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.

Patient Referral

During a recent installation, a patient inquired as to whether their spouse could use the blood pressure cuff newly installed in their home to monitor his own blood pressure.

Although the answer was no, this is one example of a positive referral being made by a program participant due to their own involvement with and enthusiasm regarding the possibilities of remote monitoring.  It has not yet been determined whether this patient's spouse will be recommended for the program by their PCP, but this demonstrates the value that some patients place on being able to monitor their health independently.

Transmission Difficulties

The new equipment that has replaced older PODs has been a step forward in remote patient monitoring in the region.  However, equipment challenges persist.  The most recent encounter involved an installation in a home with a roof made of metal.  It seemed that the metal roofing of the home, which extended into the eaves, caused difficulties with the PODs ability to relay a signal.  Some patience combined with patient flexibility aided in testing the POD in different locations around the home, resulting, eventually, in a successful transmission.  This issue could be potentially troublesome due to the unanticipated amount of extra time that the installation took.       

Patient Investment in Remote Monitoring

Despite a consolidated team-wide effort, maintaining patient buy-in throughout their planned course of involvement in the program continues to be of concern. 

To ensure that patients are well informed regarding the benefits and potential challenges of daily monitoring from home, primary care providers explain the process to patients in office, when the initial recommendation is made.  During installation, the RNCC and Team Care Assistant follow-up on this information, targeting other potential challenges that may arise during the home visit, and repeating the reasons for referral. 

Although there has been much success in the program thus far, patients occasionally agree to participate in the program only to request equipment removal in a short amount of time – as little as two days, in some cases.  There are a few possible explanations that we have seen thus far.  Patients may simply agree to participate when it is recommended by their PCP in the office, viewing their PCP as an authority to whom they should comply, but re-thinking it when the reality of the program sets in.  Even with authentic buy-in initially, the demand of maintaining a consistent schedule and taking readings when necessary could pose too troublesome of a challenge.  Patients also may not be emotionally prepared to see their own readings each day, triggering anxiety and feelings of hopelessness when faced by the experience of daily weight or blood sugar checks, for example. 

Each case presents a different outcome, sometimes resulting in the early removal of a specific instrument or all equipment from the patient’s home, and other times with the patient retaining the equipment but refraining from using it regularly.  In the latter circumstance, keeping the instrument nearby may be a practical solution.  In the case that a PCP may unexpectedly require a specific reading, a simple phone call may be made to request that the patient comply at that time, even though readings are not taken daily.  Such a compromise may be a logical way for the program to continue to assist in the monitoring of patients who are not fully invested.