NC home care agency tailors telemedicine to fit patients’ needs
NC home care agency tailors telemedicine to fit patients’ needs
Clients appear satisfied with telehomecare visits
At University Home Care in Greenville, NC, what began three and a half years ago as a pilot program has spread to the use of dozens of telehomecare units for a range of different tasks. The units, which provide an audiovisual link between nurses and patients, now enable pregnant mothers with hypertension stay home longer and help cut down on hospital readmissions for elderly patients. They allow nurses to make regular telehealth visits to schools and parents’ homes, teaching them to manage infant apnea.
"One of the reasons our program is looked at as so successful is because we have a lot of diverse [uses]," says Bonnie Britton, MSN, RN, C, supervisor of special programs for University Home Care. "We’ve been using it in home health to not only control our costs as an agency, but also to try to decrease hospital readmissions, since we’re part of a health care system."
Overall, she says, patient satisfaction with the technology has been high. Most patients have no problems using the one-button audiovisual device. "Our oldest patient has been 89 and lived alone with a unit," Britton says.
University Home Care’s pilot program began in May 1997, and Britton spent the first six months evaluating the usability of the equipment, purchased from American Telecare in Eden Prairie, MN.
The units, which are connected to patients’ phone lines, have a video monitor and camera so the patient and nurse can see and hear each other. To operate the machine, the patient need only push a green button, and a connection is established with a nurse at University Home Care offices in Greenville.
The machine has a number of peripherals attached, including a blood pressure cuff, stethoscope, and glucose monitor, all of which are operated by the patient or a family caregiver.
The units have proven very successful with so-called "frequent flyers" — patients with such conditions as congestive heart failure, chronic obstructive pulmonary disease, and renal failure who frequently are readmitted to the hospital.
"We’ve put telemedicine units in these frequent-flier homes to see if we could keep them out of the hospital" by catching problems early on, Britton says.
Varied uses for telemedicine units
University Home Care has branched out, using the technology in a variety of other settings:
• Infusion therapy. A nurse now can conduct telehomecare visits after the initial setup of the medication. "Because there’s no reimbursement for an infusion therapy company when they send a nurse to the patient’s home, every time a nurse leaves the building, the agency is losing money," she says. "That’s a right-off-the-top savings to the infusion therapy portion of the company."
• In-school program. University Home Care provides planned telemedicine visits to asthmatic students in six schools in Pitt County, NC. This program will be integrated with and sustained by Pitt County Memorial Hospital’s school health program.
• Obstetrics and pediatrics. The agency uses the telemedicine program with women who are pregnant and have hypertension — women who previously would have to be hospitalized for weeks during their pregnancies. Instead, Britton says, the agency provides two home telemedicine visits a week, along with two regular home care visits and a weekly clinic visit.
University Home Care also uses the technology with asthmatic babies in the home, pediatric patients with tracheotomies, and babies who are at high risk for sudden infant death syndrome.
• Other care settings. The agency has worked with hospice patients and is collaborating with Pitt County Memorial to put units in assisted- living facilities in order to monitor those patients. Britton says there are plans to expand into pediatric private-duty care.
In every case, Britton says, data have shown that incorporating telemedicine visits helps keep hospitalizations down and saves money. "If the home care agencies are connected with a hospital, that’s extremely important," she says. "For home care agencies that are not, the reason they’re implementing telehomecare is to control their costs and to be able to survive in the [prospective payment] capitated system."
Another measure of the program’s success has been in the area of patient satisfaction. In fact, Britton says, patients are so taken with the technology that the biggest problem has been taking it away when care is completed. "They’ve gotten so used to it, they feel like the technology is making a difference and keeping them home, and don’t want to lose it," she explains.
She says the agency handles that problem as it does any other aspect of discharge planning, starting on the day the units are installed. "We give them an estimated time that we believe the unit will be in there, based on patient need."
Unlike some agencies, where a large number of nurses are trained to conduct telemedicine visits, University Home Care has only one full-time nurse and one part-time nurse assigned to the program. Other field staff have been cross-trained to fill in during vacations and other absences.
Britton says she believes having many nurses handle both field and telehomecare visits defeats the purpose of the technology, forcing nurses to drive back and forth between the office and homes just as they did before. "Other agencies are doing it, and it’s working out great, but we’re in such a rural area, I don’t want the staff driving more than they have to. We’re doing it in a way that actually lightens their load," she says.
Handling patient flow
The telemedicine nurses conduct visits only by appointment during regular office hours. Patients who call at another time are routed through their primary nurse or the on-call nurse. But if that nurse is busy, the telemedicine nurse may be asked to conduct a telehomecare visit.
"We don’t have them call us directly, because I can’t guarantee I’ll have a nurse available. The liability would be too great in our setting," Britton says.
Training staff in the use of the office’s PC-type telehomecare unit is fairly simple, she says. The nurse can see and hear the patient clearly and read the results of the vital sign tests the patient self-administers.
Britton says that when the agency’s new pediatric nurse came on board, she was conducting telehomecare visits within two days. "Really, it’s just learning the equipment. I’d say a week, maybe, to be safe. But if I had somebody who couldn’t grasp this in about three days, I’d be concerned."
Training is even simpler on the patient’s end. The most difficult part is teaching the patient to put on the blood pressure cuff. Britton estimates that most installation visits, where patients learn how to use the units, take about 15 to 20 minutes, and that’s serving a population with high rates of poverty and illiteracy.
The only barrier she sees to putting the units in some homes is a practical one: Some clients don’t have phones or even electricity.
Choose patients, uses for technology
Just because patients can use the unit doesn’t mean they need it, Britton points out. She says her nurses work to identify who would benefit most from telehomecare visits. "We’re looking for patients who are going to require a large number of visits or who live far away from the agency," she says.
She also recommends the units for patients who have problems with compliance and says the technology has the advantage of requiring patients to participate in their care more fully.
"We’re finding that patients who never have really taken an active role in their care before are actually now starting to take an active role in their care and learning what their body is saying to them," she says. "They are able to identify problems earlier, which also affects emergency usage."
An agency looking to start a telemedicine program, she says, needs to have a clear idea of how it will be used. Often, that use will be tied to the reimbursement an agency can expect to receive. "If it’s an independent agency and they primarily have contracts with HMOs, they need to be thinking reimbursement directly for that. If they’re looking at controlling PPS dollars, they need to identify which patients are the most costly, so you can be truly focused on which patients are going to benefit the most. For every agency, it’s going to be completely different."
She says agencies need to remember that telemedicine is a tool to be integrated into day-to-day care like any other tool.
"It’s just like a bandage," Britton says. "If you need it, you use it. If a patient needs quicker access to care, more frequent visits, is having compliance issues — it really depends on what you’re trying to accomplish."
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