1. Tennessee Oncology, Nashville, TN, and
MD Anderson Cancer Center, Houston, TX
DOI: 10.1200/JOP.2016.013698;
published online ahead of print at
jop.ascopubs.org on August 30, 2016.
Use of a Case Management System
to Reduce the Response Time for
Symptom Management Calls in a
High-Volume Practice
Natalie R. Dickson, MD, Larry E. Bilbrey, Pamela E. Lesikar, RN,
Laura W. Kaufman, MSN, RN, Linda F. Hays, RN, Ansley T. Tillman, RN,
Aaron J. Lyss, MBA, Martha J. Sarratt, MS, David W. Scrugham, Angi Sivakumar,
Kathy G. McGee, MSN, RN, and Jeffrey F. Patton, MD
There has been significant focus in recent
yearsonimprovingthequalityandpatient-
centered approach of medical oncology
caredeliverysystems.In 2013, theInstitute
of Medicine published its report Deliver-
ing High-Quality Cancer Care: Charting a
New Course for a System in Crisis,1
which
has stimulated significant growth in the
development of oncology medical home
programs focused on enhanced access
to care and patient experience. These
programs have established that timely,
appropriate management of symptom-
related calls is integral to the patient’s
experience.2,3
Tennessee Oncology is a community
oncology practice with 87 physicians and
35 midlevel providers in 33 locations. The
Saint Thomas West clinic (a participating
process improvement site) has five physi-
cians and three nurse practitioners, and it
manages 5,000 unique patients annually.
This clinicreceives 350 to 400 calls per day.
The clinic lacked an effective process to
appropriately categorize or prioritize in-
coming telephone calls from patients or
to address symptom management calls
according to evidence-based protocols.4
The lack of these processes led to delays
in addressing symptom management calls
appropriately or in a timely manner, as
detailed in staff focus groups and patient
surveys, as well as to potential increases in
hospital and emergency department visits.
We approached this problem by map-
ping our process of telephone triage,
organizing focus groups throughout the
clinic, and brainstorming with our project
team. Areas of opportunity were identified
in the following: processes and technology;
patient and staff education; physician is-
sues; and staffing. We concentrated on the
number of staff tasked with addressing
symptom management calls, as well as on
the development of software that could
prioritize calls and allow the nurse to ad-
dress the calls as guided by evidence-based
protocols. We assumed that these inter-
ventions would have the greatest impact
on response time.
The aim of the project was to increase
the percentage of symptom management
calls that receive a clinical intervention
within 2 hours from 54% to 80% by
September 2015.
Baseline data were collected using a call
logthatwascompletedbytriagenursingfor
the week of April 20, 2015, for 159 calls
to triage nursing. Among the 22 symptom
management calls, only 12 (54%) were
answered within 2 hours (Fig 1). Baseline
secondary data collected during the same
period detailed the purpose of every call
routed to triage nursing. This identified
Copyright © 2016 by American Society of Clinical Oncology Volume 12 / Issue 10 / October 2016 n jop.ascopubs.org 851
Special Series: Quality Care Symposium PRESENTATION SUMMARY
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2. 56 nonclinical calls that were deemed inappropriate for nursing,
which accounted for 35% of the triage calls received (Fig 2).
A multidisciplinary team composed of a physician, nurses,
and operations/clinic managers placed all possible interven-
tions in a priority pay-off matrix. High-impact changes with
ease of implementation included the following: changing the
daily call process to assign a telephone operator; combining
the roles of the triage nurse and the care coordinator in order
for two people to address symptom management calls; and
redesigning the automated telephone tree to allow staff
to answer calls in lieu of voicemail. High-impact changes
that were more difficult to implement on the basis of time
and cost included the following: creating evidenced-based
triage protocols using Oncology Nursing Society guide-
lines; expanding the patient portal access; and using client
relationship software as a case management system.
Forthesubsequent4-monthperiod(ApriltoAugust2015),
primary data were retrieved from the electronic health record
(EHR), telephone system, and case management system by
the application support team. An internal, trained process
improvement specialist with a master’s degree performed a
retrospective data sampling using the telephone system and
the EHR reporting capabilities by cross-referencing the caller
identification data with the EHR patient demographic data;
only symptom management calls documented within the
EHR were included. Twenty-nine percent (202 of 691) of
symptom management calls were identified for the sample.
The time from the symptom management call to clinical
intervention was determined from the time a call was placed
in the telephone system to the close-out stamp on the triage
questionnaire in the EHR.
On July 1, 2015, telephone triage process changes, training
on the case management system for the operator and care
coordinators, and a relaunch of the patient portal were imple-
mented. On August 17, 2015, the case management system and
evidence-based symptom management standing orders were
implemented. Follow-up primary and secondary data were
collected daily and electronically for 6 weeks (from August to
September 2015) using the case management system. Of the
calls routed to triage nursing, 100% were captured in the case
management system;callresponse time and call purpose were
recorded.
The primary outcome measure was the percentage of calls
that received clinical intervention within 2 hours. The pop-
ulation included all patients who called for symptom-related
issues; the numerator was the number of calls with clinical
intervention within 2 hours; and the denominator was all
symptom management calls received. The secondary process
measure was the percentage of calls that were inappropriately
routed to the triage nurse. The population included all calls
referred to the triage nurse; the numerator was the number of
inappropriate calls routed to the triage nurse; and the de-
nominator was the total number of calls routed to the triage
nurse.
The data show the weekly percentage of symptom man-
agement calls that received a clinical intervention within
30
28
26
24
22
20
18
16
14
12
10
8
Mean
6
4
Goal2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Hours
Number of Calls
FIG 1. Baseline data: Time from symptom management call to intervention.
852 Volume 12 / Issue 10 / October 2016 n Journal of Oncology Practice Copyright © 2016 by American Society of Clinical Oncology
Dickson et al
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3. 2 hours (Fig 3). A baseline mean was calculated at 48% and
was recalculated at the times of our interventions. There
was an increase in the mean from 48% to 68% after staff
changes on July 1, 2015, and from 68% to 73% after im-
plementation of the case management system on August
17, 2015.
During the baseline observation period (April 20 to 24,
2015), 35% (56 of 159) of calls routed to the triage nurse were
inappropriate nonclinical calls. After the implementation of
the case management system, the percentage of nonclinical
calls routed to the triage nurse was , 1% (three of 643 calls).
A notable discovery was that the number of calls that were
addressed beyond 2 hours were mostly attributed to a delay in
physician response.
Efficient and effective telephone triage exemplifies a
patient-centered initiative that can improve outcomes and
patient experience in value-based reimbursement programs,
such as the Center for Medicare & Medicaid Service’s
60
55
50
45
40
35
30
25
20
15
10
5
0
Nonclinical
Calls
Medication
Refill
Symptom
Management
Laboratory
Questions/
Test Results
Medication
Instructions
Paperwork
(FMLA, PA,
etc)
Referrals Pretest
Instructions
NumberofCalls
FIG 2. Diagnostic data: Categorized calls. FMLA, Family Medical Leave Act; PA, preauthorization.
Upper control limit
Mean
Lower control limit
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
4/20/20154/27/20155/4/20155/11/20155/18/20155/25/20156/1/2015
6/8/20156/15/20156/22/20156/29/20157/6/20157/13/20157/20/20157/27/20158/3/20158/10/20158/17/20158/24/20158/31/20159/7/20159/14/20159/21/2015
Date
PercentofCalls
FIG 3. Symptom management calls receiving clinical intervention within 2 hours (p chart, 3 sigma).
Copyright © 2016 by American Society of Clinical Oncology Volume 12 / Issue 10 / October 2016 n jop.ascopubs.org 853
Presentation Summary
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Copyright © 2016 American Society of Clinical Oncology. All rights reserved.

4. OncologyCareModeland comparablecommercialprograms,
and what our company believes is good medical practice.5
In this improvement project, the percentage of symptom
management calls that received a clinical intervention within
2 hours increased from 54% in April 2015 to 73% in September
2015 with the use of the case management system and reallo-
cated clinical staff. The number of nonclinical calls that reached
the triage nurse decreased sharply with the new process.
Reallocating our triage nurse and care coordinator, which
allowed for two nurses to handle symptom management calls,
not onlydecreased the amount of time taken toaddress symptom
management calls but increased nurse job satisfaction. The case
management system has provided the management team with
the ability to analyze many aspects of each call, which has led to
the discovery of other opportunities not associated with triage.
Additionally,thephysiciansare ableto spend more timefocused
on patients in the clinic as a result of the efficiencies gained.
Actualcostsassociatedwiththisprojectwerelimitedtothe
purchase of a customer relationship system (ie, enterprise
software to help manage customer data and interaction) and
thedevelopmentofthesoftware.Thesecostswerefullyfunded
by Tennessee Oncology with no outside assistance. Realloca-
tion of front office and nursing staff at the project clinic avoided
the costs of hiring additional employees.
The initial primary data were limited by the reporting ca-
pabilities of the EHR and telephone system. The systems were
not integrated; therefore, compiling and analyzing data required
manual intervention. Due to the limitations of the systems, a
samplewasusedfromtheprimarydatageneratedbetweenApril
and September 2015. After the case management system was
implemented, we were able to capture all data.
To sustain the improvements at the participating clinic,
trainingon the new processes was provided for all of the nurses
and front office staff. Triage policy and procedures were
updated, and a weekly performance report was created and
shared by the management team. The project results were
presented to staff at the participating clinic, the Board of
Governors, and the larger practice via newsletter and Chief
Medical Officer’s Bulletin. These changes and results were
favorably received by clinical staff and administrators. The
process changes and implementation of the case management
system were rolled out to the rest of the practice and com-
pleted by July 1, 2016.
Further process changes are needed to achieve additional
gains. Changes in physician workflow are expected to further
shorten response times for symptom management calls. This
illustrates the importance of engaging all parties involved in
process improvement.
Acknowledgment
The production of this manuscript was funded by the Conquer Cancer
Foundation Mission Endowment. Research support provided by ASCO Quality
Training Program. Presented at ASCO Quality Care Symposium, Phoenix, AZ,
February 26, 2016.
Authors’ Disclosures of Potential Conflicts of Interest
Disclosures provided by the authors are available with this article at
jop.ascopubs.org.
Author Contributions
Conception and design: Natalie R. Dickson, Larry E. Bilbrey, Pamela E.
Lesikar, Laura W. Kaufman, Linda F. Hays, Ansley T. Tillman, Aaron J. Lyss,
Kathy G. McGee, Jeffrey F. Patton
Administrative support: Larry E. Bilbrey
Provision of study materials or patients: Larry E. Bilbrey
Collection and assembly of data: Larry E. Bilbrey, Martha J. Sarratt,
David W. Scrugham, Angi Sivakumar
Data analysis and interpretation: Larry E. Bilbrey, Martha J. Sarratt
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
Corresponding author: Larry E. Bilbrey, Tennessee Oncology St Thomas West,
4220 Harding Pike, S&E Building, Suite 200, Nashville, TN 37205; e-mail:
lebilbrey@tnonc.com.
References
1. Levit L, Balogh E, Nass S, et al (eds): Delivering High-Quality Cancer Care:
Charting a New Course for a System in Crisis. Washington, DC, National Academies
Press, 2013
2. Sprandio JD: Oncology patient–centered medical home. JOP 8(no. 3S):47s-49s,
2012
3. Waters TM, Webster JA, Stevens LA, et al: Community oncology medical homes:
Physician-driven change to improve patient care and reduce costs. JOP 11:461-467,
2015
4. Hickey M, Newton S: Telephone Triage for Oncology Nurses. 2nd Ed. Pittsburgh,
PA, Oncology Nursing Society, 2012
5. Kolodziej M: Oncology care delivery reform: Carpe diem. JOP 11:468-469, 2015
854 Volume 12 / Issue 10 / October 2016 n Journal of Oncology Practice Copyright © 2016 by American Society of Clinical Oncology
Dickson et al
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Copyright © 2016 American Society of Clinical Oncology. All rights reserved.

5. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Use of a Case Management System to Reduce the Response Time for Symptom Management Calls in a High-Volume Practice
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are
self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript. For
more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.
Natalie R. Dickson
Employment: Tennessee Oncology
Leadership: Tennessee Oncology
Stock or Other Ownership: RainTree Oncology Services
Larry E. Bilbrey
Employment: Tennessee Oncology, Sarah Cannon Research Institute (I)
Stock or Other Ownership: Hospital Corporation of America (I)
Travel, Accommodations, Expenses: Tennessee Oncology, Sarah Cannon
Research Institute (I)
Pamela E. Lesikar
No relationship to disclose
Laura W. Kaufman
No relationship to disclose
Linda F. Hays
No relationship to disclose
Ansley T. Tillman
No relationship to disclose
Aaron J. Lyss
Employment: Tennessee Oncology
Martha J. Sarratt
Employment: Tennessee Oncology
David W. Scrugham
No relationship to disclose
Angi Sivakumar
No relationship to disclose
Kathy G. McGee
No relationship to disclose
Jeffrey F. Patton
Consulting or Advisory Role: Cardinal Health, Amgen, Johnson &
Johnson, Tsaro, Pfizer, Gilead Sciences, Boehringer Ingelheim
Copyright © 2016 by American Society of Clinical Oncology Volume 12 / Issue 10 / October 2016 n jop.ascopubs.org
Presentation Summary
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Copyright © 2016 American Society of Clinical Oncology. All rights reserved.