Clinical Advice Services

It was 3:00 in the morning. The patient couldn’t sleep because of an upset stomach. She tried a few home remedies without success, and at 6:00 am she decided to call her Stanford Primary Care doctor’s clinic to request some heartburn medication. The call routed to Clinical Advice Services (CAS), which led to a CAS nurse reviewing the patient’s chart and taking her history. The nurse was able to assess the patient on video and use critical thinking along with CAS clinical protocol before advising the patient to go to the nearest emergency department (ED), which the nurse would notify in advance. At 6:45 am the patient was seen in the ED and admitted for a heart attack.

Since its creation in 2015, CAS has managed over 240,000 such calls from patients and caregivers with patient safety as the focus. In that time, close to 10,000 patients who interacted with CAS had not realized the urgency of their condition. Indeed, without speaking to CAS, they would have stayed at home hoping for symptoms to improve or waited for a clinic appointment or callback.

Recently recognized for service excellence with the Malinda Mitchell Award, CAS is meeting its two primary goals:

• Improve patient safety and patient experience by providing seamless connectivity to patients after hours and weekends when clinics are closed and during care transitions.
  
  
• Improve clinician wellness by reducing the number of pages and interruptions to the on-call teams (including house staff, fellows, advanced practice providers, and faculty).
   

“Prior to CAS, all calls from patients, pharmacies, or home health agencies would be transferred to the already burdened on-call clinical teams. The burden on the patient and caregiver was equally immense, with gaps during critical care transitions. With a patient experience aspirational aim of “Know Me, Show Me, and Coordinate for Me,” CAS was established as an enterprise solution. Almost a decade later, aligned with enterprise priorities and supported by a continuous improvement ethos, the team is striving to optimize in the areas of efficiency, care coordination, telehealth, medication management, and meeting the unmet needs of our most vulnerable patients,” says Fouzel Dhebar, vice president for health navigation, global and corporate partner services at Stanford Health Care. 

Today, a frontline team of registered nurses, registered nurse coordinators, and patient administrative specialists manage calls for patients from 166 clinics that cover 31 services [see sidebar]. Over 80% of the calls are clinical, and in the past nine years CAS managed 92% of the clinical calls and avoided escalation to the on-call clinician by using clinical protocols and established workflows.

“Clinical and operational excellence, alignment with our organization’s strategic goals, and providing high value care are important goals for us at CAS. Since 2015, CAS has been able to avoid an ED visit for 24,000 patients,” says Nidhi Rohatgi, MD, clinical professor of medicine, who has served as the medical director for CAS since day one.

“The CAS team is a group of highly qualified Stanford nurses and staff who can help connect the dots for patients, especially after regular office hours. Not only do they help provide the right level of clinical advice as appropriate, but they also act as the bridge between when somebody may be discharged from the hospital and their next clinic visit.  Because the team is very well trained, can cover a number of specialties, and follows the guidance of our physicians, they're very well positioned to be connectors in the organization,” says Alpa Vyas, senior vice president and chief patient experience and operational performance officer at Stanford Health Care.

“Before CAS staff take any calls from a new service or new clinic, there is a rigorous and systematic process of onboarding. It involves visiting ambulatory clinics and/or rounding with inpatient teams to build relationships with different services. We need to understand their workflows, the types of calls to expect, the urgent symptoms specific to the patients on that service, and their call schedule. CAS then builds customized workflows for each clinic and each service. We create clinical protocols in concert with each of the services to ensure our patients can have timely and clinically appropriate access to care,” Rohatgi says.

Since 2015, CAS has avoided healthcare costs of $19 million a year on average by implementing strategies to reduce low-acuity visits to the ED, by minimizing unnecessary pages to clinicians that saved physicians' time, by optimizing workforce efficiency, and by driving other quality improvement initiatives.