Telehealth: Lessons Learned

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Telehealth Lessons Learned

• Vicki Mohr, BSN, MBA
• Kessa Englert, RN, BSN

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Island Health CaresTelehealth Story

• Island Health Care purchased 25 monitors in 2000
• Purchased specifically to improve quality of
  patient care
• Implemented telemonitoring into home
  health care in 2001
• Three months into program, blew
  it up

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School of Hard Knocks

• Kept looking for the right patient to monitor
• Thought nurses and doctors would love it
• Thought telemonitoring could be dropped into
  existing care management model
• Used monetary compensation to motivate monitor
  placement

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Reality of Telemonitoring

• Decided that all patients could benefit from
  daily vital sign monitoring
• Learned that doctors do not like to be inundated
  with information
• Nurses were motivated by improved quality of care
  for patients
• Changed labor intensive care management model
• Telemonitoring became the standard of care

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Telemonitoring Versus Telehealth

• Simply dropping monitors into the current model
  will not achieve telehealth
• Monitors are the nurses tool to both assess and
  manage care
• In order to achieve telehealth, the entire agency
  must be immersed, not just a single nurse or
  stand-alone program
• Must redefine what constitutes a visit

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Common Pitfalls of Telehealth

• Avoid becoming reactionary to vital sign readings
• Some agencies actually see increases in
  re-hospitalization due to knee-jerk reactions to
  monitoring
• Treat the patient, not the monitor
• Set parameters for vital signs realistically
• If an alert is not meaningful to the nurse or
  physician, then the parameters should be changed

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Telehealth as the Nurses Tool

• Accurate assessment from the start of care
• Watch closely for early insidious trends
• Intervene early, dont wait for a crisis
• Use trended information to critically think and
  make relationships between data. This will help
  guide patient education and reinforcement
• Dont ignore non-compliance with monitoring

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Who Should Be Monitored?

• High risk patients
• Place monitors on a variety of patients to catch
  hidden problems (ie. patient admitted with TKR
  for physical therapy but find they have atrial
  fibrillation)
• All patients can benefit from monitoring
• Keeps the agency on the patients mind

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New Framework for Visits In-Home Visits

• Reserved for necessary, hands-on care
• No computerized arbitrary scheduling
• No standard 9-week plans of care
• Question what is being done in the home that
  cannot be accomplished remotely

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New Framework for Visits Telephonic Visits

• Scheduled, completed, and documented
• Patients seen daily via monitoring
• Trends and remote assessment drives decisions to
  schedule In-Home Visits
• Basis for targeting of In-Home Visits

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Telephonic Visits

• More than just a telephone call
• Performed by care manager, RN
• Preceded by comprehensive review of patient
  record for vital sign trends, medication changes,
  lab results, MD orders, and interdisciplinary
  notes
• May require follow-up phone calls with physician,
  lab, caregiver, etc

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Telephonic Visits Increase Patient Contact

• Make more Telephonic Visits than In-Home Visits
  per patient
• Call the day after admission
• All patients receive a minimum of one Telephonic
  Visit per week and as needed for symptoms
  identified via remote care technology

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Why Patients Dont Call Us First When They Need
Help

• Patients do not always trust monitor data
• Monitored (senior) patients may not feel
  comfortable with technology
• We dont adequately sell the idea to call us
  first
• We dont communicate clearly
• We have not built a sufficient rapport with the
  patient and caregiver
• Physician does not think to tell patients to
  call us first

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Drill Down! Examine

• Responsiveness to patient calls
• Clinicians confidence in remote care technology
• Communication with internal and external
  customers
• Physicians confidence in remote care technology

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Partner with Physicians

• Communicate with the physicians
• Educate them regarding what the agency is trying
  to accomplish with telehealth
• Let them know what home health can do for them
  (improve their quality scores for P4P)
• Partner with them for specialized orders or
  protocols for handling common problems

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Ask for an Intervention

• When reporting problems to physician, if
  possible, fax the vital sign trends and ask for
  an intervention
• Instead of Mr. Jones has gained 3lbs, has a PO2
  of 90, and hes very short of breath. What
  should we do?
• Try Ive faxed you trends on Mr. Jones. He has
  gained 3lbs, has a PO2 of 90, and hes short of
  breath. Would you like us to double his diuretic
  today?

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Physician Customers

• The best marketing possible is to give the
  physicians exactly what they NEED
• Do not want raw data
• Want to be notified of real or potential problems
• Want concise problem-directed communications
• Want to know what you can do to mitigate the
  situationin one sentence or less!

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Best PracticesPatient/Caregiver Education

• At SOC we repeat three times to call us first
  for health care problems and concerns
• Reinforce on the admission visit that we see
  the patient each day and that they will have more
  telephone calls than In-Home Visits
• Tell patient that a nurse will call if there is a
  problem with vital sign readings
• Increase feedback to patient/caregiver regarding
  monitor trends and condition

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Best PracticesPatient/Caregiver Education

• Review vital sign trends with patient within the
  first three weeks of care
• Educate patients about when their vital signs
  will be reviewed and what to expect
• Teach patients to check vital signs whenever they
  feel it is necessary
• Provide a form for patients to keep in the home
  to record their own vital signs results

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Proactive Measures to Avoid Hospitalization

• Remote Care Technology
• Telephonic Visits
• Care Calls
• On-Call Clinician
• Physicians as partners

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It Takes Leadership

• And a whole lot of perseverance
• We thought the staff would LOVE
  telemonitoringbut
• They saw
• More work/time
• They might be replaced with technology
• They worried that the patients would not get
  needed care

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Change is Tough

• Staff did not immediately see results
• Outcomes do not show improvement overnight
• It takes time and practice to incorporate
  technology as a part of clinical practice
• Management must make it happen!

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Constant Oversight

• Daily involvement by top administration
• Reengineer processes as necessary
• Create management tools and reports
• Hold everyone accountable

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Culture of Accountability

• Top leadership must be totally committed to
  telehealth and decreasing emergent care
• Align critical incentives through internal system
  of P4P
• Manage the change! Total transformation to the
  practice of telehealth should be a top strategic
  imperative

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Questions?