“Treating in Place” in Skilled Nursing and Assisted Living Facilities: How Telemedicine Can Help

March 1, 2018

The basic idea behind treating in place means minimizing care transfers between settings. In order to treat in place, everybody within a healthcare landscape needs to understand what level of care a medical situation actually requires. Just like primary care physicians who are using patient education to reduce emergency room overuse, SNF and AL staff and administrators have a strong ability to improve the health system. In the process, they can also improve their partnerships with hospitals, the care of their patients and residents, and their staff members’ comfort in handling potentially urgent medical situations.

Transfers of care are always imperfect. Like a game of telephone, transfers produce lost knowledge, meaning repeating diagnostic lab work, tests, or imaging. Transfers of care in elderly patients have been proven to increase risks of delirium, complications and discomfort, while adding stress to caregivers.

Elderly patients and those with dementia and Alzheimer’s are disproportionately impacted when transfers of care occur. Changing their environments makes them more agitated, effects nutritional intake, and increases sundowning. Hospitals are not often as equipped as SNFs or ALs at managing these behavior changes. In addition to risking delirium, statistically, 30-day hospital readmission for dementia patients markedly increases morbidity and development of secondary complications. The same is true of post-surgical patients, who are already often confused by changes in care setting and getting used to rehabilitating their bodies.

Transfers of care are also extremely stressful for caregivers, who face trying to comprehend the changing medical care of their loved ones while losing time from their other responsibilities, worrying, and sharing the patients’ struggles with unfamiliar staff and environments.

Transfers of care not only effect patients and residents, but revenue for skilled and assisted living communities. In the SNF setting, a facility will lose financial reimbursement or be penalized while the patient is in the hospital. In the AL setting, there is a loss in service revenue that would typically be delivered to a resident on a daily basis.

In order to treat in place and achieve all of the benefits that involves, it’s important to understand where the breakdowns in care occur.

In our experience, even facilities with round the clock, telephone coverage do not always trust those on-call providers to get back to them as soon as possible when they call with a medical need. When providers do get back to staff, they may be more comfortable sending the patient to the Emergency Room than attempting to treat them over the phone, without additional diagnostic abilities.

Unfortunately all of this also means that if a situation looks like it could potentially be urgent, everyone is more likely to immediately transfer care to an acute facility, than take a wait and see approach. This makes sense; they don’t want to make decisions without being able to perform a medical evaluation, and potentially miss an urgent acute complication.

ALs and SNFs should therefore focus on increasing their capacity to do several things:

1. Determine whether a medical situation in their facility is urgent, and who is best suited to treat it

2. Increase the comfort of patients and families by avoiding transfers as much as possible and ensuring a warm hand-off occurs when transfer is absolutely necessary

3. Evaluate how to ensure staff always have the right medical experts available, 24 hours a day, 7 days a week, without resorting to an ambulance and an Emergency Department provider

Dedicated telemedicine hospitalists are acute care experts, available when in-house providers are not present. Through technology, they work directly with the SNF or AL staff members who know, and can evaluate acute changes in patients and residents. Telemedicine providers respond in minutes, at bedside, for any patient or resident requiring medical attention. Through telemedicine carts and two-way HD video, they can help guide your staff through an exam. Telemedicine physicians can order any tests your facility has the capability to perform.

Basic telemedicine devices are equipped with a 12 lead EKG, a virtual stethoscope, high definition camera, and other diagnostic tools to perform an evaluation. They are also able to access and document in your electronic medical record. Thorough evaluations allow telemedicine physicians to treat in place while keeping patients and residents in their familiar environment without the stress of unnecessary and costly emergency room visits.

All of this means better care with a peace of mind for patients, residents, family members, and staff. It also means our elderly population can receive faster medical care, for lower cost, with fewer transfers. Building relationships with telemedicine hospitalists just makes sense.

About the author—Dr. Waseem Ghannam, MBA, MHSA, is CEO and co-founder  of TeleHealth Solution, which is focused on lowering return to hospital in elderly patients nationwide. He obtained his Medical Degree from St. Matthew’s University and completed his residency at Cabarrus Family Medicine in Concord, NC. During his medical training, Dr. Ghannam also completed an MBA and a master’s in Health Services Administration from St. Joseph’s College.

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