Hospice finds telemedicine supports mission
Brings all disciplines to patients at less cost
There is usually nothing high-tech about hospice care. Taking care of the dying involves old-fashioned nursing, along with social workers and chaplains to address the psychosocial and spiritual needs of the terminally ill. But Kendallwood Hospice in Kansas City, MO, has added a modern spin to traditional end-of-life care.
Kendallwood started using telemedicine in May 1997 to keep more frequent contact with their at-home patients. Called telehospice, the Kendallwood program is used by 20% of the agency’s patients, mostly those living in rural areas.
New options available
Telemedicine is nothing new to the health care industry. Since 1986 the Rochester, MN-based Mayo Clinic, has had a satellite-based, full-motion video system to unite its clinics with sites around the world. Today, more than 300 clinical examinations have taken place involving all specialties.
In addition to patient exams, telemedicine is commonly used to interpret electrocardiography, echocardiography, X-ray, and magnetic resonance imaging (MRI) between remote sites.
Telemedicine encompasses a range of communication options. It is described as the delivery of care to patients at any location by combining communication technology with medical expertise. The goal of telemedicine is improving access to medical care at an affordable cost.
However, the application of telemedicine to hospice is in its infancy. Kendallwood’s telehospice program is a joint effort between Kendallwood and the University of Kansas Medical Center in Kansas City, MO. Kendallwood serves a high number of rural patients. The technology lessens the need for hospice workers to drive long distances for short visits and gives patients immediate access to staff.
"As we worked together, I saw that Kendall-wood had a significant rural background," says Gary Doolittle, MD, Kendallwood’s medical director and director for telemedicine services at the University of Kansas Medical School. "The hospice was being paid a per diem by Medicare. As a result, it’s a large expense to visit patients in terms of nursing time."
Doolittle proposed the telehospice project in 1997. As part of the project, Kendallwood is measuring patient acceptance of the new technology, as well as efficacy and cost.
How it works
Kendallwood’s telehospice program uses a video phone, telephone, and existing phone lines in the patient’s home to connect the patient or caregivers to the hospice. The hospice version allows patients 24-hour access to doctors, nurses, social workers, and chaplains within the hospice.
The video phone — a small television screen with a camera eye mounted above it — is connected to a telephone and placed on a table or desktop. The $600 unit is small enough to be moved throughout a patient’s home to allow hospice workers flexibility in viewing patients.
Once installed, the patient and hospice worker call each other by simply dialing the phone and pressing appropriate keypads prompted by an on-screen menu to establish a video connection. Receiving a video phone call requires the same process. The video phone allows both parties to zoom in on the other party, pan back, or change the screen angle by tilting the screen.
Not a replacement
Telemedicine is an appropriate service for all hospice patients, says Maria Hoffman, RN, the patient care coordinator at Kendallwood. Furthermore, its use goes beyond the clinical applications currently employed by most health care organizations.
For example, some hospice patients are reluctant to allow a chaplain to visit them at home, despite nursing observation indicating a chaplain visit would be helpful. Kendallwood’s telehospice service gives patients the option of talking with a chaplain via video phone rather than face to face. Telehospice also allows patients to talk with chaplains or social workers more frequently, especially during times of extreme emotional crisis.
For now, Kendallwood’s leaders are not interested in using telehospice to reduce visits. Instead, the hospice staff considers the video phone visits an adjunct to the number of visits established in the patient’s care plan. The only visits that are eliminated are those once prompted by crisis calls. Telehospice allows clinicians and counselors to visually assess the situation before sending a hospice worker to the patient’s home.
"It’s a supplemental piece of care," says Hoffman. It’s not a replacement to home visits. It’s a way to keep in touch throughout the week."
Getting used to technology
The application of telemedicine to the hospice setting shows great promise, Doolittle says. But the technology may be its own worst enemy. Despite its promise, Kendallwood’s leaders understood that the technology would not be easily embraced by either staff or their predominantly elderly patient population.
Reluctance among patients ranges from absolute refusal to have a video phone unit placed in their home to a mild fear of high-tech equipment. For those who agree to the service, hospice staff regularly attempt to ease reluctance by providing training and initiating use. Staff makes routine contact with patients once a week, which allows patients time to get used to the unit.
"Attempts are made to bring the unit into the home," says Hoffman. "We show it to them and show them how it works. If they allows us to put in their home, we make contact with them once a week."
The routine contact, says Hoffman, is used to follow up on items from previous visits, such as medication and care. Caregivers are also given the opportunity to ask questions of clinical staff or discuss concerns, just as they would during a home visit.
Staff, on the other hand, must be more involved in order to gain needed internal acceptance. Just like patients, staffs need both training and time to get used to the technology, says Doolittle.
Doolittle offers the following steps for hospices considering implementing telemedicine:
• Training. Staff should become very familiar with the technology. Any hint of unfamiliarity with the technology undermines the training of patients. Doolittle recommends applying the technology to office operations to get staff accustomed to it. For example, a hospice could set up the video phones for meetings with remote staff.
• Identify key staff. Single out staff from each discipline to champion telehospice. Choose staff members who are excited about the new technology to push its implementation and act as consultants for other staff that have questions.
• Target rural patients. While telemedicine is an appropriate service for all hospice patients, Doolittle says patients in rural settings are particularly well suited for telehospice.
Stay flexible
Two years after Kendallwood implemented its program, it is still trying to understand how to use telehospice to its maximum effectiveness. "There isn’t a standard protocol for its use," Hoffman says. "We are continually revising our protocol."
"I’m seeing some great things," Doolittle says. "I feel very positive about the results we’re seeing, but we’re still in the process of measuring its efficacy and comparing home visits to a telehospice visit."
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