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Remote Care and Telehealth Resources

Remote Care and Telehealth Introduction

We've all had positive experiences where we've sat in a room with a health care professional who checked our vital signs, listened to our health concerns, asked the right questions and made strong recommendation to us.  Face-to-face care is great - until it isn't. One of the silver linings of the COVID-19 pandemic is the emerging importance of remote care.  With the increased attention legislation to expand and reimburse for telehealth across the healthcare world is beginning to pass.

But even in a pandemic-free world there are incredible benefits to telemedicine. Some of these benefits are:

  • Remote visits reduce the spread of diseases between patients in waiting rooms as well as between patients and clinical staff
  • Reduced travel for patients who find travelling for medical appointments difficult, especially when they're sick
  • Patients can follow their care plans independently while clinical staff only need to intervene for alerts and non-compliance.

The goal of this page is to provide education and best practices about remote care. It's organized like a book with chapters listed on the left so you can jump to the topics that interest you most.

Telehealth Solution Elements

A comprehensive telehealth solution lets medical professionals to engage live, but also enables patients to manage their own care with professional oversight.
 
Here are the elements you should look for in a comprehensive solution:
  • Secure Chat and Video Chat: You need a Facetime-like capability that is secure. It should also capture the times of your communications and let you take notes on what was discussed.  It should also have secure chat (so you can message and hear back asynchronously)
  • Care Plans that you can monitor remotely: In many cases, we know that our patient can turn their health around if they can stay on their care plan and let you know how they're doing.  With multiple clients of diverse needs, you need to manage by exception and see at a glance who has alerts or isn't staying on their plan
  • Rich Care Plans: The best way to think about remote care plans are in terms of simple elements including Reminders (take your meds), measurements (like pain or weight), and activities (like exercises).
  • Simplicity: When we think of telehealth, we might be picturing a complicated device with wires, scales and screens. That doesn't cut it any more. Today's telehealth should serve most patients with just their cell phone. 

Self-Guided Patient Plans

At some point we've all thought that if we could check in with our patients daily, keep them engaged and remind them what it will take to achieve their goals that we know they would succeed. But, of course we can't... we're all overseeing care for too many people for that to feasible

As described above, a comprehensive telehealth solution includes "Care Plans that you can monitor remotely." This implies that the patient is managing their own plan.  In order for patients to adhere to their care plans, you need to key ingredients:

  1. Convenience: No offense is intended, but when medical people try to come up with the minimum list of things that the want to check with their patients about, it's usually a pretty long list and leads to non-compliance. As such, you need to challenge yourself to think of the most important question(s) to ask. In fact, some of the best plans for avoiding Congestive Heart Failure (CHF) readmissions don't ask any questions at all. Instead the best plans just want the patient to get on the scale every morning.
  2. Reminders: People aren't generally good at remembering to do the items on their health care plan without a nudge. A well designed system will give the patient a chance to comply on their own, but will then remind, gently. A simple text message is a great reminder especially when they can click on the text to check-in.

That said, even the best designed care plans won't ensure compliance. This leads into our next topic...

 

Managing by Exception

As a clinician overseeing a large number of patients, one of the biggest concerns is that you won't have the time to monitor alerts or non-compliant patients. This is where you need the computer to help you. Best practice are as follows:

  • Set aside time each day to check on your alerts: Most people set aside 15 minutes a day to check on their alerts and they only need 5. 
  • If you see an alert that you don't care about, turn it off: Make sure that your telehealth solution has the ability to make these adjustments simply and quickly.
  • After checking alerts, check for non-compliance: Similarly, this need to be simple and take just a few minutes per day. 
  • Respond Asynchronously: If you see an alert or non-compliance that warrants follow-up, send a message to the client that they'll receive similar to a text. Save your phone calls for the cases that really warrant follow-up.

 

What comprises a patient plan?

This is a very important question! As we've established, we want our patients to self-manage their care so that we can manage by exception, and that in order to do so, we need compliance to be simple and to have gentle reminders.

The next question is what should be in their plan. Let's start with the kinds of things that you may wish to include in a care plan:

  • Activities: What do you need the patient to do? Take meds? Do exercises? Remember to focus on a few critical things. Where possible (for example with exercises) provide a video to remind them how to do it.
  • Measurements: Depending on the patient's condition, you will need to ask different things. Yes or no questions are great, like "Did you take your medications?" Answering on a scale is effective, but make sure that they know which end of the scale is good and which is bad. For example, "What is your pain level on a scale of 1 to 5, where 5 is the worst?" Of course, vital signs tell us important information, but in order to scale your remote care, you want to assume that most of your patients have only a mobile phone (iPhone or Android). Congestive Heart Failure (CHF), has been studied extensively, and while  telehealth with a Bluetooth scale and blood pressure cuff has been proven to be effective, it is also expensive. An alternative to achieve relative results is to ask questions like "How is your congestion compared to your last check-in?" with answer choices "better," "about the same," and "worse." 
  • Reminders: A best practice is to give your patient a chance to adhere to their care plan on their own but to have a gentle reminder if they don't. Also, you don't want to remind them about each item, instead you only want to remind them to check in.
  • Assessments: Our industry has developed numerous Patient-Reported Outcome Measures (PROMs), and asking the multiple choice questions is pretty easy via telehealth. The key as shared numerous times, is to make compliance achievable. So if you can use a PHQ-2 instead of a PHQ-9, you should. For important measures that are infrequent and can avoid a physical visit, put them in the plan and set up an alert if they aren't answered.
Note that setting up care plans is considered "practice of medicine" and thus all care plans must be approved by clinical staff. As a convenience, your telehealth software vendor may provide "out-of-the-box" care plans based on evidence-based clinical pathways, but the care plans that you assign to patients are the responsibility of licensed clinicians.

Collecting Vital Signs and other Measures

A comprehensive telehealth solution needs to be able to collect vital signs and other measures. There are multiple ways to do this, including the following:

  • Connected Devices: There are a multitude of devices including scales, blood pressure cuffs, pulse oximeters, Fitbit-like devices and more that can connect to your telehealth system with no wires needed. 
  • Disconnected devices: Another approach is to have disconnected devices and to ask the patients to enter their readings.
  • Smartphone only: The final approach is to forego devices and to fall back on asking questions that indicate the same things that you get from vital signs, such as asking if the patient feels feverish?

There are many factors to help determine which approach to use. Read more below in the section titled Telehealth with Large Populations.

 

Communicating with Patients

Perhaps the first thing we think of with telehealth is the ability to have a video-chat (like Facetime) with a patients. This is a critical element of telehealth. A few key features that you want to look for are 1) the ability to document the date and times of your video chats, and 2) the ability to annotate the key takeaways for your session.

Secure Video Chat

Equally important are the ability to have voice conversations and to be able to chat securely. A great thing about chat is that it is asynchronous - you can send messages to patients at any time and they can get back to you at their convenience.

 

 

Telehealth with Large Populations

The Triple Aim of Healthcare (from the Institute for Healthcare Improvement) inspires us to deliver the best experience of care, at the lowest cost, to the maximum population. Population health is the hardest to achieve, but telehealth can help get us there.

The key to serving the maximum population is to deliver remote care that matches but doesn't exceed the patient's need. Think of the care level in tiers like a pyramid. Starting at the bottom of the pyramid, here are the layers:

  • Text or Automated Calls: Sending texts or using automated calls is a very affordable way to reach out to a large population and costs less than 50 cents per outreach.
  • Self-directed care plans: Putting a patient onto a self-directed plan requires that they download an app and get instruction on how to use it. Note the the app itself should be simple and self-explanatory. It is important to remember in clinical instruction that informing the patient about the benefits of their plan and the importance of complying improves outcomes.
  • Telehealth "sessions:" The majority of the growth in telehealth visits during the COVID-19 quarantine have been phone calls. This is for good reason. Everyone has a phone and can answer it. To have a video chat requires more coordination and prep for the patient, but still it's affordable.
  • Connected Devices: Telehealth with connected devices is warranted for some patients and conditions but it comes with multiple costs (some obvious and some less obvious). First there are the costs of the devices themselves and the connectivity, but there are also  hidden costs.  These  are referred to as "last mile problems." Connected devices are generally Bluetooth enabled and connected to a phone or tablet which connects securely to your telehealth system. Provisioning, tracking and supporting these devices is tricky and costly. One best practice is to use "device kits" that are pre-connected.

 

 

Authoritative Telehealth Sites

Some Authoritative Telehealth sites are as follows:

  • American Telehealth Association
  • mHEALTH Intelligence
  • Home Healthcare News

Remote Care / Telehealth Assistance

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