An elderly patient develops difficulty breathing and swollen ankles. She resides in a long-term care facility and has a history of dementia. Transferring the patient to the emergency department would be difficult and often traumatic for the patient, especially with her underlying dementia. Fortunately, the facility has a telehealth cart. The nurse wheels the cart into the patient’s room and connects via Wi-Fi to a health care provider. Utilizing the cart’s built-in Bluetooth stethoscope and wound camera, the nurse can assess the patient’s lungs and share the images of the patient’s ankles with the health care provider, who is at another location.
The patient is diagnosed with congestive heart failure and appropriate medication is prescribed. The patient starts to improve quickly. An unnecessary hospital transfer is prevented and the patient is treated in the long-term care facility, a place that is familiar to the patient.
Dr. Laura Crimm, Director of Duquesne’s Family Individual across the Lifespan Nurse Practitioner program, shares that this is a common scenario in health care and has grown more so since the start of the coronavirus pandemic. Crimm believes telehealth has become a standard part of health care; nurses need to learn how to assess patients using telehealth equipment at the graduate level, as well as how to diagnose and treat patients remotely to be successful advanced practice nurses. She provides several insights and updates on the role telehealth is playing in health care and at Duquesne University.
Benefits of Telehealth
Telehealth allows patients to receive care from a provider without being in the same place, and it is transforming health care. Before advances in telehealth, a provider would take a call from a nurse at the patient’s bedside, and then would have to rely on that nurse’s assessment of the patient to diagnose and develop a treatment plan. Now with this technology, a provider can see a patient, utilize the tools available with a telehealth cart to assess the patient, and develop a definitive diagnosis and an individualized treatment plan based on the findings.
Telehealth does not always occur in a hospital or long-term care setting; the platform can be utilized from the comfort of the patient’s own home. A person with mobility issues or a non-serious medical issue, like a rash, no longer needs to travel to a doctor’s office to be treated. The patient must have access to a computer, tablet or smartphone to utilize this option for care. This platform is useful under normal circumstances, but in today’s COVID-19 environment, it is especially valuable.
Telehealth also offers potential cost-saving benefit to patients as well as the health care system as a whole. Patients can eliminate the need for childcare and lost time at work, as well as the time and expense of travel. In addition, health systems that utilize telehealth offer a set fee for the service and posts this fee on their websites. This transparency is helpful for patients who are paying out of pocket for a telehealth visit. The fees for this visit are significantly less expensive than an evaluation in the emergency department for both the patient and the health system. Emergency departments should be reserved for patients requiring a higher level of care.
Medicare Changes Improve Telehealth Access
In March 2020, Medicare created the 1135 waiver to provide expanded reimbursement for telehealth services. Prior to that, patients often chose an in-person appointment over telehealth due to reimbursement difficulties. However, with COVID-19, health systems began to seek out ways to treat as many people as possible while reducing the risk of exposure. Telehealth is particularly helpful for high-risk patients (like the elderly and immunocompromised) seeking care for non-urgent health issues.
With the introduction of the 1135 waiver, telehealth has become a safe, affordable option to expand delivery of care.
Medicare now offers older adults an annual telehealth wellness visit to perform a risk assessment. They are helping people stay up to date on their screenings while minimizing exposure risks. Additionally, telehealth is effective for mental health visits. I believe that we will continue to see this platform utilized to deliver care when appropriate. Telehealth has been an effective alternative to in-person encounters, and patients enjoy the option for their care.
How it Looks
For patients, all they need is access to a computer, tablet or smartphone. Their health care provider will send an email with instructions on how to access the session. Often, patients simply need to download an app and when the time comes, click on the “Start Visit” button.
Health care providers will typically utilize the electronic health record or patient portal system of choice for their health system. Smaller practices will utilize other secure options like Doxy.me. Regardless of what they use, it must be a secure network to protect patient information. It is very important that patients know the HIPAA form they sign to protect their rights also applies when using telehealth.
Telehealth, Here for the Long Run
COVID-19 has opened the door to telehealth, and I do not believe it is going to close. Providers have found it to be an effective way to deliver care, and patients, for the most part, like the convenience it offers. I believe that once we begin to transition back to our regular routines, the ease of seeing a provider without missing work or taking a sick day will be hard to resist. It may also help reduce health care costs and free up emergency room resources. Individuals without health insurance or a primary care provider who may choose to utilize the emergency room for non-emergency issues will have an effective, affordable alternative for their care.
Introducing Students to Telehealth
Duquesne incorporated telehealth into its undergraduate and graduate nursing curriculum long before anyone heard of COVID-19. We are very fortunate to have an innovative Dean, who purchased a telehealth cart several years ago. I am not aware of any other nursing schools in the country that have one.
We want undergraduate students to be comfortable with the cart because they will be the person at the bedside assisting with a patient assessment for a provider on the other end of the computer. For our family nurse practitioner (FNP) students, we want them to understand the format and to have hands-on experience with the cart’s different tools. Our cart includes a Bluetooth stethoscope to assess heart and lungs sounds, an otoscope to examine ears, a wound camera, a scanner and even a 12-lead ECG.
As part of our FNP on-campus residency experience, we utilize standardized patients (SP) to provide our students with an episodic telehealth visit. The SP is in our School of Nursing Learning and Simulation Center, while our students are in a classroom in the building. The SP utilizes a tablet while our students use a classroom computer that projects onto a screen at the front of the classroom. Students must use their observation skills to determine a definitive diagnosis, a treatment plan, and follow-up care if needed. Later in the semester, I hold a live, virtual class where, as a group, we work through several cases in the long-term care setting, utilizing the School of Nursing’s telehealth cart.
Since COVID-19, certifying and credentialing bodies for nurse practitioner programs now permit FNP students to use the telehealth platform to earn limited clinical hours. Many of our FNP students have utilized this option.
At the graduate level, the FNP program utilizes the telehealth cart, but I see how this could also benefit students in our new adult-gerontology acute care and psychiatric-mental health nurse practitioner programs.
Back to the Basics
Nurses use their observation skills every day. That does not go away when they become an advanced practice nurse. I really stress this with my students. Because when you conduct a telehealth session, you may only have a tablet. You cannot place a stethoscope on the patient. You must be observant: Are they in any respiratory distress? What does the color look like? Are they able to communicate with you? Do they look uncomfortable? All of these things together, along with taking a very thorough history, is vital to making an appropriate patient diagnosis.
The same challenges encountered in an in-person setting can occur with telehealth. A patient must be honest about their history. Creating symptoms in order to get an antibiotic is not helpful, and in fact, can be harmful with the current issues of antibiotic resistance. In addition, you must have a patient that is able to provide an accurate history. If your patient has a mental impairment, such as dementia, they may not be able to provide an accurate history. It is imperative in these situations that a caregiver is available for an effective telehealth visit.
Elderly patients not comfortable with technology also pose a challenge. In fact, some may be completely averse to using a computer, tablet or smartphone and refuse telehealth altogether. Therefore, the simpler that we can make it for a patient to utilize telehealth, the better.