An In the Trenches Session Telehealth Summary

I was so honored to present a summary of the work that my organization, Los Angeles Jewish Health is doing in Telehealth at the recent CALTCM Summit for Excellence.   Los Angeles Jewish Health is the lead program that works in partnership with the California Technology Fund in a statewide coalition. We received FCC funding to demonstrate the value of telehealth in PALTC facilities. Our purpose is to inform those who are seeking to adopt or expand telehealth in facilities, and to educate policy makers, to better understand the potential benefits and challenges of implementing telehealth in facility-based care.  

The data from our pilot project showed several key results.  Telehealth visits prevented nearly 20% of transfers to acute care facilities. Residents indicated a high degree of comfort with the telehealth visits and clinicians were very comfortable with the process. Most importantly, those conducting the visits felt that they improved the quality of care.   

The very first telehealth visit I conducted, I had my resident’s daughter participate. By her doing so both my resident and her daughter got their needs met. The daughter told me things that she was aware of that the resident did not volunteer. How many times has it happened to you that you call a family member after a visit with your resident and they tell you something that you did not know from the resident’s history? It happened to me and sometimes it required that I go back and examine something that I did not look at carefully. The telehealth process is a more person-centered approach, and it made my work more efficient.

 At Los Angeles Jewish Health, the majority of our residents have PCPs that are employed by us and it is their full-time job. One of our doctors was not going to be able to come onto our campus right away for a new admission. As you may be aware, doctors have up to 72 hours to see a new admission. It clearly benefited our doctor, our resident, our staff and our organization by arranging for the visit to be done via telehealth. It improved care, reduced anxiety, and reduced our nurses’ workload. The doctor later came in and completed the full admission note, both visits were billable, per the newest regulations. 

Several other unanticipated positive outcomes occurred from our telehealth visits.  

We realized that the project can help improve nurses’ clinical skills. Our carts have very good digital stethoscopes as an attachment. On an early visit, we found out that the nurse could not hear the sounds of the stethoscope. We provided an additional headphone on the cart, and the nurse heard the same sounds that the doctor was listening to. That allowed point of care education to the nurse from the doctor. Explaining to the nurse that the sounds they were both hearing were more likely heart failure rather than pneumonia. For me, one of the most challenging clinical situations when I am on call is when a nurse calls me and tells me that the resident’s lungs sound “congested”. I do not know if the acute change is heart failure or pneumonia. Now with the aid of the telehealth carts, our nurses are better at knowing the reason for the resident’s change in condition.  

We assumed that it would be challenging to get our seniors and their families to agree to the visits. We thought that they would believe the project was completely focused on the needs of the doctor and a way to save money. That they would be afraid of the technology and perceive it as depriving them of the opportunity to connect directly with their doctors. Therefore, we sent three letters to the residents and their surrogate decision makers. An introductory letter from me announcing the program and what it was all about, and that they had to sign and send back a consent if they wanted to participate. The consent and a Frequently Asked Question that was based on some of the questions we got from our first few pilot patients. We got incredibly high percentages of returned consent forms. Our residents, whose average age is 91, gave enthusiastic feedback regarding using the technology. 

Another top lesson from our experience was learning successful methods that facilitated the adoption of new technology and new processes to a workforce that has been overburdened, under supported, and emotionally exhausted. 

Over previous, countless, rollouts of equipment, in less challenging times, healthcare programs should have learned that just providing the equipment and training staff on its use, was insufficient to get the results they wanted. Before literally rolling out the carts, we queried staff and asked what their greatest concerns were. We then created another FAQ document that educated our nurses on how the program makes their lives better, and more importantly connects to their own personal values. They got the document.

This process was similar to what my program did when we educated our staff about the importance of getting vaccinated. That effort led to 99% of our staff being up to date (prior to the new definition) with vaccination.  

Getting physicians to use the equipment was harder for some of the programs in our coalition than others because of the physicians’ understandable concerns. Many of the doctors that work in PALTC programs are older and not as comfortable with the technology. Also, most clinicians in SNFs have other work responsibilities and try to minimize the time that they spend on SNF residents. What worked best is scheduling just one session, at a time of the physician’s choosing. We conducted the session with our most experienced operators, added additional support and then emphasized with them in a quick debrief after the session the benefits to them and their patients.  What did not work so well was listening to the doctor who wanted to schedule multiple patients in their first session. Naturally, that was when technical problems often occurred. The reality of the current way physicians practice in PALTC facilities will unfortunately, unless things change, make physician adoption a challenge in PALTC.

Most nursing homes in California were built well before the need for Wi-Fi signals and data infrastructures to transmit data. Before rolling out the carts, our IT department did a heat map to determine if we would have signal issues bringing the carts into the resident’s rooms. Although surprisingly the map did not show any critical issues in most of our areas, we proactively installed several signal boosters. Yet, we still had occasional connectivity issues. We discovered that a few of our residents were using data or network devices that interfered with our network. Their personal equipment resulted in our carts poor signal strength and unstable connections. We added a Wi-Fi signal booster to our telehealth cart to improve the network connection and that provided a more consistent data transfer. We created a room on the unit that had an Ethernet port to serve as a backup in case the cart’s Wi-Fi signal remained poor. In this manner, if we could not conduct the visit in the resident’s room, and the resident could safely move to where the cart could be directly connected to the internet, we still could conduct the telehealth visit.

Currently, consents are required prior to conducting a visit. They can be done verbally or in writing and can be done at the very start of the telehealth session. We sent written consents to all our residents and their decision makers and as I said earlier we got a great response rate. We then added a label on the ribbon of our electronic health record that shows if that particular resident completed a telehealth consent. That way the nurses can quickly identify when a resident has a change of condition if they are already consented for a telehealth visit.

Clearly, one of the greatest challenges in PALTC communities to start a new telehealth program, is the financial burden to purchase the equipment, and train the staff. Some of the cost can be made up from the facility's ability to submit claims for conducting visits. I had no idea how many visits it would take to break even, but my guess for most facilities is it would be years.   

For me, a real problem with telehealth is the current lack of requirements of what equipment can be used and that reimbursement is by encounter type and time. Two phones are acceptable and there is no additional reimbursement when more sophisticated equipment is used that has attachments such as a stethoscope or a sophisticated camera that can zoom in to see the auditory canals, mouth and the smallest skin lesion. Obviously, our carts can do all those things. 

One of the most important lessons we learned, and the advice I would like to give you, is to embrace the benefits of failure. For completely understandable reasons, our pilot programs did not generate the volume of data that we thought we would. It is pretty hard to do a nurse based activity if there are not enough nurses on the unit to provide even basic patient care. Or, when the only people who have been trained in the cart are out due to a positive Covid test. Or when the doctor says that they just do not have time or are not in a location to do a telehealth session privately. 

What I would like you to realize is an important lesson that the members of our coalition learned. We learn so much from each other’s experiences when we share both the good and the bad.  It is as important to learn the unexpected and unanticipated challenges, as it is the successes. I like to think of it just like any ongoing quality improvement project. There is a quote on my wall that helps me. “When you aim for perfection, you discover it’s a moving target.”  

Yes. There are a lot of barriers to starting a telehealth program. Successfully implementing a telehealth program requires recognizing and addressing potential and real challenges. One thing you might find valuable is to review Kotter’s 8 step change model. It is an award-winning methodology that has been used to produce lasting change.  Things for you to consider before you launch a program is to recognize how much resistance to change there is in your organization, and how much preparing and paving the way you need to do in order to get staff and physician buy-in. It will really help if you can identify a champion that will lead your effort and if administration ensures that sufficient training and support is available. The key takeaway is to first introduce, then address the concerns in a supportive manner, and then train. Or in other words, don’t put the cart before the course.  

No other project that you can work on has the potential to address so many of your most critical challenges. It provides care that is better for the doctor, better for their patient, and better for the nurses. Unfortunately, it may not help you much with your recruitment challenges but it might improve your census.

Noah Marco, MD
Chief Medical Officer Los Angeles Jewish Health
CALTCM Board Member
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