OBJECTIVE: To characterize the nature of telephone communication in the care of patients in skilled nursing facilities, noting numbers of calls, reasons for communication, and the outcomes of the interactions, and to implement a voice mail system to manage the burden of communication more effectively and describe the impact of this system. DESIGN: An archival descriptive study of phone message data covering a period of 1 year in a defined population of nursing home patients, with an intervention and an evaluation of a voice mail system at the conclusion of the year's study. SETTING: A long-term care practice associated with an urban family practice residency program. PARTICIPANTS: Medical care providers, the staffs of 13 skilled nursing facilities, and an average of 207 covered patients followed for 1 year. INTERVENTION: At the termination of the descriptive study, a voice mail system was instituted, and the impact on phone communication was documented. MAIN OUTCOME MEASURES: Total numbers of calls were tabulated by patient and by facility. Reasons for calls, outcomes, and timing were tabulated. The impact of a voice mail system on the communication between nursing home staff and medical providers was characterized. RESULTS: A total of 10,264 calls were received from 13 skilled nursing facilities in regard to an average of 207 continuously covered long-term care patients, which is an average of nearly 50 calls per patient per year. Acute illness accounted for only 5% of calls, and most communications were routine. Though a new treatment was instituted about one-third of the time, no new order was issued in response to 23% of received calls. Hospitalization occurred as the result of about one in two hundred calls. A recent tabulation of 692 calls received during 1 month revealed that 93% of calls are now received through voice mail and about one in five of these calls do not need to be returned. CONCLUSIONS: There is a significant telephone call burden associated with care of patients in skilled nursing facilities. Most of these calls are routine, regulation driven, and often no return call is necessary. For many reasons, including poor reimbursement, much of the medical care delivered occurs as a result of these calls, and methods of managing the communication burden to allow prioritization both by the staff nurse and the physician need to be found. In the practice described, the voice mail system is a positive step in this direction.
