key: cord-0942426-nsger7p0
authors: Ford, James H.; Jolles, Sally A.; Heller, Dee; Langenstroer, Madeline; Crnich, Christopher
title: Recommendations to Enhance Telemedicine in Nursing Homes in the Age of COVID-19
date: 2021-10-16
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.10.002
sha: 06bb0cd8506a3df29a0e03d2b042f12720c40b18
doc_id: 942426
cord_uid: nsger7p0

nan

Nursing homes (NHs) have been at the frontline of the COVID-19 pandemic. 1 

Despite representing <1% of the U.S. population, NH residents account for nearly 33% 2 of all COVID-19 deaths. 3 The Center for Medicare and Medicaid Services implemented 3 sweeping telemedicine (TM) regulatory relief in an effort to reduce COVID-19 spread in 4

NHs. Telemedicine activity in U.S. NHs has expanded dramatically 4 but has not been 5 without its challenges. Herein, we report 12 recommendations to enhance and sustain 6 TM (Table 1 ) from a TM adoption study, certified as quality improvement by the UW-7

Madison Health Sciences IRB. 8

A convenience sample of NH (n=9) in South Central Wisconsin were recruited based 9 on geography (rural vs. urban), ownership and profit status. Each NH had newly 10 adopted or significantly expanded TM during the COVID-19 pandemic. Key informants 11 (n=27) involved in the structure and conduct of TM encounters were interviewed or 12 surveyed including NH staff, long-term care advanced practice providers (APPs), and 13 regional healthcare sub-specialist providers. 14 Study participants identified five technology enhancement needs, including: 1) 15 improvements to connectivity and bandwidth; 2) an increased supply of TM devices; 3) 16 availability of sound amplification devices; 4) availability of telehealth-ready 17 stethoscopes, and 5) enhancements to video quality. Internet connectivity and 18 bandwidth as well as TM device availability improved in all participating NHs although 19 technology bottlenecks were still a problem in several facilities. The volume capabilities 20 of the TM devices employed in NHs was often inadequate and participants identified 21 secondary sound amplification devices as a critical need for encounters with hearing-22 impaired residents. Although many TM encounters did not require a heart or lung exam, 23 J o u r n a l P r e -p r o o f APP participants noted having a telehealth-ready stethoscope available would further 24 alleviate the need for face-to-face encounters when encountered with a scheduling 25 conflict or a facility outbreak. Some respondents noted the video quality on existing TM 26 devices was inadequate for performing skin and wound assessments and expressed a 27 desire for high-resolution camera/video devices in residents with these issues. 28

Study participants identified three scheduling enhancement needs, including: 1) 29 availability of a common scheduling system; 2) centralization of NH scheduling 30 responsibilities; and 3) development of blocked TM scheduling. Successfully scheduling 31 a TM encounter requires coordinating the provider, NH staff and resident schedules and 32 ensuring availability of TM equipment. A common scheduling system that was used and 33 viewable by all the participants could potentially reduce the frequency of calls and 34 rescheduled appointments. In lieu of a technology fix, participants noted significant 35 scheduling efficiencies could be achieved by centralizing scheduling related tasks to a 36 limited number of trained individuals who were given sufficient time to complete this 37 work. Participants also noted that scheduling activities was improved by developing 38 fixed times during which providers were allowed to conduct their TM encounters. While 39 this enhancement has the potential to conflict with provider schedules, blocked 40 scheduling greatly reduces NH workflow disruptions, and most facilities were able to 41 negotiate blocks of time that were mutually acceptable to their providers. 42

Deficiencies in information exchange was identified as a common problem area by 43 study participants and has been reported by others. 5 Giving providers and their clinic 44 staff remote access to NH electronic health record would facilitate TM encounter 45 preparation and pre-charting activities. Establishing standard procedures for information 46 J o u r n a l P r e -p r o o f exchange that include the type and quality of information that should be collected, how it 47 is shared and who is responsible for these tasks was also identified as a critical need by 48 study participants. 49

The individual facilitating the TM encounter was another problem area identified by 50 study participants. While non-clinical staff were capable of participating in scheduling 51 and set up of equipment, TM encounters facilitated by these individuals were limited by 52 poorer information exchange and reduced capacity to conduct key aspects of the 53 physical exam. Centralizing TM encounter facilitation to a limited number of trained 54 clinical staff enhanced inter-professional rapport and improved overall quality and 55 efficiency of these encounters. 56

Implementing these twelve recommendations come with costs that must be offset if 57 TM is to be sustained. Gillesipie et al. have previously argued that existing TM 58 regulatory waivers implemented in response to COVID-19 must be made permanent. 6 

Provider and NH reimbursement models will also need to be modified in order to 60 correctly incentivize provider use of the TM modality and provide facilities with the 61 resources to purchase and maintain TM equipment as well as hire and retain staff 62 responsible for critical TM tasks. While navigating this path forward will not be easy, the 63 potential benefits of sustaining the current TM expansion 7, 8 are too great to go back to 64 the pre-COVID status quo.

Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

COVID-19 in a Long-Term Care Facility

Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data

An evaluation of telehealth expansion in U.S. nursing homes

Maximizing Efficiency of Telemedicine in the Skilled Nursing Facility during the Coronavirus Disease 2019 Pandemic

Innovation Through Regulation: COVID-19 and the Evolving Utility of Telemedicine

Standards for the Use of Telemedicine for Evaluation and Management of Resident Change of Condition in the Nursing Home

Telemedicine and Telehealth in Nursing Homes: An Integrative Review

J o u r n a l P r e -p r o o f 1. NHs should invest in the infrastructure necessary to support telemedicine encounters through improved connectivity and bandwidth 2. NHs should invest in dedicated and adequate/appropriate equipment to conduct telemedicine encounters (e.g., laptop or tablet) 3. NHs should have ready access to secondary sound amplification devices to use during telemedicine encounters with hearing-impaired residents 4. NHs should have ready access to a telehealth-enabled stethoscope that allows providers to remotely perform a heart and/or lung exam when necessary 5. NHs should have access to high-resolution video or camera equipment that enhances remote assessment of skin and wound findings Scheduling 1. NHs should develop or invest in a common platform that allows key individuals to schedule telemedicine encounters 2. NHs should centralize scheduling of telemedicine encounters to a core individual(s) 3. NHs should adopt telemedicine block schedules that factor in sufficient time before and after encounters for inter-professional information exchange and care-planningInformation Exchange 1. NHs should provide clinicians and their staff with remote access to NH electronic health records 2. NHs and providers that engage in TM encounters should develop and implement procedures and staff training that standardize: 1) the types of information shared between NH staff and providers; 2) how these types of information should be shared; and 3) who is responsible for these information sharing tasks Telemedicine Encounter Facilitator 1. NHs should identify and dedicate staff to facilitate telemedicine encounters 2. The telemedicine encounter facilitator should be a clinician (I.e., RN or LPN)