Background

Peña Verde S.A.B, one of the largest Mexican insurance and reinsurance groups trading on the Mexican Stock Exchange, with annual revenues of more than $5300 million pesos, decided to invest in cost reduction solutions due to rising service’s costs from its insured population.

The Challenge

Previous investment had led to the creation of Centro de Contacto De Servicos De Salud (CCSS), a health call center service that offers clinical assessment, health advice and information (via medical phone guidance) to more than 50,000 users.

The purpose behind the call centre is to direct users to the most appropriate level of care in order to increase efficiency and reduce costs of healthcare for both users and providers.

Capita Healthcare Decisions (CHD) has worked with CCSS Peña Verde (CCSS) to enable them to be a provider of telephone triage to their clients and patients.

During the 6 month pilot CCSS and the National Pediatrics Institute (INP) conducted a statistical study of hypothesis testing concerning the dispositions reached by Capita’s clinical algorithms in TeleGuides™ against conclusions reached via an in person Pediatrician assessment. This was to verify the dispositions reached by the clinical content that is to be used in the solution provided to both CCSS and their clients and patients.

CCSS used its years of research and expertise to adapt the 200 symptomsrelated algorithms provided through CHD’s TeleGuides™ and delivered through Salus™ to Mexican Clinical standards.

During this process CHD worked closely with CCSS in order to ensure that health issues specific to Mexico are catered for.

Additionally CHD has trained CCSS staff to enable them to adapt their clinical algorithms as required over the coming years, so new guidelines can be adhered to easily.

The Result

Over 1000 completed calls were used in the study. The conclusions were that the teletriage TeleGuides™ dispositions reached were matched with an ‘in person’ Pediatrician assessment disposition in 98% of cases. In the remaining 2% of cases there was a significant difference in the algorithm result; however the CCSS physicians identified and modified the final recommendation based on their wide medical experience reducing the non-matching final results.

This proves the safety of working with teletriage algorithms and certified doctors simultaneously.

 

Benefits

• CCSS´s clients benefit from increased productivity and efficiency using Capita technology and customised clinical protocols
• Users of the service receive fast, consistent and safe health advice directing them to the appropriate next level of care
• The solution enables CCSS to provide its clients with effective tools to improve their patients satisfaction
• CCSS’s service will now enable them to offer health services in the most cost efficient manner

Conclusion

Following this work CCSS can offer the most robust algorithm based telephone triage and medical orientation in Mexico. CCSS delivers its services through a professional team of certified doctors who follow the algorithms to achieve the effective assessment and referencing of patients to the appropriate care level and institution, and who are also prepared to identify unusual symptoms and react accordingly.