Teleworking nursing care

Whether nurses work in hospitals, private practice or dispense medical advice over the phone, they are social animals, caregivers. At the call centers of McKesson Health Solutions, nurse-agents are quick to celebrate birthdays and organize potluck dinners -- developing strong bonds with colleagues.

So when McKesson Health Solutions asked its 400 call center RNs about working from home in 2003, it got a mixed message. While interest was very high, and 40 percent of the nurses already had the required broadband connection, only 15 nurses signed up for the pilot program. Despite some early reticence and a few technology hurdles, McKesson's Work@Home program is thriving, and yields the company impressive cost savings.

McKesson's goals were specific: The division of the corporation wanted to reduce call center nurses' hourly wage (at home nurses would make 20 percent less), increase its pool of applicants in new geographic areas and reduce its real estate footprint.

The division has call centers in several states. It conducts two services: inbound triage, where people call about a health problem, and outbound support, where nurses monitor patients with chronic health problems such as diabetes. The latter service is growing considerably. As McKesson wins contracts with state Medicare and Medicaid agencies, it needs to hire nurses in those states. This is because state agencies are pushing to increase local jobs and provide callers with an agent of similar geography and accent.

When McKesson won the Mississippi Medicare contract, it spent US$400,000 to set up a call center. "We were looking at spending that much in each state. Now we don't have to," says Mike Modiz, vice president of operations and strategic projects. "We have a call center in Dallas, but we're more successful recruiting Spanish-speaking nurses in San Antonio and Houston. So we could hire them straight into the home, avoiding that cost."

Initially, McKesson nurses provided their own PC and broadband connection; the firm provided the softphone and a $300 ergonomic chair. When nurses log on to the Citrix Secure Gateway and launch the softphone, the voice system calls their dedicated landline, "nailing up" a connection. McKesson says it relies on custom-built applications and E-Quality, a data and voice monitoring system from Witness Systems. Nurses also rely on the secure messaging application Jabber.

"I loved working in the call center," says Evette San Nicolas, a single mother living near Denver. "So when I first came home, I suffered from withdrawal. But I wouldn't want to go back. When my kids are sick, I'm here. On my break, I make them lunch."

US Health Insurance Portability and Accountability Act regulations requires patient information not be viewable by anyone other than the nurse, but McKesson lets nurses work in a shared area and when family members are home.

"We're adults, we can manage our life, we can manage our work," says Kim Kenote, a nurse and instructor who works from home in the Chicago area. "Some nurses put signs on the front door saying 'I'm working.' Others tell their kids, 'Don't bother Mommy unless you're bleeding.' It's OK to have family around so long as they don't disrupt the work environment."

Elana Bluestone, a 24-year hospital veteran who works in the Denver area, doesn't miss the call center. Her husband, an artist, also works from home and "rubs my shoulders and brings me tea," she says.

Each call center provides two hoteling spots for at-home nurses who occasionally work in the office. Many have used them to east the transition.

But just as nurses were settling into their new roles, McKesson corporate expressed security concerns -- not about exposing network data but about delivering virus updates to remote systems. The IT department outfitted the at-home nurses with a Wyse thin client running Microsoft XP Embedded, a Linksys router and KVM switch for toggling between work and home systems.

McKesson also is testing Rapport, a Wyse program that provides remote management. "Right now, the client configurations are static. But with Rapport, we'll be able to push [operating system] updates to the thin clients," says Kurt Bergman, manager of field technical services.

For redundancy, calls are routed to two data centers in Colorado and California. "Having agents buy their own broadband connections gives us some disaster-recovery protection because we haven't spread our network over one vendor," Modiz says.

There is a downside to this approach. "Ninety-plus percent are working just fine. But some nurses have been using very cheap DSL service, the kind providers usually advise shouldn't be used for telework. It goes down a lot," Bergman says.

Nurses must use cable or DSL. Some who can't get either are paying double for ISDN. Bergman admits, "We need to put some definition around [the broadband policy]. We've been so focused on the core infrastructure, it's time to consider a wider range of options."

A downed connection is a nurse's responsibility, says Linda Casey, Work@Home operations and workforce manager at McKesson. "If your car breaks down, you don't expect the company to fix it."

Today, most of the recruiting and training of new hires is done remotely, although Casey brings them into their proximate regional offices for two days of "McKessonizing." "We need to create a relationship and a bond," she says.

Nurses follow up with four weeks of training -- a mix of group Web conferencing sessions and self-study lessons. "We've learned to spread out the tech training, otherwise, it's overwhelming," Casey says.

While McKesson's initial goal was to transition 50 percent of its nurses-agent home, it's since upped that goal to 70 percent, and promises to send every nurse-agent home who wants to go. Modiz has no plans to close all the centers. Many nurses prefer the call center or see it as a path to advancement. And McKesson still needs to showcase brick-and-mortar call centers to clients -- although it does let interested clients visit an agent's home.

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