Resistance to home care telemedicine overcome through proper training
Nurse, patient acceptance is key
As home care agencies increasingly use telemedicine technology to strengthen communication with patients, the biggest challenge may not be training nurses in the nuts and bolts of video visits and remote monitoring. The hardest part could be overcoming resistance to the idea, says Barbara Johnston, MSN, California Children’s Service Coordinator for Kaiser Permanente in Sacramento, CA, which has been working with telemedicine since 1996.
"The best way is to go in and explain that you want to improve the quality of care, that that’s what the intent is," Johnston says. "You want to improve access to care."
Although telemedicine has been around in one form or another since 1959, it has only been in the past several years that the technology has become popular. Interest has accelerated thanks to greater ease of use for both patients and medical professionals, says Jonathan Linkous, executive director of the American Telemedicine Association in Washington, DC. "The technology has changed a lot in the past year," he says. "Units now are relatively simple to use. There’s been design work, working with patients so that they only have to touch one button to dial and make contact." He says use also has been simplified on the nurse’s end, integrating telemedicine into existing computerized patient information systems and making the software more user-friendly.
Linkous divides telemedicine into two broad categories. The first is single-purpose patient monitoring, which covers an array of devices designed to monitor one aspect of a patient’s health. Examples would be home cardiac monitors for heart patients, fetal monitors for pregnant women, and peak flow meters for people with asthma or emphysema. In each case, information about the patient’s vital signs can be gathered and transmitted across phone lines to a central station in a hospital or home health agency.
"It used to be if you were a pregnant woman with complications, you could be in the hospital for two months," Linkous says. "In some cases, people now can be at home and have these monitors hooked up at home, which is a significant cost savings."
In more widespread use in home health are units equipped with video that can link patient and nurse via a phone line to monitor a wide range of patient symptoms and responses. At Kansas Care Health Services in Salina, KS, five clients have telemed units installed in their homes, chief operating officer Dale Blomquist says. Each unit, which is smaller than a personal computer, contains a small screen that transmits a color video image. It has only a few buttons, each a different color, including one to answer a call and one to initiate a blood pressure reading. There are various peripheral attachments, including a blood pressure cuff and an electronic stethoscope.
"We can listen to heart-lung sounds, bowel sounds, anything we need to listen to with the stethoscope," he says.
A camera mounted in the nursing station gives patients a view of their nurses. The nurses use a personal computer to view a live video image of the patients and can attach headphones to listen through the stethoscope.
Blomquist says there are a number of things the nurse can monitor using the video hookup. "They can monitor wounds — they can watch the patient change the dressing to make sure they’re doing it right, . . . monitor the size of the wound, and capture an image of it for the patient’s files," he says.
"If they have a liquid display pulse oximeter, we can monitor that," he says. "If you hold a pulse oximeter or a glucometer up to the camera, there’s a real good image that comes across."
He says medications can be monitored with the help of a magnifying lens that slips over the camera lens. If a patient needs to fill a syringe, the nurse can make sure it contains the proper dosage. The nurse can read a medication label to be sure the patient is taking the proper amount and that the medication hasn’t expired.
Also, Blomquist says, "You can monitor gait with it, since the camera has about a 30-foot range. You can have them walk away from the unit and back, or you can monitor exercising."
Jacalyn Lenz, RN, Telemedicine Service Coordinator for American Telecare, a telemed vendor in Eden Prairie, MN, says the technology is ideal for patients who have a history of frequent trips to the emergency room.
"Those are the people you want to monitor, make a video connection with them two or three times a week so you can catch the early warning signs, before they go into a full-blown crisis and have to go into the hospital," Lenz says.
As an example, she points to a patient with chronic obstructive pulmonary disease (COPD). A nurse can monitor heart and lung sounds to hear the early signs of pneumonia. "Maybe in that case, you may be able to send the patient to a clinic, change the medication, whatever it takes, as opposed to waiting a few more days until they’re really sick and bringing them to the emergency room," she says.
Resistance overcome by understanding
As useful as telemedicine technology may seem to administrators and telemedicine supporters, Johnston warns that an agency is likely to encounter resistance from nurses when initiating a telemedicine program.
The problem, she says, isn’t so much a fear of the technology as a fear that the technology will lead to a loss of care for patients.
"These are caregivers whose basic philosophy and attitude is compassionate, caring, and nurturing, caregivers who advocate strongly for patient care," Johnston says. "This is sort of their whole heart and soul. That’s why they should be in nursing care. To go in and tell them that you can use a computer or remote piece of technology comes across as and is perceived as less than caring."
It’s important, she says, to present the program as a supplement to regular visits that can enhance the quality of the patients’ care by giving them more immediate access to help and making more frequent contact possible for rural or other patients who otherwise wouldn’t have it.
She notes that when many home health agencies are closed, often at night or on weekends, patients with a problem are routed to emergency room nurses or to advice desks. Providing a telemed link between an on-call home health nurse after hours is an important improvement to patient care, she says.
"A home health nurse has very different training than a hospital nurse or an ER nurse," she says. "Home health nurses’ educational training [and] their critical thinking skills are so excellent. They’re trained in a different way, so they know what to do."
As an example, she says a patient on a morphine drip begun in the morning could experience a problem in the middle of the night that normally would be handled by a call to the ER. "You know what happens then — it’s an ambulance ride in. During the time from when that call came in to when they’re going to the ER, they are not in pain control. And during the time they’re waiting for a doctor who can figure out what to do, they’re still waiting."
On the other hand, if the same patient were able to be connected via telemed to a home health nurse, "the nurse can see the pump and say, See that button up on the top right? Press that one.’ It’s a completely different scenario."
Even in cases where a patient still requires treatment in the ER, Johnston says they’re getting care before they ever leave their homes that can ease symptoms and provide reassurance.
Program needs an internal champion
Lenz, who conducts training for agencies that use American Telecare’s equipment, says she generally doesn’t train an agency’s entire staff at once. She teaches a small group, which then is expected to train others.
"We usually train on average four to six people per company, since most of them are starting out small," she says. "They usually start out with one or two telemedicine nurses, and they’ll have one or two who can fill in if those people are on vacation or sick. Then, when they bring on more patients, they’ll train more nurses as needed."
Johnston says her agency tried that when they initiated home care telemedicine, but "everybody else got kind of curious, so we decided within the first week we’d train the entire staff so they at least were comfortable with and had demonstrated the ability to do it."
Then, she says, supervisors were trained to use the system, something they weren’t really interested in doing until they realized the advantages, Johnston says. Now, when all the nurses are out in the field and another call comes in, a supervisor can handle the matter using the telemed unit rather than having to call someone else in.
"They have the luxury of doing the video visit themselves, which means the patient gets the care instantly," she adds.
Johnston and Lenz agree it is vital to find an enthusiastic person — an "internal champion" — to run the program within the agency.
"Normally, it’s a home care nurse, someone who’s not afraid of new technology or not opposed to change," Lenz says. She says it is important to make sure that nurse’s schedule can be adjusted to allow time to learn the system and work with others.
The training itself is relatively straightforward. Lenz says her company installs a personal computer with the necessary software already loaded.
"We usually take three hours or so to do a group of four to six," she says. In addition to background about home telemedicine, staff learn how to screen patients to choose those who are best suited to the technology. The first to be screened out would be those requiring hands-on care that cannot be delivered in a video visit.
Blomquist says patients who may not be suited to telemedicine also include those who are severely visually impaired, confused, or not mentally cognizant enough to understand directions unless a caregiver can fill that role. But Kansas Care’s biggest screening factor is reimbursement because Medicare doesn’t reimburse for use of the units his agency uses. He says Medicaid does cover the service in Kansas, as do some private insurers.
Trouble-shooting 101
In providing training for American Telecare clients, Lenz devotes the longest portion to teaching nurses how to use the software. They’re shown how to log in required documentation — agencies can opt to have their telemedicine and patient information programs tied together — how to take video snapshots of patients, and how to store them.
Nurses also get basic instruction in troubleshooting so simple problems such as bad phone connections can be fixed.
Because the nurses install the units in clients’ homes, installation is handled in the training as well. It is an easy process, Lenz says. The nurse simply connects the machine to a patient’s phone line and plugs the unit into an electrical outlet. The nurse checks to be sure the area is well lit. (Kansas Care nurses bring along a desk lamp in case supplemental lighting is needed.)
Teaching the patient to use the system takes about 30 minutes, she says. "When we do an installation, we walk through everything. But the one thing I always tell the patients is, I’ve given you a lot of information today, but you don’t have to remember any of it. The most important thing to remember is to press the green button when I call. Then when I have you on the phone, I can walk you through the rest.’ So really all they have to remember is how to answer it. Once they do that, we’ve got them live on video so we can see everything they’re doing."
For Johnston, patients’ quick acceptance of the new technology has been a surprising result of the home care telemedicine program. She said their enthusiasm about the units has helped change the minds of some nurses.
"The patients are funny. Some of them really think of this as Queen for a Day’ time," Johnston says. "We’ve had a couple of elderly women — they’re COPD — who had not put on rouge and lipstick in 20 years. You put this little home video system in front of them and they want to comb their hair and put on lipstick."
She says patients have asked nurses who were preparing for a home visit to conduct it via video instead.
Linkous says it is a misconception that older people are resistant to technology, noting that the fastest-growing use of computers by age group is among the elderly. The elderly, he notes, tend to be late adopters of technology, accepting it once its usefulness is apparent. "Look at the use of microwave ovens among the elderly or cellular phones or handheld phones."
And they have been quick to see the usefulness of telemedicine, Linkous says. "They see it provides them instant access to assistance."
Both he and Johnston stress that telemedicine services shouldn’t be pushed on a patient who doesn’t want them. "We tell people that if they’re in interested, we could try to do some of their visits this way," Johnston says. "Some people upfront will tell you, No way. I’m not interested.’ There’s no discussion after that. We just offer them an opportunity to participate."
Linkous is hopeful that use of the technology will increase, particularly if home telemed units are included as an eligible service under Medi care. The single-purpose monitoring devices such as cardiac monitors already are covered. His organization is working with others to get legislation passed, while working directly with the Health Care Financing Administration to try to achieve the goal through that route.
"[If it were reimbursed], we expect quite a few home care agencies would use it to at least supplement what they provide for home care right now," he says.
Neither Linkous nor other telemedicine advocates, however, see telemed as a substitute for home visits, even with patients who are receptive to the technology.
"That’s not ever the intent of telemed to do that," Blomquist says. "It’s to supplement so [nurses] can spend more time with the patients who need it. It improves flexibility."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content