialing; research; publications and presentations; transparency. Clinical risks - adverse events monitoring including critical incident management; clinical audits. Customer complaint and compliment processes.

38 Doing its share: but wait there s more

39 Opportunities Telenursing is more than Healthline; Syndromic surveillance Mental Health Line MeNZB Line Taranaki pilot - after hours enhanced services Disease Management telephone coaching Secondary triage for 111 Pandemic and other public health situations McKesson@Home workforce

40 Telenursing in Australia HealthDirect triage and advice; HealthInfo information and health policy; SouthWest24 mental health services; Residential Care Line; Sexual Assault Referral Centre Crisis Line; Drug Cautioning Line; Health Incident Lines (public health emergency lines as required, e.g. SARS line); PEP (post-exposure prophylaxis for HIV). Secondary triage for the St John Ambulance; Chest pain program for insured patients; Outpatient bookings (an appointment, reminder and tracking system); Surgical patient follow up. Greater Murray Access Line, gambling line, chronic disease management.

41 Doing its share for primary care High quality evidence-based advice Experienced registered nurses using robust decision support software More than 400 guidelines ensure clinical safety and consistency. The clinical guidelines assess the urgency of the caller s symptoms, so nurses can advise where and when to go for help. Guidelines and procedures are continuously monitored and updated. Well established clinical governance framework; ISO 9001 certified All calls are captured in CECC and are voice recorded for quality purposes. The service is transparent and accountable.

42 Doing its share for primary care Health providers and health sector Free, high quality, evidence-based advice available to your patients 24/7. After hours call diversion Significant role in pandemic and health alert situations, such as national pandemics reducing the burden on other health services. Health and communicable disease surveillance, by collecting call data for analysis of specific health events e.g. Influenza like illness (ILI) monitoring data, measles outbreaks.

43 Doing its share for primary care Your patients Access to triage and health advice 24/7, including for those in isolated areas or on a lower income. Free from landline or cell phone Registered nurses to direct callers to GPs, emergency services or support callers to self-care, where appropriate. Information on the location and availability of health care services including after hours primary health care. Links to other services so callers have access to a range of health and wellness information. Call backs to check on progress.

44 Doing its share for primary care Performance assured Healthline handles over 350,000 calls per year, helping to reduce demand on other services More than 80 percent of calls are answered within 20 seconds Less than 5% of calls unanswered Low level of complaints (one per 7500 calls) Able to reach groups with greater needs, including Maori and Pacific populations High levels of customer satisfaction.

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46 nzherald.co.nz - Tuesday March 9, 2010 Little Emily Cotton is smiling again and her mother, Susan, is singing the praises of the Healthline service after her call produced the right answer.

47 any questions?