Telephone health assessments can be a useful way to provide a fast and effective OH service. Catherine Darcy-Jones and Anne Harriss look at good practice, in the third and last in a series on management reports in occupational health.
Occupational health as a speciality has had to respond to the changing face and demands of business, especially with the cost of long-term sickness absence (LTS) impacting on businesses’ financial bottom line. There is increased pressure on agreed sickness key performance indicators (KPIs) for OH to have assessed the employee and given the advice in a written format within a quicker time frame.
LTS absence and its costs have a huge impact on businesses. In 2014, sickness absence equated to an average of 2.8% of working time per year (6.5 days) per employee costing £11-16 billion. Prevalence of sickness absence was noted as being higher within the public sector than the private sector. In 2015 alone, long-term absence equated to £1 billion in the manufacturing sector (EEF, 2015).
This focus has gained increased importance when it comes to the services OH provides, as practitioners respond to business demands and become more aware of the commercial pressures placed on them to deliver added value.
One way to address this increased business pressure is to move away from the more traditional face-to-face assessment typically carried out by OH advisers to offering telephone assessments for advice. It can be argued that this is a more efficient use of an OH adviser’s time as it means you can deliver more assessments over the telephone than face to face.
Clinical information entered on to standard templates for both clinical notes and reports reduces the wait for a separate administrator to type up a dictated report. If a face-to-face assessment is required, the telephone assessment acts more like a triage service and the assessment can be progressed on to this, therefore more effectively using the diminishing OH adviser resource.
More than 80% of a diagnosis is formulated from the clinical history taken (Gray and Toghill, 2000), but there is growing evidence that this history can be gained just as effectively through a telephone assessment as it can through the traditional face-to-face approach (Burton et al, 2013).
There are common concerns linked to telephone assessment from all parties – the employer, the employee and the OH adviser – but if the telephone assessment is carried out within an evidenced-based format, it can successfully address all or some of the OH needs.
How should a telephone health assessment be conducted?
The OH adviser must have the skills to enable the employee to discuss their health symptoms and issues with someone that they have never met and cannot see. Therefore, it is important that the initial contact with the employee is professional, with all the necessary checks surrounding employee identification and consent carried out as per NMC guidance.
Especially important is that the employee is in an environment where they feel comfortable to talk on the telephone about confidential health matters. They should be expecting the call within a designated appointment time frame, so calling the employee within this parameter goes some way to reducing the anxiety of receiving a call.
The skill in carrying out a telephone appointment is to gain a quick rapport with the employee. However, as the time for the assessment will be allocated in your diary, it is important to establish early boundaries in regard to time allocation for the appointment.
This can be done by informing the employee of the process the assessment will follow, including the time frame, outlining all the areas you will cover so the employee is confident that you will be taking all the factors into consideration.
It is the OH adviser’s role to guide the employee through the assessment process at a steady pace and in an empathic way, with the disclosure of personal information, but keeping the focus on the OH aspect of work and health. One of the most difficult aspects of a telephone consultation is keeping the employee on the point you are discussing and to move them on when you have gained enough clinical information to make your decision.
For some employees, talking during a telephone assessment can be cathartic so it is the role of the practitioner to make them feel listened to while directing them on to the next set of questions. It may be beneficial to time check with the employee half way through the appointment, informing them of the time left for the assessment. This will assist with keeping the discussions and answers focused.
What tools are there to help?
Occupational health, unlike other forms of diagnosis, relies 100% on assessing an employee’s functional capability with regards to the impact of work on health and health on work. As with any OH assessment, it is good practice in telephone consultations to use a set of evidenced-based tools against which you conduct your assessment. These should cover both musculoskeletal and mental health tools and include a system, such as the flag system, to easily identify any causes for concern. There are plenty of evidence-based tools to use (Anderson and Cocchiarella, 2009; American Medical Association, 2011). The Patient Health Questionnaire (PHQ-9) is particularly useful for assessing depression.
Such tools allow the OH adviser to make a judgement call as to whether or not they can continue to assess the employee over the telephone, or if the case needs to be progressed to a face-to-face appointment or moved to an appointment with an occupational physician. Whichever situation arises, that means the telephone method is not adequate to assess the employee further, consent for this forward assessment should be gained during the telephone conversation and clearly documented in the clinical notes.
The style of questioning is key to obtaining the most appropriate information from the employee to make your clinical decision. There should be a mixture of closed and open questions.
There is caution attached to the open style of questioning as this may allow employees to talk at length, and although you want to gain as much information, it is advisable to bring the employee back to the next question once you feel sufficient information has been gained.
This boundary is easier in a musculoskeletal case than a mental health case, but the skill is to recognise within a mental health case if counselling is a more appropriate forum for the employee to talk and progress to this. The telephone assessment in this way can be viewed as a signpost to ensure the employee is progressed to and receives the most appropriate input for their health situation.
What are the advantages and disadvantages of telephone assessments?
As with any system of work, there are advantages and disadvantages to be considered on different levels, from the OH practitioner’s perspective, and the employer and the employee’s point of view.
For the OH practitioner, a telephone assessment could be seen as advantageous, bringing an element of convenience to the role. This could include working from home, although an efficient IT system and clinical back-up to check decision making is a necessity.
Systems such as writing straight into templated clinical records and reports will ease the administrative side of telephone assessments for a company and ensure a standard assessment approach for the customer. If this is used, there needs to be a robust IT system that allows safe transfer of data under the Data Protection Act 1998 to enable the clinical report to be sent securely to the employee’s manager.
Working in this way would incur less travel costs to the company and is therefore more cost effective from a business perspective. One could also argue that the nature of telephone health assessments would enhance an OH practitioner’s communication and questioning skills when talking with a client to enable all the relevant information to be obtained during the assessment.
However, working in this way can be lonely and isolating for the practitioner. It is essential the appropriate clinical support is in place if assistance is needed on a decision to be made or to discuss a clinical position with another colleague.
Employers using telephone assessments may find there is a quicker turnaround in delivering clinical reports to the customer, therefore meeting or even exceeding expectations of the agreed OH service. This enhances customer satisfaction with a quicker turnaround for the KPIs and less waiting time for the OH appointments. It also means that if the employee is not at their home address then an OH assessment can still take place and the timely advice can be sent to the referring manager.
The quicker delivery of an OH service will have a knock-on effect on the customer’s budget as they are able to implement the OH advice quicker because they have received the clinical report on the day of the appointment and they can reduce the financial cost of LTS on their bottom line.
Where the OH referral has been made on a proactive basis, it can also be more cost effective for the employer as the employee does not have to have time away from work to gain OH advice. The employee can take a call during work time if they can talk in a quiet confidential environment. Working in this way means that OH is being appreciative of and responsive to changing business needs.
For the employee, the impact of a telephone assessment would mean less travel to OH appointments, either in or out of work time. Although some employers may offer transport to assist employees attending OH appointments, on the whole, many employees have to organise this themselves, and there may also be the cost factor of attending the appointments while on sick pay that affects attendance.
Employees will find that it is often more convenient to choose and fit an OH appointment into their day around existing medical appointments or when they are functioning best in the day. They are more likely to attend if they have a mobility issue or have a workplace stress issue restricting their perceived ability to cross the workplace threshold.
When would you not use a telephone assessment?
There are situations where the telephone is not the most appropriate form of assessment. These could include where there is the need for a physical examination or if there is a difficulty in understanding the employee over the telephone. The employee may also need an interpreter or a signer to assist their understanding of the assessment.
It could be that consent for the telephone assessment is refused at the outset of the appointment or at the point of referral by the manager. It must be remembered that if consent is refused, the employee may be happy to attend a face-to-face assessment instead.
One of the main clinical reasons a telephone assessment would not be appropriate would be where there is an inconsistency in the clinical reporting from the employee. As an OH practitioner you are aware of many of the causes, as well as treatment and recovery, of clinically treated conditions.
During any assessment, there is an unconscious reference between the employee’s treatment for their presenting symptoms and recovery and the standard treatment and recovery of such conditions. If during the telephone assessment it becomes apparent there is a vast difference between the two then it would be necessary to meet in person to allow an OH adviser to assess with sight as well.
A telephone assessment is only as good as the questions asked, and if the appropriate information cannot be gained to give a sound clinical decision, then the further medium of visually assessing how someone is walking, sitting or standing may be required.
There is a place for telephone assessments, as in other areas of health care such as cognitive behaviour therapy, GP appointments, and physiotherapy assessments, where it is being increasingly used more widely. Research conducted by the DWP in 2013 concluded that telephone assessments can be as effective as the face-to-face method if conducted appropriately for the right conditions (such musculoskeletal or mental health). However, the research highlights the importance of strong telephone and clinical skills, supported by focused training and the use of standardised protocols to refer to.
Used effectively and with the correct case types, telephone assessments can be a safe and efficient way of providing OH advice to businesses in a timely fashion. OH advisers are able to add additional value to businesses and the increased demands of business efficiency with the advantages it brings. However, the approach should be chosen as the preferred assessment type with the restrictions of the service in mind so the correct level of service can be secured for both the employee and the business.
Catherine Darcy-Jones MSc, BSc (Hons) Nursing, BSc (Hons) Occupational Health Nursing, RGN is an occupational health adviser at OH Assist. Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, NTFHEA, PFHEA, CMIOSH is associate professor occupational health and reader in educational development at London South Bank University.
American Medical Association (2011). American Medical Association Guide to the Evaluation of Work Ability and Return to Work. Chicago: American Medical Association.
Burton K, Kendall N, McCluskey S, Dibben, P (2013). “Telephonic support to facilitate return to work: what works, how, and when?“. London. DWP.
Anderson GBJ, Cocchiarella L. (2009). Guides to the evaluation of permanent impairment, 6th Edition. Chicago: American Medical Association 2001.
Gray D and Toghill P (Editors) (2000). Introduction to the Symptoms and Signs of Clinical Medicine: A Hands-on Guide to Developing Core Skills. London: Hodder.
Sickness Absence Survey 2015 sponsored by Jelf.
Sickness absence rates revealed in UK’s largest survey. Occupational Health & Wellbeing.