Webinar: Transform your approach to after-hours phone triage

Webinar: Transform your approach to after-hours phone triage

October 20, 2021

Every home health and hospice organization is different, but one issue remains: compassion fatigue and nurse burnout. An emerging approach to leveraging after-hours triage support poses to change that by becoming an extension of your staff, increasing nurse efficiency and giving you access to key metrics.

Hear from Three Oaks Hospice Senior Director of Clinical Services Christy Samuel on her experience using a tailored approach to outsourced after-hours triage support. Sharing their strategy, she dives into how it has helped optimize operations, cut down on nursing staff compassion fatigue and gives caregivers access to resources they need in a timely manner.

She is joined by IntellaTriage CEO Daniel Reese who sheds light on industry benchmarks and key strategies to transform your approach to after-hours phone triage.


  • Daniel Reese, IntellaTriage CEO
  • Christy Samuel, RN, Senior Director of Clinical Services, Three Oaks Hospice

“Being a hospice nurse or anyone in hospice, you feel like you need to be there 24/7 for your patients. So our nurses were not only exhausted and stressed, they were also just tired, feeling like they needed to be available constantly.” – Christy Samuel

Show Notes

(2:22) The state of the nursing shortage within the hospice industry

(7:44) Discussing the intersection of after-hours care and nurse burnout

(15:22) The traditional approaches to after-hours care

(18:20) How an after-hours nurse triage solution can reduce nurse burnout and address patient and caregiver needs

(28:57) Christy touches on how this solution has helped Three Oaks Hospice

(31:48) How IntellaTriage works and the IntellaTriage staffing model

(40:44) Reporting, insights and an example daily activity report

(45:16) How to get started with IntellaTriage and closing

Webinar Transcription

[00:00:03.770] – Jim Parker

Good afternoon and welcome to today’s Hospice News webinar: Transform Your Approach to After-hours Phone Triage Sponsored by IntellaTriage. My name’s Jim Parker. I’m editor of Hospice News. And today we’ll be talking about an emerging approach to leveraging after-hours triage designed to increase nurse efficiency, reduce staff burnout, and give providers access to key metrics. Before we get into our program, I’d like to cover a few housekeeping items. First, phones have been muted for sound quality. Today’s Webinar is being recorded and will be sent via email afterwards along with the slides and following the presentation, there’ll be a question and answer session. If you have questions, please feel free to write them into the designated box in the Go to Webinar app.

[00:00:54.160] – Jim Parker

I am pleased to introduce today’s speakers. We have Christy Samuel, Senior Director of Clinical Services for Three Oaks Hospice in Dallas, and Daniel Reese, CEO of IntellaTriage. Christy and Daniel, thank you both for being here. 

[00:01:11.010] – Daniel

Thanks for having us, Jim.

[00:01:11.610] – Christy


[00:01:18.310] – Daniel

I was going to have Christy and I do a little bit of brief introductions to ourselves and then we can kick it off if that’s okay.

[00:01:24.810] – Jim Parker

Absolutely. I will turn it over to you.

[00:01:27.440] – Daniel

Thanks, Jim. So Christy, do you want to just do a brief introduction of yourself and then I’ll do me and we can start moving forward.

[00:01:33.740] – Christy

Okay. My name is Christy Samuel. As I was introduced, I’m a senior director of clinical services for Three Oaks out of Dallas. I have been a nurse for 18 years, in Hospice exclusively for the last 16 plus. I’ve done everything in this field from case management to triage to on-call nursing. I’ve worked as a patient care manager. I’ve done a lot of different things and now I’m a director over all of the clinical services for the Dallas office.

[00:02:09.420] – Daniel

Excellent. Thanks, Christy. Hi, everyone. I’m Daniel Reese, the CEO of IntellaTriage. I want to give a little background. So Intella Triage has been serving the Hospice client since 2008 when we were founded, making us one of the oldest triage companies in the country. Today we do specialize in the post-acute care segment of the market, and our services continue to evolve as that segment of the market has evolved. I’ve been with the company since 2019 and oversee the overall strategic direction of the company while also pretty heavily allocating my time to the day-to-day operations of the service to make sure we’re serving our clients well.

[00:02:46.500] – Daniel

Prior to IntellaTriage, I worked in a variety of different operating roles, but I started my career in the US Navy as a nuclear submarine officer. Excited to be on this webinar with all of you today and hopefully providing some educational material for everyone to think about.

[00:02:59.780] – Daniel

With that, we will just jump right in.

[00:03:05.850] – Daniel

Given that all of you are joining the webinar, I’m sure that everyone is aware of the state of the nursing shortage, especially in hospice. But we wanted to kind of introduce a few fast facts here to truly highlight the severity of the situation. So number one, some stuff that I think surprised me from some recent surveys, and we’ll get into some focus groups here in the next couple of slides. But we have an average turnover rate of hospice nurses right now of 22.8%, which is a little bit wild. If you have a staff of 20 nurses, on average you are going to turnover four every year.

[00:03:37.890] – Daniel

And the cost of that ranges depending on where you live and the training regimen you have for your staff, but the range that was provided in that survey was $33,000 to $56,000 per year. So for those four nurses every year, you can expect to spend approximately $180,000 in recruiting, training and administrative costs of getting those nurses, your new nurses that turned over, trained up and ready to provide service.

[00:04:03.980] – Daniel

Finally, with the expected growth in demand for hospice nurses, which is expected to be around 20%, there are really no signs of the problem slowing down. Burnout is the number one reason for turnover, and the rate could actually accelerate for the hospices that don’t have a plan in place for their nurses to be satisfied and keep engaged with their organizations. One of the things we wanted to highlight today is how we could potentially work with you to improve that.

[00:04:31.080] – Daniel

Another interesting fact about some of the most recent studies is there was a focus group that was conducted with hospice nurses specifically, and this was very surprising to me, but the fact that patients are dying or the patients and families are suffering was not actually mentioned at all in this focus group of a direct source for burnout. Obviously, it was mentioned in a variety of other factors, but as far as contributing to burnout, it didn’t play a role. It was actually the structural and administrative characteristics of the work that was being done that led to the burnout, which I think was surprising to me, and Christy I discussed it and I think it was a little bit surprising to her as well.

[00:05:11.580] – Daniel

So, we wanted to kick off our session today with a question for the audience and understand what your perspective is on this topic. So how much do you think after-hours care contributes to nurse burnout?

[00:06:05.680] – Jim Parker

Responses are still coming in. Right now we have 73% of respondents saying that it is a major contributor. 18% say it is the main contributor. We have 4% saying that it’s a minor contributor. 7% said they’re not sure. No one has said that it’s not a contributor.

[00:06:32.820] – Daniel

Excellent. Okay. We’ll do a few more seconds for answers to come in.

[00:06:38.660] – Jim Parker

It says 73% of participants have voted so far.

[00:06:44.770] – Daniel

Excellent. Give just a few more seconds, and then we’ll talk a little bit more about that. So I think number one, this is interesting for me because when we have our discussions with potential customers or people at conferences, I think it’s something that we don’t usually get as a response from a major or main contributor. So this is interesting to hear that this group is highlighting this as a main or major contributor.

[00:07:19.100] – Daniel

I think as we kind of go through this, it’s interesting that this group is thinking that, “hey, this is actually a major contributor,” and we wanted to highlight from our internal data what we think is interesting information and actually a question we ask during all of our sales meetings that we get an interesting response to. So there’s no poll here, but just a question for you to think about and keep in your head a number here. So how many after-hours calls do you think if you have a 250 patients census you would receive during an average week?

[00:07:50.210] – Daniel

And I’ll ask Christy to chime in here as well, because we talked about this and curious, I want her to share her answer with the audience as well.

[00:07:57.460] – Christy

Yes, because I was surprised for sure. So just to give you all an idea, our census is about 230 to 240. And I was quickly trying to analyze the reports that I got from IntellaTriage during the week, and I guessed 110, I believe is what I guessed. Between 110-120. Which I was wrong.

[00:08:23.730] – Daniel

I think it is one of those things that we see pretty regularly is an underestimation of how many calls you would expect for a 250 patients census. So the answer that we would say we see across our entire census on average, is around 222 phone calls for a patient census of 250 patients. So think about that just for 1 second. On top of all the other things that your after-hours or on-call staff are having to do, they must at a minimum – whether you use an answering service, whether it goes directly to them – at a minimum, they have to be aware of 222 other calls that are coming in during the week that they have to in some way process whether they have to take care of it now, if it’s something that waits until tomorrow, and that really just contributes overall to this after-hours burden that we see.

[00:09:13.330] – Daniel

Going in a little bit further and going back to overall what we see as far as after-hours contributing to burnout, we wanted to provide just a few other stats that stand out to us, but I think a lot of times people don’t necessarily think about it in the same way. 75% for 123 hours of a total week is after-hours. And unlike other healthcare settings like primary care or provider groups at a hospital, the distribution of times that something could come up medically that you need attention – I’ll speak from personal experience here with Hospice with my father – it doesn’t really matter if it’s 3:00 am or 3:00 pm. If something changes or you need some guidance because there’s an unfamiliar situation, it really doesn’t matter what time of day it is.

[00:10:00.750] – Daniel

So that 75% really is the true amount of time in the week that a patient or caregiver could be needing a little bit of help. And if they’re waiting a long time or your nurses are getting on another call, it can contribute overall to that patient experience and the satisfaction of care you’re getting.

[00:10:21.180] – Daniel

So we also wanted to dig a little bit just so again, sharing a little bit of internal data of what this looks like for an average week. So the chart here you have the red is our weekend call volumes and the blue is the weekday call volumes. We just layered it and said, hey, during the course of a day or during the course of a week based on weekend or weekday, what does the distribution of calls look like for an average customer that has a 250 patient census.

[00:10:51.970] – Daniel

What we see here is, we think tactically about this, we see the highest call volume during the part of the day when your team, especially if they’re part of your daytime team, is really trying to wrap up their day or have dinner with their family. So if you think about 5:00 pm and 6:00 pm hours here, this chart shows that this is the highest call volume. Right after the office typically closes right when on-call, nurses are starting to get those calls.

[00:11:23.330] – Daniel

And so what you see is right when nurses or staff members or the whole team is really trying to unwind and maybe have dinner with their family, you’re getting the highest influx of calls. We also see this on the weekend. I have a daughter myself and so thinking about a soccer game on a Saturday and all of sudden now you’re getting calls right in the middle of the day, if you’re on-call or maybe you have to miss the soccer game because you’re taking you have to take all these calls.

[00:11:46.880] – Daniel

So it can be a huge stressor just from the day-to-day of what you’re actually having to miss or give up in order to be able to address these calls and can significantly contribute to their burnout. I also wanted Christy to weigh in here on what you see day to day with your team, obviously you utilize IntellaTriage services, but just how your nurses are feeling generally irrespective of what happens after-hours on the day-to-day stresses of the job.

[00:12:15.260] – Christy

You know, for us, like everyone we’ve been dealing with COVID, you know, since the start, and that was a huge stress to our patients, our families, our nurses. The nurses, of course, were worried about it because of their own personal selves, their families and then worrying about their patients. And being a Hospice nurse or anyone in hospice, you feel like you need to be there 24/7 for your patients. So our nurses were not only exhausted and stressed, they were also just tired, feeling like they needed to be available constantly.

[00:12:54.600] – Christy

But they haven’t had to be available constantly because of  IntellaTriage. Which I think we’re going to talk about later on, but this is one of the great benefits that we’ve experienced with our staff, especially right now during COVID, is when they’re done with their day, they’re done. They can turn off their phones, they send us a report, we pass it on if we need to, and they don’t have to worry about answering that phone after five or waking up and making sure that they didn’t miss a message for a family at 2:00 am.

[00:13:28.770] – Christy

They actually can relax. They can go home, be with their families, document because we all know they’re probably documenting at that time, too, but they can truly just stop working. So that’s a good benefit. Very good benefit.

[00:13:43.820] – Daniel

Thanks for that context, Christy. I think the takeaway here is just that regardless of after-hours, there’s enough stressors during the regular day that contribute significantly to nurse satisfaction levels. So we’ll move from here, “hey, here’s the problem and the real burden of after-hours,” into “okay, so what are the common models to address this? And how does IntellaTriage play in that arena?”

[00:14:08.370] – Daniel

So this is another poll. And again, this is, I think, more for data collection purposes for us. But I would be very interested to know what your current approach is to after-hours. I think these are what we see are the most common approaches to after-hours. There should be a poll, I think going right now and I’ll give everyone a few seconds to fill that out.

[00:14:29.260] – Daniel

But really, what we’re trying to do here is highlight the most common models and talk about – Christy is going to jump in here in a minute and just talk about her experience with a few of these models. I think the answering service model in particular, and we can talk through what that looks like on a day-to-day basis.

[00:15:09.000] – Daniel

Christy, if you want to go ahead and jump in, I know you have some experience with an answering service prior to Three Oaks. It’d be great to hear about that as well.

[00:15:16.640] – Christy

Yeah, absolutely. I have been doing Hospice for quite a while, and before Three Oaks – so I’ve been with Three Oaks for about three years, I think they officially acquired the hospice I’m at about two years ago or a little over two years ago – I worked in an agency where we had an answering service where it’s someone who is non-medical, definitely not a nurse, answering calls from upset families, a patient has died, they’ve had a change in condition, and it’s an answering service. So they’re talking to someone who doesn’t really understand what they’re even talking about.

[00:15:52.370] – Christy

And then they had to take a message and then take that call and then give it to the triage nurse at the hospice. So basically, the family was having to go through multiple steps. Another thing that I’ve done before is I’ve worked for a very small company where when it was my turn to be on call during the week, phone calls came straight to me. Which seems like it would be a good thing cause it’s going straight to a nurse who is in the field, but that was the problem – I was in the field. So I could be with another patient, I could be at a death, and I’m having to answer a call. And it could be from a family who’s upset, who needs something. Those are truly the only two other experiences other than my new one with IntellaTriage that I have.

[00:16:50.380] – Daniel

To Christy’s point here, there’s a couple of primary models here and we’ll get into some of the pros and cons here in a second, but the three most common models that we see – the on-call nurse handles all the calls. So again, this is where your phones are rolled over after-hours directly to whoever is on-call typically is an on-call number that it’s routed to, and that nurse is responsible for maintaining that phone. Sometimes it’s routed to their individual cell phones. Happens in a variety different ways, but the spirit of this model is that the on-call nurse is the one who’s actually making the visits and taking the calls

[00:17:26.430] – Daniel

The answering service is the most traditional model that we see where you just have a non-medical answering service taking the calls. So patients are getting to someone quickly, but then they’re able to get routed directly to a nurse. So the answering service takes the call down, records a message and then forwards onto the on-call nurse. So again, the on-call nurse is seeing every single call, just over a little bit less of a time frame as far as taking themselves. And then finally, the internal triage nurse, which is a nurse dedicated to not going out in the field, but actually just taking the phone calls and then dispatching out for the field.

[00:18:01.660] – Daniel

And again, that’s getting a little bit more common in the market but we do see significant costs that we hear about required to staff this model and also you have to worry about if your triage is off what do you do?

[00:18:13.250] – Daniel

So I wanted to go through just some high-level pros and cons. I think generally what we’re trying to do here is not say one model is better than another, but we really do want to increase visibility into the options of the models and really increase the visibility into what the pros and the cons are and the trade-offs that each make.

[00:18:33.560] – Daniel

I don’t want to read through these individually, but I think at a high level – and again, I think we’ll send this presentation out – but I think at a high level, what we see here is there’s a trade-off between this triangle of patient experience, your own internal nurse satisfaction and cost. And all three of the most traditional models kind of layer in different pros for those and different cons.

[00:18:57.060] – Daniel

So as an example, an answering service really doesn’t do much for burnout because your nurse is still getting all of the calls. Now they can pace that out a little bit. If they’re at a death visit, they don’t have to get that call right then, they can pace it out to after the visit, but they’re still getting every single one of those calls. Still 222 of 222 calls are going to get routed to that nurse at some point.

[00:19:18.800] – Daniel

What we do see is fast answering times for answering services. Generally, we’ll talk about the metrics that you should be looking at at the end here. But generally, you talk about a speed to answer somewhere between 15 and 30 seconds for answering services. And they’re really cheap. So there are pros and cons to each model here that I’ll let you read through. I think it’s just something we’re trying to increase a little bit of visibility on. And I know Christy spoke to at least a couple of those models just a second ago.

[00:19:43.960] – Daniel

So we’ve talked about the models that exist, the burden of after-hours. So how can IntellaTriage help you? What other options are there out in the market that could potentially help alleviate and provide a lot of benefit to all of the stakeholders in your ecosystem – your administration, your nurses and your patients? We want to start out with a fast fact and then I’ll bring in Christy again.

[00:20:15.200] – Daniel

The fast fact is did you know that 65% of after-hours calls, on average, can be handled by an outsourced, registered nurse? I think most customers or most potential customers are surprised to hear that number. Across our entire hospice/home health census of over 10,000 patients, we see an average of 65% and as high as about 80%. And we can get into what drives that difference here in a few slides, but I did want to bring Christy back in here to talk about her experience since being at Three Oaks with IntellaTriage.

[00:20:45.450] – Daniel

I know you talked about it a little bit, Christy, but you could maybe talk a little bit more on the impact you’ve seen from us being able to answer or address those calls?

[00:20:56.650] – Christy

Yeah, definitely. I mentioned this earlier, it’s knowing that the phones after-hours are being answered by a registered nurse who has access to our electronic medical record, is able to document in real-time, can pull up the patient’s chart, see what’s going on, see if there are any alerts, it gives our nurses peace of mind. They know that the patients that are calling after hours are truly going to get the best answer possible in real-time. And they’re going to know immediately when they wake up in the morning because we get a report every morning and of course, there’s documentation in the chart.

[00:21:33.180] – Christy

So the nurses, it gives them that security of being able to just turn off their phones at five. Another thing is we tell our families. We tell them, “you know what, you have access to a nurse 24/7. But that also means when you call after five, you’re actually going to be talking to a registered nurse. You don’t have to talk to someone, give a message, or wait for a callback. You’re actually going to be talking to someone.”

[00:22:00.120] – Christy

And then on those occasions that the triage nurse is not able to triage a call because either they need a visit or something is going on that requires further action from us, they immediately call our staff, we have protocols in place with IntellaTriage that we set up and tweak every once in a while, and so the next call they get is from our staff.

[00:22:24.800] – Christy

 So it feels like a team. It feels like IntellaTriage, yes, they’re not here physically but they do feel like part of the team. We get pretty much the same nurses most of the time, so our staff after-hours and on the weekends actually even develop relationships with these nurses, which is kind of fun when I have to get a recording of something for any reason, hearing these conversations, you can tell it’s like teammates talking. So I mean, it’s truly a team.

[00:22:55.580] – Daniel

Yeah, absolutely. I couldn’t agree more. I think our nurses say the same thing, Christy. And so I wanted to talk a little bit and dig into the 65% and what that actually looks like. So we have a couple of different cuts of data here. So one thing I’ll preface this with – at IntellaTriage we’re data nerds. We like to really understand what happens after-hours, what kinds of calls come in, how we can help your team as best we can. So we break out a lot of data in a bunch of different ways.

[00:23:28.580] – Daniel

So using our hypothetical example of an average customer where we had 222 calls during an average week – again around 145 of these calls are 65% – is going to be able to be addressed by us. The question we most often get next is “okay, so what happens to the 35%?” Well, of the other 35% that’s broken out pretty much equally 50-50 between what we can – say the hospice is a hospice-managed call where we have to notify you. So you can think of that as being maybe a death call or a referral call, something like that, something that we’re going to let your field nurse know no matter what. And then on the other half, we would say this is where we have the most flex. So I said we have up to 80% addressable calls. This is what we consider a hospice-managed visit likely required, but we can be pretty flexible. The example we always give here is we like to be an extension of your team, and your clinical directives can be customized to whatever you see fit for our nurses to handle.

[00:24:36.320] – Daniel

So again, the example that we always use is falls. Some of our customers have us call for all falls. If someone calls to report a fall, we notify their on-call nurse. Some only have us notify them if it’s a fall with an injury or a fall that needs a lift assist. And so that kind of detail goes across a ton of categories and really helps us act as an extension of your service and it helps us if you want us to be a little bit more aggressive on our triage, we can address even more of your calls, if you want us to be a little bit more conservative because you have a patient relationship where you just want to be high touch, we can do that as well.

[00:25:12.020] – Daniel

So that’s just one cut of the data we have. And I think the question that we get most frequently next is, “so how do you do this?” So I wanted to touch a little bit on what we do when we triage a call. I’ll start off with saying it’s not that different from what you would do or your nurses would do if they were the ones taking the call themselves.

[00:25:35.390] – Daniel

We kind of bucket things into these six major buckets, but I think there’s a lot of detail in these, and we’ll get to a little bit of a cut of data on the next slide as well of what this can look like. But I think by far our most common types of calls are these first two, which are pain and symptom management and emotional support. So again, I’ll kind of go back to my own personal experience of hospice, which is you really just don’t – if it’s your first time going through a hospice – you don’t really know what to expect. You have questions. Whether that’s 3:00 am or 3:00 pm, if there’s a change in condition or breathing is labored or there’s gurgling, you have these questions that you really just need emotional support and people to talk through with what’s going on and understand that this is normal or maybe this isn’t so normal and we’ll get a nurse over there. We’re sure to take an active approach in that emotional support and then the pain and symptom management.

[00:26:29.150] – Daniel

Some of the other things that we do fairly frequently, and we see a pretty high impact just because it takes the workload off of your team, is medication refills and DME ordering. So again, we access your systems so we can call your pharmacy, we can call your DME company after-hours, within the scope of what you want us to. So if there’s certain things in your formula or you don’t want us to order or require special approval, we work with you to understand what that is. We don’t do medication orders. We don’t want to have any kind of grey area with the conditions of participation for CMS, but we do refills for medications that are already in the medication profile.

[00:27:05.900] – Daniel

As Christy mentioned, we do access the EMR directly in your system, so we have the most up-to-date patient information, and we can do those medication refills as needed if it’s already ordered. One of the things we also do is a medication follow-up. So if we advise a different dosage of medication – so maybe morphine is prescribed up to a certain amount every 1 hour but the caregiver has only been giving it up to every other hour, and we advise, “hey, why don’t you go and try every hour?” We then will call back 30 to 45 minutes later and make sure that that was effective. And if not, we can follow up with the field nurse to make a home visit.

[00:27:41.240] – Daniel

And then lastly, but certainly not least, is referral capture. We do like to differentiate this between intake, but the lifeblood of any hospice is the referrals, and sometimes those come in after-hours. Sometimes it’s 5:15 pm, sometimes it’s midnight. But what we do is take down the standard referral information to get back to your intake team so that way it feels – from a caregiver perspective – as if they’ve already engaged with the Hospice, they’re less likely to look for another hospice in the area, and it allows your intake team time to actually get out there to the home and process the referral.

[00:28:14.560] – Daniel

Christy, anything to add there or any of these areas that you noticed have been particularly helpful for your team?

[00:28:20.900] – Christy

Yeah. Actually, I was thinking about on the other slide, too, about all of the data that you’re able to give. It helps me as the director be able to pinpoint what is going on with our staff and what they need education on. For example, I was really concerned about refills because we’ve changed our pharmacy recently, and apparently our refill calls were down like 25% from the month before. So that was good to hear. But it lets me know if I see a bunch of refills after hours or a bunch of calls about what to do for pain, then I know that I need to give some reminders to my staff to work on that during the day. So it really helps with education.

[00:29:10.060] – Daniel

Yeah absolutely. Great segue for me, Christy. Thank you.

[00:29:15.160] – Daniel

We also kind of break out, as Christy was mentioning, what each of the calls look like after-hours, and we group them into categories and we sub-categorize them. So we have the clinical calls, which are almost always the highest incident of calls that we get. And this is blinded across all of our hospice customers. “Hey 38% of your calls were clinical,” and then we can break that into, “this percentage of calls was about bladder,” or “this percentage respiratory.” And so something we are able to do since the beginning of COVID is trend historic data with real-time data around respiratory calls. We saw a sharp uptick in respiratory-related calls due to everyone’s sensitivity to COVID, and so having those real-time insights is helpful, to Christy’s point, of just letting your team know. 

[00:30:05.200] – Daniel

As Christy mentioned, we talked about the medication we break this out into, “hey, is this a refill call or is this an information call?” And if we’re seeing a departure from what we see across our overall average or your historic trends, we’re able to dig in there and say “here’s what we’re seeing over time. And maybe you could provide this education to your team.” So really, we look at this as a partnership process and we’re really wanting to be able to provide as much data to you after-hours as possible so you can make informed decisions during the daytime care and vice versa as well.

[00:30:37.030] – Daniel

And so I know we’re going to talk a little bit more specifically about our partnership with Three Oaks. This is an interesting quote that I think Christy had when we were talking as to how hesitant she was when we started. So, Christy, maybe you could provide a little bit of background around that hesitation because I do think it’s something that is common. People just have worry and unfamiliarity.

[00:31:02.800] – Christy

Absolutely. Up until I came to Three Oaks, I was dealing with answering services or a nurse or myself answering the calls after-hours, so I know when I first started here and they’re like, “oh, no, we have a triage company.” I’m like, “what? There’s no way this can be good. I just don’t see how it’s a nurse from who knows where answering calls on our patients.” It was probably within that first month of me being here that I realized “oh, okay, they’re part of our team.” They have access to our patient information. They know what they’re talking about. I mean, they’re Hospice nurses. They understand that we have a lot of protocols in place for different things – when to call us, when not to call us, when to send a nurse. We even have it down by facility on some of our patients. Like, if anyone from this facility calls, you send someone regardless, regardless of what it is, unless it’s like a refill, maybe.

[00:32:13.330] – Christy

I can’t imagine now not having a triage company. I can’t imagine going back to one of the older models that I had used before. It’s been great. I was thinking about examples the other day, and I live in the Dallas area, so sometimes we have tornadoes around here. I remember we were about to close the office down for the day, and I reached out and it was probably last minute, and I was like, “Is there any way you all can take our calls?” Otherwise, we were going to try to triage ourselves until five. And within, like, 30 minutes, I had it set up, which may not always happen because it was in the middle of the day, which are not typical triage hours. But I was basically told that we were going to do whatever we can to help you, to support you, to get you all home so you’re safe. So my hesitance went away.

[00:33:08.300] – Daniel

Thanks for that context, Christy.

[00:33:11.520] – Daniel

So what we wanted to do next is walk through the tactical,”hey, what this looks like.” Because I think that’s where there’s – not being familiar – there’s a lot of hesitance. So the more familiar we can get with this model, the better. So we thought we’d walk through a sample workflow here of what this looks like and I’ll provide a little bit of detail. Christy, to the extent that you have something you’d like to add on this, please just jump in and you can talk about how it works internally or tactically as well.


Generally, the process goes something like this: the call forwards directly to us. So after hours, 5:00 pm, most of our customers have an automatic roll-over from their phone system, and it forwards directly to either a cue or several cues for your organization that routes it to IntellaTriage. One of the things that we always pride ourselves on is really being an extension of your service. So there’s always going to be a customized greeting with your hospice’s name and really making sure that it feels like, in this case, Three Oaks Hospice answering not just some nurse and who knows where. But the second part of that is, and something that we think differentiates us pretty significantly is that we always have a licensed registered nurse answering the phone.

[00:34:25.340] – Daniel

We don’t have patient coordinators, or there’s a bunch of different names for them, but essentially non-nurses answering the phones and that routes the calls or tries to get the call to the appropriate priority. We always have a licensed registered nurse answering the phone, we don’t have anyone else, and we also don’t have any voicemail. So it’s always going to be answered by a licensed registered nurse. I’ll note here I’ll talk about the metrics here in a little bit, but on average, our calls are answered – we look at wait time versus speed to answer, which I’ll talk about again in a minute – but our average wait time across our entire company for all of last year and year to date, is 40 seconds. So very quick to actually get to a nurse. And we always ask for customers to think about speed to nurse, not speed to answer. But how long does it take in your current process, on average, to get to a nurse or what are your outliers for how long it takes to get to a nurse?

[00:35:17.720] – Daniel

If you have your nurses answering and one of them is a home visit, what does that outlier look like as far as how long it takes a patient to actually connect with a nurse? And for us, on average, it’s 40 seconds. From there, as Christy mentioned, we do have access directly to your EMR. We know that charting sometimes happens after the end of the normal workday, and if you do a push-pull integration, where you’re pulling all the records at 5:00 pm and then pushing them back to you at 8:00 am, you may not capture the most recent encounter with that patient, and it’s not surprising that a lot of the times the patients who received as it’s that day because of either the declining or had to change a condition or oftentimes the ones who call in.

[00:35:58.590] – Daniel

So having that up-to-date and real-time information is really important. So our nurses review the patient record directly in your EMR, and we have experience with the vast majority of EMRs and we also chart there as well. Christy, was that new to you as far as accessing the EMR and having that real-time exchange?

[00:36:24.460] – Christy

Oh, absolutely. Because the answering service, at least the ones I’ve worked with in the past, didn’t have access to EMRs. So when I heard that I was like, “oh, this is even better. They’re actually going to document in my system. This is amazing.”

[00:36:40.060] – Daniel

An important part of what we think is good communication back and forth is real-time communication or the most up-to-date chart review and vice versa for your nurse. From there, after we’ve reviewed the chart and medication profile, the plan of care, our nurses – as Christy mentioned, we have hospice/home health trained nurses. We don’t just have any nurses, but we actually have nurses that have significant experience in the specialty. So for our nurses, we have over 20 years of experience, on average, for nursing experience and over eight years of experience on average, for our hospice experience.

[00:37:18.250] – Daniel

These really are well trained and seasoned hospice nurses, not just a nurse coming out of nursing school and taking the calls. So we’re able to triage those calls, referencing all the clinical directives that we’ve developed with you, again to act as an extension of your service, and provide the care instructions back to the patient and the caregiver. We have then what we call the work of the call. So the work of the call really is a broad bucket term for everything we do that is after we hang up with the patient. So that could be refilling a medication, ordering new DME, contacting all coroners because it was a death visit.

[00:37:57.660] – Daniel

All of that stuff falls into that to perform the work of the call bucket. It’s quite varied and quite detailed depending on how specific you want to get for your patient population or different facilities. As Christy mentioned, we even have it for them at the facility level. So that all falls under the perform the work of the call bucket.

[00:38:16.400] – Daniel

Six is that documentation step. Again, we want to make sure there’s no gap in communication. So there’s actually two different pieces of documentation that we do. The first is in the EMR so that way, all the notes are up to date and your team has access to the encounters that happen in the middle of the night. They can review those in the morning when they get up. The second, which Christy will talk through in just a couple of slides, is our Daily Activity report, which is really just a summary of the report that is, I think, really helpful for the team in understanding what their work is the next day because they can see who called in.

[00:38:49.410] – Daniel

And then finally, I already mentioned we’re data nerds. We are always trying to take a look at analytics and provide opportunities for continuous improvement for ourselves, for our customers and really making sure that we’re all aligned providing the best possible patient care and providing the best patient experience. Anything you want to add there, Christy?

[00:39:11.380] – Christy

No, I don’t think so. Not on this slide, because if I start talking now, I’ll mess up the next slide.

[00:39:17.760] – Daniel

So I will now let Christy talk through – we wanted to make sure we provided a tactical example of what that looks like for the Three Oaks team and how they’re structured and how they work with us. So, Christy, if you want to take it away.

[00:39:28.740] – Christy

Yeah, absolutely. So during the week, how we have it set up is IntellaTriage answers the calls, of course, and then they call our nurses directly. We have three RNS on call each night and they just rotate through each one. They know ahead of time if we’ve got visits that are already scheduled, and so they will skip that person and go to the next one and kind of go into a rotation.

[00:40:01.100] – Christy

We have an AOC or administrator on call every single night of the week and on the weekends, and rarely do I get a call. If I get a call, it’s usually a complaint call or there’s a death and both of my nurses are at admission, and they’ll be like, “who should I send?” We just kind of talk it through. I think the last time I got a call was last Tuesday. To me, this was a great example of how we were a team and we were able to tag-team the situation.

[00:40:36.550] – Christy

I had an issue with some triplicates for some morphine and the family was needing it, so I talked to the triage nurse and I was like, “okay, I’m going to call the pharmacy, I’m going to approve the stat. You do this part, and then we’ll be done.” And that’s what we did. I took a piece, she took a piece, and it was great. It’s just a good example to me of how we work together and the types of calls I get during the week, which is really not very many personally.

[00:41:03.150] – Christy

On the weekends, we do it a little bit differently because weekends are so much busier and we have double the staff on the weekend. So we actually have our own – we call her a triage coordinator. It’s one nurse who takes all of the calls from IntellaTriage. So the IntellaTriage nurse is still attempting to triage the calls so my triage coordinator is not getting all of these calls. She’s only getting the ones that need visits. And then that person assigns what nurse is going to go out because we just found that having six nurses working during the weekend, it’s hard to keep track. So we have one designated person on our staff who does that, and it works really well. Both plans are a little bit different, but it just works great for us.

[00:41:56.730] – Daniel

We affectionately refer to the weekends as the air traffic controller, she coordinates everything for us.

[00:42:05.300] – Christy

Yes. And we have pretty much the same person every week who does it, sometimes it’s someone new. And again, she’ll tell me, she’s like, “oh, my gosh, I love the nurses who are on this weekend.” We would just develop relationships with these people because we talk to them. And then every day, we get a daily activity report. So before I even come into the office, I already know, and I don’t know how it is possible, but I swear I get it at 8:16 every single morning.

[00:42:35.780] – Christy

I don’t know. I just know at 8:16, I’m getting my report and it looks just like this. For us, part of how our calls are arranged is we have teams. We currently have four colors, and so we can quickly see – usually on the far left it’ll say our team color, and that way we know what team is having a lot of calls after-hours and what type of call. But I get this every morning. So I know before I come into the office what happened overnight, and then I can also go into the portal also and pull these different reports. So it’s great. It’s great to know exactly who the patient is, what happened and if I need to follow up.

[00:43:32.000] – Daniel

Yeah, exactly. Thanks, Christy. We wanted to use a specific example  – call it a case story is what we usually say – us and Three Oaks partnered recently to make sure a situation was resolved. So essentially, the high level here is that we had a concern that we received from a long-term care facility that one of Three Oaks’ patients was residing at. The facility stated that the overnight nurse didn’t offer any guidance on the symptoms and was rude. One of the best things about our system is that we record all incoming and outgoing calls, so we have a record of everything.

[00:44:10.110] – Daniel

And again, we don’t think people are intentionally misleading, but we think high stress situations can leave a lot of room for interpretation on communication. So our nurses are trained to be as precise and over-explanatory as possible, but occasionally we do get a concern. We were able to pull the recording, though, from this call, and we sent it over to Christy and her team and said, “Hey, we answered. We think it’s appropriate. We resolved all the triage questions, provided some guidance on medication administration, and so maybe it’s something we can use as an opportunity to work with your facility to make sure we’re all on the same page.”

[00:44:47.360] – Daniel

And I think that doing that, we were able to salvage a relationship with the facility. I don’t want to put words in your mouth, Christy, but I think overall, it was a good outcome for everyone involved and made that relationship a little bit stronger.

[00:44:59.640] – Christy

Yeah, absolutely.

[00:45:02.580] – Daniel

So I know we’re running out of time, we want to make sure we leave enough time for Q & A so wrap up here and cover just a few things in the next two sides. So number one is what this means really, to not just your nurses, but your families. And number one is it helps reassure them they’re going to have support in their time of need. You’re able to say, “Hey, we have 24/7 access to a registered nurse, access to patient records. They’re going to be there quickly, and they’re going to know your medical history as it relates to this plan of care.”

[00:45:35.210] – Daniel

Either experienced nurses with again 20 years of nursing experience, on average, with eight years or more of experience on hospice, on average. Number two is the patient experience is just pretty dramatically improved. You’re getting to a nurse again, time to nurse under a minute. You’re not having transfers between non-nurses and nurses and callbacks or frustrating menus. You’re calling into your hospice agency and you’re getting us and we’re able to provide that care anytime, day or night.

[00:46:02.900] – Daniel

We’re also able to act as an extension of your team to these customized clinical directives so the patients are getting the same quality of care, day or night. As Christy referenced earlier, we are always tweaking those, saying, “Hey, maybe we do this a little differently.” We have monthly meetings to review these procedures and make sure that we’re aligned with what you’re doing. And then finally, helping reduce or even eliminate the stress of after-hours care on your team, which is going to allow them to provide better care during the day. It really allows them to recharge in the evenings. Christy’s quote, around having their case manager’s ability to turn their phones off at 5:00 pm I know just has to pay dividends for their mental health so that when they are engaged with patients, they’re really providing the best quality care that they can.

[00:46:49.500] – Daniel

So we do want to provide a few criteria as you’re thinking about services like this. I think there are questions you should be asking whether it’s an answering service or thinking about some other model. There are a few questions here that we think you should be asking. So number one is who answers the call. Is it a registered nurse or someone else non-clinical? Is that all the time, is it some of the time? What happens there? Is it a first-line of defense model? So we always say we have a nurse-first model, which means yes, only a nurse is going to answer first. However, it also means we act as the first line of defense. So when your calls come in, we’re that first layer there to make sure that we’re addressing as much as we can before we send it back to your team. There’s some models out there that are backup models, and that really doesn’t do much for nurse burnout, because if your nurse is available, they’re going to be getting the call. So I would ask if it’s a first line of defense model.

[00:47:40.660] – Daniel

A few tactical things: do you customize clinical directives? Do you access our EMR? Do you chart in our EMRs or some other mechanism for doing that? What kind of analytics do you have? And then the biggest thing we always say is wait time. So we like to use what we call wait time, which is from the time that the caller places the call to the time that we answer, not from the time that it gets to the right queue to the time we answer which people call speed to answer. Someone could have a speed to answer of 30 seconds but an average wait time of two minutes because it goes to a bunch of different queues before they’re measured. We like to measure what it looks like from the patient’s perspective, so our average wait time is around 40 seconds, our average speed answer is actually closer to 28-29 seconds. So just make sure you’re asking those distinctions.

[00:48:30.420] – Daniel

And then also do you have experience in the hospice and home health space? And who are your customers? Are they willing to provide references? I think that’s the best way to get comfortable with the provider.

[00:48:42.120] – Daniel

We’d love to talk with any and all of you about your after-hours care. It doesn’t have to be engaging saying, “Hey, talk to us about your service.” We are happy just to engage in what we call a strategy session to understand what your model looks like, what kind of data are you collecting now, are there areas for improvement. We also have a special report on this very topic as well. It’s linked here, we’ll send this out. But please reach out to myself, we have a contact form on our website if you want to reach out there as well. We’d love to get in touch and just learn more about you and your organization, and if we can help. So with that, we’ll turn it back over to Jim for Q&A.

[00:49:21.820] – Jim Parker

Thanks so much, Christy and Daniel, for your insights today. I really appreciate your being here. We do have a few questions to get into, and as a quick reminder, you can submit questions through the box on your Go to webinar app. But first, would you like to run through the numbers from your second poll?

[00:49:41.120] – Daniel

That’d be great.

[00:49:43.570] – Jim Parker

Excellent. So the question was, what’s your current approach to managing after-hours calls. 64% of our participants voted, and we have 50% said they use an answering service. 30% use an internal triage nurse. 9% said a field nurse answers all calls. 7% weren’t sure and 4% said other.

[00:50:18.690] – Jim Parker

Moving into the questions, there seem to be other services like this in the market that don’t use the nurse-first model. Why is that the model that you use for this service?

[00:50:31.960] – Daniel

Yeah, that’s a great question. I would say this goes back to our over a decade of experience at this point. I know our founder, Susie Meschbach who’s still with the company, when she and our first employee, Kathy Blazek, who’s currently our Chief Nursing Officer, were building this service, they tried a bunch of different things. They tried patient coordinators, they tried to be non-clinical person first, they tried being a backup version, and I think what we found is if we’re trying to address the issues of nurse burnout and patient experience, you really do need a nurse answering right away and also not going in a roundabout way to that nurse.

[00:51:17.270] – Daniel

So I think what we found is that the nurse-first model really does help reduce burnout. As a backup model, the field nurses are still taking all the calls unless they’re on a home visit. And that really doesn’t do much for them being able to not have that after-hours burnout. And through experiences,  it’s shown, whether it be CAHPS scores or patient satisfaction scores, that being able to get to a nurse really quickly right away just dramatically improves patient experience.

[00:51:48.550] – Jim Parker

Thank you. And do nurses need to learn a new technology platform in order to get the benefit of the service?

[00:51:56.740] – Daniel

Another very good question. So the short answer is no. We know that there’s always new technologies coming out, and we look at that as a little bit of a burden on your team having to learn yet another piece of technology that they interact with an outsourced team on. What we really try to do is live in your current process and current systems so that way, they’re not having to learn anything new and there is no learning curve there for our team or your team.

[00:52:29.390] – Jim Parker

Excellent. And what can you tell us about the cost of the service?

[00:52:34.730] – Daniel

This is the most common question we get at this point. You know what I would say is it depends on a lot of things. It depends on size, depends on hospice versus home health versus palliative care, depends on coverage hours, depends on a lot of things. What I will say as a blanket statement is this service is less than 1% of your daily reimbursement for your patients. We intentionally try to make this as affordable as possible because we think it’s a great service that adds a lot of value and we want people to be able to use it.

[00:53:11.620] – Jim Parker

Thank you. And how does your solution integrate with a hospice’s secure messaging platform?

[00:53:20.850] – Daniel

Another good question. So it depends on the secure messaging platform. What I would say is generally right now we do that a little bit, but generally we try to rely on phone calls. What we have had experience with in the past when using these secure messaging platforms is sometimes a nurse doesn’t get the message or we’re unsure if the nurse gets the message and then something falls through the cracks. So we try to be really active in our communication and just make a phone call. And if they don’t answer, we leave a voicemail, we wait, we call back. If they don’t answer again, we can escalate. Again, this is all part of the clinical directives, but we really do prefer the phone call method because it ensures that what has happened is being accurately communicated and is being received.

[00:54:11.240] – Jim Parker

Have you seen a significant impact on CAHPS surveys, satisfaction surveys?

[00:54:19.200] – Daniel

I can speak to that a little bit, but curious if Christy has any insights there.

[00:54:25.260] – Christy

I do. Actually, I was just looking at my year-to-date Fazzi report and our ratings on the after-hour attention, we’re above the national average on the families answering definitely yes, we are responsive. So that’s including, of course, Triage and our nurses who are actually making the visits.

[00:54:51.880] – Daniel

Thanks, Christy. Important context is after-hours, there’s a couple questions specific to after-hours, but it’s the whole team, not just IntellaTriage. What I’ll say is we actually have a case study with a hospice in the Mid-Atlantic region that they went from about a ten-point below average CAHPS score on after-hours to about a ten-point above national average on the CAHPS scores for after-hours. So we’ve seen significant movement on several of our clients.

[00:55:21.180] – Jim Parker

Excellent. I’m going to try and squeeze a few more questions in before we run out of time, we have quite a few. What percentage of calls have to be routed to the on-call staff after speaking with IntellaTriage?

[00:55:39.670] – Daniel

So that is that 35% on average, go to the on-call staff. So we’re usually able to address that 65% – there’s some wiggle room there, so we do have a few customers that are closer to the 80%, a few customers that are close to the 50%, it really depends on the clinical directives we develop with your team on how attentive you want us to be. Christy, does that resonate with what you see?

[00:56:03.720] – Christy

Yes. I was just thinking back. I know last month we were, I think, right at 65%. I think we’re usually between, like, 64-70% is handled by the triage nurse, which is great. Very good.

[00:56:20.130] – Jim Parker

Excellent. And Christy, the next question is directed at you. You spoke of being able to use the analytical data to focus your education. What do you think has been the most significant impact on your QAPI findings?

[00:56:39.280] – Christy

Honestly, it goes back to medications. Medication and refill after-hours always seems to be such an issue. So being able to tell a staff this is the number of calls that are coming in, we need to focus on making sure we tuck our patients in for the weekend, making sure that they have all the medications they need. If that means they need to organize the meds and not just rely on a facility or family to give them the refills. It’s made us be able to streamline our process for getting refills taken care of.

[00:57:13.090] – Christy

That’s probably one of my best examples, because that just seems to be such a – maybe it’s just one of my pet peeves, but when I see a refill call after-hours, I reached out to the nurse like, “What happened? Where’d we mess up here?”

[00:57:30.320] – Jim Parker

Thank you. And does IntellaTriage serve only hospice providers or does that extend to other types of organizations? And if yes, how are those triage models different from what you see in hospice?

[00:57:46.420] – Daniel

Yeah. So we don’t just serve hospice. We have two segments of our business. We have what we call the Nurse Triage side of the business, which is all things post-acute so home health, home infusion and palliative care hospice. And then we have another service called Nurse Advice Line, which is health plans and provider groups. I think the biggest difference in the two different service lines is the goal of the Nurse Triage service is to make sure the patient is getting the right care after-hours. The goal of the nurse Advice line is to make sure the patient is getting to the right level of care.

[00:58:18.280] – Daniel

So avoiding any ED visits or urgent care visits, making sure if they can take care of it at home, they can. So it’s just slightly different goals for both models. But I would say there’s a lot of similarities as far as the actual workflows, and it’s a very tailored approach. So we customize those clinical directives to meet the needs, whether it’s palliative or hospice or home health.

[00:58:42.230] – Jim Parker

Excellent. Well, we are just about at the end of our time again, I really appreciate you both being here. I’d like to thank everyone who tuned in to this discussion today. I’m sure they benefited from both of your insights. So I hope you take care.

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