July 2020

Vol. 47   No. 7

 Cover Story



Providers Plug In: Telehealth Catches Onhttps://www.providermagazine.com/Issues/2020/July/Pages/Providers-Plug-In-Telehealth-Catches-On.aspxProviders Plug In: Telehealth Catches On<p>Prior to COVID-19, long term and post-acute care providers interviewed for this article were at different stages of adopting telehealth technology—while some had only discussed the possibility, others had selected a vendor partner and were close to implementing strategies. All credit the federal government’s relaxing of telehealth regulatory restrictions via pandemic-related <a href="/Issues/2020/July/Pages/Telehealth-Waivers-Impact-Assisted-Living,-Skilled-Nursing.aspx" target="_blank" title="Telehealth Waivers Impact Assisted Living, Skilled Nursing">waivers</a> as the catalyst to act now on telehealth versus down the road. </p><h2>Putting A Plan Into Action</h2><p>The staff at Burgess Square Healthcare and Rehab Centre, which provides post-acute nursing and rehabilitation care services in Westmont, Ill., was in the process of implementing new telehealth technology when the COVID pandemic forced the center to go into lockdown.<br></p><p>Located just outside of Chicago, one of the largest COVID hotspots in the country, staff acted quickly to set up a separate COVID unit, and most of the residents there have recovered. Today, the center is taking new admissions and has <a href="/Issues/2020/July/Pages/Technology-grows-amid-pandemic.aspx" target="_blank" title="Technology grows amid pandemic">implemented a software platform</a> to keep residents, staff, and physicians connected.<br></p><p><img src="/Issues/2020/July/PublishingImages/KristinThrun.jpg" alt="Kristin Thrun" class="ms-rtePosition-1" style="margin:5px;" />“We had done the setup and had purchased the supplies, and we were starting to do the training with our managers, and then COVID hit,” says Kristin Thrun, Burgess administrator. “At that point we basically accelerated the implementation and made it available.”<br></p><p>Investments were made not only into the software but into iPads and Bluetooth-enabled devices such as stethoscopes. iPads are used to conduct telehealth visits, and Bluetooth devices are used to record information during patient assessments and integrate that information on the software platform. <br></p><p>“We did buy dedicated equipment for the isolation unit so that was easy to rectify,” says Thrun.</p><h2>Challenges Make an Appearance</h2><p>Challenges arose. Physicians reported that it was difficult to hear patients and vice versa, and the role of a dedicated nurse to conduct telehealth visits became even more important. <br></p><p>“The physicians do rely on the staff in the facility to do the assessment,” says Thrun. “So, it really has to be a nurse who is with a patient because they will ask them to give a report on how their lungs sound, for example, or ask them to check for edema.” <br></p><p>Once Burgess’ physicians and specialist partners were set up and got the hang of it, things got easier, but it’s still a learning experience, says Thrun. In the future, she’d like to get equipment that has better audio capabilities, she says.<br></p><p>While the time is not right to make more investments, Thrun and her staff are dealing with their audio issues as best they can. This often means a nurse is repeating information, which extends the session. On average, visits take about 30 minutes per patient.<br></p><p>The visits have become a fundamental part of operations, says Thrun. Being in an urban location, doctors would often visit patients at the center, but the COVID pandemic changed that, and now the center averages 30 telehealth visits per week. <br></p><p>Another challenge has been figuring out the billing and at least recovering some of the costs associated with the telehealth program, says Thrun. <br></p><p>“When we first started this, we were not able as a facility to recoup any of our costs even though we dedicated a lot of resources to it,” she says. “Now with the waivers that the government put in place for telehealth, we can bill an origination fee under Part B even if they are a Medicare A stay.” </p><h2>Jumping Right In</h2><p>How telehealth services were regulated by the Centers for Medicare & Medicaid Services put the brakes on telehealth adoption for American Medical Facilities Management (AMFM), a provider operating 18 skilled nursing and rehabilitation centers in West Virginia. But that all changed. Vickie Powell, an AMFM nurse practitioner who oversees other nurse practitioners in the facilities, has been coordinating telehealth implementation since March. <br>“We have 18 centers, and each one of them now has telehealth capabilities, with seven centers using it routinely,” says Powell. “We’ve had over a thousand calls since the middle of March.”<br></p><p><img src="/Issues/2020/July/PublishingImages/VickiePowell.jpg" alt="Vickie Powell" class="ms-rtePosition-1" style="margin:5px;" />Prior to COVID, Powell and her staff explored telehealth options but couldn’t figure out how it would work at AMFM’s centers based on the regulations of the time. Once regulations relaxed, Powell and her staff jumped in, a move they are happy they made. <br></p><p>“We have a lot of partners that would not only come into our facility, but they would go back and forth to the hospital, and we realized this may be a source of transmission,” says Powell. To implement online visits instead, Powell and company invested in iPads for the nursing staff. Noting that audiovisual quality of a patient’s health information could make or break a telehealth visit, they also invested in a digital stethoscope for each building. Bluetooth wireless technology helps exchange data between the stethoscope and the iPad. Powell led education for staff on using the new technology, including how-to guides.“We can do auscultation of lung sounds, heart sounds, abdominal sounds, etc.,” says Powell. “And that has been very helpful for us to have a full assessment going on.”<br></p><p>In a facility, a nurse would carry an iPad and the digital stethoscope to the meeting with the patient and proceed to dial into the online conference room via Zoom or FaceTime. The provider outside the facility would participate via iPad and converse with the patient with added ability to hear the input from the stethoscope.<br></p><p>Powell says staff are able to auscultate patients’ lungs, determine their status, and keep them in house while treating them.<br></p><p>“One of our doctors was telling me he was able to pick up that a patient had a heart arrhythmia,” says Powell. “He was able to treat it successfully in-house and not have to send the patient to the hospital where he would be exposed to not only COVID-19 but all other infections out there.”</p><h2>Features Matter</h2><p>Picking up on a patient’s changed or new symptoms sooner rather than later has helped tremendously, says Powell. <br></p><p>“We have avoided unnecessary hospital readmissions and have kept transmission of the COVID virus down,” she says. “We were able to treat patients sooner rather than later, and the other aspect of this is not only for our attending physicians using this technology to make their regular rounds and see patients who are acute, but specialists as well.”<br></p><p>Orthopedic specialists, cardiologists, pulmonologists, and others have made follow-up visit calls with patients. “We’ve been able to avoid the hardship of transporting these frail patients to the hospital,” says Powell.<br></p><p>Follow-up visit capability also attracted Burgess staff to the new technology platform. Specifically, it was the emphasis on its development of customer service modules and extensions into the community, says Thrun.<br></p><p>“We have a program here with nurse practitioners; they typically track the patients who go back home with follow-up visits. This is especially for helping high-risk residents who are at risk for readmission to keep them safe at home and give them access to the care they need. Our technology partner is working toward doing telehealth at home, so that was another factor that we really liked about them.”<br></p><p>One of the other benefits of the new software is that it integrates with Burgess’ electronic medical record platform, PointClickCare. “We like the fact that our physicians can use it,” says Thrun. “We have a lot of doctors who take their own calls, so they can use it even at night if they want to.”</p><h2>On the Same Page</h2><p>Getting physicians and other partners to speak together on a new technology platform was one of the benefits that appealed to Coleen Kohaut, an independent owner of three facilities—The Villa Rehab Center, a skilled nursing facility, The Holiday House, a residential care community, and Franklin County Rehab Center, a skilled nursing facility, all located in St. Albans City, Vt. Kohaut is also administrator at Franklin. <br></p><p>“If we are dealing with someone who is sick, we can get an infectious disease provider and a vascular provider on the same call together, along with my clinicians and clinical team and our therapy team,” says Kohaut. <br></p><p>“This opens things up for a more comprehensive clinical evaluation, with the providers working together on a more cohesive plan.”<br></p><p>Kohaut recalls a patient on a short-term rehab wing who entered the facility with a vascular podiatry wound. “We were able to connect with the specialist on the call and had a very good result,” she says. “The plan of treatment has really been effective, and that patient has gone home and is doing very well.”</p><h2>How it Works</h2><p>Kohaut says her facilities have had their mobile X-ray company on a call with an orthopedic surgeon, the facility’s attending physician, and the entire clinical team so they can all have a conversation about a patient. <br></p><p><img src="/Issues/2020/July/PublishingImages/ColeenCondonKohaut.jpg" alt="Coleen Kohaut" class="ms-rtePosition-1" style="margin:5px;" />“It’s been great,” says Kohaut. “It’s obviously very efficient time-frame wise, and I think we have better communication with everyone talking together and on the same page. It’s so much better than having to transport someone who is somewhat fragile and having them be in a vehicle for over an hour.” <br></p><p>Kohaut purchased iPads and an account with Zoom, a cloud platform for video and audio conferencing, collaboration, chat, and webinars across mobile devices, desktops, and phones. Partners of Kohaut’s centers also have Zoom accounts, allowing them to coordinate meetings, calls, and information via Zoom’s shared screen feature.<br></p><p>When it comes to risks, Kohaut said that security was on top of her mind. But after some research, she discovered that Zoom provides a standard security technology for establishing an encrypted link between a server and a client, also known as a Secure Sockets Layer. <br></p><p>While Kohaut’s centers have stable coverage from internet providers, she points out that Vermont still has areas that are in need of stronger internet coverage, especially in rural areas. </p><h2>The Assisted Living Story</h2><p>While Kohaut has implemented telehealth technology at The Holiday House and is seeing good outcomes, running a residential care home during the COVID-19 pandemic is financially no easy task, she says. She points out that a very large share of her budget has been spent on personal protective equipment.<br></p><p>“Both of my skilled nursing facilities have been a part of the CARES Act and [Department of Health and Human Services] funding, but unfortunately the federal money at this point has not assisted my residential care home,” she says. <br></p><p>The Holiday House accepts Medicaid patients and is licensed as an enhanced residential care provider and participates in the Medicaid waiver program, so the impact has been fairly negative financially, says Kohaut. <br>All three of Kohaut’s centers were approved for the Paycheck Protection Program, a loan of the Small Business Administration designed to help small businesses keep their workforce employed during the COVID-19 crisis, and this has helped, she says.<br></p><p>The state of Vermont has also helped with a Medicaid retainer fund, and the Holiday House has been receiving small payments, but challenges still remain. “Like a lot of the industry, we have not been taking admissions, so we have seen a drop in census,” says Kohaut. “We have really seen a decrease of our occupancy at both the SNFs and the residential care home.” <br></p><p>“It would certainly be wonderful if there was some relief for residential care and assisted living federally,” she says. “I know the states are trying to do what they can.” </p><h2>Lessons Learned </h2><p>Thrun says that overall, implementing new technology was a user-friendly process, thanks to the ease of the technology and the partnership with the vendor. Also, the investment in equipment was reasonable. “You don’t have to spend a fortune on things like special equipment,” she says. “You can do it cost-effectively if you need to do so. I think that’s a real benefit for facilities that may not have a lot of resources.”<br></p><p>However, she says, be prepared to invest dedicated staff. “You have to have one nurse educator to do telehealth visits, otherwise you will run into problems and get backed up,” says Thrun. “It’s just like if you go visit your doctor and have to wait 15 minutes. It can be time consuming, and your staff can get frustrated.” <br></p><p>A floor nurse could conduct the visit if it is about a quick change in condition, says Thrun. But if it is a planned visit, it’s best to have a dedicated nurse. <br></p><p>Powell stresses that telehealth is not about taking away face-to-face visits, which are important, but telehealth technology is still a valuable tool. <br></p><p>“We can pull it out when we have situations such as this,” she says. “It may be we have a flu epidemic going on, or maybe we have an immunocompromised patient and this works better for them than a face-to-face visit.”<br></p><p>When implementing telehealth technology, Powell encourages providers to consider all that nurses are dealing with during COVID-19, and that staff trying something new will take some time. However, the investment is worth it, she says.<br></p><p>“I would say be open to it,” says Powell. “I think it’s not going to go away when COVID goes down, it’s here to stay and will grow as a valuable tool.” <br></p>Prior to COVID-19, long term and post-acute care were at different stages of adopting telehealth technology—while some had only discussed the possibility, others had selected a vendor partner and were close to implementing strategies.2020-07-01T04:00:00Z<img alt="" src="/Issues/2020/July/PublishingImages/0720_CS.jpg?RenditionID=22" style="BORDER:0px solid;" />COVID-19;Health Information Technology