Communicating Effectively and Managing Care

Creating opportunities to communicate withpatients and providers on the care deliveryprocess–and taking advantage of these opportunities–are the keys to effectively managing healthcarein America. In general, patients and providers have difficultycommunicating with each other in timely, meaningful,and cost-effective ways. At the system level,however, managed care plans have had some success inreaching out to their members through mailings, Websites, and data-driven interventions. Increasingly, theseplans have also developed ways for patients to reach outwhen they need medical advice and communicate withthe plans. Health plans and provider organizations nowhave the ability to manage e-mail, Internet, and telephonecommunications from their members.

Journal

But have these increased opportunities for communicationbeen effective? A host of questions arise relatedto the timeliness, meaning, and costs of the manycommunication modalities. In this issue of the ,Bogdan and colleagues present an analysis of a nurseadvice line–communication initiated by patients to aprovider–and consider the outcomes and cost-effectivenessof the program.¹ Nurse advice lines are now thefastest growing specialty in nursing.² The study byBogdan et al adds to a growing body of evidence on theeffectiveness of telephone advice lines in terms of compliancewith the advice given and goes beyond otherstudies by considering the marginal effectiveness of theprogram and its cost.

The findings of this study are consistent with otherrecent studies in terms of compliance, as measured bythe percentage of patients following advice on the use ofemergency department, physician office, and self-treatmentat home. The results show 75% of callers followedemergency department advice, 52% followed physicianoffice advice, and 91% followed home advice. Theseresults are similar to O'Connell's findings of 79%, 57%,and 66%, and Labarere's findings of 64%, 84%, and 61%,respectively.^3,4 One factor that makes the Bogdan studyunique is the researchers' attention to the marginaleffect of the program. Bogdan et al asked patients abouttheir original intentions when they initiated the call.The researchers found that nearly 70% of patientschanged their plans for seeking care after calling theadvice line, with nearly two thirds of these patientschanging to a lower intensity of care.

Clearly there is selection bias in terms of who callsan advice line. One would expect that callers would bemore likely to accept a recommendation for changingplans than someone who doesn't call an advice line.Therefore, increasing the scale of program operationsmay not yield the same level of effectiveness. Further, ifpatients were required to call an advice line, the distributionbetween changeable and unchangeable patternsof care is unknown. Still, for providers consideringadopting a voluntary advice line, a receptive and compliantpopulation may be waiting to use the service.

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It is not enough to know what an advice line canaccomplish, however. Others considering adopting sucha program also need to learn such a program operates.A host of messages and communication stylescould be adopted by advice lines–from matter-of-factcommunications comparing symptoms and guidelinesto sympathetic persuasion in the use of appropriateservices. One study found that compliance was similarfor a nurse advice line and on-call physician advice inpediatrics, but the style of communication was not considered.^4,5 Comparisons among alternative programs interms of style and for adult services have yet to be consideredin the literature.

Also unique in Bogdan's study is the consideration ofcosts. The organization studied spent $647 000 to handleapproximately 30 000 calls–a cost of $1773 per day or$21.57 per call. Others considering the adoption of sucha program need to develop a budget that takes intoaccount the size of the target population, the expectedvolume of calls, and the cost and revenue implications ofproviding advice. Costs could vary substantially, dependingon whether (a) the program can share services withother telephone-based services, (b) it includes any fixedcosts of operations, and (c) it can be purchased on a per-callbasis or must be created in-house.

The present study compares the cost of the programto the net costs avoided through the reduction in theintensity of care ultimately provided to callers. Chargesand costs are reduced, on net, for physician office andemergency department services. The incentives for savingcosts may vary, owing to the likely variation amongorganizations considering adopting such programs andthe patient populations being served. Bogdan et al evaluateda safety net provider, for which revenues associatedwith callers' care may well be close to zero. In sucha setting, reducing the number of patient visits toproviders reduces costs, but does not affect revenues. Amanaged care organization would face similar financialincentives. However, for healthcare systems servinginsured populations, such a program may reduce netprofits if revenues lost from not providing services areexpected to exceed the costs of providing services. Amanaged care organization's financial benefits mightoutweigh the costs of a nurse advice line within ahealthcare system, but managed care benefits don't payhealth system's bills. If it is found that such advice linesare more effective when sponsored by provider organizationsas opposed to managed care organizations, partnershipsand side-payments could be used to betteralign financial incentives.

On balance, the study by Bogdan and colleagues providesa good example of a nurse advice line that is aseffective as similar programs considered in the literature.It shows that the program makes a truly meaningfuland cost-effective difference for a safety net provider.For managed care organizations, such programs, eitherindependently or in partnership with provider organizations,may be a means for cost control if the managedcare organizations can learn how to operate the programswithin acceptable budgets and systems of incentives.Hopefully, other providers in similar positions willfollow this lead and adopt, adapt, and take advantage ofthis and other communication modes as they evolve.

From the Department of Health Management and Policy, School of Public Health,University of Michigan, Ann Arbor, Mich.

Address correspondence to: Dean G. Smith, PhD, Department of Health Managementand Policy, School of Public Health, University of Michigan, 109 Observatory, Ann Arbor,MI 48109-2029. E-mail: deans@umich.edu.

Am J Manag Care

1. Bogdan GM, Green JL, Swanson D, Gabow P, Dart RC. Evaluating patient compliancewith nurse advice line recommendations and the impact on healthcarecosts. . 2004;10:534-542.

J Nurs Adm

2. Valanis B, Tanner C, Moscato SR, et al. A model for examining predictors ofoutcomes of telephone nursing advice. . 2003;33:91-95.

Med DecisMaking

3. O'Connell JM, Towles W, Yin M, Malakar CL. Patient decision making: use ofand adherence to telephone-based nurse triage recommendations. . 2002;22:309-317.

Am J Emerg Med

4. Labarere J, Torres JP, Francois P, et al. Patient compliance with medical advicegiven by telephone. . 2003;21(4):288-292.

Clin Pediatr

5. Lee TJ, Baraff LJ, Wall SP, Guzy J, Johnson D, Woo H. Parental compliancewith after hours telephone triage advice: nurse advice service versus on-call pediatricians. (Phila). 2003;42(7):613-619.

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