VA has telehealth model that’s opening nationwide
Experts predict a bigger role for telehealth in the hospice industry as model programs demonstrate high patient/caregiver satisfaction and improved staff efficiency and quality of care. Hospices and home health agencies increasingly are using a variety of telehealth services, says William A. Dombi, JD, vice president for law at the National Association for Home Care and Hospice in Washington, DC. "The types vary from vital-sign checks to monitors that offer high-resolution pictures of a patient that allow monitoring of everything from wound sites to skin tone," Dombi says.
Hospice agencies are the latest to explore the advantages of telemedicine, experts say. "I’ve been involved in doing research in telemedicine since the early 1990s, and one of the areas that has emerged over time as being an important area is hospice and palliative care services," says Pamela Whitten, PhD, associate professor at Michigan State University in East Lansing. "Telemedicine has huge ramifications for hospice and palliative care," Whitten adds.
The Veterans Health Administration (VHA) in Bay Pines, FL, launched a telemedicine care coordination service in 2000 as a way to provide home services while keeping patients connected to the health care system, says Patricia Ryan, RN, MS, director of the Veterans Integrated Service Network 8 (VISN-8) and acting associate chief consultant to the VHA Office of Care Coordination in Bay Pines.
VISN-8 recently added hospice and palliative care services to the program, and there are plans to roll out the telehealth program in other states, Ryan says. "We’re not taking over any other of the health care programs we have in the VA system, but this is a complex system," Ryan says. "So what we wanted to do was make sure that those patients who were very sick and clinically complex could participate in their own care at home, and if they needed hospice care, we were there for them."
The Michigan telehospice program was limited to home health for the purposes of research, but it shouldn’t be limited to that segment of hospice patients over the long term, Whitten says. "We decided to determine what type of technology could be brought into the home in a realistic manner, and we decided to use video phones that use analog phone lines," Whitten says. "We wanted to look at areas where there was a potential challenge in access, and so we provided telehospice services to rural areas and an urban area."
The rural areas were located in Northeastern Michigan, where severe winter weather sometimes makes it difficult, if not impossible, for home health professionals to visit patients, Whitten explains. The urban area selected was in parts of Detroit, where one challenge is to provide evening home health services to some low-income patients because of safety issues, Whitten adds.
The Bay Pines VHA’s telemedicine project is divided into 21 programs across the state of Florida and Puerto Rico, and each program serves a different population, Ryan says. For example, one program at the San Juan, Puerto Rico, VA serves only diabetes patients, and another serves wound care patients. In northern Florida, there is a palliative care program, and another program serves most chronically ill medical patients, Ryan explains.
Program targets clinically complex patients
The hospice/palliative care program has a chaplain who serves as care coordinator. While that was the first formal telehospice program, many of the other programs will also help patients stay at home at the end of their lives, Ryan adds. "Not everyone in the VA system is enrolled in these programs," she notes. "We look at those who use the system the most — the most clinically complex patients."
Dombi, Whitten, and Ryan describe some of the features of telehospice programs and how they may fit in with existing hospice services. Here are their observations and advice regarding starting a telehospice program:
• Understand the licensing and legal issues.
While a telehospice program doesn’t need a special license, there are circumstances when its use could be in violation of state licensing laws, Dombi says. For instance, if a physician is licensed in New Jersey and is providing health care services to a New York resident via telemedicine, then this could be a violation of licensing laws because the doctor is not licensed to practice medicine in New York. It’s also important to understand the special liability and malpractice concerns that affect telehealth programs, Dombi says. "There are some issues that arise regarding practice acts for nurses," Dombi points out.
Nurses must comply with state nurse practice acts. States commonly only give nurses limited authority to act without a physician order, and in most states nurses can usually only provide care consistent with a physician’s order, Dombi explains. So the question arises: "Do they need an order to use telehealth service in the fashion they are using it?" Dombi says. "We’ve long recommended having specific physician orders for telehealth, for both liability and licensing issues," he adds. "The liability concern relates to someone who has the responsibility to the patient, and then something goes wrong and leads to injury; if the nurse is acting consistently with the physician’s order, then you’re at least sharing risk with the physician."
• Select the telehospice model that works best for your clientele and staff.
The telehospice study conducted in Michigan found that patients uniformly liked the telehealth service, and many even wanted to use it more frequently, Whitten says. "Some providers loved it from day one, and some providers resisted it," Whitten says. "The challenge was not with the patients accepting telehealth and liking it; the challenge was with the providers."
This project used video phones and video monitors plugged into existing telephone lines. All patients would have to do is push a button for a video connection, making it a very simple process, Whitten explains. The hospice staff would conduct home visits via the video phones in the same way they would conduct a visit in person, with each visit tailored to the particular patient, Whitten says. "Some might need a pain assessment and to talk about issues with pain, and others might need counseling of some type," Whitten adds. "Sometimes the providers would just call in to check on their comfort and check on bed sores or wounds." At other times, hospice providers might provide support services to family members or caregivers.
Care coordinators direct telehealth services
The VA telehealth program provides a nurse practitioner and chaplain for palliative care services, but also provides easy access to physicians, an interdisciplinary team, and anyone else who is needed, Ryan says. The first step is to assign the patient a care coordinator who selects the technology that will be used to provide the telehealth services, Ryan says.
Typically, the technology is a 365-day messaging unit, about twice the size of a caller ID box, that is connected to the patient’s telephone. Each morning the unit will beep until the patient responds to 10 to 15 questions that require four simple button presses to answer. Based on these answers, the care coordinator labels each person as "green" for okay and "yellow" if the patient needs to be watched, Ryan says. The patient’s answers to the questions are sent to a computer, where the care coordinator can evaluate all the patients’ results to determine who needs to be called that day, Ryan explains.
System tailors education to patient
The system then automatically delivers education to the patient based on how the patient answered questions, Ryan says. "Instead of giving patients a three-inch notebook with information, you give them education based on their answers and on their behaviors," Ryan notes. For patients who are unable to use that technology, a video phone also is available, Ryan adds. Either way, patients are monitored by the technology, but they always have someone they can call in case of an emergency or if they have additional questions.
• Provide initial home visits, emergency care, and follow-up support.
It typically takes one home visit to set up the messaging device if patients need assistance, Ryan says of the VA’s telehealth system. "Everyone who receives a telemonitor will receive a home visit, but there are some patients you wouldn’t visit at home at all," Ryan says. "We screen everyone to see if they need a home visit, and for the palliative care population, we make at least one or two visits to their home."
For palliative care patients, the care coordinator will establish routine communication with the caregiver to assess the caregiver’s burden, Ryan notes. "A lot is done by the phone, but as more of a scheduled activity to relieve the caregiver’s stress," Ryan says. "Also, for palliative care patients, we’ll arrange for respite care if it’s needed, because a lot of time there’s access to a lot more community services."
The program provides some patients with added support through the use of a video phone that the patient can use to speak with another family member who is too ill to visit the patient, Ryan adds. The chaplain will keep in touch with the patient and family by telephone and may schedule regular appointments for spiritual counseling. The chaplain, like other care coordinators, also serves as a conduit to the primary care physician and other providers, so if a patient needs access to some service, the chaplain will arrange it for the patient, Ryan says. Patients who need help outside of scheduled calls and visits can call a 24-hour nurse during off-hours, Ryan says.
So far, the system has helped reduce unnecessary emergency room visits and hospitalizations, Ryan notes. Hospice nurses, physicians, and other clinicians know that the care coordinator is keeping a close eye on the patient, so if the care coordinator calls to request that someone see the patient, the visit is scheduled immediately, Ryan says.
Sometimes, hospice patients in the Michigan program will call in for assistance via the video phones, but usually their telehospice visits are scheduled, Whitten says. There have been occasions when the telehospice service has saved a nurse hours of commuting time when an emergency has occurred, Whitten notes. For example, one patient’s caregiver in northern Michigan called to say the patient was having some abdominal discomfort, and the caregiver didn’t know what the problem was. The nurse asked the caregiver to move the video phone camera down the patient’s body so she could look at the patient, and she discovered a kink in the Foley catheter. Once the caregiver unkinked it, following the nurse’s instructions, the patient’s discomfort eased, Whitten recalls.
"That would have been a 60-mile visit out and back in the middle of the night for the nurse," Whitten says.