Telehealth for Wound Management in Long-term Care
Telehealth refers to the contact between a patient and a healthcare provider through electronic communications (ie, use of audio, video, and other telecommunications) to administer healthcare services at distant sites.
This broad definition includes several means of transmission, including telephone and fax, interactive video, store-and-forward technology, electronic patient records, and emails. Nurses began to formally use the telephone to interact with patients as early as the 1970s.1 Telehealth can be used to provide a number of services such as patient care and staff and patient education. While much attention has been paid to the technology itself, evaluation of the efficiency and effectiveness of telehealth applications has been limited.
Telehealth applications have the potential to improve access to healthcare and reduce costs.1 The former has been consistently demonstrated in telehealth studies; however, few cost studies regarding nursing application of telehealth have been published. Most studies are cost minimization analyses, which compare the cost of at least two alternative interventions assumed to be equally effective — for example, the costs of an interactive video consultation compared to traditional face-to-face consultation.2
Telehealth systems vary greatly. The number and size of these projects is growing throughout the country but total integration of telehealth into the healthcare system is not without obstacles, including inconsistent reimbursement policies.3 The Balanced Budget Act of 1997 authorized partial Medicare (the federal health insurance for senior citizens) reimbursement for telehealth services. However, Medicare required the referring physician and the consulting physician to share teleconsultant fees, which was thought to be too restrictive.3 The Benefits Improvement and Protection Act of 2000 expanded the payment for telehealth services, eliminating the provider fee-sharing requirement and broadening telemedicine services, including payment for nurse practitioners at distant and originator sites.3
Unlike Medicare (which is nationally run and managed), most state Medicaid programs provide reimbursement for healthcare-related costs. A number of states collaborated with their individual state Medicaid programs to develop telehealth reimbursement policies in anticipation of transportation savings from telehealth. Currently, 27 state Medicaid programs offer at least some reimbursement for telehealth services.3
Private insurers tend to follow Medicare’s lead. Improved Medicare reimbursement is anticipated to pave the way for broader private payor reimbursement. Five states have enacted laws requiring reimbursement for services via telehealth if the same service is reimbursed in a clinic or office setting.3
Telehealth provides a viable alternative to “seeing” patients with chronic wounds in the long-term care setting because it can transfer audio and visual patient information from remote locations to health professionals with specialized wound knowledge and skill. In the case of chronic wound consultations, nurse experts can provide diagnostic and evaluative support to nurses caring for patients with chronic wounds in long-term care settings. In addition to improving chronic wound outcomes of individual patients, these consultations also provide an opportunity to enhance the wound care skills and knowledge of the remotely located nurse.
Chronic wounds are a common problem in elderly patients and they require frequent, regular monitoring to maximize wound healing. According to the Guideline for Prevention and Management of Pressure Ulcers,4 seniors are at high risk for skin breakdown. Once they develop a wound, healing is complicated by many comorbid conditions such as diabetes and cardiovascular disease. Many older adults with chronic wounds reside in nursing homes where access to healthcare professionals with wound assessment and management expertise is lacking. The use of a telehealth system provides these patients more expedient evaluation and assessment by clinicians with specialized wound care training. Clinic appointments and transportation do not need to be coordinated and the costs traditionally associated with treating the wounds of frail elderly patients (outpatient clinic visits and transportation expenses) are avoidable with the provision of telehealth visits.
According to Aoki,5 112 articles evaluating telemedicine were published from 1966 to 2000. Two types of evaluations were conducted — clinical and non-clinical. Most clinical evaluations included patient satisfaction (26) and diagnostic accuracy (49). Clinical effectiveness (3) and cost-effectiveness (9) are important parameters but they received little attention.
The literature contains examples of home care agencies using digital photos to assess wounds and prescribe treatments.6,7 However, digital photograph technology does not replicate the in-person view of the wound where positioning and lighting can be changed to enhance the image.
Johnson-Mekota et al8 conducted a pilot study of 11 patients in a long-term care facility to compare provider and patient satisfaction with wound consultations done in person to those completed via interactive video technology. Of the 11 patients, six were “very satisfied” with the telehealth visit and five were “very satisfied” with the on-site consult. The referring associate nurses (n = 7) reported that they were “very satisfied” with the telehealth consult.
Gardner et al9 examined the accuracy of chronic wound assessment that used an interactive video communications system. They compared the nurse expert’s in-person wound assessments with those completed from taped telehealth sessions. Agreement on the absence or presence of eight of nine wound characteristics exceeded 75%, suggesting that telehealth does not alter wound assessment data essential to guiding treatment decisions.
Few studies have evaluated the costs of nursing and use of telehealth technologies. Specht, Wakefield, and Flanagan2 documented the costs of using telemedicine in a chronic wound clinic for 15 patient visits. Circuit charges, equipment depreciation and maintenance, line charges, and personnel time were included in the cost of the clinic visit, along with consultant travel time, transporting the long-term care patients to the acute care setting for the clinic appointment, and average time patients were gone from the facility. In this study, the average cost of a telehealth chronic wound consultation was $136.16. Travel time for the consultant at a cost of $36.66 per consultation and transporting the patient from the long-term care facility to the acute care facility at an average cost of $191.28 were avoided. Additionally, patients spent 20 minutes in the telehealth consultation compared to the average 8.5 hours spent for transportation to and from the acute care facility and actual clinic waiting and appointment time. The cost of a traditional face-to-face consultation was $246.28 compared to $136.16 for a telehealth chronic wound care consultation, a cost savings of $110.12.
Location, equipment, and staff. The telehealth encounters in this study occurred between a patient in the company of a geriatric nurse practitioner in an exam room in the healthcare clinic of the long-term care facility and a wound care clinician at the University of Virginia (UVA). The encounters were facilitated by UVA’s telemedicine department via a broadband wireless connection. Equipment requirements for the facility included the videoconferencing device (PolycomEX@ cost $5,000), TV monitor (cost $500), and a patient camera (cost $350). Initially, technicians from the telemedicine department set up the equipment and operated the camera at the clinic. Ultimately, the geriatric nurse practitioner was trained to do the same and independently set up and filmed with minimal assistance from a facility staff member.
Sample. Study participants were selected from the population of residents with one or more chronic wounds in a long-term care community. Patients with wounds were referred by staff members and the geriatric nurse practitioner. Patients were eligible if they had a chronic wound regardless of its etiology. The geriatric nurse practitioner met with the resident and/or family members to describe the project and obtain informed, written consent. For cognitively impaired individuals, consent was obtained from the legal guardian.
Procedure. The patient was brought to the telehealth consultation room monthly for assessment by the offsite wound nurse practitioner who used the interactive video mode. The wound nurse practitioner asked the geriatric nurse practitioner a series of basic wound assessment questions. A treatment plan was developed based on the visual examination of the wound and responses to the wound assessment questions. The wound nurse practitioner also dictated a report that was transmitted to the long-term care facility. Wound assessment information, including a digital photograph, was recorded for each wound at each telehealth visit. Depending on the wound, a monthly telehealth follow-up visit was scheduled.
Nine patients were seen during the period of 1 year for a total of 21 visits (see Table 1). Transportation cost savings averaged $650 per visit for a total of $13,650 for the 21 visits. Each telehealth visit lasted approximately 30 minutes. Because patients were allowed to stay at their facility rather than be transported to and from the wound clinic, time and related costs were reduced by approximately 3 hours for each clinic visit.
The four men and five women were ages 73 to 94 years (mean 82). The most common type of wound was a heel pressure ulcer (four wounds). Seven patients had one wound and two patients had multiple wounds. Patients averaged two telehealth encounters with a range of one to six visits. The wounds of all nine patients healed.
Despite the limitations of the study, which include a small sample size and the fact that the study involves only one institution, this pilot project demonstrated how telehealth technology can be applied to the wound care arena. Using telehealth, long-term care-based nurses can access nursing expertise to improve patient care. Under the guidance of the consultant wound nurse practitioner, the geriatric nurse practitioner operated the patient-site camera and performed wound assessments and gained valuable experience and expertise in wound assessments skills and the use of the telehealth equipment. Using live, interactive videoconferencing has several advantages over previously described still, digital imaging: it allows for visualization of the wound from a variety of angles and positions with immediate feedback from the wound nurse practitioner and affords patients and their family members the opportunity to actively participate in the telehealth encounter.
A number of barriers to using telehealth technology exist. The facility must have the infrastructure to initiate a successful telehealth program. This includes funding the equipment and telecommunication service, which can be costly at the outset and may require maintenance and upgrading. Another barrier is related to space. Ideally, a dedicated location for encounters that is private, has accessible to hook-up with the telecommunication network, and is spacious enough to accommodate equipment and a stretcher must be available. Adequate staffing for a telehealth project also may be an issue; at least one staff member should be trained to set up and operate the equipment. Plus, the facility’s administration must commit support and time to the project.
Increasingly, these barriers are being overcome. As communication capabilities evolve, the cost of equipment and teleconnection continues to decline. The portability of the equipment used at the facility allows for multiple facility use; thus, expenses can be shared. Medicaid and Medicare reimbursement is evolving and expanding, further offsetting staffing and equipment costs. A creative approach to space availability at the facility may increase its feasibility — for example, a corner of a recreation area may be transformed to a telehealth consultation area with the addition of screens and a table.
Successful communication during the encounter was of primary concern and necessitated recognizing and accommodating patients’ cognitive, hearing, and visual deficits. Adapting communication style often is challenging in face-to-face encounters; it was even more of an issue for the offsite practitioner who needed to convey her professionalism, compassion, and caring from a distance. Addressing the resident and family members directly and involving them in the discussion of the plan of care promoted the personal connection with the offsite practitioner that might otherwise be lacking.
A variety of technical considerations became apparent as the project evolved. Proper lighting in the room and positioning of the resident were critical to optimizing image transmissions. The telehealth area space was small so positioning the participants to capture the best possible image, particularly with patients confined to stretchers, was challenging. Operating the camera and describing/manipulating the wound is difficult for one person; therefore, having someone hold the camera in position while the long-term care nurse practitioner manipulated the wound was ideal.
Factors beyond clinician control included weather conditions, primarily wind and snow, which can affect the ability to telecommunicate. These conditions affected the telehealth consultation at least once that year. Recognizing that technical difficulties will be encountered and having telemedicine staff readily accessible by phone to address any problems that may arise was essential to the efficiency and success of the encounters.
Mr. D is a 72-year-old man with severe dementia who lives at a long-term care facility. His previous medical history is significant for Lewy Body Dementia with Parkinsonism. On September 23, 2002, he fell and broke his hip. One week after surgical fixation of the fracture, he returned to the nursing home. His recovery was complicated by recurrent lower extremity deep vein thrombosis, keeping him wheelchair bound. Despite meticulous nursing care, he developed a right lateral heel ulcer for which he was referred to the wound clinic. The ulcer had a 3-cm soft brown eschar that was debrided on the first wound clinic visit to reveal pink healthy tissue. No clinical signs of infection were present but the quantitative culture was positive. Antibiotic ointment was ordered for the ulcer as well as an offloading orthotic to minimize pressure to the heel while sitting. Subsequently, Mr. D was followed monthly via telemedicine for 6 months until the ulcer healed. Transportation for this patient to and from the clinic had been $650, for which Mr. D was responsible. By participating in the telemedicine clinic, the patient saved $3,900. In addition, he did not have to worry about the travel time involved, which averaged 4 hours every time he traveled to and from the clinic. His wife became a staunch supporter of the program and continues to lobby for its expansion.
Telehealth technologies have the potential to enhance access to and availability of healthcare services for older patients. Until now, older adults not living near larger medical centers providing specialized care were required to travel long distances to receive needed services. Using advanced telecommunications, access, availability, and timeliness of care are improved. Telehealth also helps address concerns of gerontological nurses in long-term care facilities who are isolated from other practitioners and lack access to nurses with specialized training.
Telemedicine technology is rapidly evolving and the possibilities for telemedicine are endless. Although telehealth requires consideration of legal and ethical issues, it may soon become as common as home health visits. This pilot program is an example of a successful nurse-managed telehealth application that provides expert wound care for residents of a long-term care facility and can be replicated elsewhere.