Monday, November 9, 2020
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COVID-19: The Use of Telemedicine in Nursing Homes During the Pandemic
Steven M. Handler, MD, PhD, CMD
Associate Chief of Staff, Geriatrics and Extended Care VA Pittsburgh Healthcare System
Associate Director, GRECC VA Pittsburgh Healthcare System
Associate Professor of Geriatric Medicine and Biomedical Informatics, University of Pittsburgh
Approaches to diagnosing and reducing COVID-19
- Symptom-based screening may fail to identify those with COVID
- Symptom assessment may be harder for persons with cognitive impairment or disabilities
- SNFs can take steps to prevent introduction of the virus, including visitation restrictions, staff screening, use/limited reuse of PPE
- Telehealth can prevent the number and type of people coming in and out of facilities
Anne Kimball et al., Asymptomatic and Presymptomatic SARS-CoV-2 Infactons in Residents of a Long-Term Care Skilled Nursing Facility--King County, Washington, March 2020, CDC MMWR, March 27, 2020, https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e1.htm?s_cid=mm6913e1_w
- Residents should have discussions with their primary care team to ensure and drive goal-concordant care using frameworks such as the VA Life-Sustaining Treatment Decision Initiative (LST)
- National quality improvement initiative to promote personalized, proactive, patient-driven care for Veterans with serious illness
- Outcome is to ensure the values, goals, and life-sustaining treatment decisions of Veterans with serious illness are proactively elicited, documented, and honored
- This is especially important in the setting of COVID
- LST progress notes are used to document goals of care conversations, easily accessible from within the EMR, and includes a variety of codifying orders
- Process can be supported and/or enhanced by using telemedicine which:
- Allows for the inclusion of healthcare POA and/or family
- Expands access and reach to those who have expertise in having difficult conversations
- Allows for revenue generation as a provider incentive
Life-Sustaining Treatment Decisions Initiative, Implementation Guid for VHA Handbook 1004.03--Life-Sustaining Treatment Decisions: Eliciting, Documenting, and Honoring Patients' Values, Goals, and Preferences, https://www.ethics.va.gov/LST/ImplementationGuide.pdf
- Triage is defined as the process of determining the priority of patients' treatments by the severity of their condition or likelihood of recovery with and without treatment.
- Triage is traditionally done in the Emergency Department (ED)
- Forward triage is defined as the sorting of patients before they arrive to the ED
Forward triage using in-field telemedicine
- Extends the practice of Paramedics in times of resource constraint
- Assesses patients and allows for alternative care destinations including non-transport
- Provides clinical guidance for emergent management/notification to the receiving facility
- Reduces risk to other patients and providers
- Can improve patient and provider outcomes
- Can improve patient and provider satisfaction
Judd Hollander and Brendan Carr, Virtually Perfect? Telemedicine for Covid-19, New England Journal of Medicine, March 11, 2020, 10.1056/NEJMp2003539, https://www.nejm.org/doi/full/10.1056/NEJMp2003539
Forward triage: combining tele- and paramedicine
- Triage can begin during 9/11 call, even before transport service initiated
- Paramedics use telehealth to initiate remote treatment on-site, reducing need for transport and increased risk of exposure for patient
- We have expertise in this at the University of Pittsburgh/UPMC where we have 12 ambulances with forward triage capabilities
CMMI Emergency Triage, Treat and Transport (ET3) Model, https://innovation.cms.gov/innovation-models/et3
Using Telemedicine to Diagnose and Recover from COVID-19 in Older Adults Across VISN 4' Continuum of Care: Background
- VISN 4 spans PA, DE, NJ, OH, WV, and NY, and is a fully integrated network of 9 VA campuses serving 3,766 high-risk high-need community-dwelling Veterans.
- VISN 4 also serves 9 nursing homes/Community Living Centers serving 824 Veterans, and 8 State Veterans Homes serving 1,608 Veterans.
- Eight out of ten COVID-related deaths reported in the U.S. have been in older high-risk high-needs adults.
- Moreover, 40% of these deaths have taken place in institutionalized settings such as nursing homes, Community Living Centers, and Veterans Homes.
- Provide COVID triage and testing directly where vulnerable Veterans live (i.e., forward triage in the home, nursing home, or Veterans home) to reduce ED use, hospitalizations, and the risk of community spread of COVID-19
- Provide COVID telerehabilitation directly in the home or nursing home to improve recovery and function as soon as possible following infection with COVID
- Scale rapidly and disseminate the program across VISN 4 using largely existing personnel and approved telemedicine software and hardware
Rapid On-demand COVID Telemedicine (ROCIT) Forward-Triage Case
- Veterans who exhibit symptoms associated with COVID-19, would contact the call center for triage.
- An in-home forward-triage visit will be scheduled for any Veteran that has non-emergent COVID symptoms AND is unable to get transportation to a drive-thru clinic.
- Within 2 hours, a nurse who has specialized training in the use of VA telemedicine and connectivity technology (i.e., telemedicine nurse), will be dispatched with a ROCIT case directly to the Veteran' home.
- The telemedicine nurse will assess the Veteran, complete a telemedicine consultation, collect a COVID specimen, and leave the ROCIT for enrollment into telerehabilitation.
- Nurses who suspect that a Veteran in a CLC or Veterans Home has COVID will contact the Tele-MOD.
- The Tele-MOD will triage and convert all appropriate consult requests from a telephonic to telemedicine.
- The nurse and Tele-MOD will complete a telemedicine consultation using iPads carts and VA Video Connect.
- If the Veteran can remain in the nursing/Veterans Home, but requires testing, the telemedicine nurse will collect a COVID-19 specimen, carry out other orders under the direction of the provider, and coordinate the delivery of the specimen to the closest VAMC for analysis.
- Veterans who were managed by the in-home forward-triage program, will be referred to the in-home COVID Recovery Telerehabilitation Recovery Rehab program.
- The program will address those Veterans who have difficulty exercising, shortness of breath, weakness, anxiety, falls, and/or depression.
- To manage these problems we will: 1) Conduct home safety evaluations; 2) Assess the need for assistive devices or adaptations to the home environment to successfully participate in telehealth visits; 3) Develop an initial exercise treatment plan; and 4) Train on the use of in-home rehabilitation equipment.
Forward triage benefits
- Allows for initial assessment directly in the Veteran' home/ nursing home
- Ensures access to a qualified, responsive, knowledgeable and dedicated provider workforce
- Standardizes clinical approach using best evidence and most current recommendations
- Makes certain that clinical documentation is shared in a timely manner
- Coordinates transitional care with pre-hospital transport
- Improves satisfaction
- Optimizes survival and resources, while reducing the risk of community spread
Using Telemedicine in the CLC
- Main value proposition is to increase access to clinical subspecialists that don’t usually provide care in the CLC
- Previously telemedicine consults were conducted as e-consults
- Utility in adding synchronous video especially for dermatology, wound care, and the post-operative period
- Significant value proposition related to reduced transportation costs and the need for placement of Veterans into observation status
Developing and Assessing the Feasibility of a Screening Tool to Determine if Veterans may Benefit from Tablet Technology in the HJH Community Living Center
Kimberly A. Eichhorn, Steven M. Handler, Rebecca Ruffing, Lauren Smilek, Brad Krushinski, Mallory Wolfendale, AnnMarie Kelleher, Amy Rebovich, Emily Saylor
- Residents of CLCs experience unique risks related to COVID-19
- Baseline vulnerable nature of the population
- Congregate living/activities = concern for outbreak -- high rates of infection, morbidity/mortality
- Efforts to reduce spread have included
- Limiting congregate activities
- Limiting visitation
- Reducing the number/types of Providers
- Providing alternative approaches to clinical care (in-patient telehealth)
- Tablet Technology: a valuable solution, but not for everyone!
- Create screening tool with goal to:
- Identify residents who may benefit from tablets
- Cognitive and/or communication support
- Life Participation (social/recreational)
- Outline the level of support needed for successful use
- Streamline the tablet acquisition process
- Develop templated note in CPRS to provide summary of recommendations
- Identify residents who may benefit from tablets