A recent study revealed how healthcare organizations can design a telehealth pilot program for elderly and at-risk populations with long-term health conditions.1

Researchers found that using the Model for Developing Complex Interventions in Nursing (MDCN), healthcare providers could design a multifaceted telehealth intervention to minimize reinstitutionalization of people with multiple chronic conditions. The intervention includes remote patient monitoring and assessment of pain, mental health, and care coordination.

The study focused on the overall design of the project. Now, researchers are working with the state bureau of medical services, which administers Medicaid, to pilot a study that tests whether the telehealth intervention can help people in long-term care facilities go home, says Steve Davis, PhD, associate professor in the department of health policy, management, and leadership at West Virginia University School of Public Health.

“We’re setting people up with telehealth with the goal of seeing if we can effectively manage their chronic conditions and ultimately help them live in their homes,” Davis explains.

Some patients who transition home after staying in a long-term care facility will exacerbate their chronic illness. This can cascade into events that end up with the person back in the long-term care facility. “We want to keep them safe at home,” Davis adds.

The telehealth intervention uses these methods:

  • Asynchronous. These are telehealth interventions that include remote patient monitoring. A device is collecting patients’ data, such as vital signs, but these are not monitored in real time. Instead, a case manager can review the data on a regular basis, and send the information to a nurse if there are problems, such as a diabetic patient with a high glucose reading.
  • Synchronous. A case manager or nurse calls patients to assess their health and condition over the phone, including their pain and mental health status.
  • Care coordination. Care coordination also is synchronous and can include live video conferencing, Davis says.

“If you have a participant on 10 to 15 medications, and you’re worried about medication errors or interactions, then you can interact via live video, asking the patient to hold up the pill bottle,” Davis says. “If there are worsening conditions, we can facilitate getting the patient connected with a primary care provider.”

Davis’ research had been underway before the COVID-19 pandemic began, but its tactics and interventions are particularly meaningful at a time when healthcare providers across the globe are finding ways to monitor patients without exposing them to the virus.

“That’s the beauty of the technology,” Davis says. “It could be used by different types of providers.”

For this study, a project nurse and project team are the clinician experts. They contact primary care providers as needed and work with care management personnel, Davis says. When nurses call people, they follow a script, explaining that they’re calling on behalf of West Virginia University.

“A lot of those discussions will be about the transmission of vital signs and whether the equipment is working,” Davis says.

The technology depends on each person’s needs. “That’s the beauty of the model,” Davis explains. “We start planning and working with participants before they go home, and we customize their actual course or plan.”

Each person uses some type of remote monitor. These could be for blood pressure, glucose monitoring, checking a person’s temperature to watch for a new infection, pulse oximetry, and tracking a patient’s weight, Davis explains.

“Those are the main five we’re looking at with remote patient monitoring,” he says. “In addition to that, every patient will receive a phone call every two weeks for a standard assessment of mental health issues and pain.”

Some of the challenges of telehealth include broadband issues that make live video conferences difficult.

“There may be some participants who live so far back in the country that they don’t have good coverage. For those participants, we won’t do live video,” Davis says. “But we can do remote patient monitoring of vitals and good, old-fashioned telephone calls.”

The telehealth study was set up in a way that did not require changes when the pandemic began to shut down much of American life. “We don’t have to change anything because the participants will be in their homes,” Davis says. “They have equipment that is mailed to them, and the equipment is designed in a way that they can set it up on their own in their homes and troubleshoot any problems.”

It is easier to set up than cable, he adds. “From a COVID-19 standpoint, that is a real plus. We don’t have to change anything with our particular program,” Davis says. “We’re going to monitor people’s temperature, and see if anyone develops a dry cough and other things related to COVID-19.”

Participants who report symptoms suggesting the viral infection would be told to stay in their homes if they are safe there. But if they struggle to breathe, they would be advised to go to the hospital, he adds.

“I think the telehealth program is quite powerful because it provides a direct mechanism for achieving the advice we’ve all been given: Unless you’re having a true emergency, try to limit and avoid contact with the healthcare system, especially those who are at high risk,” Davis says.

“Telehealth is a mechanism for accomplishing that goal,” he adds. “It enables participants to be linked with healthcare resources without the requirement to present in person and be exposed to viral carriers who may be asymptomatic and shedding virus.”

Telehealth will continue beyond the pandemic, Davis says. “Viral illnesses will always be around, and there will always be disease processes for which it is important to provide social distancing, especially if people are immunocompromised,” he says.

“Telehealth is going to be the wave of the future as a way to promote health, catch things in real time, and keep us all safe,” Davis adds. “Healthcare workers minimize their exposure, too.”


  1. Davis SM, Jones A, Jaynes ME, et al. Designing a multifaceted telehealth intervention for a rural population using a model for developing complex interventions in nursing. BMC Nurs 2020;19:9.