Is a primary care physician considering switching a patient to methadone, having trouble managing a patient with delirium, or in need of input on what medication is best to manage a patient’s shortness of breath? Growing evidence suggests that telepalliative care is a viable solution for this scenario.
A recent qualitative study of 18 home-based patients in the Netherlands showed that the introduction of specialist palliative care team-patient teleconsultation led to collaboration between primary care physicians and specialist palliative care team clinicians in all 18 cases.1
“In the Netherlands, many people — 83% of the population — prefer to die at home,” says lead author Jelle van Gurp, Msc, a palliative home telecare researcher at the Netherlands’ Radboud University Medical Centre. “This results in a great responsibility for Dutch family physicians, who are primarily responsible for providing palliative care at home.”
The researchers set out to investigate whether and how teleconsultation would contribute to more personalized palliative care.
“There remains a substantial group of family physicians who have only general knowledge of treatment options, and limited knowledge and competencies when it comes to specific medical-technical treatments,” notes van Gurp. These providers could very much use specialized support and/or education, preferably delivered at the right time, he adds. “What surprised us was that although the technology is quite simple and almost everywhere available by now, human collaboration is still so multifaceted,” van Gurp says.
Multiple professionals talking to a patient at the same time ended up hindering communication. “Professionals felt they could not say everything they wanted to say in front of the patient,” explains van Gurp. The study suggested a more promising approach: several providers each talking to the patient at different points in time, then having “backstage” conversations with one another.
The University of Rochester (NY) uses teleconsultation to provide geriatrics psychiatric consults. “It seems to have wide acceptance, and people are coming up with good cases,” says Timothy E. Quill, MD, professor of medicine, psychiatry, and medical humanities in the University’s Palliative Care Program.
The University’s Palliative Care Program will soon start a pilot project using a similar approach for palliative care consultations. “I think a lot of them could be done by providing input to the primary treating people, which they can then implement,” Quill says. “That would have a lot of plusses if we did that.”
This increases the expertise of the treating clinicians, and the family doesn’t have to meet yet another doctor or team. “We could restrict consultations to the tough cases where the basics aren’t working,” Quill says.
Teleconsultations, on the other hand, can be used to improve symptom and pain management in the majority of cases. “If you can improve the basics, you can improve the care of a huge number of people,” says Quill. “You can do a tremendous amount of good just by raising the floor in terms of symptom and pain management.”
Telepalliative care consults allow multiple providers to conference with one another. “If the patient is seeing a pulmonologist, a cardiologist, and a primary care doctor, the odds of them all talking to each other are low. Maybe nobody is looking at the big picture,” says Quill.
Robert M. Arnold, MD, director of the University of Pittsburgh’s palliative care service, says telepalliative care is especially important in rural areas. “You need to utilize technology to expand your reach,” says Arnold. “As important as that is, the telemonitoring is also important.”
This allows palliative care specialists to electronically track how the patient is doing. “Some of that is already happening in the healthcare world, but we are at a pretty early stage of it. Newer technologies allow patients to report on a regular basis,” he says. This allows providers to treat pain or other symptoms early.
“Our health system is very interested in this, and is working quite hard to roll out ways to better integrate these technologies,” reports Arnold.
Arnold says the best data comes from heart failure patients whose palliative care needs are very high. By stepping on a scale and having the data transmitted, clinicians can tell whether the patient is gaining weight. “That’s a perfect example of keeping people out of the hospitals by controlling symptoms early,” says Arnold.
The vast majority of palliative care is delivered by primary care doctors, “as well it should be,” says Arnold. “The question is, how can technology help doctors do a better job of being more centered on patient goals?”
Lack of reimbursement for telepalliative care is one obstacle. “Most of clinical medicine is based on a doctor seeing a patient face to face and getting paid for the visit,” notes Quill.
Having primary care physicians consult with palliative care specialists is “a very efficient use of time and can improve care,” says Quill. “But that is not the economic model we are used to working on.”
Under the fee-for-service model, telepalliative care is bad for business, he explains — even though it’s good for patient care. If systems move to capitated payment, says Quill, “this model makes a tremendous amount of sense, because you want to spend money most efficiently.”
Switching to a telepalliative care model, concludes Quill, “requires a thinking through at a systems level, and investing in a completely different way of how we do things.”
REFERENCE
- Van Gurp J, van Selm M, van Leeuwen E, et al. Teleconsultation for integrated palliative care at home: A qualitative study. Palliat Med 2015. pii: 0269216315598068. [Epub ahead of print]
SOURCES
- Robert M. Arnold, MD, Director, Palliative Care Service, University of Pittsburgh (PA). Phone: (412) 692-4834. Email: [email protected].
- Timothy E. Quill, MD, Professor of Medicine, Psychiatry and Medical Humanities, Center for Ethics, Humanities and Palliative Care, University of Rochester (NY) School of Medicine. Phone: (585) 273-1154. Fax: (585) 275-7403. Email: [email protected].
- Jelle van Gurp, Msc, Researcher, Palliative Home Telecare, Radboud University Medical Center, the Netherlands. Email: [email protected].
There is growing evidence that telepalliative care consultation is an effective approach, but fee-for-service systems and lack of reimbursement are obstacles.
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