Associate Professor New Courtland Center for Transitions and Health University of Pennsylvania School of Nursing USA.
Telehealth provides remote physiologic monitoring of patients with chronic illness such as diabetes mellitus or heart failure. Most commonly, it is provided at homes in conjunction with nurse home visits. Chronically ill patients use devices that measure blood pressure, weight, blood oxygen or glucose levels on a daily basis. Healthcare providers, patients and family caregivers closely monitor the readings and rapidly respond to deviations from normal. Several studies have shown the benefits of telehealth in providing rapid response and, therefore, reducing hospitalisation and emergency department use. The benefits are many, but the technology does present some challenges for the agency providing the services. Here is a look at suggested strategies to overcome the challenges and provide successful, cost-effective telehomecare.
The outcome of telehomecare intervention is heavily, if not completely, dependent on the people providing the intervention. Their attitude towards the value of the technology is important to a successful programme. Often, the attitude starts from the top management. Management must communicate the value of the programme to their staff and implement support structures that enable operations to proceed. For example, managers must recognise that telehealth adds time to the nurse’s day because of equipment set-up and patient teaching. Expectations about productivity may need to be adjusted. Also, the staff must be properly trained for installing and using the equipment. One strategy when developing the procedures for the programme is to get staff at all levels of operation involved in conversation, education and feedback. Any barriers should be identified and solutions devised.
Successful telehealth requires teamwork and coordination. There are two models of care delivery. In one, the home care nurse is responsible for home visits, monitoring the telehealth data, and responding to deviations in the telehealth data. In another model, the home care nurse does in-person visits only and another telehealth nurse monitors the data and coordinates a response with the home care nurse. Either model requires teamwork and coordination to install the equipment in a timely manner and to assure a rapid response to patient needs. Often, the type of equipment used dictates which model is most practical. If the equipment is web–based, then the first model works well; if video is used then the latter model is required because the nurse must be at the office to use the video equipment and interact live with the patient.
Telehealth is best used in patients with illnesses that respond to monitoring and rapid intervention. It is ideal for patients with heart failure because the weight monitoring provides information that is responsive to health interventions. Telehealth is best used with patients who are cognitively intact, able to pull a blood pressure cuff on their arm and stand on a scale. Also, motivated patients are necessary to gain cooperation in using the devices regularly. Those recently hospitalised are often ideal since the fresh memory of hospitalisation can be motivating and a recent hospitalisation puts them at risk for future events.
Equipment selection and installation is another important challenge. Determine the devices needed by matching them to the population being served. For example, with diabetics, a glucometer is needed, but perhaps not a scale. Also, decide whether to use video or just monitoring and ask if wireless devices are available because they are easiest to install and place into the patients’ home environments. Choose a reliable vendor with a good reputation and strong business history. Seek equipment that is simple to set up and use. Consider initial and ongoing cost of the equipment and ask about data storage or monitoring fees. Consider direct delivery right to the home from the manufacturer and determine how the equipment will be installed, collected, cleaned and redeployed. Home care nurses prefer that these tasks are not their responsibility. Some manufacturers provide these services for a fee.
Early on, map out the work flow and define roles and responsibilities. Some roles and responsibilities include delivering the equipment and supplies, installing , monitoring and acting on the data, and training the patient and caregiver on its usage.
The period of highest risk for the newly admitted home care patients is the first 24-48 hours. Therefore, the goal should be to deliver and begin using the equipment within the first week of home care. Agencies must also determine how long to leave equipment in the home and how to use the technology in conjunction with in-person visits to be most efficient and effective. A suggested pattern is found in Table 1.
Once the equipment is installed, several process strategies can be employed to promote successful telehealth. Provide guidelines for nurses on the content of the conversation via video or telephone. This assures consistency in the monitoring procedures and teaching content for patients. To assist with rapid response, secure collaboration with physicians for medical orders based on monitoring results. Seek standing orders for faster response. For example, often physicians may have a standing order for heart failure that whenever the patient’s weight increases by >2 pounds in 24 hours, the nurse should instruct the patient to take an additional diuretic. Nurses should also use the data as a ‘teaching moment’. Nurses can show the patient changes in their readings and how they correlate to their behaviours. This helps to reinforce healthy behaviours and adherence to diet to medication.
Track outcomes continuously to measure and communicate the value of the programme to payers. Most commonly, hospitalisation and emergency department use are measured. Others monitor patient knowledge about healthy behaviours, adherence to therapies, symptom improvements and use of the equipment for self-care. Costs in time, personnel and equipment should be compared to gains in efficiency and savings due to preventable readmissions.
Finally, it is important to publish and present results and lessons learned so that others learn the value of this technology for chronic illness and how to administer the programme most effectively. Further, payers may decide to adopt the model for their patients and reimburse it as a valued service.
Adequate training, staff attitude, management support, careful selection of equipment and the right patients all contribute to a successful telehealth programme. Developing a satisfactory and efficient workflow is crucial to match nurse, agency and patient needs; install the equipment in a timely manner; and provide coordinated care efficiently. The main goal is to use the technology to improve patient outcomes and prevent costly readmissions and emergency department use.
Possible visit pattern
Kathryn H Bowles is an Associate Professor in the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, leads an interdisciplinary programme of research that blends transitional care and the use of health information technology to improve the care of the elderly. Bowles has led as Principal Investigator or been a Co-Investigator on 5 telehomecare studies in a variety of home care agencies in Pennsylvania. Her NIH funded work includes an ongoing clinical trial testing the effects of telehealth with heart failure patients.