Maine Nursing Home Telehealth Network

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Maine Nursing Home Telehealth Network

• Ronald L. Emerson, RN, BSN Director, Maine
  Telemedicine Services

• Michael Edwards, PhD Dir. of Research
  Evaluation
• Sandra Hare, RN, BSN
• Clinical Coordinator
• HealthWays/Regional Med. Ctr. at Lubec, Maine

ATA Annual Meeting, San Diego, May 2006 Funded by
the Office for the Advancement of Telehealth
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Maine Health Access Issues Large rural areas
e.g. 6 counties, 300K pop., 21K sq. mi., 17/sq.
mi. Many HPSA/MUAs Often 2-4 hrs. driving
time from tertiary care hospitals Specialty
care doctors scarce 50 elevation over state
poverty unemployment rates
Most Rural Counties
Maine Hospitals
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Maine Nursing Home Telehealth Network
Relevant Health Care Needs

• High fraction of elderly residents17 for
  project counties, 14 for Maine, 12 for U.S.
• High state rates for lung disease and cancer
• mortality ranks 6th and 4th among states, 99-02
• High ER utilization ratesranks 5th among states
• High rates of asthma among elderlyranks 6th
• Substantial rural vs. urban health disparities
  linked to economics and health care access
• e.g. project county rates of hospitalization for
  elderly 15-50 above state averages for
  pneumonia, COPD, asthma/bronchitis, diabetes
  heart disease

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• Maine Telemedicine Services
• Solutions for Connecting People
  Interactively
• Clinical and technical team with seven years
  experience
• --non-aligned with major health care
  organizations
• --acts as glue between provider and client
  access agencies
• Clinical service development
• Equipment /service contracts
• Education/training
• Grant, evaluation and research services
• Statewide conferences
• Advocacy for favorable regulatory infrastructure

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Maine Telehealth Network
Infrastructure

• Primarily ISDN
• 128-384 kbps
• Open-architecture
• IP-based hospital use w/ISDN gateway

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Maine Telehealth Network
Network Partners

• Hospitals
• FQHCs/Rural Health Centers
• Physician Offices
• Social Service MH Agencies
• State Agencies
• Health Human Serv.
• Corrections

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Maine Nursing Home Telehealth Network
Major Project Components

• Recruiting nursing homes and providers
• Clinical telemedicine application development
• Develop distance education program
• Pilot videophone program for linking patients
  with distant family members

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Maine Nursing Home Telehealth Network
Goals

• Assess feasibility and effectiveness of ISDN
  based interactive telemedicine to deliver
  specialty health care consults to nursing home
  patientscurrently under review for reimbursement
  by CMS
• Enhance relevant staff skills and knowledge
  through distance education
• Explore use of IVC for primary care
• Explore use of videophones to enhance patient
  well-being through family linkages

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Maine Nursing Home Telehealth Network
Expected Benefits

• Patients
• More timely specialty care
• Reduction of stressful transports
• Families
• More participation in plan of care and clinical
  visits
• Relationship maintenance through videophone calls

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Maine Nursing Home Telehealth Network
Benefits (continued)

• Nursing Facilities
• Reduced expenses for transports
• Improved access reduced cost for staff
  education
• Reduced worker injuries IVC-facilitated training
• Specialists/Practitioners
• Improved ability to assess the patient in
  residential settings
• Reduce travel cost and disruption of work flow
• Greater provider collaboration and peer education

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Maine Nursing Home Telehealth Project
Nursing Home Recruitment for Project

• Four rural facilities added in northern Maine in
  Year 125-50 skilled beds
• Another added in Year 2 to replace planned site
  where ISDN service unavailable
• A larger facility from southern Maine added late
  in Year 2100 skilled beds (city of 20,000 vs.
  1,000-4,000 for others)

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CMS Nursing Home Quality Indicators
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Maine Nursing Home Telehealth Network
Basic Workplan

• Install equipment
• Train Site Coordinators
• Provide targeted in-service education to nursing
  home staff
• Develop primary care telemedicine
• Develop specialty care applications
• Implement videophone program

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Maine Nursing Home Telehealth Network
Initial Phase

• Establish management and oversight system
• Set up infrastructure
• Develop policies, protocols, and procedures
• Site Coordinator identification training

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Maine Nursing Home Telehealth Network
Location of Nursing Homes Providers
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Maine Nursing Home Telehealth Network
Specialties Care Services Requested

• Dermatology
• Geriatric psychiatry
• Wound care
• Pain management
• Mental health counseling
• Rheumatology
• Post-op orthopedics

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Maine Nursing Home Telehealth Network
Specialty Care Services Developed

• Wound Care
• Pain Management/addiction medicine
• Mental Health
• Developed--not used
• Asthma/allergy
• Occupational medicine
• Available--not used
• Sign Language Interpreting
• Endocrinology

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Maine Nursing Home Telehealth Network

• Specialty Care Telehealth Activity
• 86 consults over 30 months--3/month
• 36 Wound Care, 48 Mental Health, 2 Pain
  Management
• Overall provider satisfactionvery87
• Could adequately assess patient88
• Helped with diagnosis, treatment-63, 67
• Improved quality of care75
• Helped avoid patient transfer71

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Maine Nursing Home Telehealth Project
Consulting Provider Quarterly Survey Responses on
Telemedicine Use-N31

• Patients benefited from not having to be
  transported100
• Clinical, educational, and administrative uses
  saves my practice time money100
• Prevents worsening of patients condition100
• Positive impact on patient care100
• Use can save money for insurers92

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Patient Satisfaction with Clinical ConsultsN27,
12/-4-2/06
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Patient Satisfaction with Clinical
Consults(continued)
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Maine Nursing Home Telehealth Network
Survey Input from Facility Staff
(N8)--Directors of Nursing, Charge Nurses,
Administrators

• Telemedicine is effective for delivery of
  specialty care consults for nursing home
  residents88
• Setting up telemedicine consults is a major
  barrier to useonly 13 agree
• Barriers you think prevent some needed
  telemedicine consults from happening?
• PCPs work hard to address medical problems
  themselves50
• PCP and staff are effective at preventing and
  managing resident pain and wounds13
• Getting doctor to make referral13
• Staff just too busy13

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Maine Nursing Home Telehealth Network
Estimated Savings on Transport Costs Wound care
consults judged to have averted needed transports
to doctor for direct care
(Average roundtrip distance between patient and
provider for all 84 tele-consults208 mi.)
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Maine Telemedicine Network
Education-- Monthly Sessions targeted to CNAs
RNs22 topics

• Antibiotic resistant infections
• Wound care
• Pressure ulcers
• Colstomy management
• Pain management
• Swallowing disorders
• Nutrition and diabetes
• Respiratory infections

• Polypharmacy issues
• Geriatric psychiatry
• Dementia and pain
• Combative patients
• Dementia assessment
• Food safety
• Injury prevention
• Emergency preparedness

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Staff Satisfaction with Distance Education
Mane Nursing Home Telehealth Network
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Staff Dissatisfaction with Education
Mane Nursing Home Telehealth Network
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Maine Nursing Home Telehealth Project
Primary Care Telemedicine

• One PCP used 6 times for patient oversight
  between Lubec and Machias (30 mi.
  distance)reported satisfied with efficacy, but
  dropped use due to regular in person visits
• Other PCP providers showed resistance to use--
  distances were often not significant and system
  use was more cumbersome than usual monitoring by
  telephone calls to staff nurses
• Pilot use of videophones with one PCP was not
  perceived as effective

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Maine Nursing Home Telehealth Network
Virtual Family Visitation

• POTS-based home video units placed by staff with
  distant family and in patients rooms
• To date, 3 units placed with patient relatives in
  Florida, Tennesee, Connecticut and 2 in-state

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Feedback on Virtual Visitation
Maine Nursing Home Telehealth Network

• Responses from patients suggested effective in
  enhancing their sense of connectedness
  well-being in one case, patient dementia
  hindered use
• Daughter of 92 yr. old patient
• I loved thisits made the holidays so
  enjoyable. Its as if we were sitting there for
  a visit. I use it all the time.
• 100 of 8 staff surveyed agreed
• Videophone links between patients and family
  can enhance the patients quality of life

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Maine Telemedicine Network
Lessons Learned

• Look at acuity of residence and not just rurality
  of the nursing home
• Staffing time constraints providing services not
  previously provided
• Reimbursement amount needs to be consistent with
  prevailing rates

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Barriers to Success of Telemedicine

• Both primary care and consulting specialist
  providers are resistant to adopting new
  technologies or changing their routine mode of
  practice
• The high cost of telecommunications, including
  line charges for ISDN or dedicated T1 lines
• Additional personnel resources and training are
  required at both spoke and hub sites
• Solutions to liability and credentialing/privilegi
  ng issues must be worked out
• Reimbursement development in some states is slow
  Maine has been forthright in reimbursement