Featured Guest Contributor
Alpa Vyas, Vice President, Patient Experience
About five years ago, we discovered the challenges faced by patients in our outpatient clinics who tried to navigate our health system after hours, when their clinic was closed. What we learned was that all of the calls coming in after hours—between 50 and 100 every night—were being directed to one of the residents, fellows or attendings on-call at the hospital. This system was a real dis-satisfier for physicians and house staff busy caring for inpatients, and difficult for patients who sometimes experienced delays in care.
Clinical Advice Service
To alleviate the burden on our on-call physicians and to improve the patient experience, we created the Clinical Advice Service (CAS). This after-hours clinical decision service gives patients access to appropriate medical advice from Stanford Health Care (SHC) registered nurses who can resolve issues, often without paging the on-call physician. Since implementing the CAS, we’ve been able to reduce calls to our on-call physicians by about 95 percent. Patients’ satisfaction with the ability to get questions answered after hours has also improved.
The CAS team is available throughout the night to answer medical and care-related questions, clarify medication usage and help resolve administrative issues. Nurses follow set protocols for directing medical care, protocols developed by the providers in each Stanford Medicine faculty clinic.
The program came together under the direction of CAS Medical Director Nawal Atwan Johansen, MD; Director of Service Eric Escobedo; and Executive Director Fouzel Dhebar, who worked together with CAS nursing staff and providers from each of our Stanford Medicine faculty clinics to develop protocols for the most common patient calls. Each protocol is built into the electronic health record, and nurses document each encounter in Epic.
Depending on the patient’s disposition and medical issue, the CAS nurse may prescribe medical advice, direct the patient to follow an at-home medical regimen, page the on-call physician for a consult or direct the patient to call 911 or go directly to the emergency department. CAS nurses also conduct follow-up calls the next morning to see how patients are doing and to ensure that they follow-up with their physicians.
The program, which currently serves patients seen in Stanford Medicine faculty clinics, now receives 1,000 calls per night on average.
Post-discharge follow up
Our team of Clinical Advice Service nurses is also supporting their inpatient counterparts by taking over responsibility for making post-discharge follow-up calls to patients 24 to 48 hours after discharge from the hospital or emergency department. In the past, inpatient nurses on the floors were required to make these post-discharge calls while also actively caring for patients on the floor. The CAS team is now making about 100 outgoing patient calls a day.
In a separate pilot project with Stanford Internal Medicine West, we looked at the call volume to our primary care practices around medication refills. About 60 percent of after-hours calls are for medication refills. Before the pilot, all medication requests went into a queue to be handled by clinic staff during normal business hours. On average, it took 72 hours for a patient to get feedback from the clinic on a medication request. With our Clinical Advice Nurses handling these requests, turnaround time has dropped to one day. Results were so positive we are looking to expand this service to other primary care and specialty care practices in the future.
First contact resolution is one of the guiding tenets of the Patient Experience Department. In every patient interaction, we try to answer patients’ questions and resolve their issues while they remain on the phone, reducing the need to call them back or transfer their call.
All of our Clinical Advice Services help us create a more connected experience for our patients. They also help us relieve the administrative burden on physicians and clinical staff, freeing them to focus on the patients who are in their care.