In Part 2 of this series we look at how we can successfully integrate virtual care into Long-term Care without the removing the personal touch.
Technoline: Using technology in Longterm Care Part 2
Technoline: Using technology in Longterm Care Part 2
Since remodeling our long term care model in 2018, I constantly asked myself how we could integrate virtual care into the model that was now cloud based. The COVID pandemic certainly expedited the need to adopt a more virtual integrated model, but the goal of this post is to stipulate how we can successfully utilize platforms like ZOOM to enhance care to this vulnerable population.
The good physician treats the disease; the great physician treats the patient who has the disease. William Osler
When I did this infographic, I thought about all the communication coming into the EMR on a daily basis and how I could simplify it to make it easily adaptable to any environment. To understand the icons, I will briefly explain what each of them mean and how they could form integral part of an effective communication system within EMR.
- Phone – Phone calls are still the primary form of relaying acute problems to a physician.
- Virtual Care – This can refer to any virtual care platform that is secure and acceptable within your region or country. I have an encrypted video link through ZOOM that I am using.
- Fax – SBAR’s and Med Reviews are best dealt with using fax.
- Microblogging – We are fortunate to have access to this communication tool that works like a text message within an encrypted environment and delivers a message to the physician’s personal device.
Lets explore each of the legs of the algorithm in more detail.
In the time of COVID and probably beyond, care conferences would in my opinion be best conducted through Virtual Care. The advantages of utilizing virtual care for this specific interaction is as follows:
- Scheduled in advanced within the physician EMR and Long-Term care EMR.
- With ZOOM, their is the added benefit of sending a link invitation to the physician, the pharmacist and a family member living close-by or far. (multiple people in one conference)
- The physician has the ability to remain within his/her office and gather and relay important information from within the EMR.
- The mobility associated with ZOOM enables the physician to attend, even when stuck at the hospital.
Urgent issues are best dealt by phone and the decision can then be made by the physician to visit the patient face-to-face or conduct a virtual visit using ZOOM. I will use a recent case-study to illustrate the effectiveness of using this modality:
Ms JM is a 93-year-old mobile lady with advanced dementia and anxiety. She was given Ativan for her anxiety and fell. After the fall, she is having trouble mobilizing, in fact stopped walking and staff is worried that she might have a lot of pain.
Your receive the phone call and her BP is 130/80, PR 78, Temp 36.5, SATS 98%. You dig a little deeper and found that she is favoring her right side and points to her left hip when asked what is wrong.
In this case, the answer can only be revealed by imaging and as transferring her to hospital is within her wishes, she is transferred and the X-ray confirms a suspected pelvic ramus fracture on the left and a new T11 stable compression fracture.
She is repatriated back to her care home and the following day they have trouble waking her up and you receive another phone call. You dig a little deeper and the history is that she was given Ativan 2 hours prior and at shift change that had a hard time waking her up. You initiate a virtual visit through ZOOM, as you saw a lady this morning in the ER with suspected COVID, and you ask them about the vitals.
BP 130/80, PR 87, SATS 98%, Glucose 7.1
You ask the nurse to see her pupils and it is 4mm and reactive. She responds only to a sternal rub and seems sedated. You ask them to watch her, as it is likely due to the Ativan and you initiate a video call with her daughter, explaining your findings. You stop the Ativan and advice the facility to start simple analgesia and avoid neuro-supressive drugs and to phone you once she is awake.
2 hours later, you receive a call that she is awake and is now complaining of pain and you initiate simple analgesia with a follow-up the next day.
Routine communications pertains to SBAR’s regarding falls, minor complaints, admission summaries and things that can be dealt with on a scheduled basis. For this specific communication we elected a fax. In a facility that has access to Microblogging, this modality can also effectively be used here.
Chronic issues for example med reviews, MOST updates and PPO updates can be communicated via fax.
Care Conferences and Family Conferences
In my experience, families form the most important variant in the management of long-term care patients. Having a relationship with the family members involved in your patient’s care will streamline decisions and ultimately improve care to your patients.
With the ability to connect with family members via ZOOM, you are able to conduct a face-to-face visit with someone that might not be able to be with their loved one in the time of COVID-19 or who lives in another town or city. You can built a relationship with them as they can see you and experience your facial expressions when you discuss the care of the parent that they lost to cognitive impairment. You can do all this from your office, while you try and get through your busy day.
A lot can be said about de-prescribing in LTC, however this post is focusing on the technology aspect of caring for your patients. All pharmacies have templates for medication reviews that lapses every time a patient is admitted to acute care or 6 months after the review was completed.These are best communicated by fax.
In our setting, we decided to print these documents, fill them in and send them to :
- Our LTC practice
- By doing this, we ensure that a paper trial remains within the e-chart at all times.
- The Pharmacy
- The LTC Facility
In certain circumstances, pharmacists will phone us with urgent orders that requires clarification.
Pro-active visits are very important in LTC, as physicians can ensure that care plans are met, but also recognize new problems and manage them appropriately or communicate them with family members. In my opinion, most of these can be done via Telehealth, as it includes an interview with the LPN or RN caring for the patient to find out about stool habits, urination, behaviour changes, sleep and more.
I would recommend a face-to-face visit every 3 months to ensure that an examination is done to detect problems before the surface,
Advice regarding a patient in LTC
Simple advise or changes can simply be communicated via fax. We integrated a template for this type communication and will copy and paste it on a progress note of the specific facility.
- Disclaimer: The views expressed in this post is my own and related to my experiences within the Long-term Care.