Medical regulation or medico-social assistance, a service to improve health and costs management.

Symptoms or pains often generate concern and especially a question: what should be done?  How do you direct a patient who is suffering to the right service or health professional? 📰 Through the case of Meriem, we will discover the positive impacts of medical regulation on health and on the costs of the care process. 👉Read more here.  

D0 : Meriem, 56 years old and employed in a company in Casablanca presents lumbar pain following a hike.

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

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

A discussion with the doctor or nurse regulator concludes with the need to quickly make an appointment with an orthopedic doctor; three names of specialist doctors are provided in case she doesn't know where to go.

Day 1: The next day she goes to the clinic where the doctor of her choice works and the latter, after the appointment, prescribes adapted imaging exams that she has done immediately.

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

How is this medical regulation exemplary?

First of all, thanks to the patient herself.

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

This exchange, usually by telephone, with a nurse and / or a regulatory doctor, is decisive in defining what the risk is and how serious the situation is.

Secondly, the intervention of the doctor or nurse regulator.

This healthcare professional is trained and trained specifically for this mission. He is competent to qualify and refer the patient at the right time and in the right place. In the event of difficulty in evaluating the case, he is able to escalate the processing of the file to an expert.

His mission is to help control this situation from a distance, by making every effort 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 structure or in a more specialized establishment, or even transfer her to a foreign country if the situation requires it and if the insurance contract provides for it.

For this, establishing a climate of trust with the patient, from a distance, is an essential step.  Making it possible to establish an open and serene dialogue from the start of the call is genuine know-how. 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 of asking questions with high added value and reformulating the answers to better understand the symptoms described by the patient. These techniques make it possible to make the caller speak "without influencing him."

To do this, the practitioner relies on his knowledge, but also on a triage tool developed based on algorithms and artificial intelligence, which allows, from the answers to the questions asked, to reduce the field of possibilities and ''understand the urgency" of the situation to be dealt with.

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

He can then inform the patient about the possible consequences of abstaining from therapy, on the course of the pathology. To avoid any possible recourse, the doctor fills in the medical file using the tool at his disposal, as exhaustively as possible.

If the patient is aggressive, the doctor must ensure the same level of demand. It is therefore imperative to maintain the quality of this regulation step. The regulating doctor knows that he must have the opposite attitude of that of his caller, that is to say to remain calm, patient and empathetic.

If exchanges are not possible, the doctor should ask to speak to another person present next to the patient.

The advantages of an attentive and tailor-made assistance service

Let’s go back to Meriem’s situation.

She is anxious by this unprecedented situation and the pain she feels.

His optimistic bias takes over. After all, this is an opportunity to activate the medical assistance that her HR director has been raving to her about.

All she had to do was call the assistance number indicated on her insurance contract to talk to a competent contact person and open her medical file directly.

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

Her care path would be able to start with confidence thanks to :

  1. The benevolent welcome from the technical platform teams who created a climate of active listening,
  2. The clear procedure that allowed her to project herself into a reassuring environment with minimum risk taking,
  3. The expertise of the regulatory doctor who constructed a care option, and monitored its implementation and adjustments during setbacks,
  4. The close collaboration between the practitioners of the two entities allowed for fluid exchanges, for rapid and efficient decision-making.

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

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

How to ensure a smooth care path to serve the health of the patient?

Once the patient's medical and environmental situation is understood, the regulator does not make a remote diagnosis. He begins to formulate hypotheses and diagnostic leads.

Based on the information collected during the call and with any assessments, the regulator can also choose an option, a destination adapted to the patient's need for care.

This stage is mainly represented by healthcare establishments and / or by healthcare professionals able to temporarily welcome the patient to their practice.

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

The doctor also intervenes on operational aspects, by setting up various logistical means to ensure the continuity of care.

This health actor is the first link in the relief chain. He is responsible, but is not the patient's attending physician. This is why, following its regulatory mission, he will issue a clear summary and an assistance prescription responding to his conclusions.

The patient then begins his care path.

According to the definition by the Haute Autorité de Santé, the course of care corresponds to "the right sequence and at the right time of different professional skills directly or indirectly linked to care: consultations, technical or biological procedures, medicinal and non-medicinal treatments, support of acute episodes (decompensation, exacerbation), other forms of care (notably medico-social, but also social) …”

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

The importance of combining the quality of regulation while respecting costs.

If the contact with the regulation platform had paid little attention to the details Meriem had described to him, the back pain could have been misinterpreted as signs of potential pyelonephritis.

Regulatory assistance therefore would have referred her to a urologist.  

The investigation would have given rise to additional expensive examinations, with little interest but potentially additional stress.

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

Good medical regulation allows for :

  • immediately reassuring the patient by putting them in capable hands which will direct them,       
  • optimizing the care path through improved communication and established processes to provide access to efficient and faster care,       
  • improve direct access to qualitative care thanks to a solid network of health professionals and preferential conditions for their clients,       
  • to support new approaches and solutions to make the provision of care less expensive, more efficient, safer and more accessible.       

Result: the definition of an optimized treatment path with a cost evaluated as accurately as possible.

Referring the patient to the right place, at the right time, at the right cost are the pillars 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 request for unscheduled care as part of the medical regulation - Haute Autorité de Santé - https://solidarites-sante.gouv.fr/soins-et-maladies/qualite-des-soins-et-pratiques/pertinence-des-soins-10584/pertinence