McKnight, S. (October 2012). Telehealth: Applications for Complex Care. Online Journal of Nursing Informatics (OJNI), 16 (3), Available at http://ojni.org/issues/?p=2034
Providing affordable accessible health care for individuals with complex health issues living in remote areas is a prominent healthcare problem of our time. Telehealth holds great promise in providing accessible quality healthcare in the home setting. There exists a need for telehealth applications to be expanded to focus on the complex care needs of the population of patients with chronic medical/mental-health conditions residing in remote areas that require frequent healthcare access. Expanded informatics applications for complex home nursing care are presented along with the development process of a telehealth care plan focused on resolving complex care issues addressing the care needs of patients with chronic illness.
This article presents expanded informatics applications for complex home-based nursing care and the development of a telehealth care plan focused on resolving care issues of medically complex individuals with existing mental-health diagnoses. One of the great challenges in health care today is providing affordable, accessible, high quality healthcare in the home to individuals with complex, dual diagnoses of medical illness and co-existing mental-health conditions (Chanussot-Deprez, C., & Contreras-Ruiz, 2008). Telehealth is one of the largest areas of growth in home-based healthcare for reaching remote populations. Telehealth applications for complex medical conditions, such as diabetes requiring blood glucose monitoring, and co-existing mental health conditions such as depression or bipolar disorder, have yet to be fully explored and developed. Expanding telehealth to encompass applications for complex medical/mental-health care in the home is essential to meet this vital healthcare need for patients living in remote areas and requiring frequent in home monitoring (Artinian, 2007).
Telehealth nursing is the utilization of telecommunications and information technology for providing nursing services to deliver healthcare over distances, including to remote areas. Telehealth nursing is also referred to as telenursing, which is a part of telehealth care. Telehealth is a broader definition of telemedicine. Telemedicine is the use of medical information electronically exchanged to improve health status. Telehealth encompasses remote healthcare that does not always involve clinical services. Telehealth and telemedicine terms are many times used interchangeably. Telehealth and telemedicine both encompass videoconferencing, electronic transmission of still images, and remote transmission of vital signs and other patient data. Unlike telemedicine (which has a narrow focuses on the curative aspect) telehealth encompasses preventative, promotive, caring and curative aspects involving both clinical and non-clinical services for holistic application (American Telemedicine Association, 2012).
Skyrocketing transportation costs are financially devastating those seeking healthcare. Telehealth for home care can be an affordable alternative to meet the healthcare needs of vulnerable populations with complex care needs requiring frequent healthcare services (Huang, Hung, Chiou, Liu & Liou, 2011). Patients with complex medical/mental-health problems who reside in geographically remote regions experience unique healthcare delivery challenges, including (a) poor or absent transportation access, (b) poverty or diminished financial public assistance, and (c) limited or non-existent access to healthcare professionals or community based healthcare facilities (Chan, & Hart, Goodman, 2006; Luptak, 2010). The recent economic downturn, which resulted in unemployment, poverty, and diminished finances available for transportation to medical facilities for healthcare, has greatly impacted the chronically ill with limited incomes. Poverty is a substantial barrier to patients in remote areas as the cost of travel can far exceed limited incomes. Telehealth nursing can diminish the impact of inadequate healthcare access in vulnerable populations by providing quality accessible healthcare in the home (Johnson, & Weatherton, 2010).
Telehealth nursing is one of the best options to provide versatile, inexpensive access to lifesaving healthcare and preventative care to distant, rural areas. Telehealth nursing’s utilization in rural home-based patient care can become a vital part of today’s healthcare to improve patient outcomes (Liu, 2011). Effective assessment of medically complex patients with mental-health conditions can now be conducted in the home setting, using advanced information technology, Internet access, and a home computer (Romero, Sanchez, Garcia, Cortina, Vera, & Garrido, 2010; Godleski, Cervone, Vogel, & Rooney, 2012; Hailey, Roine, & Ohinmaa, 2008).
The process of developing a focused telehealth nursing program for complex patient care needs begins with an in-depth assessment of the patient and identification of healthcare needs for the home environment (Schopi & Flytkjaer, 2011). The second step is to define primary care issues found in the home setting (Kang et al 2010). The third step is to create and implement a telehealth care plan to guide home care, with nursing care interventions and time frames for home care follow up.
Step one of this process begins with physical assessment, not only of medical/mental illnesses but also of treatment options for each condition. Along with physical assessment, a medical history is obtained. Mental-health conditions present are also noted as well as acuity of symptoms. Treatment interventions and monitoring necessary are considered for incorporation into the telehealth care plan.
Step two of developing a telehealth nursing plan is to identify and match primary care medical/mental healthcare needs to resources available in the home. Primary care needs of data collection, monitoring with transmission of data, and webcam video conferencing are enabled by Internet access. Resources in the home are identified such as phone lines for Internet access or wi fi access and electricity. Telehealth remote monitoring devices are set up and enabled by the telehealth nurse during an initial in-home visit. A patient’s physical ability to utilize the equipment and educational needs are assessed. Patient and family education on use of the equipment is initiated with users completing a return demonstration (Field, & Grisgsby, 2002). Laptops with webcams are common in most homes, but demonstration of proficient use of the equipment is encouraged.
Step three is developing the telehealth care plan for complex care issues, based on healthcare goals. First, data from the in-depth patient assessment, medical history, mental-health assessment, medications, physical capabilities, medical/mental health diagnoses, and identified physical/medical, and mental-health care needs are utilized to create the care issues parameter of the telehealth complex-care plan (see Appendix). Evidence based practice interventions are used to guide follow up care. Time frames for care activities are established, based on patient acuity and best practices for optimal recovery outcomes (Kang et al, 2010).
A hypothetical but typical complex scenario for development of a telehealth care plan is provided below. Table 3 illustrates a completed telehealth care plan for the hypothetical patient with complex medical/mental-health care issues. This telehealth complex-care plan addresses each care issue with a follow up plan, rationale, and expected outcomes, demonstrating the advantages and versatility of telehealth options for home care to improve the health of vulnerable populations.
The medically complex, dual diagnosis patient in this hypothetical case study is a 55 year old male with a history of myocardial infarction (MI) in 2001. Patient has a prior closed head injury with resultant brain injury from a motor vehicle accident (MVA) in 1997. Patient is alert and oriented, and has hyperlipidemia, gastrointestinal reflux disease (GERD), hypertension, and diabetes. Patient also has a lifetime psychiatric history of bipolar disorder and is currently stabilized on psychotropic medications. Patient has a history of skin cancer with removal of 12 epithethial cancerous lesions in the past. Patient is being discharged to home after removal of a large squamous cell carcinoma from his forehead with skin grafts to site and resultant wound care. Patient is a recent widower who lives alone in a rural area and is no longer able to drive. The patient is on a large number of medications listed in Table 1 to treat existing complex medical/mental-health conditions. Patient states “I don’t want to go to any nursing home. All I need is just some help, and I can stay at home”.
Table 1. Complex-Care Case Study Patient Home Medications
Patient has been an inpatient at the hospital for three days, primarily due to concerns about discharge care issues. The patient is alert and has refused placement to a nursing home. The hospital staff was finally able to reach a family member who will assist the patient with telehealth monitoring and care at home. Due to these conditions, patient has been referred to a program in telehealth and telemental-health nursing to provide care in the home.
Care issues for this patient include multiple areas of care and monitoring. Medical management and follow up for diabetes, skin cancer, hypertension, closed head injury, MI, hyperlipidemia, and GERD must be maintained. Wound care education and wound monitoring for healing must be implemented and electronically monitored (Chanussot-Deprez & Contreras-Ruiz, 2008). Diabetic education on diet, exercise, skin care, and blood glucose monitoring must be implemented (Kang et al 2010). The electronic information received on blood glucose and pulse oximetry must be electronically transmitted to the telehealth nurse and monitored. Education also must be implemented on self administered measurement of vital signs and daily weight recording and electronic monitoring (Kang et al, 2010). Education on medical conditions, medications, and medication compliance also is needed. Patient is receiving cogentin to treat extrapyramidal symptoms from prescribed psychotropic medication and must be monitored for further adverse reactions. In addition, home psychiatric monitoring is necessary due to psychiatric diagnosis, and follow up by a psychiatrist must be implemented for these existing mental-health issues. A summary of the complex medical/mental-health conditions is listed in Table 2.
Table 2. Complex-Care Case Study Medical/Mental Health Issues
The first informatics application in the home care of this medically complex patient is installation of a laptop computer with an interactive webcam for video teleconferencing. The patient is informatics literate and able to utilize both a laptop and webcam with ease. The webcam will facilitate video face-to-face conferences with the patient’s telehealth nurse, primary-care physician, and psychiatrist (International Council of Nurses, 2009; Smith-Stoner, 2011). Webcam conferencing will be implemented by the telehealth nurse for two-way simultaneous viewing during all medical and mental-health education and also to observe patient for return demonstrations of skills. The telehealth nurse will utilize the webcam to observe the forehead skin graft site for healing and compliance with prescribed skin care. The webcam also is used by the telehealth nurse to observe patient for signs and symptoms of medical complications such as shortness of breath or chest pain (University of Minnesota, 2009). The telehealth nurse will utilize the webcam to visually monitor for side effects of medications such as tardive dyskinesia, akathisia, dystonias or vomiting. Webcam teleconferencing can be instrumented at any time by the patient to request a discussion on any medical concern.
Another informatics application is electronic transfer of data obtained from the patient. Electronic data such as vital signs, weights, blood-glucose checks and pulse oximetry can be obtained, either manually or from a home-based physiologic monitoring systems, and electronically transferred to the telehealth center for evaluation (Luptak et al, 2010). Physiologic monitoring equipment in patient homes can be sent electronically via satellite link, phone lines, or Internet to a central repository for storage and evaluation (Versweyveld, 2009). Centralized transfer of electronic data is implemented during face-to-face actual home visits by the telehealth nurse and has informatics applications. Informatics provides telephone-based Internet access in even the remotest area of the region, allowing a telehealth nurse on a home visit to upload all documentation of the day’s visit to the agency’s telehealth center. Various ways to transmit data by “store and forward” devices that acquire and store clinical information to be retrieved at another site allows a telehealth nurse to download patient data from the host computer during the night for review the next day (Kang et al, 2010).
Utilization of telehealth technology can achieve improved patient health outcomes. Studies of telehealth care have shown improved clinical outcomes such as decreased recovery times and diminished repeat hospitalizations (United States Department of Veterans Affairs (USDVA), 2009; Chanussot-Deprez & Contreras-Ruis, 2008). Improved access to medical care via telehealth technology also allows healthcare teams to anticipate and prevent avoidable medical complications and provide earlier access to treatment (Brooks et al, 2012).
Patient safety is improved by utilization of telehealth technology. Safety is improved due to continuous monitoring devices transmitting real-time data to the telehealth center and availability of the telehealth nurse to provide in home consultation and referral. Studies indicate patients with telehealth care are noted to have a 25% reduction in the number of inpatient hospital days and a 19% reduction in the rate of hospitalizations (USDVA, 2009).
Table 3: Telehealth Complex-Care Plan
The application of telehealth into mainstream nursing care is one of the most efficient and effective methods of improving healthcare delivery to remote areas in today’s healthcare environment. Telehealth methods of electronic monitoring and education via webcam have potential for future utilization to improve health care quality and patient outcomes. With utilization of electronic technology into the healthcare environment, more frequent monitoring and education is implemented, preventing and reducing patient complications. In addition, with telehealth nursing, one nurse is able to effectively monitor larger numbers of patients, resulting in fewer nursing staff being required for care. In this time of a nursing shortage, this can be a great advantage. Healthcare facilities also benefit by being able to maximize their healthcare dollars by reducing healthcare costs through more frequent patient monitoring and efficient utilization of staff (Verhoeven, Tanja-Dijkstra, Nijland, Eysenbach & Gemert-Pijnen, 2010).
Physicians and nurse practitioners, as well as rural, older-adult patients, will greatly benefit from utilization of telehealth technology for complex patient care needs. Home telehealth is truly the future of healthcare. Implementation of telehealth technology is essential to improve care and provide accessible, quality, patient centered care. Research is needed into advanced application techniques of telehealth into the home setting for all types of complex patient care needs. Telehealth is versatile and can provide optimal recovery outcomes, improving the lives of vulnerable populations and promoting health, wellness, and recovery from devastating illness.
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Dr. Sylvia McKnight is a career mental health educator serving for over 23 years in nursing practice. As a scholar Dr. McKnight completed a DNP at the University of Alabama Tuscaloosa, holds a Master’s degree in Nursing ,and a Bachelor’s degree in Anthropology/Psychology from the University of South Alabama in Mobile. Dr. McKnight earned an Associate degree in nursing from Bishop State College in Mobile Alabama. The clinical experience of Dr. McKnight has included psychiatric consultation/liaison nursing, and as an educator in inpatient adult, geriatric, child and adolescent behavioral health facilities. Presently Dr. Sylvia McKnight is a professional mental health nursing instructor training the next generation of healthcare professionals in holistic nursing care.