presentation 223 rebecca brittain als tele health_ a patient centered approach to care
DESCRIPTION
The ALS Association 2014 Clinical Conference Phoenix, AZTRANSCRIPT
ALS Tele-healthA Patient Centered Approach to Care
Rebecca Brittain, RNNeuroscience InstituteUF Health Jacksonville
Objective Discuss the process of developing an alternative
model for current best practice care of ALS patients that maintains patient and team member satisfaction in the ability to provide adequate examination data
Discuss the training required and the implementation of the new process
Discuss the project roll-out, changes needed after first few patient encounters, and work-flow of the Nurse Clinical Coordinator involved in the project
ALS Tele-health• The Bitner-Plante ALS Clinic
Initiative is funded by The ALS Association Florida Chapter and The State of Florida Department of Health
• Project was budgeted for equipment purchase, hire and to train a Nurse and provide reimbursement for clinical work
• Project for year one was developed into IRB approved research
Tele-health• Tele-health and tele-medicine are defined as
patient encounters using either real-time, two-way video conferencing or store and forward of video information
• Platform must be secure - encrypted - for HIPAA compliance. Skype and Face Time are not complaint platforms.
• A “Patient Presenter” is normally used during encounter
Project Objective
• Project must maintain Provider and Patient satisfaction at a level equal to that achieved at the ALS clinic
• Offer clinic opportunities to patients who are unable to attend a clinic
• Expand the clinic access to patients who do not have a clinic located in their immediate area
Project RequirementsEquipment used must be “off-the-shelf”
Equipment must be fully HIPAA compliant, meet compliance approval, and have built-in safety measures
Equipment and process must be able to be used by one person at the patients home
PlanDevelop procedure to deliver the clinic
experience to ALS patients who have difficulity or the inablity to attend a clinic
Encounter must be comparable to live clinic encounter - all disciplines must be able to have examination data collected in order to contribute to the plan of care
Patient/Physician interaction must be comparable to in-person encounter
Finding the “Right” Nurse
Nurses are identified as uniquely qualified in working/performing examinations/assessments commonly used by other health professionals
Intensive Care Nurses have specialized assessment skills
Nurses with experience in the care of ALS patients are few
Finding a nurse who would be willing to take control of this new project
TimeThe clinic encounter requires patients to remain in an
examination room, and each provider rotates thru during the encounter
The team meets to formulate a plan of care for the patient
The plan of care is then presented to the patient by Clinic Coordinator
Clinic experience will usually require the patient to remain in exam room for 2 to 4 hours. Also consider travel time
Assessment ToolsEach discipline was required to either identify
standardized (and when possible validated) examinations or develop one
Equipment necessary to complete the examination was identified and ordered
Notebook of each tool and any additional questions prepared for use during patient encounters
Assessment Tools
Assessment Tools
Assessment Tools
Plan for AssessmentsEach assessment must be performed and recorded
by the Nurse
Problem - Assessments may require the Nurse to come between camera and patient, thereby blocking view
Solution - record from at least 2 different locations, using two or more cameras, based on patient environment/home
Place both videos into side by side or picture in picture format for team review
Video - IssuesVideo Cameras store data on either internal
devices - hard drives - or removable devices - disc or memory cards
Cameras are easily stolen or lost
Data can be recovered from hard drives, disc or memory cards with free, readily available software even after being deleted
Video - SolutioniPad Mini tablets used to record examinations
Require password to open, able to track/locate lost devices, able to remotely erase flash memory
Camera is HD quality. Storage size 32GB -large enough to turn on and record for several hours
Light weight, easy to use, easy to transfer data
My “Co-Worker”
Voice RecordingAs ALS progresses, speech becomes more
difficult as does breathing
Voice pick-up by iPad was good for normal voice volume, but environmental noise or patient condition caused issues
Solution- Blue tooth wireless microphone, recording directly into video
Video ReviewData from tablets transferred to apple
desktop
iMovies used to edit and format
Each specialty assessment partitioned into separate video
Videos loaded onto hospital server for review by team member and notes forwarded to lead physician
ResearchFew articles are available looking at patient
satisfaction using tele-health
None address a hybrid version - store and forward combined with live two-way video
Developed short surveys for completion by patient and provider after each encounter
Project Goals
IRB approval for pilot study
Look at patient and provider satisfaction with process
Study the feasibility of the process
Eligibility ProcessA confirmed diagnosis of ALS by Dr. Pulley
Patient must have attended at least one appointment at the UF Health ALS Clinic
Signed consent and a completed survey of their satisfaction on an office visit
Live in the State of Florida
Encounters2 visits by the Nurse to the patient’s home
equal one encounter
First visit is recording of each team members assessment
Recording is of entire visits non-stop, with editing completed after visit.
Second visit is teleconference with patient/physician
Team DutiesTo meet the goal for turn-around
Team members had 72 hours to review recordings and develop their portion of care plan
Plan was then forwarded to Nurse and Physician
Second visit scheduled within 7 bussiness days of the first visit to meet Physician/Patient needs
Technical Issues
Training
Recording size, transfer rates, storage
Team Member access to files
Wifi Connections
Patient Survey
Patient survey
Provider Survey
ResultsOverall patient satisfaction with telemedicine
was universally high with all survey questions receiving strongly agree or agree
Regular clinic visits more often received responses of neutral, disagree, and strongly disagree in reference to convenience compared to telemedicine
Provider satisfaction was more variable but all providers were able to develop a plan of care for ALS patients using this method
ConclusionsStore and forward method of telemedicine is feasible
as an innovative care model for ALS patientsAllows access to multidisciplinary care for patients with
mobility and other clinic access issuesVery high patient satisfaction and acceptable provider
satisfaction, particularly with the ability to formulate a plan of care for the patient
It is possible to use commercially available hardware and software for such a project
There is a significant learning curve for all involved in the start-up of such projects
Future PlansIdentification of weaknesses in the process
Continued operation of project and development of more in-depth study areas
Identify areas of needed improvement
Determine new ways to continue funding for the project
ALS WALK 2014
Questions???
References
NINDS Common Data Elements (2013). Amyotrophic Lateral Sclerosis. Neurology 76 (March 1, 2011) (Suppl 4), A48-49. Retrieved from http://www.commondataelements.ninds.nih.gov/ALS.aspx#tab=Data_Standards
Nestle Nutrition Institute (2013). Mini Nutritional Assessment. Retrieved fromhttp://www.mna-elderly.com