Telehealth Triage Nursing and Telemedicine: Joining Forces for Improved Care Delivery in a Primary Care Setting

Review Article

Austin J Nurs Health Care. 2017; 4(1): 1036.

Telehealth Triage Nursing and Telemedicine: Joining Forces for Improved Care Delivery in a Primary Care Setting

Lee MR¹*, Ruehmann LL¹, Dively-White MT¹, Mathsen RL¹, Johnston JM¹ and Jensen TB²

¹Department of Nursing, Mayo Clinic, USA

²Department of Family Medicine, Mayo Clinic, USA

*Corresponding author: Lee MR, Department of Nursing, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, USA

Received: March 21, 2017; Accepted: April 12, 2017; Published: April 20, 2017


Changes in the United States’ system of providing health care are evolving from the health of individuals to population health management. More care is provided through non-visit care such as internet portals and telehealth triage. The following is a description of the telehealth triage system for ambulatory primary care at the Mayo Clinic, Rochester, Minnesota, which is based on a team model for community care. We describe the roles of members of the team, including the pivotal role of the telehealth triage nurse in collaboration with the Secondary Triage Additional Resource (STAR) providers in providing care while improving access and reducing emergency department visits. Telehealth nursing is a subspecialty of ambulatory care through the American Academy of Ambulatory Care Nursing and the American Nurses Association.

Keywords: Telehealth nursing; Telehealth triage; Primary care triage; Triage algorithms; Telehealth protocols; Team based patient care


STAR: Secondary Triage Additional Resource; AAACN: American Academy of Ambulatory Care Nursing; ANA: American Nurses Association; RN: Registered Nurse; ECH: Employee and Community Health; APRN: Advanced Practice Registered Nurses; PA-C: Certified Physician Assistants; LPN: Licensed Practical Nurses; DST: Decision Support Tool; PAC: Patient Appointment Coordinator; MMoCC: Mayo Model of Community Care; PHM: Population Health Management; PCC: Patient Care Connection; POD: Provider of the Day


The United States’ health care system is constantly evolving. Our focus is changing from the health of individuals to management of entire populations of patients. As the demand for affordable, highquality health care is on the rise across our nation, primary care organizations are challenged to create new, more efficient ways to deliver patient care. Reimbursement models and reduced access to a limited number of providers has led to the use of non-visit care, including internet portals for patients to access their care team to ask questions, obtain prescriptions, and communicate test results. Telehealth care has developed since the 1970’s as a quality, costeffective way to provide care to more patients, especially after regular clinic hours. Telehealth care reduces the off hours call burdens to the providers in primary care and visits to the local emergency departments. The use of triage tools provides consistent information and recommendations. The long-standing telehealth goal of ensuring the right patient receives the right level of care at the right time with the right provider is foundational to controlling the escalating cost of health care. Expanding the use of technology in health care delivery holds a promising solution [1-3].

Telehealth nursing is now a nursing subspecialty of ambulatory care through the American Academy of Ambulatory Care Nursing (AAACN) and the American Nurses Association (ANA) [2]. We will describe our institution’s current model for providing telehealth care to our employees and community through a population health management model.


In 2012 the process for a comprehensive redesign of our triage model of care delivery began. Our goal is to provide timely, safe, reliable, effective telephone triage for our patients. A multidisciplinary workgroup including front-line staff, nursing leadership, providers and administration identified four initiatives: call distribution (auto attendant), virtual centralization, complex patient care and secondary triage. The call distribution is intended to ensure the patient’s calls are appropriately triaged, scheduled and or resolved. Virtual centralization provides efficiency by utilizing telehealth triage RNs at different locations to answer phone calls within the primary practice. The complex patient program implements a reliable process for the management of complex patient care needs within the care team. The Secondary Triage Additional Resource (STAR) provider program uses a secondary provider covering all sites while maintaining RN autonomy. The initiative that we would like to explain in further detail is the STAR provider program.

Mayo Clinic’s primary care department, Employee and Community Health (ECH), embarked on a unique partnership between the telehealth triage RNs and primary care providers in November, 2014. Combining the expertise of the telehealth triage RNs with the provider’s clinical skill and knowledge has successfully expanded the services of the telehealth triage system to provide more non-visit care and patient centered advice beyond the triage algorithm tools.

STAR providers are staff physicians, Advanced Practice Registered Nurses (APRN) and Certified Physician Assistants (PAC) who are virtually available to the telehealth triage RNs to provide assistance with patient dispositions, pre-visit care or non-visit care. Family Medicine Providers are able to provide assistance for patients across the age continuum, while Internal Medicine Providers serve adult populations. The STAR provider’s primary responsibilities are to assist with level of care decisions, provide non-visit care, and assist with managing access challenges. It has been well received by patients, nurses, and providers.

Practice Demographics

Our primary care practice consists of seven clinics within a 15 mile radius in southeastern Minnesota. As a community practice, patients live within a 30 mile radius. Each clinic includes Family Medicine, Internal Medicine, and Pediatric and Adolescent Medicine divisions. As a teaching facility, three of our sites host a Physician Residency Practice. There are 308 providers (MD, APRN, PA-C, and resident physicians), 430 nurses (RN, LPN), and approximately 154,000 empaneled patients.

The telehealth triage RNs are virtually centralized, answering calls from all seven primary care clinic locations, serving patients of all age populations. There are 54 telehealth triage RNs with a designated full time equivalent of 34. There were greater than 152,000 calls managed by telehealth triage RNs in 2016. Staff is scheduled to work load, adjusting staffing numbers based on highest call volume times of the day. There are approximately 21 STAR providers who have dedicated time to the role in four hour increments. This results in approximately 1.0 to 2.0 full time provider equivalents.

The telehealth triage RNs are within Mayo Clinic’s Department of Nursing and are supported by a Medical Director, Nurse Administrator, Nurse Manager, Nursing Education Specialist (NES) and Telehealth Nurse Coordinator. The Telehealth Nurse Coordinator assists with the orientation process for new hires, but has a primary focus of maintaining the integrity of the program. To ensure patients receive high quality, safe telephonic care, the coordinator provides routine and targeted call monitoring, including documentation review. Coaching and mentoring new and seasoned staff is an important part of the coordinator’s role.

Decision Support Tool (DST) and Algorithms

Mayo Clinic’s Primary Care Ambulatory ECH Practice supports the clinical needs of patients by offering access to experienced registered nurses during business hours to assist with safe, efficient disposition recommendations. The telehealth triage RNs use an electronic Decision Support Tool (DST) built on a binary logic system to guide them through a network of sophisticated, evidence-based algorithms. The algorithms are designed to complement the critical thinking skills of experienced telehealth triage RNs to provide a comprehensive, efficient assessment of the patient’s acute symptoms. The DST delivers a suggested disposition for the patient including: ambulance, emergent care, urgent care, acute appointment, routine appointment, provider advice, or home care. The RN embraces a holistic approach by considering the patient’s medical history and current symptom pattern before agreeing or disagreeing with the system recommendation. The nurse may change the endpoint of the DST to either a more or less acute intervention.

The integrity of the system is maintained with continuous review by the Triage Algorithm Review Board, which is a multidisciplinary team, with front-line telehealth triage RNs heavily involved. They identify system revisions needed and test for accuracy after any changes have been made. Specially trained RNs make the desired edits to the DST system, and everyone on the team is involved with reviewing the most current evidence-based literature.

The successful pairing of experienced registered nurses using the DST to guide the most appropriate disposition for the patient, based on the nurse-patient interaction, has proven to provide safe, timely care. However, as the climate of healthcare provision evolves, patients are accessing the services of primary care with increased complexity of their healthcare needs, often complicated with underlying chronic conditions. The trend of increased patient acuity coupled with the demand for non-visit care by “healthy” patient populations creates new challenges for telehealth nursing.

The STAR provider adds another layer of expertise to the nurses’ knowledge and use of the DST. The telehealth triage nurse can contact the STAR provider by phone for any question or concern. Each STAR provider for Family Medicine and Internal Medicine is located at another site and uses the same type of telephone system as the PAC and telehealth triage RNs. Most of the sites have access to an electronic display board showing triage RNs and STAR providers who are currently logged into the system. The boards provide a constant visual of which nurses are on a call, who is available for the next call, and who is taking a break. This improves efficiency and yields statistics that help with staffing and service improvements. The STAR provider makes recommendations for additional advice for the patient, orders pre-visit tests to expedite office visits, may prescribe medication for patients who fall out of RN treatment protocols, assist with routine medication refills and may conference call with the patient and nurse for additional information and recommendations. Use of the STAR has improved the safety and dispositions of our increasingly complex patient population. It also has reduced emergency department visits, reduced the online portal messages to the care teams and helped ECH provide half of our patient care as non-visit care.

Process Flow

The flow of the ECH telephone triage is seen in Figure one. The calls are sorted into emergent, complex care patient, care coordinated patient and routine appointments. Patients needing forms or administrative information are routed to the secretaries. Those with acute issues are triaged by the telehealth triage RN and those needing routine appointments are directly scheduled (Figure 1).