While both Prineville and Madras demographics reflect similar percentages of patients aged 60-69, Redmond's data reflects the highest percentage in the 50-59 age range.  

All three site demographics reflect the ethnic diversity of the patients support by each clinic.  Notably the Non-Hispanic/White population is the majority in all three; however, Madras' patient population is largely Spanish speaking in nature.

The Prineville clinic sits in Crook county, population as of 2013 is 20,815. The town of Prineville has a population of 9,223.  

The Madras clinic sits in Jefferson County, population as of 2013 is 21,145.  The town of Madras has a population of 6,363.

The Redmond clinic sits in Deschutes county, population as of 2013 is 165,954.  The city of Redmond has a population of 27,427.

 

 

 

More NRTRC Annual Conference Notes

In addition to the presentation by our team going extremely well, there were many attendees discussing what role telehealth can and does play in behavioral health. It was encouraging to realize how long the concept of telehealth has been in practice and to see how its grown as technological advances have grown to support it. There are some thoughts on how this might implemented into our current program; early stages as of yet, but certainly something to look into.

 

FUTURE GROWTH

We continue to investigate partnering with the larger care organizations in our area to see where this program might fit to support their patients. Identifying the population and how to tap into is remains a high priority. The idea behind it always being continuity of care, patient engagement and supporting patients in a way that will encourage their engagement.

Observations

What are the staffing needs for a program like this? Based on best practices to date, this largely depends upon the number of patients brought onto the program at one time. The ideal manageable number for our locations and patient population 1 RN for every 75-100 patients. Ideally during the first year of implementation there should be at least one fulltime employee dedicated to the program then once it is in place 1 RN with 1 Per Diem Nurse seems to be sufficient.

Surveys Results: Prior to Implementation and One Year Later

Based on results of the survey given to staff prior to training and launch of the program, the majority of respondents viewed the project positively. Once training was accomplished, there was an 8.5% increase in the overall excitement of site personnel with a correlating decrease in responses that leaned toward a "wait and see attitude".

Prior to training and launch of program there was a wide range of concerns; however, the majority dealt with how the program would affect each individual's job responsibilities, the technological support for the remoteness of patients and patient compliance. During the past year these areas have become more clearly defined. Most notably the technology used at first wasn't sufficient to ensure continuous monitoring. This area is one of the most critical and will vary greatly depending on population specific demographics; cell tower vs land line vs VOIP. Understanding patient and site technology capabilities prio to launch could ensure a smoother implementation.

Additional comments provided during the survey addressed the tech issues with suggestions including options that would allow patients to view results and offer healthcare support literature which might encourgage patients to better engage in their care.

Efficiency issues were also mentioned such as ensuring there is a streamlined interface between the Healthcare Records Management System (Epic) and the software used by RNs to input program information (Ideal Life). This would decrease the burden of recordkeeping placed on personnel.

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. 

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.

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.

We'll Go the Extra Mile!

Our super staff goes to great lengths to get equipment to our patients. Here, MosaicMedical Care Assistant Maureen is delivering remote monitoring equipment on a typical Oregon winter's day.

The Central Oregon Telehealth Project is a partnership between MosaicMedical in Central Oregon and the Roanoke-Chowan Community Health Center in North Carolina. Our patient-centered care team understands that even a nationwide connection needs people willing to go the extra mile!

Everybody's Getting into the Act!

We usually expect our patients to be human. It's the nature of the care we provide.

But as humans often find out, their cats have minds of their own and have certain expectations of us.

Here's a look at one of our participants' feline friend suggesting that it's time to weigh in and check in!

Good work, Athena!

"How am I doing?"

Stay with us to find out more about the Central Oregon Telehealth Network.