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Telemedicine Not So New To Nursing Homes and Rural Hospitals

By Deborah Borfitz

May 19, 2020 | Four years ago, a small group of hospitalists launched TeleHealth Solution to address identified issues in the existing healthcare delivery model—among them, a shortage of physicians at Critical Access Hospitals (CAHs) in small towns across America and fractionated, disruptive care for patients in skilled nursing facilities (SNFs). So, it was already an established industry leader in both arenas when the pandemic hit with many of their contracted facilities located in COVID-19 hot spots, according to Timothy Turbett, M.D., founding partner and medical experience officer/national director of post-acute care.

Those facilities now have a whole new set of needs tied to limiting patient and provider exposure to the coronavirus, he says.

Turbett is employed full-time as a nocturnist at 117-bed Watauga Medical Center, the main hospital of the Appalachian Regional Healthcare System (ARHS) in North Carolina. Twenty-five miles outside the town of Boone, ARHS also operates Cannon Memorial Hospital in Linville, which has been using telemedicine to provide care in conjunction with advanced practice providers since 2016, he says. A local nursing home where Turbett serves as medical director also began using telemedicine in 2018.

Watauga Medical Center licensed its first unit in the wake of the pandemic, says Turbett, thanks to financial donations made to the facility.

The two facilities are among a growing base of customers that license the cart and platform of TeleHealth Solution as well as the services of the company’s expanding team of on-call clinicians. The team includes physicians, physician assistants (PAs) and nurse practitioners (NPs), says Turbett. The bulk of the physicians are practicing bedside hospitalists, in addition to several board-certified practicing emergency room physicians.

Turbett says he is especially grateful that he can make virtual visits with nursing home patients in the environment of exposure containment with the novel coronavirus. Working in a hospital, he understands he may be the exposure a nursing home patient needs to avoid. “The last thing I need is do is take [the virus] to my nursing home.”

It remains to be seen if the sweeping legislative changes behind the recent surge in telemedicine will stick once the pandemic is contained. Although TeleHealth Solution could have hospitalists practicing outside the states where they’re licensed, the company has opted to hold off on exercising that option for the time being, Turbett says.

Over the long term, the surer business driver for TeleHealth Solution is not COVID-19 but “providing the full spectrum of care at the point of need,” he adds. “Avoidance of federal readmission penalties on skilled nursing facility residents is one of many benchmarks that are quantifiable and objective. Treating in place not only saves healthcare dollars but demonstrates improved outcomes and the avoidance of transfer trauma. [It’s] a is a big deal… if we can save a facility one or two [patient] returns to the hospital in the course of a month, that more than pays for the service.”

Built on AGNES

The backbone of the TeleHealth Solution offering is AGNES, a platform of AMD Global Telemedicine, says Turbett. AGNES is highly modifiable, an important feature since the needed peripherals—e.g., stethoscope, pulse oximeter and EKG—varies by client. As a demonstration of video quality, he recently read the fine print on a pen being held by a woman 20 feet from the cart during a teleconference call. You can’t do that with Zoom, he notes.

The electronic stethoscope that functions through AGNES uses Bluetooth recording technology, Turbett continues. With good Wi-Fi, it provides better acoustic quality than he typically gets at the bedside because body sounds can be amplified. If an arrhythmia is detected, patients can be remotely monitored via an external cardiac device.

On the facility side, the entire system resides on a cart that Turbett describes as an “elegant … industrial-strength IV pole” featuring a monitor and large camera resembling an eyeball. All the peripherals are tucked in the back and pulled out as needed. Once the system is powered up, TeleHealth Solution hospitalists take control and navigate, he says.

In some cases, the facility also has the platform loaded on tablets so the hospitalist can take a quick look at patients and decide if a more comprehensive evaluation using peripherals is needed, he adds. This could potentially avoid having to go through lengthy decontamination procedures following visits with patients infected with potential COVID, influenza, Methicillin-resistant Staphylococcus aureus or Clostridium difficile.

Happily, AGNES (and many platforms like it) can be configured to communicate with various electronic health record systems so providers only need to document each patient visit once, Turbett says. TeleHealth Solution has also developed an online notification system allowing facilities and their staff to enter and deliver encrypted pertinent patient data to a provider without using a telephone answering service.

The call log can be used to quickly track quality metrics, including response times and communication between facilities and providers, he points out. At the completion of each shift, a detailed call log that includes the care administered is relayed to the resident’s attending provider.

TeleHealth Solution has an entire team devoted to the onboarding process. Staff physicians are often welcoming of their virtual colleagues, especially if it means they’re being relieved of taking calls at night, says Turbett. Any resistance is usually overcome through discussions, the sharing of care plans and protocols, and by defining roles at the facility. “We hire hospitalists who are practicing at the bedside and managing ICU-caliber patients and we pay them a fair wage that is comparable to what they would make working at a hospital.”

No Dumb Questions

TeleHealth Solution provides hospitalists to critical access hospitals (both larger hospital systems and solo facilities) and skilled nursing facilities around the country, says Turbett. The biggest trend over the past four years has been the pace of work for contracted providers. But while downtime during shifts is rare, the lifestyle is hard to beat. “I work from home, so I have my scrub shirt on, and my shorts and slippers, with my dog sleeping on my feet.”

Traditionally, TeleHealth Solution has supported CAHs in one of several ways, says Turbett, including doing morning rounds with on-site PAs and NPs and helping with admissions as well as providing coverage from 7 p.m. to 7 a.m. in lieu of overnight staff. Today’s primary care physicians work almost exclusively in outpatient clinics with inpatient care covered by hospitalists. Recruitment of both is difficult for small town America and, for CAHs, exorbitantly expensive.

Typical coverage at skilled nursing facilities is overnight Monday through Thursday and weekends starting on Friday at 7 p.m. until 7 a.m. on Monday, Turbett says. Facilities are advised to page a TeleHealth Solution provider for everything—including lab and X-ray results, a new cough, or a fall without injuries. “We want to intervene before they’re sick … nurses are [told] there is no such thing as a dumb question. They’re encouraged to include us in the decision tree early.”

New Standard of Care

Video is the “gestalt” for well-trained hospitalists, who can tell in a glance when patients are sick and need immediate attention, says Turbett. There are some diagnostic limitations to telemedicine since doctors can’t physically push on patients’ belly or feel their pulse, but a team effort with a skilled nurse at the bedside has proven effective. Some acute conditions, such as acute limb ischemia, are visually obvious (e.g., purple foot).

For patients with chest pain, a real-time EKG could reveal an ST-elevation myocardial infarction—a life-threatening emergency commanding immediate attention, he says. In the appropriate patient, a call-ahead to a referral center can ensure the cardiac catheterization lab is prepared to do their angioplasty procedure the moment they arrive, he continues. While nursing homes don’t have lab and X-ray capabilities on-site, these tests can generally be obtained in a timely fashion.

Increasingly, of course, Turbett and his colleagues are spending more of their time diagnosing potential cases of COVID-19. Patients presenting with influenza-like illness with fever, hypoxia, cough, and generalized malaise generally get admitted to the hospital for care. Workups are initiated based on a video consultation and discussion with the resident, family, and staff. If the resident doesn’t want to be transferred out of the facility, appropriate care is administered as requested by the resident and family.

The hospitalists getting beamed in from TeleHealth Solution are unfamiliar faces to most patients, says Turbett, but with few exceptions respond well to the online interaction. Nursing home residents are especially enamored with the technology and “most of them are blown away that they are interacting with a physician at 2 in the morning, and super thankful. Many don’t want to go the hospital and [the tele-physician] can talk to them openly about their illness and treatment options, including risks and benefits.”

When it seems best to transfer patients to the hospital, TeleHealth Solution makes it a habit to call family members and present them with the treatment options as well, Turbett says. That “unheard of” level of communication tends to be well-received by families.

Unexpectedly, telemedicine has also helped facilitate end-of-life decision-making, he adds. “Sometimes when I’m doing video with a sick patient, the nurse will FaceTime the family or put them on speaker phone and we’ll have a group conversation. The encounters have gone really well.”

No one is expecting a post-pandemic retreat from telemedicine, which Turbett predicts will be the new standard of care that is both expected by patients and popular with providers. Telemedicine will be essential to the continued operation of many rural hospitals as they seek to provide best-in-class care with limitations inherent to areas with small patient populations. “It puts physicians everywhere and anywhere in real time.”

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