Pros and Cons of Kits

Sending equipment kits home with patients versus completing individual in-home installments has proven to be a successful and effective model.  Since switching to kit installations, the COTN team is able to utilize their time more efficiently.  This method ensures that in the future, as enrollment rises, they will be able to accommodate larger numbers of patients, keeping up on readings and ensuring adequate communication with patients and providers.

The only drawback to this strategy thus far is a decrease in the level of personal connection between the COTN team and the patients whose health they monitor.  Meeting the patients in their home environment provided an opportunity for the team to get to know the patients better and learn more about their lifestyle.  Though still more efficient, it is now sometimes necessary to spend a little more time examining patient charts, or speaking on the phone with patients in order to create a clear picture of what is happening for them health-wise, the effectiveness of their medications, and what habits or activities may contribute to the state of their health.

The COTN program RNCC states that since switching to the kit method, the level of care provided to patients remains comprehensive, though the level of personal connection is not the same.

Patient Enrollment at Mosaic Redmond

Since the rollout to the Redmond clinic in late August, 2014, a total of thirteen patients have been enrolled.  In order to promote Telehealth and encourage provider buy-in, the COTN team followed up the rollout meeting by with welcome and thank you letters.  In the future, all rollouts will be followed up in this manner in order to create camaraderie between the COTN team and program, and all providers within the network.

Form Translation

Although progress has been made regarding the translation of written materials into Spanish, challenges persist.

The onsite translator at Mosaic Medical has created Spanish versions of the Inventory and Consent and Welcome letters.  However, the survey that measures the effects of the program on patient self-management ability, the PAM Scores questionnaire, was created by Insignia, and worded in such a way as to produce specific desired information.  Mosaic’s translator is unable to translate the questionnaire, as a direct interpretation would not yield the same meaning.  This form is available in Spanish by Insignia, but has not yet been made available to COTN.

Equipment Retrieval Challenge

With enrollment numbers on the rise, it is increasingly important that Telehealth equipment be returned promptly when one’s participation in the program ends.  Although patients are given explicit instructions to do so, the equipment is not always returned.

In an attempt to encourage timely return of the equipment, the COTN coordinators at the Prineville Clinic are keeping a list of patients with items checked out.  There are notes in two areas of these patients’ charts in EPIC, viewable by the front and back office staff at the clinics.  Reminder notes are also attached to upcoming appointment notices.  The COTN staff has also sent out letters and made regular phone calls to patients, requesting them to return the equipment.

COTN’s RNCC has recently created a new letter, which will inform the patients of the cost of the equipment, which they will be responsible for if it is not returned.  The next step, if all of the above steps have failed, will be to send an invoice to the patients, billing them for the cost of the equipment.

PAM Scores

As per the HERSA grant which is funding the expansion of Telehealth into Central Oregon, patients are required to complete pre- and post- Patient Activation Measure scores.

One challenge with this process is that some patients are reluctant to complete the surveys.  Others fail to return their completed surveys.

A second hurdle has been sorting out how to keep track of the scores.  When COTN first launched Telehealth in Prineville in 2013, the process involved scanning the completed forms so that they were accessible electronically.  Once scanned, the forms were saved in in “other orders” – this was prior to there being a specific place in EPIC for the forms to call home.

Heading forward, the scores will be saved in the “referral” section in EPIC, and pre- and post- scores will be entered into an Excel Spreadsheet as they are collected.

COTN Highlighted in Regional Newspaper

The launch of Telehealth in Prineville and Redmond has created a buzz around Central Oregon.  On October 8th, COTN was featured in the health section of the Bend Bulletin.

The article provided an overview of the Telehealth program, including the successes of the project thus far.  Two currently enrolled Telehealth patients were interviewed, and lent their opinions regarding their participation in the program.  Andy Eck, Clinic Manager of Mosaic Medical Prineville, and Aimee Priest, Mosaic's RN Care Coordinator, were also interviewed.

The following link will direct you to the Bend Bulletin website, where the article may be read online:
http://www.bendbulletin.com/health/2465399-151/patients-learn-to-monitor-own-vital-signs?entryType=0

Balancing Equipment and Demand

In general, patients enrolled in Telehealth participate in remote patient monitoring for a standard three months.  This amount of time has been found to be effective in determining whether a patient will benefit from further monitoring.  However, not all patients show much progress in the initial three months.  After this time period has passed, it is up to the provider to extend the referral, requesting for further remote patient monitoring. Some patients participating in the Central Oregon Telehealth Network (COTN) have been enrolled for nearly a year, and depending on specific health issues and provider concerns, this may be necessary.

For patients who are not ready or willing to make lifestyle changes, continuing to monitor their health from afar may not be helpful to their care.  Due to a potential increase in demand for equipment, especially with new sites being added to the COTN, it may be necessary to distribute limited equipment to new patients who may use the feedback from their daily readings to proactively take charge of their health.

While this balance of equipment with patient demand is an issue to be aware of, it is a challenge that program administrators believe will balance itself out as they continue working with providers to ensure that patients involved in remote monitoring are benefiting from the program.  

Patient Interview, Sep. 10, 2014

A 69-year-old patient reports that her experience with Telehealth has been “an eye opener,” helping her to be more accountable for her own health.  The patient has been on the program for eleven months.  It is difficult for her and her spouse to get to the hospital due to the remoteness of their home and the unwieldy road leading to and from it.  The task is insurmountable during Central Oregon’s severe winter storms - twelve-foot drifts of snow have been known to isolate their home from thoroughfares for up to three months at a time.

The patient has experienced multiple health complications, and has recently undergone a successful gastric bypass.   Telehealth has helped her to feel more at ease being active following the procedure.  During hot summer months, the pulse oximeter helps her to know if she needs to wear an oxygen pack while working outdoors.  She states that she “feel[s] more secure knowing that my blood pressure is not going out of whack, if my oxygen level is good or bad.”  Further, the patient has become more prudent regarding her diet, knowing that loading up on salty foods will be reflected in her readings. 

While her experience with Telehealth has been very positive overall, she has had trouble with the equipment.  At times, she takes her blood pressure two to three times before receiving a reading.  When her pulse oximeter failed to read accurately, she was unable to receive a new one in a timely manner due to incline weather.  Despite equipment hassles, she is hopeful that she will continue to benefit from Telehealth, and is grateful for the relationships that she has cultivated via the program - “it’s good to know that I am in reach of medical care.”      

Redmond Clinic Rollout Meeting

          On August 27^th, the Prineville Clinic Manager, RN Care Coordinator, Team Care Assistant, and the Epic Site Specialist visited Mosaic Medical Redmond to introduce the Telehealth program to the clinic staff.  The team presented a general overview of Telehealth, including the benefits and potential challenges of the program, introduced the blog, went over the draft workflow, and gave a demonstration of how to use the equipment and present the kits to patients.

         In attendance were Mosaic's Redmond providers, including a nurse practitioner filling in for one absent provider, the nursing team, and medical assistants.  The providers responded with a balance of enthusiasm and uncertainty, as well as a host of questions, concerns, and suggestions. 

         One provider query was whether blood pressure values could auto populate (in EPIC) with normal limits in order to make the initial referral process quicker.  After discussing this suggestion in follow-up, the COTN team reached the consensus that auto-populated BP limits would not be appropriate for all patients.  Since each Telehealth referral is made for a specific reason, parameters vary from patient to patient.  

          Another concern raised by providers was the location of remote patient monitoring reports within EPIC.  To date, reports have been posted under the initial referral, as an ongoing referral result note.  Prior to this system, results and reports were documented as a telephone encounter under chart review, which was the request made by Redmond providers.  After switching the location of the remote patient monitoring reports for a trial period, Prineville providers preferred to access the bi-weekly reports in result notes.

          Overall, the meeting was successful, lasting for just over an hour.  Despite an initial incongruence in practitioner buy-in, three Redmond patients have thus far been referred to and enrolled in Telehealth.  These patients have successfully set up equipment in their homes using the equipment kits, and the COTN administrators are receiving regular alerts for these patients. 

New Site Troubleshooting - Telehealth Equipment Kits

            The Fall 2014 Telehealth rollout to Mosaic Medical’s Redmond Clinics brings a fresh wave of challenges, but the solutions to each issue are being executed in tandem by the team in Prineville.   

            Mosaic Prineville’s two resident Telehealth managers have been solely in charge of enrolling patients in Ideal Life, educating patients on equipment use, installing the equipment in patient homes, and monitoring and forwarding transmitted readings for all enrollees.  It is anticipated that Redmond’s rollout will add 25-50 new patients to their caseload.  With a 30 minute drive separating the clinics, plus many more miles to the rural homes of patients, it is logistically impossible that the RN Care Coordinator and Team Care Assistant could continue to provide equal and quality care to existing and new patients in both cities given the current process.  Each home installation may take up to 2 hours, leaving no one at the clinic to check on alerts for current patients and complete other obligations.  Sending one employee out for an installation could place that team member at risk of harm, and is still less efficient than possible.

            To troubleshoot this issue, Telehealth equipment kits have been created by the RNCC and TCA, containing different combinations of equipment that could be ordered by Redmond providers.  These kits streamline the process and allow the patient to take responsibility for home installation.  In the provider’s office, patients may be given a demonstration of how to use the equipment, just as had previously taken place in home.  Instructions for installation, and phone number from troubleshooting are included with the equipment to guide the patient once they arrive at home.  To date, ten Prineville patients have been sent with kits from their providers, and have experienced no difficulties in getting the equipment set up, with readings successfully transmitting back to the clinic. 

            It is anticipated that this standardized process can be duplicated at the Redmond clinics.  Once a provider makes a referral, the Medical Assistant will bring the appropriate kit to the patient.  The MA will ensure that the Remote Monitoring Consent Waiver and Release is retrieved from the kit, stamped with the patient’s Medical Record Number, filled out by the patient, and faxed to the Prineville clinic, so that the RNCC and TCA can enroll the patient in Ideal Life.  Further, this communication will enable the Prineville team to contact the patient, answering any further questions about the program, completing any troubleshooting, and provide any additional education if necessary.  One concern from the Redmond clinic was that explaining the equipment to the patient might consume an excessive amount of MA time – the clearly articulated instructions included in the kits should eliminate this issue.

           

             

Patient Interview, Aug. 26th, 2014

            A 65-year-old male was referred to Telehealth for weight and blood pressure monitoring.  The patient refused a remote weight scale, but willingly accepted a kit containing a blood pressure cuff and transmitter pod.  Since July 25^th, the patient has consistently transmitted blood pressure readings to the Mosaic Medical Prineville Clinic, performing checks up to five times per day.  He is confident that he will complete the three months of monitoring initially ordered by his provider, and looks forward to the possibility of continuing use of the Telehealth equipment past the scheduled discharge date.

            When questioned regarding his intention to remain in the program, the patient stated: “I like it because I can keep track of my blood pressure instead of having to worry about it.  I don’t have to find some place to go check it.”  The patient explained that prior to enrolling in Telehealth, he would seek out places to check his blood pressure, making extra visits to his provider, or driving to a pharmacy.  This posed an inconvenience, as he lives in a remote area.  Having just begun a new medication, he was increasingly concerned about keeping track of his blood pressure - Telehealth allows him to do so conveniently.  The patient has traveled with his equipment, independently trying different locations for transmitter placement when in a new area to ensure that the readings are sent.    

            The patient’s only concern about the program is leaving for extended hunting trips, when he will be unable to plug in the transmitter cell pod.  Such a concern may be addressed by suggesting that a patient continue to monitor their blood pressure under such circumstances, even if they are not transmitted to the clinic.  Telehealth has enabled this patient to monitor his own blood pressure regardless of his location, encouraging him to experience greater self-efficacy regarding the management of his health.

           

Consent Form Language Translation

With a relatively high population of patients in this region who are English language learners, or otherwise not fluent in English, the unavailability of translated patient consent forms could be problematic.  The first language of many patients in Central Oregon is Spanish, however, the site has not yet received consent forms in any language other than English. 

In attempt to circumvent this issue, the Mosaic Medical language specialist has translated a portion of the necessary forms, and the translated draft is currently under review by Mosaic’s document review committee.  The specialist, however, is not in a position to translate all necessary documents in their entirety for the following reasons:

·      Ethical question of placing responsibility on medical interpreters to translate legal documents, as they may not be properly trained in this language

·      Difficulty of translating a technical English document, maintaining sensitivity to reading levels and nuances of language

Thus far, only one patient has been unable to independently read and sign the consent form due to it’s being unavailable in Spanish.  In this case, a translator was unavailable to accompany the RN and TCA to the installation.  The necessitation of a translator during home installations can pose a burden for the clinic, and may slow the process of delivering remote care to patients.

Possible resolutions of the consent form translation predicament will be discussed during the next meeting of COTN and RCCHC.