Background/Purpose: Rising healthcare costs have resulted in greater patient burden, higher health insurance costs, deductibles, and copayments. Access to care is delayed and problematic. Many of our patients have well controlled disease, yet scheduled follow up is based on patterns of behavior rather than disease control or patient needs.  How we can deliver the right care for the right patient at the right time?

Methods: We proposed and developed a new visit type within our electronic health record (EHR) – a Nurse Scheduled Telephone Visit (NSTV).  This was a scheduled encounter with the nurse via telephone.  The nurse called the patient and collected data including disease activity measurement (RAPID3), events, problems, or symptoms that occurred since the last visit (probes) and assessed need for medication refills. The assessment was assigned one of two statuses – 1) RAPID3 with low disease activity AND all probes negative AND no refills needed, or 2) ANY of these items needed attention.  The encounter was routed to the patient’s rheumatologist.  If status = 1, the encounter could be closed.  If status = 2, further action was needed by the provider. Using PDSA (plan do study act) process improvement methodology, a pilot (cycle 1) was conducted. Patient travel cost and co-pay cost savings were calculated. The patients completed a survey after the NSTV. Based on the positive results in cycle 1, cycle 2 included presenting results to other rheumatologists seeking their insight to use this visit type across a broader array of patients and providers.

Results:  Cycle 1: 6 of the 6 completed NSTVs had status = 1 and 1 requested a call back from his physician (status = 2) (Table 1). Cycle 2: 70 patients were enrolled over 2 months. Out of these, 14 completed visits thus far. 13 had status =1 and only 1 requested a call back from his physician (status = 2).  Patients showed similar savings by avoiding co-pays and transportation costs in both cycles (Table 2).  Our survey results showed 100% patient satisfaction.  By extrapolating these results to our database of RA patients where 50% (1,200 patients) are in low disease activity or remission, using NSTV will reduce 1 visit per year and open up an additional 300 hours of clinic time.  

Conclusion:  As healthcare moves towards a value-based system, we propose the NSTV as a solution to improve patient experience, minimize cost burden to the patient, and increase access to care.  It was well accepted by the patients and providers as an efficient resource in a busy clinic setting. It improved access in the clinic and reduced cost for the patient.