Have You Experienced the Benefits of a Robust Telemedicine Program?

The Covid-19 pandemic has radically changed how providers deliver health care.  Realizing that in-office and in-facility clinical care risks transmission of SARS-CoV2, CMS has removed all restrictions on the adoption of Telemedicine.  Multiple organizations including CALTCM, AMDA, and AGS (American Geriatric Society) have provided helpful webinars and resources that have helped providers implement Telemedicine in their work flow.  Understandably, seniors have had difficulty embracing this technology.  Medical offices have enhanced their MA’s (Medical Assistant’s) training so they can contact patients prior to the telemedicine visit, to help them with technical issues and to gather pertinent information for that appointment.  

In our Nursing Homes and Senior Living Communities, our residents may require in facility help accessing this new and safer way of receiving medical care.  In Sonoma County, due to the pandemic threat, our local Public Health Department has developed a virtual work group for Senior Living Communities and one for Nursing Homes which meet each week.  We have partnered with the major health systems in Sonoma and Marin Counties that includes CMOs, Hospitalists, Geriatricians, Palliative Care experts, and discharge planners.  The Chief of Palliative Care at Kaiser, Marin, shared how telemedicine had proved very beneficial with urgently needed advance care planning conversations in a facility with COVID-19 outbreak.  He found that visually connecting with residents and their families improved understanding and trust since each could now see the facial expressions behind what was said and heard.  Other providers at our meetings have subsequently commented on the value of having multiple family members from across the country on a Tele-visit in addition to the resident.   We now know that most of the HIPPA compliant platforms (Zoom Health, Doximity, and Kaiser Connect) allow for easy simultaneous family connectivity.    In addition, COCs (changes of condition) assessments may improve since they allow providers to see and interact directly with the patient, their surrogate, CNA, and nurse during the course of the visit.  From the provider perspective, this improves communication, rapport, and supports a more precise assessment and agreed upon care plan.  Some geriatric clinics report that telemedicine has improved their clinicians efficiency managing many medical encounters and has helped them identify conditions that will require subsequent in-person care.  A local clinical psychologist is now providing virtual capacity declaration services, which has significantly sped up this process.  Some facilities are beginning to use this technology to address pandemic driven staff and family anxiety through use of virtual town hall meetings. 

In my county we are still learning how to make the most of these visits and as expected have identified multiple barriers to fully implementing a telemedicine program.  These barriers include:

1.     An older workforce that has previously not embraced technology and is change resistant

2.     Medical legal concerns about privacy and facility liability despite federal waivers during this pandemic

3.     Families no longer on site to help their loved one with the details of the virtual visit

4.     ALF (Assisted Living Facilities) & RCFE (Residential Care Facilities for the Elderly) & Congregate Senior Living Home believe they may not help residents access this technology due to their interpretation of regulations from DSS (Department of Social Services), CCL (Community Care Licensing)

5.     The cost of employee training, time, new tablets, & need for technology cleaning protocols at a time when their budgets and staffing are already stretched.

6. Challenge of learning how to use different virtual platforms and working with providers and office MA’s (medical assistants) to ensure that the visit technology performs optimally during the visit.

7.     Consent for a telemedicine visit needs to be obtained from the patient (surrogate, if lacks capacity) prior to the visit and they need to know there will be a charge for this service. 

8.     A private area for the encounter is mandatory.

9.     Prior to the telemedicine visit, the facility/provider needs to identify who else should be on the call, such as family or friends.  If so, they need to be willing, available, and have an email address to receive the invitation.  

10.   Facilities will need to contact the provider to request the initial telemedicine visit since most providers don’t know where their patients live and rely on patients to set up their appointments.

11.  A successful telemedicine visit requires much more information to be collected prior to the visit than would be necessary for a traditional office or facility visit. 

Within our work groups, we have been able to come up with some potential solutions:

1.     We have developed a template letter for facilities to send to a patient's PCP which informs them that telemedicine is welcome and requests their office schedule a telemedicine visit to update the patients care plan so that it is contextualized to the COVID Pandemic (attached)

2.     As a part of this project, we have requested facilities to fax me the current % of residents with AHCD (advance health care directives), PIT (preferred intensity of Care) and POLST forms, so that we know if this outreach improves completion of advance care planning documents (attached).

3.     We have obtained verbal approval that current guidance from DSS/CCL permits facility assisted telemedicine in ALFs and RCFEs as long as consent is obtained and privacy is provided.  An official state PIN has been requested.

4.     Tablets can be protected by shell devices like Otterbox Defender Series Case, which allows cleansing with bleach and removal of residual bleach on the screen with an alcohol pad.

5.     For use for COC’s after normal business hours, your Medical Director or office based clinician should encourage their on-call physicians to use telemedicine for change of condition assessments rather than traditional phone-only medical care.  

6.     As your telemedicine program develops you may add peripheral connections that may include a stethoscope, EKG/Rhythm strips, or ultrasound.  These have been added by early adopters at a reasonable cost and enhance the clinical bedside assessment.

7.     Pre-visit checklists have been developed which include:

  1. Pre-visit check-in: Scheduled pre-visit with the office MA to make sure that potential technology glitches are addressed.

  2. Office forms:  Faxed or email pre-visit forms to clinician so that they are completed and returned prior to the scheduled visit.

  3. Prior to the visit, clinicians will likely appreciate a fax list of all current medications, recent Lab/imaging results, and most recent AHCD, PIT, or POLST Forms

  4. At the visit, this data is usually desired: vital signs, Sa02, weight, Height (allows BMI auto-calculation), and finger stick glucose measurements (if a diabetic)

One of the most encouraging aspects of the adoption process has been the stories from work group members about their implementation experiences.  These narratives have been very inspiring.   

If your community hasn’t yet developed a partnership with your local health department and community senior care experts, I encourage you to do so.  These virtual work groups have spurred innovations like our telemedicine and telehealth implementation projects and have reduced the adverse impact of this pandemic on our community.

CALTCM welcomes your stories about the adoption of telemedicine in your communities.  

Tim Gieseke MD, CMD

Implementation Templates and Links to recent technology webinars:

Templates for implementing Telemedicine and auditing its impact on completion of ACP documents

CALTCM Webinar (free) – COVID-19:  The Use of Telehealth in Long Term Care; March 31, 2020 https://www.telehealthresourcecenter.org/event/covid-19-the-use-of-telehealth-in-long-term-care-settings-during-this-national-emergency/

AMDA Webinar:  Establishing, Billing, and Coding for Telehealth Services during the COVID-19 Pandemic April 22, 2020    https://apex.paltc.org/local/catalog/view/product.php?productid=402

AGS Webinar (free) – COVIDE-19 and Updates to Telehealth April 7, 2020:  https://geriatricscareonline.org/ProductAbstract/covid-19-and-updates-to-telehealth/W015

When Doctors and Patients Talk About Death over Zoom: https://www.wired.com/story/when-doctors-and-patients-talk-about-death-over-zoom/


COVID-19 Provider Virtual Visit Request - letter_Revised Final_051120

SC Senior Homes and SNF  Learning Collaborative Ask_051120_Final


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