Implementing Telemedicine in a Skilled Nursing Facility To Reduce Emergency Department Visits

The care continuum increasingly relies on the skilled nursing facility to extend patient care beyond the acute care facility before the patient is sent home.  The hospitals are under pressure to treat only the most acute conditions and then move the patient to facilities with lower costs of care.  Accordingly, skilled nursing facilities are accepting patients who are frailer and more complicated.  “Between 2005 and 2009, the percentage of Medicare SNF patients with eight or more co-mobidities increased from 74.8 to 86.9 percent..”  And, the “proportion of patients in SNFs categorized as having major or extreme severity of illness increased from about 45 percent in 2005 to 53 percent in 2009.”

The staffing model at skilled nursing facilities relies largely on paraprofessionals, including nursing assistants supervised by a registered nurse.  The physicians are mostly located off-site with weekly or bi-weekly rounds to supplement telephone availability.  The staffing model puts the paraprofessional medical staff in a difficult situation.  They are accountable for patient outcomes but caring for the fragile, complicated patients often is outside of their licensure limits and skill set.  As a result, patients are routinely transported to emergency departments for assessment and care. The skilled nursing/emergency department loop creates stress for the patient, the hospital and the skilled nursing facility. 

Telemedicine offers great promise as a strategy to reduce the skilled nursing/emergency department loop.  Telemedicine can be powered by a specialized telemedicine cart or a computer with a camera that facilities a live video connection between a patient and nursing assistant at the facility and the off-site resource (physician or nurse).  When deployed and used, it reduced unnecessary patient transportation to the emergency department for non-emergent situations. 

For most facilities, the barriers to telemedicine adoption are the perceived expense of the equipment or software.  In fact, an iPad at the bedside loaded with Zoom or VSee could suffice. Important factors for success tend to be operational ones.  The facility must have physicians or nurses available for consultations.  Documentation of the visit must occur.  One strategy is to have the after-hours coverage physician or nurse staff the telemedicine platform and chart in the existing Electronic Medical Record.  Telemedicine allows the physician to assess the situation from his or her home and drive to the facility only if “hands on” treatment is required.  In short, telemedicine can be an inexpensive and effective tool to reduce transportations and increase patient access to physicians. 

Implementing Telemedicine

You have decided that your facility is ready to adopt telemedicine.  Below are some guiding factors to initiate and successfully deploy telemedicine at your facility.

First, engage the senior leadership to advocate use of the telemedicine platform.  There should be visible support for telemedicine with senior leadership clearly participating in the training, encouraging use, and offering incentives (if possible.) 

My experience is that the barriers to adoption reside almost entirely in staff’s resistance to change and fear of technology.  Although some of the telemedicine software is straightforward, due to HIPAA compliance,the software is not as simple as accessing a website.  One of the most frequent issues I encountered was password forgetfulness!

In order to overcome the barriers, robust training should occur. A workflow list clearly posted in multiple locations supports the deployment and use.  Below is a 10-step guide to implementing telehealth in a skilled nursing facility.

1. Ensure senior leadership advocates the use of telemedicine and sets achievable goals.
2. Capture data that will measure goals.
3. Ensure clinical team is fully invested in telemedicine use.  Ensure they understand the goals.  Determine if they have separate goals.
4. Select software and hardware with the input of senior leadership, physicians and nurses.
5. Develop telemedicine policies that are incorporated into existing policies (do not develop “one-off” policies that make telemedicine unique.)
6. Delineate the step-by-step operational details that are consistent and non-disruptive to existing clinical and operational processes. (Work with staff to develop.)
7. Create a training program including an overview and “at the elbow” training for staff.  Emphasize the goals, give them support tools and ease any fears about adoption.
8. Conduct trial kick-off with a few selected super-users. (Select these people during the training process.  Often, the “stars” will enthusiastically self-select.)
9.  Evaluate and adjust processes and procedures to ensure staff success during kick-off.
10. Kick-off  telemedicine use with a celebratory event that creates excitement and interest.

After implementation:

Once a week, month, or quarter is complete, measure the activity.  Determine how many telemedicine visits occurred and which ones resulted in avoiding an emergency department visit.  Revisit goals.  Are the senior leadership goals being met?  Engage with staff personnel to determine their perceptions regarding use. Use the data to adjust procedures, tasks and training.  Refresh and repeat training.  Soon, your facility will be telemedicine savvy and will be able to expand to other uses, including family visits, remote patient monitoring and specialist visits.  Good luck!