Telemedicine Applications in Nursing Homes

Written by Andrew McWilliams

When speaking of potential telemedicine applications in nursing homes, we are referring to two types of care facility, i.e., intermediate care facilities (ICFs) and skilled nursing facilities (SNFs). When this posting uses the term “nursing home”, it is generally referring only to ICFs and SNFs

• Intermediate care facilities mainly provide assistance with the "activities of daily living," such as bathing, dressing, personal hygiene, toileting, etc. Most ICFs have certified nursing assistants (CNAs) on duty 24 hours a day rather than nurses.

• Skilled nursing facilities are intended for those patients who require ongoing medical care, such as physical therapy, wound care, respiratory therapy, pain management, a feeding tube, or dialysis in addition to assistance with activities of daily living, SNFs provide 24-hour health care from licensed nurses, as well as access to registered nurses (RNs) and certified nursing assistants (CNAs). While they are generally used for short-term stays, SNFs also are able to provide long-term care where medically necessary.

In both cases physicians are mostly located off-site with weekly or bi-weekly rounds to supplement telephone availability Many facilities offer both skilled nursing and intermediate care under the same roof. Such facilities provide continuity of care with many of the same staff members, so the patient will not have to adjust to a new setting and new care providers as their care requirements change.

The Need

Even before the COVID-19 pandemic, having physicians off-site placed nursing home staff in a difficult position. They are accountable for patient outcomes but caring for the fragile, complicated patients often is outside of their competency and licensure limits. As a result, patients are routinely transported to an emergency department or physician’s office for assessment and care due to complications.

These trips outside the nursing home typically require transport and escorts, which cost the patient money, divert nursing home staff from their other responsibilities and create risks for patients who may be prone to falls or disorientation. Follow-up trips may be required for purposes such as imaging or lab tests, increasing the number of trips as well as the risks and costs.

The risk of disorientation, and reduced functioning when the patient returns to the SNF, increases if the patient spends a night or more in the hospital. A hospital admission can also cost the nursing home money, e.g., in terms of lost Medicare reimbursements or penalties for excessive readmissions. Therefore, both the patient and the nursing home thus have a stake in minimizing the need for trips outside the nursing home for evaluation or treatment.

This already difficult situation became much worse as the COVID-19 pandemic tore through many nursing homes starting in March 2020. The pandemic hit the nursing home population disproportionately, due to their advanced age and communal living arrangements. Nursing home staff were stretched to the limit caring for the ballooning number of COVID cases, with limited or no access to outside care providers. While this crisis has abated somewhat, especially now that most nursing home residents have been vaccinated against COVID, it emphasizes the challenges of caring for a medically vulnerable population in a group setting.

The Telemedicine Solution

Telemedicine offers nursing homes a potential solution to both a future health care emergency like the COVID pandemic, as well as the longer-term need to reduce the number of trips that residents have to take outside the facility for many types of medical treatment. Using a specialized telemedicine cart, a webcam-equipped computer or even a simple tablet, a nursing assistant at the facility can facilitate a virtual consultation or evaluation between the patient and an off-site physician or nurse. The latter can either recommend taking the patient out for off-site tests or treatment or, prescribe an on-site course of treatment. Also, the off-site doctor or nurse can monitor the course of the treatment and recommend any needed modifications via the same video link, thus optimizing care at the nursing facility.

Implementing A Telemedicine Program in a Nursing Home

Nursing homes that decide to implement a telemedicine program, can take these steps outlined below, at a minimum, to ensure they obtain the intended benefits from telemedicine. The last step on the list below is “Choose a telemedicine provider”. However, we recommend that, even if the nursing home administration believes it is capable of performing most of the steps on the list unassisted, it start by talking to potential telemedicine providers in order to benefit from their expertise and experience. Some nursing homes may find a turnkey solution, in which the telemedicine provider participates in performing the preparatory steps, to be advantageous.

The preparatory steps include the following.

  1. Define program goals and success criteria. One of the administration’s first tasks will to develop a prioritized list of the goals that it wants the telemedicine program to achieve, such as
    • Reducing the burden on the nursing home’s staff
    • Improving overall quality of care at the nursing home
    • Reducing the need for residents to travel outside the nursing home for care.

    The administration should also define the quantitative performance metrics and baseline that will be used to monitor and evaluate the telemedicine program’s success in meeting its goals

  2. Evaluate adequacy of IT infrastructure and identify areas of improvement. As discussed above, it is possible for nursing homes to implement at least basic telemedicine functionality with limited hardware such as an iPad or other tablet. Access to a good broadband internet connection from patients’ rooms as well as examination rooms is important for optimum functionality of a tele visit. Moreover, while a tablet or webcam-connected PC is sufficient to provide a limited amount of telemedicine capability, nursing homes can consider investing in a specialized telemedicine “cart” with video monitor, high-definition camera, microphone, speakers, and integrated diagnostic instruments such as a stethoscope and blood pressure cuff.
  3. Review current nursing home workflows before introducing a telehealth program, in order to identify the workflows that may have to be adjusted in order to obtain the full benefits of the telemedicine investment. For example, nurses and nurses’ aides will assume more care management responsibilities under a telemedicine program designed to enable patients to remain in the nursing home rather than being transferred to an ER or other outside facility. Guided by a physician or nurse practitioner at the other end of the telemedicine connection, they will play a more active role in a patient's care.
  4. Delineate the step-by-step operational details of the revised or new clinical and operational workflows, ideally in a way that is consistent with or does not disrupt existing processes unnecessarily. Nursing home staff who will have responsibility for implementing the new processes should be involved in this process. Conduct a trial of the new workflows, and evaluate and adjust the new workflows as appropriate in collaboration with nursing home staff.
  5. Design and implement a training program to teach staff how nursing care pathways will change with the addition of telehealth and their responsibilities will evolve as a result of those new workflows. An effective training program will help mitigate staff concerns about operational process changes. In particular, administrators should make sure that the staff are properly trained in using the telemedicine equipment and are comfortable with the new service. All users should be provided with camera etiquette training prior to implementation.

Choose the right telemedicine provider

Nursing homes have the opportunity to choose the right telemedicine provider based on the requirements mentioned above. The importance of having a telemedicine program that covers all these aspects cannot be overstated. Symbian Health Telehospitalist services can provide the coverage needed at SNF’s whereby they can be rest assured that residents and staff at a nursing facility will have access to a remote provider in times of need or crisis. As described above, we can work with facilities to successfully implement the program. Our goal is to provide improved operational efficiency at a nursing facility based on their needs and ultimately better care for residents, reduced outside transfers and enhanced staff satisfaction.

Getting Help

Technical assistance is available from sources such as the Telehealth Resource Center Program. (https://telehealthresourcecenter.org). The Centers for Medicare and Medicaid Services’ publication, Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit, also contains useful information.

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