By Freda Hawver Pachter  

An older man called the Colorado Medicaid Nurse Advice Line. He wanted to talk about a rash on his body, but the experienced nurse who answered the call, Jennifer Hogestad, was having a difficult time understanding him.

She asked the man if anyone else in his home was available to talk. A woman got on phone and confirmed that she, too, couldn’t make sense of what he was saying.

Hogestad jumped into action fast. She had previously worked for several years in a hospital Emergency Department and realized that the man’s garbled speech was a possible sign of a stroke. Getting stroke victims immediate help can dramatically improve survival rates and decrease complications. Hogestad urged the man and woman to immediately call 911, then followed up minutes later to ensure that an ambulance was on its way. The man’s call to a nurse may have saved his life.

Colorado’s Medicaid program, now known as Health First Colorado, provides health coverage to low-income Coloradans and people with disabilities. Through the Affordable Care Act, the Medicaid program has expanded to cover more Coloradans, bringing health insurance to at least 400,000 additional people and helping to reduce Colorado’s uninsured rate from nearly 16 percent in 2011 to 6.7 percent in 2015. Along with the Children’s Health Plan, Colorado’s Medicaid program now covers more than 1.3 million Coloradans, nearly one in four state residents.
While health care costs for private insurance have steadily increased over the past several years, Colorado Medicaid managers have reduced the costs per client even as the caseload has nearly doubled since the 2011-2012 fiscal year.  The success of Colorado’s Medicaid expansion has won unlikely supporters, including Republican U.S. Sen. Cory Gardner, who joined three other Republican U.S. Senate colleagues this spring to fight repeal efforts that would undermine Colorado’s Medicaid expansion.

“We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services,” Gardner and his colleagues wrote.

One of the little-known programs within Colorado’s Medicaid program is the Nurse Advice Line, a free service to Medicaid members provided by a team of nurses at Denver Health.

A recent study based on six months of calls from late 2015 through early 2016 found that the Nurse Advice Line helped divert many callers from unnecessary trips to the Emergency Department (ED). About half of callers who planned to go to the ED received advice not to go. In addition to gauging the patients’ intent, the study also tracked the patients’ choices after the call. Researchers found that 73 percent of callers who thought they needed to go to the ED, but received advice from a nurse to seek a lower level of care, complied with that recommendation. At the same time, researchers were surprised to find that when nurses advised patients to seek emergency care, they followed that advice just 54 percent of the time. Managers plan to continue studying patient behavior so they can urge patients to make the healthiest decision — whether that means staying home or rushing in for care.

The Nurse Advice Line is available to clients around the clock, every day of the year. It works especially well because nurses garner such high levels of trust from people. For 15 years in a row, nurses have ranked at the top of the Gallup Poll of professions for their trust and ethics.

“Nurses rank higher than doctors and clergy members,” said Michelle Miller, chief nursing officer for Health First Colorado. “You have this non-judgmental, trusted third party. They’re going to give you their opinion on what you should do.

“The caller will describe a condition like a fever or abdominal pain. The nurse will ask what they think they need to do. Then the nurse goes through the triage,” Miller said.

In addition to years of experience themselves, the nurses use the doctor-authored Thompson & Schmidt Triage Protocols that allow them to search over 600 symptom-related guidelines and walk through relevant questions to come up with the right level of care for that client.

Jennifer Hogestad said she also benefits from the knowledge of her fellow nurses. They work together in a call center near downtown Denver. If she receives a call about a condition with which she is less familiar, she can immediately send a message to fellow nurses while continuing to counsel the patient. Or, if a call should go to the Rocky Mountain Poison and Drug hotline, which is also housed at Denver Health, the nurses can re-route the call there and vice versa.

Currently, only about 3 percent of Health First Colorado clients use the Nurse Advice Line. Managers are eager to boost use for people who need medical advice. At the same time, they face a challenge with some clients calling about non-medical issues, like where to fill a prescription.

Erin Collins, who manages the Nurse Advice Line for the state, said that when people call about non-medical advice, technicians try to take advantage of the time by giving useful referrals and dispensing timely advice. For instance, if a parent calls about a non-urgent issue, the nurse might go over critical vaccination schedules or make sure the child has appointments set with a primary care provider.

“We want to quickly help them get to a better resource,” Collins said.

Better care coordination is a priority for all Health First Colorado members. To enhance follow-up, Nurse Advice Line managers can share advice they’ve dispensed with primary care providers.

“If a parent calls at 9 p.m. and says, ‘my child is sick,’ the nurse may advise them not to go to the ER, but to make an appointment first thing in the morning. What we’re doing now is sending that call information to (care managers),” Collins said.

The Nurse Advice Line can be vital for parents and children alike.

Sharla Gallegos, RN Program Manger at Denver Health, recalls answering one call when two boys called about a parent who was on the floor and not breathing. The boys had found the 800 number on the back of their mom’s Medicaid card. Gallegos was able to immediately send an ambulance to the home.

For parents, fevers spur many calls.

“We can help decipher many severe symptoms,” Hogestad said.

Often, home care can be the best treatment for a fever.

But there are times when a child should get help right away.

“When a child is severely ill, sometimes they won’t be able to touch their chin to their chest. Nursing judgment is essential,” Gallegos said.

Typically, when people call for advice, they are under stress and the nurses know it’s hard for callers to listen to all the advice. That’s why the nurses follow up with encrypted emails that provide advice in writing.

“Research shows there’s a better chance of callers following and remembering what you have said when you have advice in writing and you’ve calmed down a bit,” Gallegos said.

Even if a patient has a gut feeling that it’s OK to stay home, the opportunity to easily get a second opinion can be very reassuring.“You have someone who can very quickly give you expert advice on the right level of care,” Miller said. “It comes from someone you trust. It’s 24/7. It doesn’t matter where you live. And it’s free to clients and it’s saving the Department and taxpayers money.”

Added Josh Rasmussen, spokesperson for Denver Health: “It’s good for the patients, good for the providers and good for the system.”