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Telehospice may be answer to staffing challenges
It’s not as expensive as you might think
Like two trains steaming full-speed toward each other, the growing aging population and the continuing shortage of nurses and other providers threaten to come crashing together, derailing whatever progress hospices make toward increasing access to their services.
The recently released report, Access to Hospice Care: Expanding Boundaries, Overcoming Barriers, recommends hospices consider implementing telemedicine to increase access to palliative care services. The study was published as a special supplement to the March/April 2003 issue of the Hastings Center Journal, a bioethics publication.
Development of telemedicine within the hospice industry will play an important part in hospices’ efforts to keep up with increased demand for services, including expansion of services beyond the hospice Medicare benefit, says True Ryndes, ANP, MPH, president and chief executive officer of the National Hospice Work Group, and vice president for mission and policy at San Diego Hospice.
Telemedicine may prove to be a technology that individual hospices of all sizes pursue and ultimately make commonplace in the industry, rather than being limited to large envelope-pushing hospices with deep pockets.
The reason: the equipment and infrastructure — a videophone and existing telephone lines — are inexpensive. Videophones cost about $400 per unit and can be purchased off the shelf at most electronics stores.
In October 2002, Michigan State University (MSU) in East Lansing and the Hospice of Michigan in Southfield completed a joint project that studied the use of telemedicine with Hospice of Michigan patients.
Researchers examined the use of the interactive video technology that was used in the care of 200 Michigan patients during a two-year period. The goal of the study, which was partially funded by a grant from the National Telecommunication and Information Administration, was to examine whether the technology could help eliminate barriers to hospice services, including access issues related to geography and cost.
"What we found was that patients love this technology," says Pamela Whitten, PhD, associate professor of telecommunications at MSU and lead researcher on the telehospice project in Michigan, which was also part of a two-state study that included the University of Kansas in Lawrence, Hospice Inc. in Wichita, Hays Home Health and Hospice in Hays, and Hospice Services in Phillipsburg. "The real barrier was the providers themselves," Whitten observes. "Most of them could recall dramatic stories of how [telehospice] helped patients; the reasons they cited for disliking the technology came down to really mundane things."
The reasons varied, says Whitten. They ranged from providers not wanting to lose their mileage reimbursement to fearing loss of autonomy.
Still, providers who opposed the technology were a small minority, Whitten says. Given the approval of both staff and patients, especially in rural areas, telemedicine represents at least a partial solution to the impending convergence of two storms.
"It can help spread a hospice’s resources, especially in rural areas," says Whitten.
The authors of the access study agree. They recommended that the Centers for Medicare & Medicaid Services (CMS) and other government agencies establish demonstration projects similar to the Michigan-Kansas telemedicine study.
"CMS or some other appropriate government agency should move quickly to fund multi-state telehospice demonstration projects in which centrally located palliative care specialists can interact at a moment’s notice with rural hospice staff, family caregivers in varied geographical settings, and staff in non-hospice inpatient settings," the authors wrote in their recommendations.
"We think that telehospice will play a role in enhancing hospice care by increasing the amount of service available to patients, lifting the pressure off hospice providers who are trying to provide greater access to care, and relieving some of the costs associated with high-quality care," says Whitten.
In the first year of the Michigan-Kansas telehospice project, Hospice Management Advisor detailed how the project worked. At the time, researchers began giving patients a 13-inch television monitor with a camera mounted on the screen. Patients were given the equipment after the technology was explained to them and they consented to being part of the research project.
Hospice workers were able to control the image of the patient using the keypad of their touch-tone phone to enhance the visual interaction. For example, the team nurse was able to zoom in and take an on-screen snapshot of a medicine bottle held up by a patient or family member.
By today’s technology standards, the setup is relatively simple. Telehospice involves the use of standard telephone lines and interactive video technology, including a speakerphone, a mini-video camera, and television monitors. Hospice patients who participated in the study were able to call members of the hospice interdisciplinary team for a video consult. That gives patients and their caregivers 24-hour access to a nurse or physician.
Whitten reiterated that telehospice should not be used to replace visits. Researchers hoped to show that the technology would enhance the services they already provide and make better use of nurses’ time.
Preventing a needless 100-mile round trip
The video connection was used a number of times when caregivers were in crisis. The videophone was used to assess the situation and determine whether a nurse should be sent to the home for an emergency visit. Hospice workers often were able to resolve the crisis using telehospice to convey instructions after a visual assessment of the patient’s condition was made.
When a caregiver is concerned about a patient’s labored breathing, for example, the caregiver can dial into the system and point the small camera at the patient so the nurse or physician can evaluate the patient’s condition. Rather than having to send a nurse to the home for what amounts to a simple solution, the clinician can instruct the patient on the next step and evaluate whether a more complicated solution is required along with a home visit.
"It has the potential to save hospice staff from 100-mile round-trip visits and reduce the number of panic calls," says Whitten.
Telemedicine is nothing new to the health care industry. For example, since 1986, the Mayo Clinic in Rochester, MN, has had a satellite-based, full-motion video system to unite their clinics with sites around the world. Since then, more than 300 clinical examinations involving all specialties have taken place by means of the satellite system.
In addition to patient exams, telemedicine is commonly used between remote sites to enable the interpretation of electrocardiography, echocardiography, X-rays, and magnetic resonance imaging.
Rural and urban applications
In May 1997, Kendallwood Hospice in Kansas City, MO, collaborated with the University of Kansas on a joint telehospice project, which later became the origin of the two-state telehospice project involving Michigan and Kansas.
The Kendallwood experience showed that telemedicine not only has applications to hospice, but also has promise for improving care and reducing costs. The original idea was that telehospice’s greatest potential is in serving patients in remote areas. Routine telehospice consults could be provided in addition to scheduled home visits without having to require nurses to make additional long drives to patients’ homes in rural areas. Urgent calls could be handled in a timelier manner.
For Kendallwood, which serves a large number of rural patients, the use of telemedicine made sense. The technology was implemented to lessen the need for hospice workers to drive long distances for short visits and give patients immediate access to staff when a crisis arises.
Contrary to rural areas of Kansas, Detroit is predominantly urban and suburban. Yet, Whitten says access to hospice care is still an issue in these areas. Researchers say more urban-based patients used telehospice because of the sheer number of them.
The authors of the hospice access study say more demonstration projects need to be done. Further telehospice projects will likely measure how the technology will improve access to hospice care, including examination of utilization data before and during the use of telehospice. Future research will probably focus on underserved groups, such as rural residents and urban shut-ins.
Researchers also will need to determine whether telehospice can provide the same or better clinical outcomes compared to care not supplemented by telehospice. In addition, they hope to gauge the range of services that can be effectively provided using telehospice.
Future research must also address the ugly "C" word: cost. Can telehospice help reduce costs while allowing hospice workers to provide high-quality care? Research in the near future will likely track and compare the average costs of care using telehospice and traditional care using only face-to-face visits.