The use of telemedicine is expanding to long-term care settings, where frail patients are likely to have emergency care needs, and caregivers need quick assessments from outside medical professionals to enable them to intervene as soon as possible.
In rural America, or on urban evenings and weekends, the nurse may not be able to wait for a physician to return a call and begin the traditional intervention by visiting the patient in the facility. With frail patients, immediate observation of a patient can be crucial, and thus telemedicine can fill the void.
“If you can imagine a community with two providers and maybe an advanced practice nurse or a PA, they are expected to provide care for the community,” says Deanna Larson, CEO of Avera Health, Sioux Falls, S.D. “And that includes all the clinic care, wellness care that goes on Monday through Friday, all the hospitalizations that go on Monday through Sunday, ED work that’s all night long. And in addition to that, oftentimes in the communities, there will be nursing homes.”
If the clinic day is already booked up with scheduled visits and acute cases that come in, and the nurse from the nursing home calls in with a resident’s medical problem, it’s added to the stack, which providers draw down according to relative urgency. The nursing home resident probably wouldn’t be seen until later in the day. And often the resident is already headed to the ED before the providers can call back, says Larson.
If the resident was there to recover from a hospital stay for a heart attack, pneumonia or heart failure, both the hospital and the nursing home get cited by federal agencies if the readmission is in the 30-day window for readmission. Too often, it’s a readmission that didn’t have to happen had a physician or mid-level practitioner been there to determine that the problem wasn’t as severe as it looked.
Avera is using telemedicine to conquer that response challenge, with a geriatrics-trained team that can be called immediately to a bedside via a video cart and assess the patient with the nurse’s assistance. “We’re in there right when they need it,” says Larson. “As soon as a nurse is able to make a call to say there is a change in this resident, we can be there with them; she can be there with us.”
The goal is to stabilize the nursing home resident rather than reflexively move the resident out of the long-term-care environment. The team is readily available and able to intervene earlier “instead of the local provider being called out of clinic or called out of bed,” she says. And it works: About 90 percent of video-response cases stay put, preventing transfers to the ED or another more intense care setting.
As of August, the “eLTC” service covered 3,200 residents in South Dakota, Iowa, Nebraska and Minnesota under a CMS innovation grant. By December, Avera expects to have 5,000 residents under its authority, and there’s a waiting list.
UPMC organized in 2012 to provide a range of medical support to 1,650 residents on nights and weekends at 19 unaffiliated nursing homes in western Pennsylvania under the same CMS innovation grant program. Telemedicine was not initially part of the initiative, but in 2014, UPMC incorporated video responses by nurse practitioners, says Steven Handler, MD, chief medical officer for UPMC’s Community Provider Services. The success of the initiative prompted the health system to expand the model to six nursing homes with 650 residents in its owned post-acute network. UPMC staffed that coverage with geriatricians from its medical group.
Program leadership developed its own technology for the nursing home setting, supplementing the main camera on a customized cart with a wound camera, electronic stethoscope, otoscope for looking into ears, and a 12-lead EKG attachment that transmits to the nurse practitioner who’s remotely responding.
At the end of each telemedicine encounter, the nurse practitioner reported whether the intervention was perceived to have avoided a hospitalization. Under that measure, a hospitalization was avoided 55 percent of the time, says Handler. The geriatricians in the UPMC expansion did the same, recording an avoidance rate of 41 percent.
Many calls are for issues that appear severe but don’t turn out to be, Handler explains. Nurses on duty don’t have the skills to distinguish the severity, so they have to report all changes in condition to a physician or mid-level practitioner. But all interaction is beneficial, if only to reassure the nurse that the situation is manageable. “Reassurance is a pretty powerful thing in an environment where you don’t have a clinician on site to help you, to give you expert advice and clinical feedback at the moment,” he says. “They have a thin nursing service to begin with, and there’s a heightened level of anxiety related to that.”
Reductions in transfers to the hospital are the end game, says Larson, “but what it’s really about is access to care for that resident.” If the situation does call for transfer, the telemedicine intervention helps to expedite it so the resident doesn’t suffer extended and unnecessary pain, she says. If a lab result calls for a specific intervention, the responding clinician can do it immediately—and then inform that local harried primary-care provider that the eLTC group took care of it.
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