Medical regulation or Medical-Social Assistance, a service for better health and cost control

Symptoms or pain, often generate concern and especially a question: what to do? How to direct a patient in pain to the right service or health professional?

📰 Through Meriem's story, you will discover the positive impacts of medical regulation on health and on the costs of the care pathway. 

J0 : Meriem, 56 years old, employed in a company in Casablanca, had back pain after a hike.

A recent similar episode makes him think that this event is not trivial.

Meriem contacts the medical assistance service to which her company gives her access.

She discusses with the doctor or the nurse regulator who concludes that she needs to make an appointment with an orthopedic doctor as soon as possible and suggests 3 names of specialized doctors, in case she does not know where to go.

J1 : The next day, she went to the clinic where the doctor of her choice practiced and, after his consultation, he prescribed appropriate imaging tests which she carried out immediately.

J2 : The diagnosis is made. Meriem suffers from a herniated disc. She begins a course of care that should lead her to a surgical procedure.

How is this medical regulation exemplary?

First of all, thanks to the patient herself.

She recognized that she was in a risky situation. Her reflex to contact her medical assistance service was life-saving. She was put in touch with a medical regulation professional who uses the appropriate diagnostic tools.

This exchange, usually by telephone, with a nurse and/or a regulating doctor, is decisive in defining the risk involved and the seriousness of the situation.

Then the intervention of the doctor or nurse regulator.

This health professional is trained and educated specifically for this mission. He is competent to qualify and refer the patient at the right time and place. In case of difficulty in assessing the case, he/she is able to escalate the case to an expert.

Her mission is to help control this situation from a distance, doing everything possible to guide the patient.

The idea is to make choices. For example, determining whether to keep the patient at home or in a local medical facility or to a more specialized facility, or even transfer her to a foreign country if the situation requires it and if the insurance contract allows it.

To do this, establishing a climate of trust at a distance with the patient is an essential step. It is a real know-how, allowing to establish an open and most serene dialogue from the beginning of the call. The practitioner's empathetic attitude confirms to the patient that she is being listened to attentively.

The objective of this exchange is to determine the reason for the call in order to establish, with the patient, the appropriate course of care.

The regulator's communication methodology consists in asking questions with high added value and rephrasing the answers to better understand the symptoms described by the patient. These techniques make it possible to "get the person to talk" without influencing them.

To do this, the practitioner relies on his knowledge, but also on a triage tool developed on the basis of an algorithm and artificial intelligence, which allows, from the answers to the questions asked, to reduce the field of possibilities and to apprehend the urgency of the situation to be taken care of.

Following this exchange, the nurse or physician has all the keys in hand to announce the care options.

He can then inform the patient about the possible consequences of a therapeutic abstention on the evolution of the pathology. To avoid any possible recourse, the physician fills in the medical file via the tool at his disposal, in the most exhaustive way possible.

If the patient is aggressive, the physician must ensure the same level of requirement. It is then imperative to maintain the quality of this regulation stage. The regulating physician knows that he must have the opposite attitude to that of his interlocutor, i.e. remain calm, patient and empathetic.

If communication is not possible, the physician should ask to speak to another person at the patient's side.

The advantages of a responsive and customized assistance service

Let's go back to Meriem's situation.

She is anxious about this new situation and the pain she feels.

Her optimistic bias takes over. After all, it's an opportunity to activate the medical assistance her human resources director had been touting.

All he had to do was call the assistance number indicated on his insurance contract to speak with a competent person and open his medical file directly.

By the end of the call, Meriem had identified all the key steps in her care.

Her care journey could begin with peace of mind thanks to :

To the kind reception of the teams of the technical platform who knew how to create a climate of active listening,

To the clear procedure that allowed him to project himself in a reassuring framework with minimal risk taking,

To the expertise of the regulating physician who has built a care option, ensuring a follow-up of its implementation and adjustments during setbacks,

The close collaboration between the practitioners of the two entities allowed for fluid exchanges, for a quick and efficient decision making.

Following this episode, she wrote a letter of thanks to her insurer:

"The mobilization and responsiveness of everyone involved allowed me to make the right choices to preserve my health. Thank you again for everything!

How can we ensure a fluid care pathway for the patient's health?

Once the medical and environmental situation of the patient is understood, the regulating physician does not make a diagnosis from a distance. He begins to make hypotheses, diagnostic leads.

With the information collected during the call and with the possible assessments, the regulating doctor will also be able to choose an option, a destination adapted to the patient's need for care.

This stage is essentially represented by health care facilities and/or health care professionals able to temporarily receive the patient in their office.

Each choice made by the physician can be beneficial or a source of risk for the patient. The challenge is to make an inventory of the means available, while remaining within the framework of the assistance contract and respecting the patient's medical interests.

The physician also intervenes in operational aspects, by setting up various logistical means to ensure continuity of care.

This health actor is the first link in the emergency chain. He/she is responsible, but is not the patient's attending physician. This is why, following his regulation mission, he will issue a clear summary and a prescription for assistance based on his conclusions.

The patient then begins his or her course of treatment.

According to the definition of the French National Authority for Health, the care pathway corresponds to "the right sequence and timing of different professional skills directly or indirectly related to care: consultations, technical or biological procedures, drug and non-drug treatments, management of acute episodes (decompensation, exacerbation), other care (medico-social in particular, but also social)...".

Ultimately, the care pathway ensures that the patient has a choice of relevant, effective and safe care.

The importance of combining quality regulation with respect for costs.

If the control room contact had been inattentive to the details Meriem described, the back pain could have been misinterpreted as signs of potential pyelonephritis.

The regulating assistance would have referred her to a urologist.

The investigation would have resulted in additional expensive, meaningless and stressful tests.

This is why medical regulation is as much an economic issue as it is a medical issue.

Good medical regulation allows:

● to reassure the patient upstream by putting him or her immediately in competent hands that will know how to direct the patient,

● optimize the care pathway through improved communication and honed processes to provide access to efficient care more quickly,

● improve direct access to quality care through a strong network of healthcare professionals and preferential terms for their clients,

● support new approaches and solutions to make care delivery less expensive, more efficient, safer, and more accessible.

The result: the definition of an optimized care pathway with the most accurate cost evaluation.

Directing the patient to the right place, at the right time, at the right cost is the basis of a successful medical regulation act.

Sources: https://www.has-sante.fr/upload/docs/application/pdf/2011-12/recommandation_regulation_medicale.pdf - Procedures for handling a call for unscheduled care within the framework of medical regulation - Haute Autorité de Santé - https://solidarites-sante.gouv.fr/soins-et-maladies/qualite-des-soins-et-pratiques/pertinence-des-soins-10584/pertinence