Using telemedicine in the care and treatment of stroke patients is widely used and accepted at this point; the approach facilitates quick access to expert consultations when time to treatment is a critical factor. However, some medical centers are finding that there are other ways to take advantage of telemedicine in the emergency setting, and they’re testing out methods to most effectively leverage its ability to connect with patients from a remote location.
For example, as part of its Geriatric Emergency Department Innovations in Care Program (GEDIWISE), Mount Sinai Hospital in New York City is using smartphone technology to conduct face-to-face follow-up communications with senior patients after their ED visits. Further, they have just begun to experiment with a new program that is sending some ED patients who meet inpatient criteria home, where they will receive hospital-level care and monitoring through a mobile acute care team (MACT).
In both instances, investigators are attempting to show that these new approaches can help to avert readmissions and trim costs, and that patients can come out ahead on both outcomes and satisfaction.
Smartphones facilitate face-to-face connections
The idea of using telemedicine to advance the emergency care of senior patients is just the latest step in Mount Sinai’s GEDIWISE program, which is funded by a Health Care Innovation Award from the Centers for Medicare & Medicaid Services (CMS). “This is a federal grant we received in 2012 to open our geriatric ED, staff it, and build in some workforce innovations, informatics innovations, and structural enhancements to better serve elderly patients in the ED,” explains Nicholas Genes, MD, PhD, an assistant professor in the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai.
The telemedicine component is an enhancement of a practice already in place in which nurses schedule follow-up calls with senior patients while they are still in the ED. The calls are used to confirm that the patients got their prescriptions filled, they are on track to proceed with any scheduled follow-up visits with their physicians, and that circumstances haven’t changed, explains Genes. “We really don’t want these patients to end up back in the ED,” he says. “That would be bad for the patients and it would just be bad care.”
While these calls have been taking place for years, Mount Sinai is now incorporating smartphone technology so that the nurses can actually engage with the patients face-to-face, much like the way people interact on video chat services, explains Genes. However, he notes that this approach utilizes an application that is compliant with the Health Insurance Portability and Accountability ACT (HIPAA) to protect privacy.
“We ask patients if they have a smartphone and if they are comfortable using it. And with them we install the [application] while they are still in the ED prior to discharge,” explains Genes. At this point, the nurse will schedule a follow-up call with the patient, and at the appointed time the face-to-face visit will take place, he says.
Visual clues add value
How much value does seeing the patient bring to a typical follow-up call? Genes admits he was skeptical at first, but even after just a couple of weeks, the nurses making these calls say that actually seeing the patient gives them a better view of how the person is doing.
“I think you are more able to gauge the person’s overall temperament and how they are really feeling,” says Cindy Amoako, RN, a GEDIWISE nurse clinical coordinator who has made several of these face-to-face calls. “You get to see their facial interaction; you have that eye-to-eye contact, so it is really more intimate, and it allows a bit more assessment.”
Amoako adds that you can also get a sense of the patient’s overall surroundings, which can provide additional clues on how the patient is faring at home. For instance, Amoako recalls speaking to one patient who had been to the ED recently for a fall. “I was making sure his pain was okay, trying to gauge his reaction … and I could tell by his facial expression that he was much better than when I saw him in the ED.”
Amoako was also able to verify that the patient was not forgetting to use his walker, an important point because that was why he fell in the first place, she says. “I asked him if he was using his walker. He said ‘yes’ and then pointed to it in the room.”
The face-to-face calls provide both the nurse and the patient an opportunity to verify that the right medications are being taken as directed. “If I can see the medication bottle right in front of me, that is definitely an advantage over just talking about it over the phone where the patient might be confused or not able to read what is on the bottle,” says Amoako.
Another plus is that the patients who have participated in the face-to-face calls thus far give the approach high marks. “They like the face-to-face interaction; they feel it is more personal,” says Amoako. “We have gotten really positive feedback.”
All of the geriatric patients receive a call the day after their ED visit, but from that point on the call schedule is individualized. “Some people need more extensive follow-up if they are more complicated or if they are less compliant,” says Amoako. “We call some people up to two weeks after their initial ED visit.”
Genes acknowledges that a lot of people were skeptical that geriatric patients would have smartphones or would be comfortable using the technology. “That is true in some instances, and so we just use the traditional phone calls in those cases, but in the handful of patients we have done the video telemedicine calls with so far, I think we are perhaps surprising some of these critics,” he says.
Mount Sinai has three interrelated goals in mind for its telemedicine push: to improve care, reduce costs, and promote coordination, notes Genes. But he acknowledges that measurement of these factors is not a simple matter. “We have to wait for the Medicare claims data which takes many months, so we have some proxy measures, and revisits [to the ED] is one of them.”
Mobile teams deliver acute care
Genes notes that Mount Sinai is, in fact, being very ambitious with both telemedicine and coordinating care throughout the health system’s accountable care organization (ACO). These efforts extend to one of the medical center’s newest initiatives — an approach focused on caring for some ED patients who meet inpatient criteria in the home setting rather than the hospital.
“Basically, if a patient needs admission from the ED to the hospital and they are medically stable, they can get admitted to their own home, and the MACT [mobile acute care team] will go to their home and see them there,” notes Genes, explaining that program incorporates both in-person home visits and tele-health communications.
Funding for this program also comes from CMS, but eligible patients over the age of 18 who present to the ED can participate, explains Linda DeCherrie, MD, an associate professor of geriatrics and palliative medicine at Mount Sinai. “The emergency physician has determined that they need hospitalization, and we are bringing them home instead and providing services that are pretty equivalent to hospitalization, with a physician coming daily to their home and a nurse going twice a day.”
Depending on individual needs, these patients may require physical therapists, social workers, IV medicines, and other types of care. “All of these services are provided in the home,” notes DeCherrie. However, she explains that the program is currently limited to a set of conditions that clinical leaders have determined can be treated safely within the program’s parameters.
These include community-acquired pneumonia, cellulitis, congestive heart failure, high and low blood sugars for diabetes, deep vein thrombosis (DVT), and chronic obstructive pulmonary disease (COPD), although DeCherrie notes that more conditions may be added later on. “We have created criteria where we know we can get all the things we need into the home within four hours [such as] nebulizer treatment, IV antibiotics, or oxygen,” says DeCherrie.
To handle any emergency situations that arise with these patients, the program is relying on community paramedics. “We are having ambulances with paramedics go out to the patient but ideally not to transport them to the ED,” says DeCherrie.
As part of this process, physicians use smartphones to see what is going on during the paramedic’s visit, and communicate any instructions through this two-way video conferencing method, explains DeCherrie.
While entry into the MACT program always begins with a visit to the ED and an emergency provider’s decision that the patient requires hospital-level care, most of the physicians providing care as part of the MACT program are internists or geriatricians, explains DeCherrie. “There was a lot of discussion about who would be the right providers — both physicians and nurses,” she says. “And we really needed people who are very comfortable in the home.”
Consequently, the MACT program has been able to draw on Mount Sinai’s large health call program which takes care of as many as 1,200 patients who are homebound in Manhattan. “Emergency physicians are extremely important [to the program]. They need to make the decision to admit,” she says. However, after that point, the MACT program takes over, utilizing the skills of physicians who are already accustomed to operating in the home environment, adds DeCherrie.
Nurse, physician buy-in takes time
Bringing both emergency physicians and nurses on board with this type of disposition took some time, acknowledges DeCherrie. For instance, getting nursing approval to send a patient home with an IV in place was one issue, and some physicians initially resisted the idea of sending home patients who met inpatient criteria. “They really needed to understand the services of our program, how it is based, and what we are able to do for patients,” she says. “We also had to work with case managers so that they would understand our program.”
One key concept that everyone needed to understand was that the program is not advanced home care, says DeCherrie. “We need to make sure that these patients truly need an admission,” she says. “So once a patient is determined to need admission and [he or she] is administratively assigned to a medicine team in the hospital, we will at that point intervene.”
Typically, a MACT provider will physically come to the ED to discuss the patient’s condition with both the patient and the emergency provider to make sure that the MACT provider fully understands what is going on, and that the patient is safe to go home, explains DeCherrie, noting that the patient must also be comfortable with the arrangement.
The MACT works frequently with patients who have been in observation for 24 hours, and are then deemed to require admission, so the emergency physicians who work in observation are perhaps most acquainted with the program at this point, although the program is still quite new. “We had our first patient in November ,” notes DeCherrie. “We are still in our pilot phase, but we are planning to have about 1,100 patients in three years.”
Also on the schedule is a planned expansion of the MACT program to a second ED in September 2015. And it is possible that MACT program administrators may at some point consider accepting patients from settings other than the ED. However, for the time being, the ED is the only entry point, says DeCherrie.
Administrators eye program expansion
While there are other hospital-at-home programs around the country, Mount Sinai is among the first to attempt the approach in a fee-for-service environment. “The programs that [already] exist are in VA [Veterans Administration] hospitals, and they exist in some closed health systems where the insurance company owns the hospital and employs the physicians and the nurses with a much cleaner package,” explains DeCherrie.
These other programs have already demonstrated that the approach is safe and that it can save money under those conditions, explains DeCherrie. “What is different here is we are doing it in fee-for-service Medicare where we have multiple vendors and multiple parties involved,” she says. “From Medicare’s point of view, this [effort] is really to show that this [type of program] can be done with the same outcomes, and that it can also save money.”
What’s more, investigators are hoping to demonstrate that, given an option, patients would prefer to be cared for in their homes rather than in the hospital. “We also think there will be fewer complications, fewer falls, less delirium, and fewer superbugs when patients are cared for in their homes,” adds DeCherrie.
Further, while the earlier programs have produced good outcomes, they have been done on a smaller scale, notes DeCherrie. “We are really going to do a much larger investigation of all of this,” she says.
Getting the program up and running has involved multiple challenges, says DeCherrie. “It probably took us 14 to 16 months to see our first patient,” she says, noting that there are multiple parties involved with the service. Program administrators also had to decide how to create an electronic medical record (EMR) for these patients, how patients would be categorized in the EMR, and how nurses would carry out medication reconciliation when they are not physically administering every medicine.
“A person’s initial response to this is often concern, liability, and they don’t get it, but almost everyone, once you talk about it, is very excited about this prospect,” says DeCherrie. “The Mount Sinai ED is always full … and the whole hospital is always full, so taking a patient out of the system is not a problem at Mount Sinai because there is always another patient waiting for the bed.”
Further, health system administrators have been very supportive of the program because they see this as the future, says DeCherrie. “Yes, there will always be a need for an operating room, and there will always be a need for the ED and the ICUs and general medicine floors,” she says. “But I think there is a level of patients we can really do this for, and this could potentially be expanded once we have all the protocols and procedures in place.”