Use technology to improve your patients’ health
Telehealth boosts outcomes, retention, efficiency
(Editor’s note: The Association of Telehealth Service Providers defines telehealth — also known as telemedicine — as follows: “Telemedicine is the use of electronic communication and information technologies to provide health care when distance separates the medical professional from the patient. It also includes educational and administrative uses of these technologies in the support of health care, such as distance learning and administrative videoconferencing. . . . Telemedicine typically involves physicians using interactive video and/or store-and-forward consultations to treat patients.”)
Home health managers constantly are looking for ways to improve efficiency without compromising patient care. At the same time, they want to improve retention of good nurses so they are not always in a hire-and-train mode. A recent study conducted by the Pennsylvania Homecare Association in Lemoyne and Penn State University in University Park shows the use of telehealth can increase efficiency as well as improve retention of nurses.
The data show agencies using telehealth have an average RN-to-patient ratio of 1 to 15, while non-telehealth agencies have a ratio of 1 to 11. Thirty-four Pennsylvania home health agencies are participating in the study. Twenty-three agencies use telehealth, and 11 agencies do not.
“We decided to participate in the study when it began three years ago because we saw an opportunity to improve patient outcomes,” says Kim Kranz, RN, MSN, vice president of operations for Home Nursing Agency in Altoona, PA. “We did not have telehealth prior to the study. We have seen improved outcomes because the information that we now receive daily through the telehealth system enables us to make decisions to intervene in a more timely manner,” she explains.
Not only has Kranz’s agency seen a decrease in the number of rehospitalizations of congestive heart failure (CHF) patients, but she and her staff have noticed additional benefits.
“Our relationship with our patients’ physicians has improved because we can call them with hard data about changes in their patients’ condition,” Kranz explains. “Physicians like data, and when we can provide readings from several days in a row to show trends, they are more responsive,” she adds.
Kranz also expects telehealth to help when recruiting new nurses. “When younger nurses are ready to leave the hospital and look at home health as an option, they see telehealth as an important tool,” she explains. Unlike current home health nurses who may not be familiar or comfortable with new technology, younger nurses have grown up with technology, Kranz continues. “These nurses are techno-savvy, and they expect to have this technology available,” she adds.
Even with existing staff, the use of telehealth is a plus, says Linda E. Bettinazzi, RN, BSN, president and chief executive officer of Visiting Nurse Association (VNA) of Indiana County in Indiana, PA. “Our nurses are proud that our agency is progressive and looks for ways to help them do their jobs and better care for patients,” she says. “Our retention rates are high anyway, but telehealth is one more way to improve job satisfaction,” Bettinazzi adds.
VNA of Indiana County has offered a telehealth service since 1999 and currently has 83 monitors that serve 90 patients. Some of their monitors can handle multiple patients who use an electronic card with their personal health information to access the monitor and send information. “This is very helpful in an assisted-living facility where you can place the monitor in one central easy-to-reach location, as opposed to providing multiple units in one location, Bettinazzi says.
“When we first began researching the technology, the video component was not very good, so we opted for a monitoring unit that collects vital signs through a unit in the patient’s home that sends the information via a phone line to a central station in the home health agency’s office,” she explains. “We can also program specific questions for the patient to answer, such as, ‘How do you feel today?’”
The patient’s case manager reviews the data each day, Bettinazzi says. These data aren’t used to replace nursing visits; instead, they are used to determine when the patient most needs a visit. “The nurse can visit the patient if there are readings that indicate a problem,” she says.
This differs from the traditional system of scheduling a visit to a specific patient on Tuesday and Thursday of each week, Bettinazzi notes. “It is more effective because the patient might be fine on Tuesday but might have a crisis on Wednesday.”
Bettinazzi’s agency has a dedicated group of four nurses to handle all 90 telehealth patients. “Their caseload is higher than non-telehealth nurses’ caseload, but they are not visiting their patients as many times,” she points out. “We’ve found that our CHF patients on the telehealth service receive an average of 10 visits, as compared to CHF patients on traditional service, who receive an average of 17 visits,” she says. “Our telehealth patients are also rehospitalized fewer times.”
At this time, the four telehealth nurses are responsible for both the installation and removal of the telehealth equipment, Bettinazzi says. “I have suggested that we could train someone else to handle these tasks to free the nurses’ time to be with patients, but the nurses want to continue the installation,” she says. “They believe it is an important teaching opportunity, as they get to know the patients and their family members.” Bettinazzi is considering setting up an employee to handle the removal of the equipment upon discharge, she explains.
At VNA of Wyoming Valley in Edwardsville, PA, home health aides install and remove the equipment, says Nancy P. Barnard, RN, BSN, MHA, director of home health at the agency, an affiliate of Wyoming Valley Health Care System. “The nurse is in the home immediately after — or at least on the same day as — the installation to teach the patients, but we’ve found that using the aides to install the equipment shortens the nurse’s visit and makes better use of the nurse’s time,” she says.
One of the unexpected challenges with managing telehealth equipment is tracking all of the equipment and accessories, Barnard notes. “You always remember to pick up the monitoring unit and items such as the blood pressure cuff, but little things like ground wires and telephone jacks often got left behind when we first started,” she says. “We now have a checklist that lists all of the items used to install the equipment, and the aide uses that checklist to make sure all of the items are picked up at discharge,” Barnard adds. “You can design your checklist to be taped to the monitor so that you don’t have to search for the list when it’s time for the aide to remove the equipment,” she suggests.
All of the nurses in Barnard’s agency work with telehealth patients. “We have an LPN who monitors the daily readings at the central station,” she says.
The LPN checks with the scheduler to see if a patient whose readings are abnormal is scheduled for a visit that day, and together they will rearrange the schedule to make sure the patient is seen. “We also talk with the patients by telephone to see how they are feeling and to see if their vital sign reading might have been affected by diet, medication, or other activity,” she says. The combination of telehealth and telephone contact with patients enables Barnard’s nurses to see patients when they most need to be seen, she explains.
Therapists find data helpful
Most agencies are targeting patients with certain diagnoses — such as CHF, diabetes, prenatal, coronary artery disease, or stroke — for telehealth, but the technology can be helpful for non-nursing cases as well, Barnard notes. “We may discharge a stroke patient from our nursing service before the therapy services are complete, but we don’t immediately pull the monitor from the home,” she says. “We found that our therapists were very interested in the data that showed a patient’s vital signs when at rest, immediately before therapy, and immediately after therapy,” Barnard says. “We started leaving the monitors in the home when therapists expressed disappointment that we were taking them as soon as the patient was discharged from nursing care,” she adds.
One recommendation that Bettinazzi has for managers implementing a telehealth program is to have standing orders for interventional activities in place. “There are things our nurses can do in the home to prevent a trip to the hospital, but some of our physicians are hesitant to allow us to intervene at home when we call to tell them their patients are experiencing difficulties,” she says. “They tend to send the patients to the hospital.” If, at the start of a telehealth service, you can set up some standing orders specific to CHF or other conditions, it will further decrease visits to the emergency department and rehospitalization, she says.
“As nurses age and we have to care for patients with fewer nurses due to the nursing shortage, it becomes more important to have data from telehealth to determine which patients need to be seen on each day,” Bettinazzi says. By making sure a nurse’s time will be used effectively, you can provide quality care without overextending your staff and risking staff burnout, she adds.
Kranz contends telehealth is an important tool for home health. “With the emphasis on reducing rehospitalizations and improving home health outcomes, and the pay-for-performance approach to home health reimbursement that is around the corner, telehealth is not going to be just a nice addition to our services; it is going to be essential to our agency’s success,” she says.
A recent study conducted by the Pennsylvania Homecare Association in Lemoyne and Penn State University in University Park shows the use of telehealth can increase efficiency as well as improve retention of nurses.
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