THIS IS THE ‘FEATURE ARTICLE’ FOR the TELE-HOME HEALTH SECTION

From July 1997 Issue

SEVERAL B/W PHOTOS

From the Home Health Dep’t, Tele-Home Health Project, Kaiser Permanente Medical Center, Sacramento, California.
*Barbara Johnston, RN, MSN. Hospice Program and Marketing and Research Manager.
Linda Wheeler, RN, MSN. Home Health Agency and Site Manager.
Jill Deuser, RN, MBA. Senior Project Manager, Interactive Technologies Initiative.
*Correspondence to B.J. at: Hospice Administration, Kaiser Permanente Med Ctr, 2025 Morse Ave, Sacramento, CA 95825-2115

The study was supported by the Interactive Technologies Initiative, Kaiser Permanente Medical Care Program, Oakland, CA. Ann Richards, BSN, was the telehealth nurse for the project.

This is an interim report of a Kaiser Home Health Department study of the use of telemedicine technology in the home care setting. We present our study design and some early findings from the first six months of the project. Preliminary findings indicate the technology is dependable, and that average telehealth video visits are cost-effective and are about 60% shorter (18 minutes vs. 45 minutes) than on-site visits, with no decrease in patient satisfaction. The study will be completed in September of 1997.

This study was initiated in 1996 to explore the improve access to health services while maintaining quality of care, and to demonstrate the cost effectiveness of remote consultation technology in the home health setting. The study, which began in May 1996, employs a randomized design approved by the Institutional Review Board and will be completed in approximately one year.

This project was titled Tele-Home Health to acknowledge that a multidisciplinary health care team would be caring for patients in their homes through the use of a telecommunications tool. Our multi-disciplinary team would be composed mainly of nurse case managers, but would also include physical therapists, speech therapists, occupational therapists, home health aides, licensed vocational nurses and physicians.

Mandate for change

The Tele-Home Health project is occurring during a time of great change in health care. Society is mandating that health care costs be controlled while maintaining quality and access to care. The highest utilizers of home health services are the elderly—also the most rapidly growing segment of our population. Kaiser Sacramento's Home Health Department alone has seen its new referrals increase from an average of 360/month in the first quarter of 1996 to 520/month in the first quarter of 1997. We felt that remote consultation technology should be explored because it might allow us to maintain and even improve patient contact while reducing travel costs.

Over the past several years hospital days have dramatically decreased and more patients have been receiving care in the home setting. The Tele-Home Health project was a natural link between the medical center and patients' homes. Although people generally prefer to receive services in their homes, this shift away from the hospital and clinic setting may jeopardize the patient/provider relationship. Remote consultation technology, if implemented successfully, could help to bridge that gap and ensure that quality health care will not be sacrificed to cost savings.

Concept to implementation

The proposal to introduce Tele-Home Health was brought to Kaiser's Interactive Technologies Initiative (ITI) for consideration. ITI began operating in late 1995 to identify, develop and evaluate new models of health care delivery using interactive technologies. Telemedicine/Telehealth technologies are key areas of interest, and have been deployed in several projects. These utilize different equipment and network solutions depending on the medical specialty being addressed, but share the goal of improving member access and satisfaction while maintaining or improving quality of care.

The home health project was undertaken in a research setting because there was insufficient peer-reviewed literature regarding quality outcomes and cost-benefits provided by tele-home health care. There were simply not enough findings available to make a business decision in support of widespread implementation of telemedicine. With this in mind, Tele-Home Health was designed to include a rigorous evaluation methodology that would measure changes to access, service, quality of care, and cost-benefit.

Research Design

This pilot project uses a randomized design with one hundred patients in the treatment (intervention) group and one hundred in the control group. Control group patients receive their home health care in the usual manner: most visits are in-person by a visiting nurse, with some visits conducted via telephone. A telephone visit is commonly used to follow up on patients who are reporting their health status or any response to medication changes. The treatment group receives some in-person visits and some visits using a remote consultation, home-based video system. The system selected for this research study was developed by American Telecare, Inc. (Eden Prairie, MN. telecare@mn.uswest.net). It operates over ordinary telephone lines, takes very little time to install, and even frail and elderly patients find it simple to use (Fig. 1 - PHOTO). Each unit has an electronic stethoscope (American Telecare) which also operates over an ordinary phone line. Because the video and electronic stethoscope cannot operate over the same phone line, participating patients had a separate phone line installed at their home. Twenty units were deployed for this study, rotated among the 100 patients as needed.

Inclusion in the study was limited to patients with specific diagnostic and utilization criteria. Participants had to have been diagnosed with COPD (chronic obstructive pulmonary disease), cardiac disease, CVA (cerebral vascular accident), wound care, and/or anxiety. Furthermore, they needed to have two or more visits per week for some period over the course of the project.

Patients were encouraged to complete satisfaction surveys. To determine cost effectiveness, the study compares: a) cost per visit and cost per case; b) numbers of outside referrals; c) staff productivity; d) reduction in unnecessary visits to urgent care, emergency department or hospital days.

Barriers

Realizing that some of our home health staff would regard Tele-Home Health with skepticism, plans were made from the onset to educate staff and take their concerns into account. We were aware that the introduction of this new technology in the Sacramento home health department would be particularly stressful in light of Kaiser Permanente's broader organizational redesign, which is ongoing. To ease the transition, we phased in use of the home health video system rather than introducing it all at once. In Phase One all the video visits were done by a designated TeleHealth Nurse (Fig. 2 - PHOTO). In Phase Two other staff were trained to do these visits, and were expected to use the system as part of their regular patient care practice.

Initially there was significant staff resistance to using the home video system. The mjor concern was that the home video system would replace nurses, resulting in lost jobs. Also, the nursing staff felt they were being asked to accept a change that might threaten their professional relationship with patients. One strategy that helped to lower staff resistance was a communication plan that apprised people of project developments and nipped in the bud misperceptions surrounding its implementation.

Staff acceptance developed as providers saw how much their patients liked using the system. Also, providers found that telehealth allows for more flexibility in their daily schedules. For instance, if a nurse has two patients requesting a home visit from 10-11 A.M., only one can be accomodated. The home video system allows a nurse to visit a patient and within 15-20 minutes be with another. The staff has found the system easy to use, but the biggest selling point has been in seeing how reassured patients are to know that they have instant home access to their health care providers.

Tele-Home Health does not replace all in-person visits. The home video system is an additional service. Some visits require hands-on care and these continue to be done in-person. In some cases, however, patients have even asked their nurses to use the remote system instead of visiting in person because it is very convenient.

Preliminary Findings

Patient satisfaction surveys, with over a 70% survey return rate, indicate patients like using the home video system, find it simple to use, and feel it is very reassuring. Staff satisfaction using the system is also very high. Preliminary findings indicate this technology is cost effective when integrated properly in the home care setting, with savings of about 33%-50% compared to on-site visits.

Typical comments from patients include: "The system was very basic and easy to use," and "Consoling to know you had help that close and I knew if I needed help I didn't have to wait".

The current organizational pressure to increase productivity has affected the degree to which home health staff was willing to participate in Tele-Home Health. Until the value of using the technology is personal and experienced by the individual nurse, buy-in will likely be limited. Adding telehealth visits to an already hectic day and not counting telehealth into productivity will decrease staff participation. Our organization is developing guidelines for telephonic and video visits, including how to integrate these methods appropriately into a patient care plan.

The profession of nursing is for the first time being confronted with job uncertainty. Remington addressed this fear by stating that telehealth will only put nurses out of the job of driving a car to see a patient. Nurses will continue to provide patient care, but in a more efficient manner. The major goal of home health care has always been to move patients toward self care. A patient commented on their survey, "When I needed them they were there." Telehealth encourages patients to become active partners in their own health care management. We will learn during this study how to use telenursing to supplement their home care and to improve access to services.

Table 1

In-person vs. telenursing visits

References

Coeling HS, Simms LM. Facilitating innovation at the nursing unit levelthrough cultural assessment, Part 1: How to keep management ideas from falling on deaf ears. J Nurs Admin 23:46-53, 1993.

Gookin L. Effects of capitation of home health care. Geriatric Nursing 15:167-168, 1994.

Mahmud K, LeSage K. Telemedicine: a new idea for home care. Caring 14:48-50, 1995.

Remington, L. (interview) Telemedicine Today, 3:22-23, 1995.

Figure legends

Fig. 1: Home health patient and his wife talk to nurse during a telehome health visit.

Fig. 2: Home health nurse uses telehealth equipment to monitor her patient.

CALLOUT. Equipment used in this study: Personal Telemedicine Module (incl. CareTone electronic stethoscope and BP cuff), American TeleCare, Eden Prairie, MN. Price for single home unit: $3,900. 612-897-0000; www.telemed-care.com.