Use of the telephone in a health maintenance service for the chronically ill: A preliminary report

J Chron Dis 1971, Vol. 24, pp, 489-494. Pergamon Press. Printed in Great Britain

USE OF THE TELEPHONE IN A HEALTH MAINTENANCE SERVICE FOR THE CHRONICALLY A PRELIMINARY REPORT*

ILL:

MAMIEKWOH WANC~and FREDERICT. KIRKHAM,JR.$ The Nursing Service and the Department of Medicine, Cornell University Medical Center, New York, N.Y. 10021, U.S.A. (Received 20 October 1970)

INTRODUCTION

on comprehensive health care shifts the management of many acute and chronic conditions to the ambulatory services. In 1969, of 7144 registered hospitals, 6041 hospitals reported 163,248,221 clinic visits by non-hospitalized patients [I, Table 33. Much of the traditional bedside observation, diagnosis, and care is now performed in outpatient clinics. Patients bear their stresses, whether physical or functional, in the clinics one day and in their own environment the next. The goal and magnitude of ambulatory service stimulates the staff toward developing a care delivery system which can reach the patients in their immediate environment. To monitor patients’ conditions and to extend care needed from the hospital clinics, public health nursing and extramural agencies function in a partnership that creates a health service milieu. If the patients’ progress, stresses, and coping patterns are to be brought into focus, effective communication is imperative. Such communication includes face-to-face interaction as well as that transmitted through written and other technological means. A number of studies have reported on the use of the telephone as an aid in diagnosis and prevention in patient care. Some of these were concerned with monitoring physical changes only [2, 31. The telephone as a medium for transmitting the sounds of children’s respiratory distress and mothers’ anxieties was reported by Kravitz et al [4]. A study conducted at the Children’s Hospital, Boston [5], analyzed the use of the telephone by low-income families. The findings demonstrated equal effectiveness among medically indigent and middle class families in the use of the telephone to communicate a child’s condition. Besides, such communication enhanced the on-going relationship between the families and the physician. In suicide prevention work 16-81, the emergency telephone number is frequently reported as EMPHASIS

*This project was supported

by the U.S.P.H.S.

Grant CHO0103-05.

tMrs. Mamie Kwoh Wang is Administrative Assistant in the Outpatient Research Fellow in the Division of Ambulatory and Community Medicine. *Dr. Frederic T. Kirkham is Clinical Associate Professor of Medicine. 489

Nursing

Service and

490

MAMIEKWOH WANG and FREDERICT. KIRKHAM,Jr.

the nucleus of the service. Skill and prompt response to the cries for help from potentially suicidal patients often constituted the significant aspect of such programs. Commercial enterprise such as the Care Ring Service, and many church- and privatelyorganized calling systems among the elderly, point to the comforting and reassuring value of telephone communication for certain segments of the population. This paper addresses itself on the telephone as a means of sensitive exchange between patients and health care personnel, and as an adjunct in effecting health maintenance service among the marginally ambulatory patients. It reports the use of the telephone by 26 chronically ill patients in a health maintenance service project in the general clinic of a large voluntary teaching hospital [9]. Objectives of this study are (a) to gather preliminary impressions of how patients and their advocates* utilize the telephone, and (b) to assess the relevance of such communication in the health maintenance care. BACKGROUND

The Health Maintenance Service was organized primarily to meet the needs of that segment of chronically ill patients who required periodic monitoring and coordinated care. Patient referral to the service could be initiated by any staff member, but must be endorsed by the patient’s attending physician. In this service, one clinical nurse, working with a panel of physicians, served as the primary health care contact to 26 patientst. Physicians and nurse functioned as co-managers; in response to the immediate needs of the patients, one or the other assumed the salient role. At intake, a letter describing the service arrangement and a telephone answering schedule was given to each patient. During a nine-month period, calls from 26 patients and their advocates were recorded. Intramural calls and those initiated by the nurse were not included. CHARACTERISTICS

OF PATIENTS

Table 1 presents the characteristics of patients in detail. The mean age of the group was 59.5 yr. All 26 patients were characterized by chronic conditions. Fourteen patients had at least four diagnoses each, among them four patients suffered 7-9 chronic illnesses. Although many patients expressed stress in traveling, all except one was able to come to the clinic by public transportation or by taxi. Their abilities in coping with basic needs, such as personal hygiene, nutrition, diversion, and their abilities in following the medical regimen, showed wide variation. FREQUENCY

AND

SOURCE

OF CALLS

Total number of calls from patients and their advocates was 204 (Table 2). Of these, 134 (66 per cent) were made by patients, 36 (17 per cent) by patients’ relatives or friends, and 34 (17 per cent) by the public health nurses from different agencies. Six patients never called directly. Five of these were men. However, their needs were communicated to the nurse on 31 occasions by their relatives and friends. *‘Advocates’ refers to those who assist in identifying the patients’ needs and in meeting such needs directly or indirectly. They include patients’ relatives, friends or nurses from the Public Health agencies. tPatient census varied from time to time because of transfer, admission and referral.

Use of the Telephone in a Health Maintenance TABLE 1. DISTRIBU~ON

Service for the Chronically 111

OF PATIENTS ACCORDING TO SEX, AGE, LIVING ARRANGEMENT, AREA AND NUMBER OF DIAGNOSES

Sex -

491

RESIDENTIAL

Residential area

8

Male Female

18

31% 69%

4 9 11 2

15% 35% 42% 8%

Yorkville area (Community surrounding Metropolitan New York New Jersey Eastern L.T.

7 27% the hospital) 17 65% 1 4% 1 40) /0

Age 20-39 40-59 60-79 80-90

Number of diagnoses

Living arrangement

8

Alone With spouse or relative Home for Aged

17 1

31% 65% 4%

12 10 4

l-3 4-6 7-9

46% 38% 16%

TABLE 2. SOURCE AND NUMBER OF TELEPHONE CALLS

Source of calls

No. of calls

Patients Relatives Friends Public Health Nurse

134 29 7 34

66% 14% 3% 17%

No. of patients

No. of calls

20 1 1 1 3

Under 10 lo-14 15-19 20-24 25 and over

77% 4% 4% 4% 11%

The highest number of calls related to any single patient was 46. Ranked in decreasing frequency were 27, 25, 22, 16 and 12. Calls from these six patients and their advocates accounted for 61 per cent of all incoming calls. The other 20 patients (77 per cent) made O-7 calls each. Illnesses and needs are perceived from different vantage points by public health nurses than by patients and their relatives. The 34 calls initiated by the public health nurses are not included in the following discussion. The total number of calls made by patients, relatives or friends was 170. Table 3 discloses that there is no consistent trend according to age. However, 19 of the 26 patients aged 50-90 yr made 94 per cent of all calls. The highest number of calls was made by two patients between 80-90 yr old. Patients living alone made four times as many calls as those living with relatives. TABLE 3. DISTRIBUTION OF CALLS FROMPATIENTS, RELATIVESAND FRIENDS BYAGEGROLPS

Total

Age

No. of patients

No. of calls

Calls per patient

20-29 30-39 40-49 50-59 60-69 70-79 80-90

3 1 3 6 3 8 2 26

5 2 3 62 6 51 41 170

1.7 2.0 1.0 10.3 2.0 6.4 20.5 6.5

MAMIEKWOH

492

WANG

and FREDERICT. KIRKHAM,Jr.

Women patients made an average of 7.3 calls per patient while most calls from men patients were made by their spouses or women friends. CONTENT

OF CALLS

FROM

PATIENTS

AND

THEIR

RELATIVES

OR FRIENDS

Telephone calls from the patients, their relatives or friends to the project nurse often provide meaningful information relevant to the patients’ physical and mental status. Table 4 presents the six major areas of patients’ concern. TABLE4.

TELEPHONECALLSBY MAJORAREASOF CONCERNAS EXPRESSED BY PATIENTS

IN HEALTH

MAINTENANCE

Concerns Physical symptoms Treatment regimen Confirming or rescheduling appointments Need for supplies Helping person(s) moved away, diseased, married or drafted Inability to cope, fear of disability and/or death Inaccessible to care facilities Inability to follow hospital procedures Stress related to living environment: Rent increase, dangerous neighborhood, eviction notice, inadequacies

SERVICE

No. of calls

Per cent

134

48

59

21

30

II

19

7

18

6.5

18

6.5

The total number of expressed concerns was 278. Reporting physical symptoms and clarifying purpose of the treatment regimen were their major preoccupation. These were discussed on 134 occasions (48 per cent). Ranked next in frequency were requests for drug supplies and confirmation of appointments (21 per cent). However, during a single telephone call, a patient often expressed more than one concern. His emphasis may shift from reporting his physical symptoms to the inordinate risks he encountered in his lonely or helpless way of living. It is of significance to note that among the 26 patients, four voiced concern over all six major areas. These four patients were among the six who made the highest number of calls to the nurse. Review of their physical and their socio-emotional status revealed that each of these four patients had experienced stress beyond that usually encountered by most other patients. All of them lived alone; their helping persons had departed from them either suddenly or recently and their socio-economic standard of living had been significantly modified by a series of events. In addition, their ability in self-care or in earning a living were progressively hampered by the degenerative processes of chronic illnesses. Living signified a precarious equilibrium, such that the increment of a minor illness could lead to major consequences [lo]. Increased telephone calls from these patients coincided with the periods during which they faced obstacles which threatened their life concerns. Three of these four patients died within ten months after compilation of these data. It seemed evident that they had perceived the limits of their own coping capacity in the face of possible crisis. Calls from these patients seemed comparable to the ‘cries for help’ described by Litman et al [7] in his observation of the suicidal patients.

Use of the Telephone in a Health Maintenance Service for the Chronically 111

493

A few telephone calls from patients were planned with the nurse. This was done when a patient’s condition showed change or when anxieties were evident. Reports from patients on their symptoms, test results, and general feelings, as well as those disclosed by their tone of voice, manner of speech and breathing patterns allowed the nurse to monitor their emotional reactions and their progress from time to time. Close query on drugs taken and drugs left in bottles helped to identify errors. Information so reported by patients facilitated early planning for home supervision, rescheduling of appointments, or for support.

DISCUSSION

Calls from the 26 patients disclosed a pattern of how patients used the telephone to communicate their needs to the nurse when such a medium is made available to them. The elderly and debilitated, in particular, expressed the opinion that access of the nurse through a single, dependable telephone number proved convenient and comforting. Besides, it provided a feeling that health care services would be available in time of critical need. Calls requesting clarification on tests, scheduled appointments and therapeutic regimen frequently gave insight to their confusion over the purpose and meaning of tests and therapies. Their questions supported Weinerman’s comment on the ambulatory services as a whole, that is, ‘the sum of the parts fail to equal the whole’ [ 1I]. This was brought out more clearly by patients who had to attend multiple clinics in the medical center, For them, interpretive and coordinating efforts from the nurse are of primary importance. Nurse initiated calls, though not included in this report, impressed us as one of the important means in effecting continuous and meaningful services to patients. Other insight gained is related to the functional relationship of physical degeneration, socio-emotional stress and patients’ coping capacity. With guidance, most of the 26 patients were able to maintain their social role in spite of their illnesses. However, when the degenerative processes of disease were accompanied by stress originated from patients’ immediate environment, their coping ability would degenerate. Crises result when coping fails. At such time, a little help, rationally directed, seemed more effective than extensive help given at other periods [12, 13). The nurse, having established a unique trusting relationship with these patients and their physicians was in the position to initiate intervening measures. Among the 26 patients, three patients made one visit each to the emergency service during the 9 month period. Two of the visits were by direction of the physician and the nurse, and one during the hours when the nurse was not available. Whether patients would have made more use of emergency and other services had the telephone been unavailable, cannot be verified by this report. Future research is necessary to assess this area. Effective use of the telephone required that the patient and key members of his family be well known to the physician and the nurse. A feeling for the patient’s threshold of concern and his ability in accurate reporting as well as full knowledge of his medical problems are necessary. Decisions made and instructions rendered over the telephone should be related to areas of responsibility appropriate for the member of the health team who responds to the call.

494

MAMIEKWOH WANG and FREDERICT. KIRKHAM,Jr. CONCLUSION

1. Telephone communication from 26 chronically ill patients with the nurse demonstrated its value as an important adjunct in providing maintenance care among marginally ambulatory patients. 2. The majority of calls helped to clarify the patient’s progress, appointment schedules, and their therapeutic regimen. Calls from the aged and debilitated patients, in particular, provided insight to their concerns over decreasing capacity to cope in their lonely and alienated environment. 3. The data suggest that when degenerative processes of patients’ chronic illnesses were accompanied by socio-emotional stress, frequency of calls and areas of concern increased. Content of such calls revealed that patients were perceptive about their critical status. 4. Accessibility of the nurse by telephone and the sensitive exchanges between the patients and the nurse facilitated efforts to provide care precisely at the crucial time of needs. REFERENCES 1. 2.

Hospitals, JAIL4 Hospital Statistics. 44 (15), 480, Aug. 1, 1970, Part 2 Levine IM, Jossmann PB. Turskv B et al: Telephone telemetry of bioelectric information. JAMA 188: 794, 1964 3. Barr N: Long-distance telephone technic is latest aid to diagnosis. Mod Hosp 91: 64, 1958 4. Kravitz H, Korach A, Murphy JB et al: Telephone in diagnosis of respiratory diseases. Am J Dis Child 106: 471. 1963 5. Heagarty MC, Robertson L, Kosa J et al: Use of the telephone by low-income families. J Pediat 73: 740, 1968 6. Litman RE: Emergency response to potential suicide. J Mich Med See 62: 68, 1963 7. Litman RE, Farberow NL, Shneidman ES et al: Suicide-prevention telephone service. JAMA 192: 107, 1965 8. Parks FM and Wolf D: Suicide Prevention Center in Chicago. Illinois Med J 133: 306, 1968 Wang MK: A Health Maintenance Service for the chronically ill patients. AJPH 60: 713, 1970 1’0: Estes EH: Health Experience in the Elderly. Behavior and Adaptation in Late Life. Chapter 6 (Busse EW, Pfeiffer E, Ed). Boston, Little, Brown, 1969 11. Weinerman ER: Yale studies in ambulatory medical care. IV. Outpatient clinic services in the Teaching Hospital. New Eng J Med 272: 947, 1965 12. Rapoport L: The state of crisis: Some theoretical considerations. See Serv Rev 36: 211, 1962 13. Huesey HE, Marshall CD, Lincoln EK et al: The indigenous nurse as crisis counselor and intervener. AJPH 59: 2022, 1969