Behind the Scenes at the New Zealand National Telehealth Service (supported by Spectrum CRM)
May 11, 2016

Medical emergencies don’t keep normal office hours and telehealth is increasingly being employed to cater for the demand for 24/7 triage and advice. Last year, the country’s various health helplines were merged after a government tender won by Homecare Medical. Cliff Taylor visits the company’s Auckland HQ to see how the service is doing, six months after going live

Just downhill from Auckland City Hospital, tucked in off the motorway in Grafton, is a building that never sleeps.

People arrive and depart con­tinuously through the doors of ProCare’s headquarters, which houses the nerve centre for Homecare Medical, the company running the integrated national telehealth service. It offers ad­vice on everything from medi­cal emergencies, quitting smok­ing and dealing with poisons, to alcohol and drug addiction, im­munisation, depression and gam­bling, plus after-hours teletriage services for 600 general practices around the country.

On level one of the building, teams of telephone operators – or “clinicians”, as Homecare Medical’s chief executive An­drew Slater prefers to describe them – work shifts around the clock, seven days a week, an­swering queries from the wor­ried and unwell.

One of the first things you see on entering the office is a small sign on the wall which says “ser­vice users”. Under it is affixed a printout: “1 November – 19 April – 311,755 contacts with New Zealanders” underpinned by symbols of the various forms of telecommunications used – text, phone, fax, email, Facebook and livechat.

“That’s kind of equivalent to a contact for one in 14 New Zea­landers,” Mr Slater says. “About 95 per cent of those come in by the phone.”

In June last year, Homecare Medical won the Ministry of Health’s tender for an unusual­ly long 10-year contract worth $257 million to combine exist­ing helplines into one integrat­ed service (>>, ‘News’, 18 June 2015). These included Healthline and a half-dozen dedicated helplines offer­ing advice on specific issues and addictions. Homecare Medical is operated in partnership by Pro­Care and Pegasus Health.

Announcing the deal, health minister Jonathan Coleman promised the new national ser­vice would be more “seamless” and ensure people can access the right advice, at the right time, no matter where they live.
“This will help reduce the pressure on after-hours prima­ry care and hospital emergency departments,” he said in a me­dia release at the time.

Most of the action at the call centre takes place behind a glass door marked “On Air”. This is where the phone operators sit wearing headsets in front of rows of ter­minals. Eleven o’clock on a Thursday morn­ing is a fairly quiet time. Large screens indicate the number of calls coming in for different helplines and the amount of time taken to answer them.

“Eighty-four per cent of con­tacts are answered within 20 sec­onds,” Mr Slater says, indicating the screen above.

Other parts of the office are occupied by clinical advisory staff and IT technicians hud­dled around screens. There is also a large kitchen area to ca­ter for staff working all hours.

It’s a bustling environment staffed by a diverse group of youngish workers. The vibe is friendly, casual; not unlike what you might find in a tech start-up company – except this one has a quarter of a billion dollar con­tract to fulfil.

MR SLATER, who previously worked in strategy for St John, says it was “exciting” building the company in the 19 weeks leading up to the 1 November launch (>>nzdoctor., ‘News’, 30 Oc­tober 2015).

The short time frame to create the new service has fos­tered “a great spirit of partnership” which he says the company is keen to build on. The Auckland set-up is replicated in smaller centres in Wellington, Christchurch and Dunedin.

Nearly six months since going live, data trends are starting to emerge. For instance, most peo­ple wanting advice to quit smok­ing use text to contact the ser­vice. Texting appeals particularly to teenagers. Those looking for help with depression will most often use email.

The company is also having to be “very focused” on how to deal with frequent callers to the service.
The most hectic time is on a Saturday morning. On other days the hours between 7pm and 11pm are particularly busy, and the teams get more calls about smoking and alcohol on Tuesdays than any other day. “I don’t quite know why, but we do,” Mr Slater shrugs.

Understanding the trends is clearly still a work in progress. On Boxing Day, the service had been bracing for 8000 contacts and ended up fielding more than 13,000. In January alone, 6000 people contacted the helplines wanting to quit smoking.

Individual incidents such as last year’s hepatitis A scare linked to frozen berries and alarm over the Zika virus have resulted in significant spikes in contacts.

“Different news events drive quite a bit of service volume,” Mr Slater explains.
“We can see in our call volumes when someone is in the media talking about frozen berries, in the hour after that we’ll have a spike in volumes.”

That was a rapid increase in volume that couldn’t have been predicted, he says.

Services have also been em­ployed in unexpected ways. One psychologist spent eight hours in text communication with a troubled teenager, trying to resolve a tricky situation.

“It took that long to build rap­port and come up with a plan for that person to access the right service, which was successful.”

One of the most challenging aspects of the work is dealing with suicidal callers. “We get a number of calls daily of suicidal ideation across the service,” Mr Slater says. “Working with those calls, and the responding police and other services to support those people is quite a regular occurrence.”

Aside from mental health and addiction staff, health advisers, support and casual staff, the company employs 165 nurses, 88 of whom work from home – “Kaitaia to Bluff – literally,” Mr Slater says.

Most of the nursing team crossed over from the previous provider Medibank, which ran Healthline. Staff need to have at least three years’ nursing expe­rience, while the mental health and addiction staff must have spent a number of years in face-to-face counselling roles. The company also employs some final-year medical students for non-urgent work.

Senior roles include a clinical director and lead psychiatrist, and the company’s approach is overseen by a clinical govern­ance committee.

THE 76-PAGE contract contains explicit references to developing relationships with primary care and general practice. These in­clude working with alliances, the Integrated Performance and In­centive Framework, developing interfaces with general practice and sharing resources.

The company must provide the consumer’s GP with an elec­tronic summary note of advice given. This will eventually be done in the patient record, and will include a handover note.

Mr Slater expects Homecare Medical’s involvement with gen­eral practice will grow, and the company is having “numerous conversations” with practices about their outbound calling and providing additional sup­port when receptionists are sick. It is halfway through a three-month pilot providing reception services for general practices in South Westland.

He is keen to dispel the fear of some in the health sector that the anonymity of call cen­tre medicine will erode stand­ards of healthcare, insisting the company’s role is a part of face-to-face care, not apart from it.

“We believe very firmly we are here to support and promote a stronger foundation for the ex­isting face-to-face providers to deliver care to their patients, as opposed to displacing patients from those face-to-face services, which is what you are starting to see in some models of care emerging in places like Australia, the US and developing countries as well – the Skype-a-doctor type services that discount that rela­tionship between general prac­tice and the service.

“There’s a whole cohort of the population that really use Healthline and EDs as their health system, so we’re really supporting family members in accessing care and encouraging them to enrol with a GP and con­necting them with a GP and talk­ing through the benefits of that.”

The goal, he says, is to ensure the service isn’t a “robotic” call centre that’s “all about pushing people through”.
He acknowledges a 10-year contract for a government-fund­ed service is unusual, but points out the company has clear re­sponsibilities in its reporting and transparency.

“Given the volume of contacts we get every day, we’re not go­ing to get it right all the time. We want feedback about how we’re doing.”

He adds the company is also expected to be the “public face” of the health system in any disaster or health emergency. A key part of that role is to have someone on the end of the line at any time of the day or night. Even when the traffic stops on the road out­side, the phones keep ringing.

“It’s a really important service. We have the same level of avail­ability as you’d see in the police and military and ambulance.”

And even being open all hours has its advantages.

“It’s nice,” he laughs. “Be­cause when you can’t sleep, you can always come in and see the team.”

Open all hours – patients’ stories

Feeding baby

A mother of three children aged under five called Healthline because her six-week-old was unsettled with diarrhoea. A nurse triaged the baby’s diarrhoea symptoms, gave care advice and, when discussing the baby’s feeding regime, discovered the mother had been crushing biscuits into the baby’s formula bottle at night to help the baby settle because she thought her baby was hungry. She had recently had a visit from the Plunket nurse and the baby was meeting developmental and growth expectations, but the mum had not discussed feeding.  The Healthline nurse discussed infant nutrition, how to increase breast milk supply and settling techniques, and suggested the mum talk to Plunket for more information around these topics and for more support. Staying on the line, the nurse was able to transfer the mum to PlunketLine, with an introduction and an explanation of the reason for the call.

Reassurance given
A young woman looking after a parent with a terminal illness rang Homecare Medical after hours wanting a GP appointment.  She was initially upset, with a fleeting idea of selfharm, secondary to stress and isolation. She spoke for some time about the issues at home. Reassurance was given and, with consent, it was suggested she may want to speak with a counsellor. She was happy to speak with a female counsellor, who advised formal counselling and a GP appointment. The caller gave reassurance that she felt safe.

Mental health meds
A woman contacted Healthline concerned about her husband who had recently been seen by an on-call GP regarding insomnia, emotional distress and panic attacks. He had taken diazepam and still hadn’t slept. She was anxious as she didn’t think she or her husband would cope without more medication or support. She was also aware there was no mental health service available over the weekend other than the crisis team. She felt her husband was safe and didn’t think the crisis team was appropriate. The crisis team number was provided in case she felt the risk had changed.  The nurse organised for one of the team’s mental health professionals to ring her back at a time suitable for her, after she and her husband had seen the on-call GP to sort out medications.

Gambling and meth
A woman phoned the Gambling Helpline to talk about her partner’s gambling.  During the conversation, it became apparent he was also a methamphetamine user. The call was managed by a mental health and addictions staff member without being transferred or signposted to another service.

Medication reaction

A caller to the Depression Helpline was experiencing postnatal depression. During the conversation, she explained she had been prescribed antidepressants by her GP and had since been experiencing burning and painful skin. The Depression Helpline mental health and addictions staff member supported her and then was able to have a Healthline registered nurse join the call to talk her through her physical concerns.

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