MODELS OF GERIATRIC CARE, QUALITY IMPROVEMENT, AND PROGRAM DISSEMINATION
High-Intensity Telemedicine-Enhanced Acute Care for Older Adults: An Innovative Healthcare Delivery Model Manish N. Shah, MD, MPH,*†‡ Suzanne M. Gillespie, MD, RD,*‡ Nancy Wood, MS,* Erin B. Wasserman, BA,*† Dallas L. Nelson, MD,* Ann Dozier, RN, PhD,† and Kenneth M. McConnochie, MD, MPH§
Key words: emergency care; geriatrics; telemedicine Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program’s operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models. J Am Geriatr Soc 61:2000–2007, 2013. From the *Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York; †Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York; ‡ Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; and §Department of Pediatrics, University of Rochester Medical Center, Rochester, New York. Address correspondence to Manish N. Shah, 265 Crittenden Blvd., Box 655C, Rochester, NY 14642. E-mail: [email protected] DOI: 10.1111/jgs.12523
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eeting the acute illness care needs of older adults is increasingly challenging for the healthcare system. Expansion of the older adult population and high and rising rates of use of acute care by older adults has increased the overall demand for acute medical care.1–3 The shortage of primary care providers (PCPs), including geriatricians, limits older adults’ ability to access medical care from within their medical home.4,5 Accessing timely acute care is also challenging for older adults. Same-day PCP care is usually unavailable, and when an appointment is available, transportation can be a barrier.6–9 A combination of these barriers and regulations precluding ambulance transportation to PCP offices creates demand for emergency department (ED) services.10 Although convenient, ED care may not be optimal for older adults. Community-to-ED and ED-to-community transitions are associated with greater risk of adverse outcomes.11,12 ED care providers may lack critical information, including baseline functional status and important elements of the resident’s medical history, leading to fragmented and inefficient care and placing residents at high risk of adverse events.13–16 Older adults may experience complications such as delirium and adverse events such as falls while in the ED.17–21 Finally, after considering their life stage, some older adults have chosen care focused on quality of life rather than aggressive interventions and do not wish to leave their residence for medical attention. These important care wishes would not be honored by going to an ED for care and might not be communicated to ED staff. Telemedicine (the use of health information technology for clinical care when distance and time separate the patient and healthcare provider) has the potential to provide older adults with timely, high-quality, patient-centered acute care. Telemedicine technology can range from low intensity, which includes only video conferencing, to
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high intensity, which includes a much broader range of functionalities such as those included in the University of Rochester Medical Center care model. Studies have demonstrated that patient-to-provider telemedicine-enhanced acute care for children is feasible, acceptable, effective, and efficient.22–24 Preliminary work has also found that telemedicine-enhanced acute care is feasible and acceptable for older adults and nursing home residents,25–31 but to the knowledge of the authors of the current study, the evidence from pediatric and nursing home settings has not been applied to the senior living community (SLC) setting. No telemedicine-enhanced programs capable of addressing a wide range of acute complaints from older adults in non-medical SLCs that have been systematically implemented and evaluated were found. This article describes the application of high-intensity telemedicine-enhanced acute care for community-dwelling older adults, the alignment of incentives that support such a program, the feasibility and acceptability of the program to participants, and lessons that groups interested in creating a similar program can use.
MODEL OF CARE Setting The Rochester, New York, metropolitan area is home to approximately 780,000 residents in urban, suburban, and rural settings. The Strong Health Geriatrics Group based at the University of Rochester provides primary care to residents of SLCs, including independent and assisted living facilities. The 11 physicians and 17 advanced practice providers (APPs) in the geriatrics practice care for approximately 750 residents in 17 SLCs. The providers offer on-site primary care services, with sessions typically held two times per week at each SLC. The practice has an office at a separate location that houses paper-based medical records and is staffed by nurses and APPs who review and address results of laboratory and imaging studies and consultants’ recommendations. The nurses and APPs in the office also triage emergent questions and problems that arise from residents, families, caregivers, and SLC facility staff.
Telemedicine Program The purpose of the high-intensity telemedicine-enhanced acute care program is to use telecommunications technology for diagnostic and therapeutic benefit when distance and time separate the patient and provider. As part of an ongoing clinical trial examining the health services use and cost-effectiveness of an acute care telemedicine program in SLCs, this program provides services at seven SLCs to residents who provided written consent to participate in this research project. The program is designed to augment, not replace, the traditional primary care practice. It offers access to acute care for complaints that need more-urgent attention than the next available outpatient visit affords but may not need the advanced resources of an ED or urgent care clinic. It also avoids the burden and cost of transporting an individual to a medical facility and the discontinuity between the primary care geriatrics practice and an ED or urgent care center.
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Staff A dispatcher, certified telemedicine assistants (CTAs), and telemedicine providers staffed this program. The dispatcher tracks pending care visits, routes CTAs to residents, and identifies telemedicine providers to complete each visit. CTAs are hospital-trained clinical technicians. To attain that designation, they complete 40 hours of practical skills training such as measuring blood pressure, interfacing with patients, and ensuring safety. In preparation for the high-intensity telemedicine program, they complete 40 additional hours of program-specific didactic and practical clinic-based training with the geriatrics practice, and they complete the institution’s phlebotomy and electrocardiogram courses. The goal of the training is to enable the CTAs to collect patient history and examination findings, obtain vital signs, measure pulse oximetry readings, perform electrocardiograms, and collect blood and urine for laboratory testing. CTAs are not able to make clinical judgments. Instead, they execute protocols and relay information. Using nurses as CTAs was considered, but it was decided to use clinical technicians instead because CTAs generally do not need specific, high-level nursing skills, so using nurses as CTAs could potentially lead these overqualified individuals to have poor job satisfaction. Also, nurses are in short supply, limiting their availability, and are significantly more expensive, which would have increased the program’s cost. The program’s telemedicine providers are licensed at the physician or APP level and are active clinicians in nursing homes, primary care geriatrics practices, or EDs. They remotely access the telemedicine electronic medical record, review the data that the CTAs collect, and make diagnoses. The providers also communicate with the resident, family member, and caregiver to share their findings and impressions and create a treatment plan. In summary, unlike some telemedicine programs that are essentially videoconferencing regarding healthcare concerns, this highintensity telemedicine program obtains health information, physical findings, and laboratory and radiographic testing and ultimately provides treatment for the acute illness.
Equipment The CTAs use commonly available equipment to collect and record resident history and examination findings. They use a digital stethoscope (Littmann 3200; 3M, St. Paul, MN), a digital otoscope (Welch Allyn, Skaneateles Falls, NY), a high-resolution digital camera (Nikon, Tokyo, Japan), and a web camera (Agent V5; Liquid Digital Solutions, Rowville, Australia) linked to a laptop computer, scanner, and printer (Dell, Inc., Round Rock, TX). Each of these devices records the audio clip, image, or video clip and then transfers the file to the laptop computer. The CTAs also carry a 12-lead electrocardiogram (DRE, Louisville, KY), supplies to collect blood and urine samples, and a digital pulse oximeter (Diagnostix 2100; American Diagnostic Corporation, Hauppauge, NY). The information collected, including text, digital images, and audio, is entered into a telemedicine-oriented electronic medical record (Trifecta Technologies, Allentown, PA). Audio files might include breath, heart, and
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bowel sounds. Digital images and videos can document a resident’s general appearance, skin abnormalities, status of tympanic membranes, and neuromuscular traits such as gait. Telemedicine providers remotely access the electronic medical record from any internet-connected computer equipped with a web camera and speakers through a secure transport protocol.
Program Processes Traditionally, when a SLC resident has an acute illness, the resident, family, or caregiver calls the geriatrics practice for assistance (Figure 1). A nurse triages the call, and a healthcare provider (physician or APP) addresses the problem by treating the resident over the telephone, establishing an outpatient appointment (on the same day or within a few days, depending on when the provider will next be visiting that facility) or sending the individual to the ED or an urgent care center. The nurse, in collaboration with a physician or APP, can also order laboratory or radiographic testing, performed by mobile technicians at the SLC, if needed. The radiographic testing is available within 24 hours, and laboratory testing takes up to 3 days. As part of this grant-funded program and study, telemedicine-enhanced acute care services were offered to members of the Strong Health Geriatrics Group at seven of the SLCs that the practice serves. Services were made available on weekdays between 9 a.m. and 6 p.m. An active relationship was not established between the
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research team and the staff at one SLC. Despite project team efforts, reasons for this lack of engagement could not be characterized. Therefore, telemedicine services were discontinued after 12 months at that facility. The provision of weekend telemedicine services was pilot-tested but discontinued because of insufficient use. When residents who are enrolled in the study call the practice to seek help for an acute illness, the triage team, comprising a nurse and a primary care physician, an APP, or both, has the option of ordering a telemedicine evaluation instead of managing the resident through traditional means (by telephone, setting up an urgent outpatient visit, or sending the resident to an ED or urgent care center). Thus, the telemedicine program offers the resident rapid access to an evaluation of his or her complaint, including laboratory testing, without leaving home. If a telemedicine visit is felt to be appropriate for the condition and is acceptable to the resident, the triage nurse documents a brief note in the telemedicine electronic medical record and chooses one of six clinical protocols that the program leaders have developed: skin, fever, shortness of breath, pain, altered mental status, or other. The protocol guides the CTA through the history and examination components that must be gathered. The triage nurse then notifies the telemedicine dispatcher of the need for a visit. The dispatcher sends a CTA by car to the resident and identifies a telemedicine physician or APP who can complete the telemedicine visit. In most cases, the program uses a real-time telemedicine model, in which the CTA collects the information required based upon the protocol that the triage nurse
Call for Assistance Patient / Caregiver / Staff Telephone Evaluation RN / Provider
Traditional Care Path
Telemedicine Care Path
Certified Telehealth Assistant Dispatched to patient’s home Care within 1-2 hours
Treat by Phone Depend on verbal description of problem
Refer to Urgent Care / ED Require patient travel Loss of continuity of care
Set Up PCP Visit Delay in care
Protocol Driven Data Collection CTA collects data and completes medical record
Real-Time Visit
Store-and-Forward Visit
Provider Evaluation Record reviewed Interventions determined Videoconference with patient / family Patient / family informed of assessment and plan
Provider Evaluation Record reviewed Interventions determined Patient / family informed of assessment and plan
Visit Wrap-Up CTA reinforces information
Figure 1. Care model. CTA = certified telemedicine assistant; ED = emergency department; PCP = primary care provider; RN = registered nurse.
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chooses, uploads the information to the electronic medical record over the internet, and then contacts the telemedicine physician or APP to teleconference or videoconference with the resident, caregivers, or both. In some cases, the program uses a store-and-forward model, in which the telemedicine physician or APP does not view the CTAcollected information until after the CTA has left the resident. In these cases, the telemedicine provider calls the resident or caregiver to discuss the findings from the visit. After the visit is complete, the telemedicine provider completes the electronic medical record, electronically orders any prescriptions or services, and writes a discharge instruction sheet. If the CTA is still on site (the real-time model) at the SLC, he or she prints the information and reviews it with the resident or caregivers. Otherwise, the information is mailed or faxed to them. Finally, a copy of the medical record from the visit is printed for the paper chart in the geriatric group’s office. This method of telemedicine has been shown to be valid and effective for acute illnesses in the pediatric setting, with a visit completion rate similar to that of regular office visits and 86% agreement of diagnoses with inperson office visits with the individual’s usual physician.32,33 Telemedicine has also been validated for diagnosis of dementia, gait disorder in older adults, and dermatological problems.34–36
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Rochester research subjects review board approved the research evaluation plan. The program was evaluated from November 1, 2010, through October 31, 2012, the first 24 months of its operation. To evaluate the program’s use, the characteristics of the episodes of telemedicine care, including the reasons for use, services provided, and outcomes of care, are described. To evaluate feasibility, the proportion of visits requested that were completed successfully, defined a priori as “visits in which the clinician is able to successfully develop a care plan” were calculated. This is critical, because failure to complete a large proportion of telemedicine visits would lead to avoidance of the technology and service. To evaluate acceptability, telephone-based followup surveys with residents and their caregivers who were involved in residents’ first telemedicine care episode were analyzed. Because of the high levels of dementia in this population, only residents who remembered their visits were surveyed. Finally, the individual at the geriatrics practice who initiated the telemedicine-enhanced acute care visit was surveyed to determine what would have been done had telemedicine not been available. Although this survey was implemented during October 2011, after the program had started, it characterizes how telemedicine changed care.
Evaluation Results Sustainability and Costs Sustaining this program at the end of grant funding will require technical and financial support. Technical support is necessary to maintain the equipment that the CTAs use and the interface with the electronic medical record. An external supplier can provide this support, as in this program, or it can be provided internally. With the existing ability to integrate audio and video into commonly used electronic medical records, telemedicine programs could use their practice’s existing electronic medical record system rather than a free-standing system. Financial support is required for staff and equipment. In an insurance reimbursement model, the telemedicine provider’s care can be considered equivalent to officebased or ED-based care. Although insurance reimbursement does not exist for this grant-funded program, it does for other models, including a program in the community. The cost for the dispatcher, CTAs, telemedicine equipment, and technical support can be conceptualized as similar to the technology fee paid to mobile radiology services or the facility fee paid to healthcare centers. Alternatively, the program could be supported as a subscription model, in which older adults or SLCs pay directly for the telemedicine services, although it is likely that this model would exclude a large proportion of individuals who lack the means to afford such care. Without a direct or indirect revenue stream (such as being part of an accountable care organization or capitated system), sustaining this program will be difficult.
Evaluation The initial evaluation of this program is structured around feasibility, acceptability, and care use. The University of
Over the 2-year evaluation period, seven SLCs participated, with start dates between November 1, 2010, and August 31, 2011. One SLC had only independent living residences, four had only assisted living residences, and the remaining two had a mix of independent and assisted living. Three hundred eighty-eight resident (60.2% of the number eligible) consented to participate and were eligible at some point during the evaluation period (Table 1). The median age of participants was 85 (interquartile range (IQR) 79–90), and 74% were female. These subjects contributed 4,793.6 patient-months to the study over the 2 years of analysis because of entry into and departure from the practice and SLCs. During the evaluation period, 301 telemedicine visits for 170 subjects were initiated (43.8% of residents who consented), the provider successfully developed a care plan for 281 of these visits (93.4%). For those instances in which a visit could not be completed, the visit was cancelled before the CTA being dispatched to the patient’s home 13 times (e.g., visit requested and subsequently cancelled), and the CTA could not collect patient information seven times (e.g., patient unavailable for care when CTA arrived). Fourteen telemedicine providers cared for residents using telemedicine (four physicians, 10 APPs). Of the 281 completed visits, 4.3% resulted in referral to the ED for added testing and interventions, and 7.5% resulted in a follow-up appointment within 24 hours. The remainder of visits resulted in follow-up as required by the resident. Table 2 describes the characteristics of the visits. The triage team that ordered the telemedicine visit was surveyed regarding all visits between October 18, 2011, and October 31, 2012, totaling 207 eligible initiated visits (Table 3); 189 (91.3%) of the surveys were completed. Of greatest importance is that the decision-maker
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Table 1. Characteristics of Residents Enrolled in the Program (N = 388)
Table 2. Characteristics of Initiated Telemedicine Visits (N = 301)
Characteristic
Value
Characteristic
Age, median (IQR) Female, n (%) Race, n (%) White Black Other Unknown Marital status, n (%) Married Widowed, separated, or divorced Single, never married Unknown Education, n (%) High school Unknown Residence, n (%) Independent living Assisted living Lives alone, n (%) Comorbidities, n (%) Dementia Diabetes mellitus Cerebrovascular disease Cardiovascular disease Chronic obstructive pulmonary disease Number of medications, median (IQR) Montreal Cognitive Assessment, median (IQR) (N = 315) Activity of daily living deficiencies, median (IQR) (N = 357)
85 (79–90) 287 (74.0)
CTA sent to resident’s home, n (%) CTA successfully collected resident information, n (%) Visits completed with care plan, n (%) Rate of visits per 100 resident-months Year 1 Year 2 Location of visit, n (%) Independent living Assisted living Testing ordered for completed visits, n (%) Radiology Laboratory New medication prescribed, n (%) Disposition of completed visits, n (%) Sent to emergency department Appointment in the next 24 hours Follow-up as needed Provider time to evaluate completed visits, median (interquartile range), min Diagnosis category of completed visits, n (%) Respiratory Circulatory Skin Musculoskeletal Digestive Mental Infectious Injury Other (sensory, genitourinary, nervous, symptom, endocrine) Domiciliary or home Common Procedural Terminology coding, established patients (%) Straightforward (99334) Low (99335) Moderate (99336) Complex (99337) Insufficient documentation to code
351 12 4 21
(90.5) (3.1) (1.0) (5.4)
68 214 47 59
(17.5) (55.2) (12.1) (15.2)
57 97 166 68
(14.7) (25.0) (42.8) (17.5)
156 (40.2) 232 (59.8) 280 (72.2) 125 90 57 53 42 10 19
(32.2) (23.2) (14.7) (13.7) (10.8) (7–14) (12–24)
0 (0–1)
IQR = interquartile range.
indicated that, if telemedicine had not been available, care would have been provided over the telephone 0.5% of the time, in an urgent clinic visit 27% of the time, and in an ED 48.1% of the time. One hundred thirty-seven of 280 (48.9%) follow-up surveys were successfully completed with residents during the first 2 years of the program. Follow-up was limited because residents could not remember the visit in 84 (30%) instances and refused the survey or could not be reached to complete the survey in 59 (21.1%) instances. A caregiver was involved in 110 telemedicine visits. Caregivers completed a separate follow-up survey for 74 (67.3%) of these visits. During the follow-up surveys, residents indicated that telemedicine saved a trip to an after-hours clinic or an ED 91% of the time (109/120 responses) and saved an estimated 3 hours (IQR 2–4) of time. Similarly, when involved, caregivers indicated that telemedicine saved a trip to an after-hours clinic or an ED 88% of the time (57/65 responses) and saved an estimated 3.5 hours (IQR 2.5–6) for the caregiver. Table 4 summarizes the acceptability of the program to residents and caregivers. To limit the introduction of experiential bias in the satisfaction information, only each resident’s first telemedicine visit was analyzed.
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Value
288 (95.7) 281 (93.4) 281 (93.4)
6.34 6.25 175 (58.1) 126 (41.9)
92 (32.7) 151 (53.7) 67 (23.8)
12 (4.3) 21 (7.5) 248 (88.3) 30 (20–40)
61 46 34 23 21 17 16 16 47
(21.7) (16.4) (12.1) (8.2) (7.5) (6.1) (5.7) (5.7) (16.7)
39 145 84 7 6
(14) (52) (30) (2.5) (2.1)
CTA = certified telemedicine assistant.
DISCUSSION This telemedicine program for older adult SLC residents with acute illnesses expands the options for healthcare providers, especially PCPs, to deliver acute illness care. More importantly, it expands the options for older adults to obtain acute illness care rapidly, with minimal burden and potentially from within their medical home. By providing high-intensity telemedicine, rather than the
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TELEMEDICINE-ENHANCED ACUTE CARE
Table 3. Survey of Triage Team Requesting Telemedicine Services (N = 189) Characteristic
n (%)
Primary reason for telemedicine visit Faster care 133 (70.4) More convenient 30 (15.6) Avoiding ED or urgent care 18 (9.5) No available appointments 4 (2.1) Avoiding travel 3 (1.6) Family refused other options 1 (0.5) Influencing factors for telemedicine visit (not mutually exclusive) Faster care 185 (97.9) More convenient 168 (88.9) No available appointments 152 (80.4) Avoiding travel 144 (76.2) Avoiding ED or urgent care 140 (74.1) Family refused other options 2 (1.1) Recommended care plan without telemedicine Send resident to ED 91 (48.1) Send resident to urgent care 51 (27.0) Schedule an outpatient 33 (17.5) appointment within 3 days Schedule an outpatient 13 (6.9) appointment in 4–7 days Manage by telephone 1 (0.5) ED = emergency department.
Table 4. Resident and Caregiver Satisfaction with First Telemedicine Visit Characteristic
Resident Could talk comfortably with doctor (n = 57) Because of telemedicine, did not need to travel to emergency department (n = 63) Telemedicine allowed him or her to see a healthcare provider sooner (n = 62) Telemedicine visit was as good as a regular in-person visit (n = 65) Would be willing to use telemedicine again in the future (n = 66) Overall satisfied with quality of services provided by telemedicine (n = 62) Would choose to use a SLC that had telemedicine available over one that did not, given the choice (n = 60) Caregiver Would choose to use a SLC that had telemedicine available over one that did not, given the choice (n = 36) SLC = senior living community.
Agree or Strongly Agree, n (%)
53 (93.0) 55 (87.3)
56 (90.3)
43 (66.1)
60 (90.9)
58 (93.5)
52 (86.7)
35 (97.2)
2005
commonly used consultation by video conferencing, this program has additional capabilities that improve access to care for older adults with a wide range of undifferentiated illnesses. Over the first 2 years of the program, it was found that the program is feasible, with a remarkable 93.4% of the requests for assistance completed successfully. It was also found that the program is acceptable to residents and caregivers, as demonstrated by the highly positive satisfaction data in Table 4. The program’s acceptability to the providers was measured through their report that telemedicine was beneficial and would be requested again in all cases. Although not definitive, the survey of the triage team, asking them to assess care options if telemedicine had not been available, demonstrates that telemedicine care was being substituted for ED and urgent care clinic visits. The one SLC whose leadership was supportive but whose staff did not engage with the research team was cryptic, particularly because staff declined to explain their concerns. Because the SLC staff are stakeholders with decision rights, particularly in assisted living, resistance from SLC staff could be a barrier to success. These findings are consistent with those of similar high-intensity telemedicine programs for acute care in other populations and settings. One group demonstrated the feasibility and acceptability of a similar program in daycares and schools.22–24 Other groups used telemedicine successfully in nursing homes, prisons, and EDs for acute illnesses,25–31,37 although to the knowledge of the authors of the current study, this is the first program to provide high-intensity telemedicine to older adults in SLCs for acute illnesses. Adopting, integrating, and sustaining telemedicine in SLCs requires value for stakeholders to adopt telemedicine and evidence to support each stakeholder’s decision to participate.38,39 In this program, the primary stakeholders are the residents and their families, the PCPs, and the insurers who would pay for services. Incentives for residents and their families include increasing access to health care, minimizing symptom severity and duration, increasing knowledge of the disease, improving health, and minimizing disruption to activities and responsibilities. Potential incentives that could accrue to PCPs include obtaining moredetailed data (than with telephone calls), improving the quality of care delivered, improving continuity of care by keeping care within the resident’s medical home, and greater revenue generated by caring for more people. Finally, insurers may benefit by reducing the use of highercost resources (e.g., ambulances and EDs). SLC staff are a potential stakeholder, having a role in assisted living settings but not in independent living settings. For SLC staff, incentives include more timely support from physicians or APPs and better access to care for residents. These findings are relevant to groups that might be interested in creating a similar program elsewhere. Based on the findings, residents, their families, and the PCPs are likely to support the program, although telemedicine is a disruptive innovation in that adoption of this model changes the way providers manage their practice, their patients, and their office processes.40 The program staff had to work with the geriatrics practice to integrate telemedicine processes with office processes. Although some
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providers readily adapted to the telemedicine system, others were more cautious and took time to become comfortable with this new way of interacting with patients. As the study progressed, finding providers available and interested in completing telemedicine visits became easier as they learned the system and participated in visits, but as with any novel technology or program, unique local challenges will have to be addressed.
LIMITATIONS This high-intensity telemedicine-enhanced acute care program has limitations. First, this article documents a case series. It does not detail a comparative study using concurrent or historical control groups to test the effect of this type of program on individual-level outcome measures or cost effectiveness. When complete, the overarching study will perform this comparison and provide this information. As of now, the survey of the healthcare providers who ordered telemedicine demonstrates that, if telemedicine had not been available, higher-cost resources would have been used in the majority of cases. Second, it is not possible to generalize from the SLC setting to locations where residents have greater acuity, such as nursing homes. Further work should develop and explore the effect of telemedicine in nursing homes. Finally, the approach of creating a new healthcare provider, the CTA, may limit the program’s dissemination because each health system or each state may create different requirements for certification. Using existing certified or licensed providers (e.g., nurses, nurse aides, paramedics, or emergency medical technicians) may be equally safe and avoid the complexity of a new type of healthcare provider. Finally, although technological challenges were not experienced often, they can limit the value of this type of program.41 Any groups replicating this model of care will need to ensure that they have sufficient support for the technology used.
CONCLUSION High-intensity telemedicine-enhanced acute care for older adults residing in SLCs is feasible and acceptable to residents and informal caregivers and offers an option for acute care that can replace ED visits or delayed outpatient visits. Sustaining the program requires the demonstration of equal or better resident-level outcomes and costs, particularly to payers, which requires further research.
ACKNOWLEDGMENTS The manuscript was copyedited by Linda J. Kesselring, MS, ELS, a freelance copyeditor in Baltimore, Maryland. Conflict of Interest: This work was supported by the Agency for Healthcare Research and Quality (R01 HS18047). Dr. McConnochie and Ms. Wood receive a percentage of potential revenues through July 2013 from Trifecta Technologies, the provider of telemedicine technology used in this Agency for Healthcare Research and Quality–funded study. Trifecta provided no funds for support of the research. Author Contributions: Shah M.N., Gillespie S.M., McConnochie K.M, Dozier A.: conception of study,
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obtaining research funding. Shah M.N., Gillespie S.M., Wood N., Nelson D.L.: supervision of conduct of trial, data collection. Wood N., Wasserman E.B.: recruitment of subjects, management of data. Wasserman E.B., Wood N., Shah M.N.: primary data analysis. Shah M.N., Wasserman E.B.: drafting the manuscript. All authors contributed substantially to revision of manuscript. Manish N. Shah takes responsibility for the paper as a whole. Sponsor’s Role: The sponsor had no role in this study.
REFERENCES 1. Roberts DC, McKay MP, Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med 2008;51:769–774. 2. Shah MN, Bazarian JJ, Lerner EB, et al. The epidemiology of emergency medical services use by older adults: An analysis of the National Hospital Ambulatory Medical Care Survey. Acad Emerg Med 2007;14:441–447. 3. U.S. Census Bureau. 2008 National Population Projections: Summary Tables. U.S. Census Bureau, 2008 [on-line]. Available at http://www. census.gov/population/projections/data/national/2008/summarytables.html# Accessed October 24, 2012. 4. Cooper RA, Getzen TE, McKee HJ, et al. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21:140–154. 5. Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Press, 2008. 6. Cunningham P, van Heeswijck R, Latch G, et al. The use of hospital emergency departments for nonurgent health problems: A national perspective. FEMS Microbiol Lett 1995;133:95–98. 7. Murray M, Berwick DM. Advanced access: Reducing waiting and delays in primary care. JAMA 2003;289:1035–1040. 8. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press, 2001. 9. Strunk BC, Cunningham PJ. Treading water: Americans’ access to needed medical care, 1997–2001. Track Report 2002:1–6. 10. Cheung PT, Wiler JL, Lowe RA, et al. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med 2012;60:4–10. 11. Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Ann Emerg Med 2009;53:454–461. 12. Forster AJ, Rose NG, van Walraven C, et al. Adverse events following an emergency department visit. Qual Saf Health Care 2007;16:17–22. 13. Parry C, Coleman EA, Smith JD, et al. The care transitions intervention: A patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q 2003;22:1–17. 14. Boockvar K, Fishman E, Kyriacou CK, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164: 545–550. 15. Stiell A, Forster AJ, Stiell IG, et al. Prevalence of information gaps in the emergency department and the effect on patient outcomes. Can Med Assoc J 2003;169:1023–1028. 16. Shepherd G, Schwartz RB. Frequency of incomplete medication histories obtained at triage. Am J Health Syst Pharm 2009;66:65–69. 17. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377–384. 18. Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. Hospital-based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press, 2006. 19. Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderly emergency department patients. Can Med Assoc J 2000;163:977–981. 20. Caterino JM, Emond JA, Camargo CA Jr. Inappropriate medication administration to the acutely ill elderly: A nationwide emergency department study, 1992–2000. J Am Geriatr Soc 2004;52:1847–1855. 21. Hwang U, Morrison RS. The geriatric emergency department. J Am Geriatr Soc 2007;55:1873–1876. 22. McConnochie KM, Wood NE, Herendeen NE, et al. Acute illness care patterns change with use of telemedicine. Pediatrics 2009;123:e989–e995. 23. McConnochie KM, Wood NE, Herendeen NE, et al. Telemedicine in urban and suburban childcare and elementary schools lightens family burdens. J Telemed Telecare 2010;16:533–542.
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24. McConnochie KM, Wood NE, Kitzman HJ, et al. Telemedicine reduces absence resulting from illness in urban child care: Evaluation of an innovation. Pediatrics 2005;115:1273–1282. 25. Bratton RL, Cody C. Telemedicine applications in primary care: A geriatric patient pilot project. Mayo Clin Proc 2000;75:365–368. 26. Bratton RL, Short TM. Patient satisfaction with telemedicine: A comparison study of geriatric patients. J Telemed Telecare 2001;7(Suppl 2):85–86. 27. Kobb R, Hoffman N, Lodge R et al. , et al. Enhancing elder chronic care through technology and care coordination: Report from a pilot. Telemed J e-Health 2003;9:189–195. 28. Hui E, Woo J, Hjelm M, et al. Telemedicine: A pilot study in nursing home residents. Gerontology 2001;47:82–87. 29. Lyketsos CG, Roques C, Hovanec L, et al. Telemedicine use and the reduction of psychiatric admissions from a long-term care facility. J Geriatr Psychiatry Neurol 2001;14:76–79. 30. Wakefield BJ, Buresh KA, Flanagan JR, et al. Interactive video specialty consultations in long-term care. J Am Geriatr Soc 2004;52:789–793. 31. Gray LC, Edirippulige S, Smith AC, et al. Telehealth for nursing homes: The utilization of specialist services for residential care. J Telemed Telecare 2012;18:142–146. 32. McConnochie KM, Conners GP, Brayer AF, et al. Differences in diagnosis and treatment using telemedicine versus in-person evaluation of acute illness. Ambul Pediatr 2006;6:187–195.
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33. McConnochie KM, Conners GP, Brayer AF, et al. Effectiveness of telemedicine in replacing in-person evaluation for acute childhood illness in office settings. Telemed J e-Health 2006;12:308–316. 34. Vano-Galvan S, Hidalgo A, Aguayo-Leiva I, et al. [Store-and-forward teledermatology: Assessment of validity in a series of 2000 observations]. Actas Dermosifiliogr 2011;102:277–283. 35. Martin-Khan M, Flicker L, Wootton R, et al. The diagnostic accuracy of telegeriatrics for the diagnosis of dementia via video conferencing. J Am Med Direct Assoc 2012;13:487–e19. 36. Salih SA, Wootton R, Beller E, et al. The validity of video clips in the diagnosis of gait disorder. J Telemed Telecare 2007;13:333–336. 37. Beach M, Miller P, Goodall I. Evaluating telemedicine in an accident and emergency setting. Comput Methods Programs Biomed 2000;64:215–223. 38. Carroll C, Patterson M, Wood S, et al. A conceptual framework for implementation fidelity. Implement Sci 2007;2:40. 39. Brickley J, Smith C, Zimmerman J. The economics of organizational architecture. J Appl Corp Finance 1995;8:19–31. 40. Christensen CM, Grossman J, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Health Care. New York: McGraw Hill, 2009. 41. Shah MN, Morris D, Jones CM, et al. A qualitative evaluation of a telemedicine-enhanced emergency care program for older adults. J Am Geriatr Soc 2013;61:571–576.
High-Intensity Telemedicine-Enhanced Acute Care for Older Adults: An Innovative Healthcare Delivery Model Manish N. Shah, MD, MPH,*†‡ Suzanne M. Gillespie, MD, RD,*‡ Nancy Wood, MS,* Erin B. Wasserman, BA,*† Dallas L. Nelson, MD,* Ann Dozier, RN, PhD,† and Kenneth M. McConnochie, MD, MPH§
Key words: emergency care; geriatrics; telemedicine Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program’s operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models. J Am Geriatr Soc 61:2000–2007, 2013. From the *Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York; †Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York; ‡ Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York; and §Department of Pediatrics, University of Rochester Medical Center, Rochester, New York. Address correspondence to Manish N. Shah, 265 Crittenden Blvd., Box 655C, Rochester, NY 14642. E-mail: [email protected] DOI: 10.1111/jgs.12523
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M
eeting the acute illness care needs of older adults is increasingly challenging for the healthcare system. Expansion of the older adult population and high and rising rates of use of acute care by older adults has increased the overall demand for acute medical care.1–3 The shortage of primary care providers (PCPs), including geriatricians, limits older adults’ ability to access medical care from within their medical home.4,5 Accessing timely acute care is also challenging for older adults. Same-day PCP care is usually unavailable, and when an appointment is available, transportation can be a barrier.6–9 A combination of these barriers and regulations precluding ambulance transportation to PCP offices creates demand for emergency department (ED) services.10 Although convenient, ED care may not be optimal for older adults. Community-to-ED and ED-to-community transitions are associated with greater risk of adverse outcomes.11,12 ED care providers may lack critical information, including baseline functional status and important elements of the resident’s medical history, leading to fragmented and inefficient care and placing residents at high risk of adverse events.13–16 Older adults may experience complications such as delirium and adverse events such as falls while in the ED.17–21 Finally, after considering their life stage, some older adults have chosen care focused on quality of life rather than aggressive interventions and do not wish to leave their residence for medical attention. These important care wishes would not be honored by going to an ED for care and might not be communicated to ED staff. Telemedicine (the use of health information technology for clinical care when distance and time separate the patient and healthcare provider) has the potential to provide older adults with timely, high-quality, patient-centered acute care. Telemedicine technology can range from low intensity, which includes only video conferencing, to
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high intensity, which includes a much broader range of functionalities such as those included in the University of Rochester Medical Center care model. Studies have demonstrated that patient-to-provider telemedicine-enhanced acute care for children is feasible, acceptable, effective, and efficient.22–24 Preliminary work has also found that telemedicine-enhanced acute care is feasible and acceptable for older adults and nursing home residents,25–31 but to the knowledge of the authors of the current study, the evidence from pediatric and nursing home settings has not been applied to the senior living community (SLC) setting. No telemedicine-enhanced programs capable of addressing a wide range of acute complaints from older adults in non-medical SLCs that have been systematically implemented and evaluated were found. This article describes the application of high-intensity telemedicine-enhanced acute care for community-dwelling older adults, the alignment of incentives that support such a program, the feasibility and acceptability of the program to participants, and lessons that groups interested in creating a similar program can use.
MODEL OF CARE Setting The Rochester, New York, metropolitan area is home to approximately 780,000 residents in urban, suburban, and rural settings. The Strong Health Geriatrics Group based at the University of Rochester provides primary care to residents of SLCs, including independent and assisted living facilities. The 11 physicians and 17 advanced practice providers (APPs) in the geriatrics practice care for approximately 750 residents in 17 SLCs. The providers offer on-site primary care services, with sessions typically held two times per week at each SLC. The practice has an office at a separate location that houses paper-based medical records and is staffed by nurses and APPs who review and address results of laboratory and imaging studies and consultants’ recommendations. The nurses and APPs in the office also triage emergent questions and problems that arise from residents, families, caregivers, and SLC facility staff.
Telemedicine Program The purpose of the high-intensity telemedicine-enhanced acute care program is to use telecommunications technology for diagnostic and therapeutic benefit when distance and time separate the patient and provider. As part of an ongoing clinical trial examining the health services use and cost-effectiveness of an acute care telemedicine program in SLCs, this program provides services at seven SLCs to residents who provided written consent to participate in this research project. The program is designed to augment, not replace, the traditional primary care practice. It offers access to acute care for complaints that need more-urgent attention than the next available outpatient visit affords but may not need the advanced resources of an ED or urgent care clinic. It also avoids the burden and cost of transporting an individual to a medical facility and the discontinuity between the primary care geriatrics practice and an ED or urgent care center.
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Staff A dispatcher, certified telemedicine assistants (CTAs), and telemedicine providers staffed this program. The dispatcher tracks pending care visits, routes CTAs to residents, and identifies telemedicine providers to complete each visit. CTAs are hospital-trained clinical technicians. To attain that designation, they complete 40 hours of practical skills training such as measuring blood pressure, interfacing with patients, and ensuring safety. In preparation for the high-intensity telemedicine program, they complete 40 additional hours of program-specific didactic and practical clinic-based training with the geriatrics practice, and they complete the institution’s phlebotomy and electrocardiogram courses. The goal of the training is to enable the CTAs to collect patient history and examination findings, obtain vital signs, measure pulse oximetry readings, perform electrocardiograms, and collect blood and urine for laboratory testing. CTAs are not able to make clinical judgments. Instead, they execute protocols and relay information. Using nurses as CTAs was considered, but it was decided to use clinical technicians instead because CTAs generally do not need specific, high-level nursing skills, so using nurses as CTAs could potentially lead these overqualified individuals to have poor job satisfaction. Also, nurses are in short supply, limiting their availability, and are significantly more expensive, which would have increased the program’s cost. The program’s telemedicine providers are licensed at the physician or APP level and are active clinicians in nursing homes, primary care geriatrics practices, or EDs. They remotely access the telemedicine electronic medical record, review the data that the CTAs collect, and make diagnoses. The providers also communicate with the resident, family member, and caregiver to share their findings and impressions and create a treatment plan. In summary, unlike some telemedicine programs that are essentially videoconferencing regarding healthcare concerns, this highintensity telemedicine program obtains health information, physical findings, and laboratory and radiographic testing and ultimately provides treatment for the acute illness.
Equipment The CTAs use commonly available equipment to collect and record resident history and examination findings. They use a digital stethoscope (Littmann 3200; 3M, St. Paul, MN), a digital otoscope (Welch Allyn, Skaneateles Falls, NY), a high-resolution digital camera (Nikon, Tokyo, Japan), and a web camera (Agent V5; Liquid Digital Solutions, Rowville, Australia) linked to a laptop computer, scanner, and printer (Dell, Inc., Round Rock, TX). Each of these devices records the audio clip, image, or video clip and then transfers the file to the laptop computer. The CTAs also carry a 12-lead electrocardiogram (DRE, Louisville, KY), supplies to collect blood and urine samples, and a digital pulse oximeter (Diagnostix 2100; American Diagnostic Corporation, Hauppauge, NY). The information collected, including text, digital images, and audio, is entered into a telemedicine-oriented electronic medical record (Trifecta Technologies, Allentown, PA). Audio files might include breath, heart, and
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bowel sounds. Digital images and videos can document a resident’s general appearance, skin abnormalities, status of tympanic membranes, and neuromuscular traits such as gait. Telemedicine providers remotely access the electronic medical record from any internet-connected computer equipped with a web camera and speakers through a secure transport protocol.
Program Processes Traditionally, when a SLC resident has an acute illness, the resident, family, or caregiver calls the geriatrics practice for assistance (Figure 1). A nurse triages the call, and a healthcare provider (physician or APP) addresses the problem by treating the resident over the telephone, establishing an outpatient appointment (on the same day or within a few days, depending on when the provider will next be visiting that facility) or sending the individual to the ED or an urgent care center. The nurse, in collaboration with a physician or APP, can also order laboratory or radiographic testing, performed by mobile technicians at the SLC, if needed. The radiographic testing is available within 24 hours, and laboratory testing takes up to 3 days. As part of this grant-funded program and study, telemedicine-enhanced acute care services were offered to members of the Strong Health Geriatrics Group at seven of the SLCs that the practice serves. Services were made available on weekdays between 9 a.m. and 6 p.m. An active relationship was not established between the
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research team and the staff at one SLC. Despite project team efforts, reasons for this lack of engagement could not be characterized. Therefore, telemedicine services were discontinued after 12 months at that facility. The provision of weekend telemedicine services was pilot-tested but discontinued because of insufficient use. When residents who are enrolled in the study call the practice to seek help for an acute illness, the triage team, comprising a nurse and a primary care physician, an APP, or both, has the option of ordering a telemedicine evaluation instead of managing the resident through traditional means (by telephone, setting up an urgent outpatient visit, or sending the resident to an ED or urgent care center). Thus, the telemedicine program offers the resident rapid access to an evaluation of his or her complaint, including laboratory testing, without leaving home. If a telemedicine visit is felt to be appropriate for the condition and is acceptable to the resident, the triage nurse documents a brief note in the telemedicine electronic medical record and chooses one of six clinical protocols that the program leaders have developed: skin, fever, shortness of breath, pain, altered mental status, or other. The protocol guides the CTA through the history and examination components that must be gathered. The triage nurse then notifies the telemedicine dispatcher of the need for a visit. The dispatcher sends a CTA by car to the resident and identifies a telemedicine physician or APP who can complete the telemedicine visit. In most cases, the program uses a real-time telemedicine model, in which the CTA collects the information required based upon the protocol that the triage nurse
Call for Assistance Patient / Caregiver / Staff Telephone Evaluation RN / Provider
Traditional Care Path
Telemedicine Care Path
Certified Telehealth Assistant Dispatched to patient’s home Care within 1-2 hours
Treat by Phone Depend on verbal description of problem
Refer to Urgent Care / ED Require patient travel Loss of continuity of care
Set Up PCP Visit Delay in care
Protocol Driven Data Collection CTA collects data and completes medical record
Real-Time Visit
Store-and-Forward Visit
Provider Evaluation Record reviewed Interventions determined Videoconference with patient / family Patient / family informed of assessment and plan
Provider Evaluation Record reviewed Interventions determined Patient / family informed of assessment and plan
Visit Wrap-Up CTA reinforces information
Figure 1. Care model. CTA = certified telemedicine assistant; ED = emergency department; PCP = primary care provider; RN = registered nurse.
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chooses, uploads the information to the electronic medical record over the internet, and then contacts the telemedicine physician or APP to teleconference or videoconference with the resident, caregivers, or both. In some cases, the program uses a store-and-forward model, in which the telemedicine physician or APP does not view the CTAcollected information until after the CTA has left the resident. In these cases, the telemedicine provider calls the resident or caregiver to discuss the findings from the visit. After the visit is complete, the telemedicine provider completes the electronic medical record, electronically orders any prescriptions or services, and writes a discharge instruction sheet. If the CTA is still on site (the real-time model) at the SLC, he or she prints the information and reviews it with the resident or caregivers. Otherwise, the information is mailed or faxed to them. Finally, a copy of the medical record from the visit is printed for the paper chart in the geriatric group’s office. This method of telemedicine has been shown to be valid and effective for acute illnesses in the pediatric setting, with a visit completion rate similar to that of regular office visits and 86% agreement of diagnoses with inperson office visits with the individual’s usual physician.32,33 Telemedicine has also been validated for diagnosis of dementia, gait disorder in older adults, and dermatological problems.34–36
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Rochester research subjects review board approved the research evaluation plan. The program was evaluated from November 1, 2010, through October 31, 2012, the first 24 months of its operation. To evaluate the program’s use, the characteristics of the episodes of telemedicine care, including the reasons for use, services provided, and outcomes of care, are described. To evaluate feasibility, the proportion of visits requested that were completed successfully, defined a priori as “visits in which the clinician is able to successfully develop a care plan” were calculated. This is critical, because failure to complete a large proportion of telemedicine visits would lead to avoidance of the technology and service. To evaluate acceptability, telephone-based followup surveys with residents and their caregivers who were involved in residents’ first telemedicine care episode were analyzed. Because of the high levels of dementia in this population, only residents who remembered their visits were surveyed. Finally, the individual at the geriatrics practice who initiated the telemedicine-enhanced acute care visit was surveyed to determine what would have been done had telemedicine not been available. Although this survey was implemented during October 2011, after the program had started, it characterizes how telemedicine changed care.
Evaluation Results Sustainability and Costs Sustaining this program at the end of grant funding will require technical and financial support. Technical support is necessary to maintain the equipment that the CTAs use and the interface with the electronic medical record. An external supplier can provide this support, as in this program, or it can be provided internally. With the existing ability to integrate audio and video into commonly used electronic medical records, telemedicine programs could use their practice’s existing electronic medical record system rather than a free-standing system. Financial support is required for staff and equipment. In an insurance reimbursement model, the telemedicine provider’s care can be considered equivalent to officebased or ED-based care. Although insurance reimbursement does not exist for this grant-funded program, it does for other models, including a program in the community. The cost for the dispatcher, CTAs, telemedicine equipment, and technical support can be conceptualized as similar to the technology fee paid to mobile radiology services or the facility fee paid to healthcare centers. Alternatively, the program could be supported as a subscription model, in which older adults or SLCs pay directly for the telemedicine services, although it is likely that this model would exclude a large proportion of individuals who lack the means to afford such care. Without a direct or indirect revenue stream (such as being part of an accountable care organization or capitated system), sustaining this program will be difficult.
Evaluation The initial evaluation of this program is structured around feasibility, acceptability, and care use. The University of
Over the 2-year evaluation period, seven SLCs participated, with start dates between November 1, 2010, and August 31, 2011. One SLC had only independent living residences, four had only assisted living residences, and the remaining two had a mix of independent and assisted living. Three hundred eighty-eight resident (60.2% of the number eligible) consented to participate and were eligible at some point during the evaluation period (Table 1). The median age of participants was 85 (interquartile range (IQR) 79–90), and 74% were female. These subjects contributed 4,793.6 patient-months to the study over the 2 years of analysis because of entry into and departure from the practice and SLCs. During the evaluation period, 301 telemedicine visits for 170 subjects were initiated (43.8% of residents who consented), the provider successfully developed a care plan for 281 of these visits (93.4%). For those instances in which a visit could not be completed, the visit was cancelled before the CTA being dispatched to the patient’s home 13 times (e.g., visit requested and subsequently cancelled), and the CTA could not collect patient information seven times (e.g., patient unavailable for care when CTA arrived). Fourteen telemedicine providers cared for residents using telemedicine (four physicians, 10 APPs). Of the 281 completed visits, 4.3% resulted in referral to the ED for added testing and interventions, and 7.5% resulted in a follow-up appointment within 24 hours. The remainder of visits resulted in follow-up as required by the resident. Table 2 describes the characteristics of the visits. The triage team that ordered the telemedicine visit was surveyed regarding all visits between October 18, 2011, and October 31, 2012, totaling 207 eligible initiated visits (Table 3); 189 (91.3%) of the surveys were completed. Of greatest importance is that the decision-maker
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Table 1. Characteristics of Residents Enrolled in the Program (N = 388)
Table 2. Characteristics of Initiated Telemedicine Visits (N = 301)
Characteristic
Value
Characteristic
Age, median (IQR) Female, n (%) Race, n (%) White Black Other Unknown Marital status, n (%) Married Widowed, separated, or divorced Single, never married Unknown Education, n (%) High school Unknown Residence, n (%) Independent living Assisted living Lives alone, n (%) Comorbidities, n (%) Dementia Diabetes mellitus Cerebrovascular disease Cardiovascular disease Chronic obstructive pulmonary disease Number of medications, median (IQR) Montreal Cognitive Assessment, median (IQR) (N = 315) Activity of daily living deficiencies, median (IQR) (N = 357)
85 (79–90) 287 (74.0)
CTA sent to resident’s home, n (%) CTA successfully collected resident information, n (%) Visits completed with care plan, n (%) Rate of visits per 100 resident-months Year 1 Year 2 Location of visit, n (%) Independent living Assisted living Testing ordered for completed visits, n (%) Radiology Laboratory New medication prescribed, n (%) Disposition of completed visits, n (%) Sent to emergency department Appointment in the next 24 hours Follow-up as needed Provider time to evaluate completed visits, median (interquartile range), min Diagnosis category of completed visits, n (%) Respiratory Circulatory Skin Musculoskeletal Digestive Mental Infectious Injury Other (sensory, genitourinary, nervous, symptom, endocrine) Domiciliary or home Common Procedural Terminology coding, established patients (%) Straightforward (99334) Low (99335) Moderate (99336) Complex (99337) Insufficient documentation to code
351 12 4 21
(90.5) (3.1) (1.0) (5.4)
68 214 47 59
(17.5) (55.2) (12.1) (15.2)
57 97 166 68
(14.7) (25.0) (42.8) (17.5)
156 (40.2) 232 (59.8) 280 (72.2) 125 90 57 53 42 10 19
(32.2) (23.2) (14.7) (13.7) (10.8) (7–14) (12–24)
0 (0–1)
IQR = interquartile range.
indicated that, if telemedicine had not been available, care would have been provided over the telephone 0.5% of the time, in an urgent clinic visit 27% of the time, and in an ED 48.1% of the time. One hundred thirty-seven of 280 (48.9%) follow-up surveys were successfully completed with residents during the first 2 years of the program. Follow-up was limited because residents could not remember the visit in 84 (30%) instances and refused the survey or could not be reached to complete the survey in 59 (21.1%) instances. A caregiver was involved in 110 telemedicine visits. Caregivers completed a separate follow-up survey for 74 (67.3%) of these visits. During the follow-up surveys, residents indicated that telemedicine saved a trip to an after-hours clinic or an ED 91% of the time (109/120 responses) and saved an estimated 3 hours (IQR 2–4) of time. Similarly, when involved, caregivers indicated that telemedicine saved a trip to an after-hours clinic or an ED 88% of the time (57/65 responses) and saved an estimated 3.5 hours (IQR 2.5–6) for the caregiver. Table 4 summarizes the acceptability of the program to residents and caregivers. To limit the introduction of experiential bias in the satisfaction information, only each resident’s first telemedicine visit was analyzed.
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Value
288 (95.7) 281 (93.4) 281 (93.4)
6.34 6.25 175 (58.1) 126 (41.9)
92 (32.7) 151 (53.7) 67 (23.8)
12 (4.3) 21 (7.5) 248 (88.3) 30 (20–40)
61 46 34 23 21 17 16 16 47
(21.7) (16.4) (12.1) (8.2) (7.5) (6.1) (5.7) (5.7) (16.7)
39 145 84 7 6
(14) (52) (30) (2.5) (2.1)
CTA = certified telemedicine assistant.
DISCUSSION This telemedicine program for older adult SLC residents with acute illnesses expands the options for healthcare providers, especially PCPs, to deliver acute illness care. More importantly, it expands the options for older adults to obtain acute illness care rapidly, with minimal burden and potentially from within their medical home. By providing high-intensity telemedicine, rather than the
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TELEMEDICINE-ENHANCED ACUTE CARE
Table 3. Survey of Triage Team Requesting Telemedicine Services (N = 189) Characteristic
n (%)
Primary reason for telemedicine visit Faster care 133 (70.4) More convenient 30 (15.6) Avoiding ED or urgent care 18 (9.5) No available appointments 4 (2.1) Avoiding travel 3 (1.6) Family refused other options 1 (0.5) Influencing factors for telemedicine visit (not mutually exclusive) Faster care 185 (97.9) More convenient 168 (88.9) No available appointments 152 (80.4) Avoiding travel 144 (76.2) Avoiding ED or urgent care 140 (74.1) Family refused other options 2 (1.1) Recommended care plan without telemedicine Send resident to ED 91 (48.1) Send resident to urgent care 51 (27.0) Schedule an outpatient 33 (17.5) appointment within 3 days Schedule an outpatient 13 (6.9) appointment in 4–7 days Manage by telephone 1 (0.5) ED = emergency department.
Table 4. Resident and Caregiver Satisfaction with First Telemedicine Visit Characteristic
Resident Could talk comfortably with doctor (n = 57) Because of telemedicine, did not need to travel to emergency department (n = 63) Telemedicine allowed him or her to see a healthcare provider sooner (n = 62) Telemedicine visit was as good as a regular in-person visit (n = 65) Would be willing to use telemedicine again in the future (n = 66) Overall satisfied with quality of services provided by telemedicine (n = 62) Would choose to use a SLC that had telemedicine available over one that did not, given the choice (n = 60) Caregiver Would choose to use a SLC that had telemedicine available over one that did not, given the choice (n = 36) SLC = senior living community.
Agree or Strongly Agree, n (%)
53 (93.0) 55 (87.3)
56 (90.3)
43 (66.1)
60 (90.9)
58 (93.5)
52 (86.7)
35 (97.2)
2005
commonly used consultation by video conferencing, this program has additional capabilities that improve access to care for older adults with a wide range of undifferentiated illnesses. Over the first 2 years of the program, it was found that the program is feasible, with a remarkable 93.4% of the requests for assistance completed successfully. It was also found that the program is acceptable to residents and caregivers, as demonstrated by the highly positive satisfaction data in Table 4. The program’s acceptability to the providers was measured through their report that telemedicine was beneficial and would be requested again in all cases. Although not definitive, the survey of the triage team, asking them to assess care options if telemedicine had not been available, demonstrates that telemedicine care was being substituted for ED and urgent care clinic visits. The one SLC whose leadership was supportive but whose staff did not engage with the research team was cryptic, particularly because staff declined to explain their concerns. Because the SLC staff are stakeholders with decision rights, particularly in assisted living, resistance from SLC staff could be a barrier to success. These findings are consistent with those of similar high-intensity telemedicine programs for acute care in other populations and settings. One group demonstrated the feasibility and acceptability of a similar program in daycares and schools.22–24 Other groups used telemedicine successfully in nursing homes, prisons, and EDs for acute illnesses,25–31,37 although to the knowledge of the authors of the current study, this is the first program to provide high-intensity telemedicine to older adults in SLCs for acute illnesses. Adopting, integrating, and sustaining telemedicine in SLCs requires value for stakeholders to adopt telemedicine and evidence to support each stakeholder’s decision to participate.38,39 In this program, the primary stakeholders are the residents and their families, the PCPs, and the insurers who would pay for services. Incentives for residents and their families include increasing access to health care, minimizing symptom severity and duration, increasing knowledge of the disease, improving health, and minimizing disruption to activities and responsibilities. Potential incentives that could accrue to PCPs include obtaining moredetailed data (than with telephone calls), improving the quality of care delivered, improving continuity of care by keeping care within the resident’s medical home, and greater revenue generated by caring for more people. Finally, insurers may benefit by reducing the use of highercost resources (e.g., ambulances and EDs). SLC staff are a potential stakeholder, having a role in assisted living settings but not in independent living settings. For SLC staff, incentives include more timely support from physicians or APPs and better access to care for residents. These findings are relevant to groups that might be interested in creating a similar program elsewhere. Based on the findings, residents, their families, and the PCPs are likely to support the program, although telemedicine is a disruptive innovation in that adoption of this model changes the way providers manage their practice, their patients, and their office processes.40 The program staff had to work with the geriatrics practice to integrate telemedicine processes with office processes. Although some
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providers readily adapted to the telemedicine system, others were more cautious and took time to become comfortable with this new way of interacting with patients. As the study progressed, finding providers available and interested in completing telemedicine visits became easier as they learned the system and participated in visits, but as with any novel technology or program, unique local challenges will have to be addressed.
LIMITATIONS This high-intensity telemedicine-enhanced acute care program has limitations. First, this article documents a case series. It does not detail a comparative study using concurrent or historical control groups to test the effect of this type of program on individual-level outcome measures or cost effectiveness. When complete, the overarching study will perform this comparison and provide this information. As of now, the survey of the healthcare providers who ordered telemedicine demonstrates that, if telemedicine had not been available, higher-cost resources would have been used in the majority of cases. Second, it is not possible to generalize from the SLC setting to locations where residents have greater acuity, such as nursing homes. Further work should develop and explore the effect of telemedicine in nursing homes. Finally, the approach of creating a new healthcare provider, the CTA, may limit the program’s dissemination because each health system or each state may create different requirements for certification. Using existing certified or licensed providers (e.g., nurses, nurse aides, paramedics, or emergency medical technicians) may be equally safe and avoid the complexity of a new type of healthcare provider. Finally, although technological challenges were not experienced often, they can limit the value of this type of program.41 Any groups replicating this model of care will need to ensure that they have sufficient support for the technology used.
CONCLUSION High-intensity telemedicine-enhanced acute care for older adults residing in SLCs is feasible and acceptable to residents and informal caregivers and offers an option for acute care that can replace ED visits or delayed outpatient visits. Sustaining the program requires the demonstration of equal or better resident-level outcomes and costs, particularly to payers, which requires further research.
ACKNOWLEDGMENTS The manuscript was copyedited by Linda J. Kesselring, MS, ELS, a freelance copyeditor in Baltimore, Maryland. Conflict of Interest: This work was supported by the Agency for Healthcare Research and Quality (R01 HS18047). Dr. McConnochie and Ms. Wood receive a percentage of potential revenues through July 2013 from Trifecta Technologies, the provider of telemedicine technology used in this Agency for Healthcare Research and Quality–funded study. Trifecta provided no funds for support of the research. Author Contributions: Shah M.N., Gillespie S.M., McConnochie K.M, Dozier A.: conception of study,
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obtaining research funding. Shah M.N., Gillespie S.M., Wood N., Nelson D.L.: supervision of conduct of trial, data collection. Wood N., Wasserman E.B.: recruitment of subjects, management of data. Wasserman E.B., Wood N., Shah M.N.: primary data analysis. Shah M.N., Wasserman E.B.: drafting the manuscript. All authors contributed substantially to revision of manuscript. Manish N. Shah takes responsibility for the paper as a whole. Sponsor’s Role: The sponsor had no role in this study.
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