VA telehealth model opening nationwide
Experts predict a larger role for telehealth in the health care industry as model programs demonstrate high patient/caregiver satisfaction and improved staff efficiency and quality of care.
Home health agencies and hospices 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," he says.
Hospice agencies are the latest to explore the advantages of telemedicine, experts say.
"I’ve been involved in doing research in tele-medicine 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, she 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 explains. "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 telehealth program was limited to home health for the purposes of research, says Whitten. "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," she adds. "We wanted to look at areas where there was a potential challenge in access, and so we provided telehealth services to rural areas and an urban area," Whitten notes.
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, she adds.
The Bay Pines VHA’s telemedicine project is divided into 21 programs across the state of Florida and in 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, she 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 telehealth program, many of the other programs also will 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 telehealth programs and how they may fit in with existing home health services.
Here are their observations and advice regarding starting a telehealth program:
• Understand the licensing and legal issues.
While a telehealth 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, he 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 usually can only provide care consistent with a physician’s order, he explains. So the question arises: "Do they need an order to use telehealth service in the fashion they are using it?" Dombi asks. "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," Dombi says.
• Select the telehealth model that works best for your clientele and staff.
The telehealth study conducted in Michigan found that patients uniformly liked the service, and many even wanted to use it more frequently, Whitten says.
Challenge came from providers’ resistance
"Some providers loved it from Day One, and some providers resisted it," she says. "The challenge was not with the patients accepting telehealth and liking it; the challenge was with the providers."
This project used videophones 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 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, she 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, she adds.
• Care coordinators direct telehealth services.
The VA telehealth program provides a nurse practitioner and chaplain for palliative care services, and also provides easy access to physicians, an interdisciplinary team, and anyone else who is needed, Ryan says.
Selecting the appropriate technology
The first step is to assign the patient a care coordinator who selects the technology that will be used to provide the telehealth services, she points out. 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 OK and "yellow" if the patient needs to be watched, Ryan explains. 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, she adds.
• 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 3-inch notebook with information, you give them education based on their answers and on their behaviors," she notes. For patients who are unable to use that technology, a videophone 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, she 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," she adds.
For palliative care patients, the care coordinator will establish routine communication with the caregiver to assess the caregiver’s burden, notes Ryan. "A lot is done by the phone, but as more of a scheduled activity to relieve the caregiver’s stress," she explains. "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," Ryan continues.
The program provides some patients with added support through the use of a videophone that the patient can use to speak with another family member who is too ill to visit the patient, she 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, she adds. So far, the system has helped reduce unnecessary emergency department 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, she says.
Sometimes, patients in the Michigan program will call in for assistance via the videophones, but usually their telehealth visits are scheduled, Whitten notes.
There have been occasions when the telehealth service has saved nurses hours of commuting time when an emergency has occurred, she 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 videophone 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," she says.