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Service Delivery Innovation Profile

Telemedicine Consultations With Emergency Department Physicians Reduce Unnecessary Transfers of Nursing Home Residents in Rural Areas


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Snapshot

Summary

Georgia Health Sciences University and the Georgia Partnership for Telehealth operate a telemedicine program in collaboration with 10 skilled nursing homes in five rural communities, with the goal of preventing unnecessary transfers of residents to the emergency department. When a resident becomes ill, a nurse brings him/her to a room equipped with a telemedicine unit and calls the Medical College of Georgia Health Medical Center for a consultation with an emergency department physician. The physician evaluates the individual's condition, determines any necessary treatment, and decides if the individual needs to be seen at a hospital. Early results suggest the program has meaningfully reduced the need for emergency department transports.

Evidence Rating (What is this?)

Suggestive: The evidence consists of a review of 20 telemedicine consults that took place in the first year after program implementation, with a focus on whether the patient required transport to the ED.
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Developing Organizations

Georgia Health Sciences University; Georgia Partnership for Telehealth
Augusta, GAend do

Date First Implemented

2010
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Patient Population

Vulnerable Populations > Frail elderly; Rural populationsend pp

Problem Addressed

Many nursing home residents who become ill are transported to the emergency department (ED) even though they do not require emergency care. These unnecessary visits come at great cost to the health care system and often cause high levels of stress for the patient.
  • Many unnecessary transports: Most on-call nursing home physicians advise staff to send any resident with a possible emergency to the ED. As a result, approximately 40 percent of nursing home residents who develop symptoms that represent a possible medical emergency (e.g., fever or significant changes in heart rate or oxygen saturation levels) are transported to an ED even though emergency care is not required.1
  • Leading to high expenditures and patient stress: On average, the typical ED visit, including round trip ambulance service, costs $2,500. In addition, nursing home residents sent to the ED often wait alone for many hours before being seen and then again after treatment for transportation back to the home. This experience generally creates significant stress for elderly individuals, particularly those with cognitive impairment.1

What They Did

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Description of the Innovative Activity

Georgia Health Sciences University and the Georgia Partnership for Telehealth operate a telemedicine program in collaboration with 10 skilled nursing homes in five rural communities, with the goal of preventing unnecessary transfers of residents to the ED. When a resident becomes ill, a nurse brings him/her to a room equipped with a telemedicine unit and calls for a consultation. The ED physician evaluates the individual's condition, determines any necessary treatment, and decides if the individual needs to be seen at a hospital. Key program elements include the following:
  • Obtaining patient consent: As part of the admissions process, residents or their medical proxy give consent for nursing home staff to use the telemedicine equipment to obtain a consult.
  • Determining the need for consultation: Whenever a resident exhibits symptoms that suggest the potential for a medical emergency, nursing home staff, in cooperation with the on-call physician, determine the need for a telemedicine consultation. If a consult is deemed necessary, a staff nurse brings the resident to a dedicated room that has a telemedicine transmitting unit comprised of a personal computer, camera, peripheral equipment (see below), and a dial-in network through a T1 line.
  • Contacting the ED: The nurse calls or sends a fax to the hospital call center, which then contacts the ED. Sending a fax allows nurses to provide patient identification information they would otherwise give by phone.
  • Conducting the consultation: With assistance from the nurse, the physician conducts the examination, using the peripheral equipment to look into the patient's ears, listen to the chest, and look at the skin with a magnifying lens. The physician also can ask the resident or nurse questions during the examination using video capabilities on mobile devices. Based on the findings, the ED physician will prescribe any necessary treatment and decide if a trip to the ED is warranted.

Context of the Innovation

The Medical College of Georgia Health Medical Center serves as the medical training arm of the Georgia Health Sciences University Medical College of Georgia. Its ED is staffed 24 hours a day, 7 days a week by the emergency medicine faculty, all of whom are board certified or residency trained in emergency medicine, and by emergency medicine residents. In the past year, the ED cared for more than 76,000 patients. The impetus for this program came from Bruce Janiak, MD, an emergency physician and professor at the school of medicine with 30 years of experience in the field of telemedicine. Based on his experience, Dr. Janiak felt that telemedicine provided a significant opportunity to reduce unnecessary transfers of nursing home residents to the ED. To test the concept, in 2009, he joined with representatives of The Georgia Partnership for Telehealth, Inc., a nonprofit focused on increasing access to health care through the innovative use of technology, and Ethica Health & Retirement Communities, a corporation serving 5,000 patients/residents throughout Georgia. Through a previous State grant, the Georgia Partnership for Telehealth had already installed telemedicine equipment in five Ethica skilled nursing facilities in rural communities. To implement the program, the Partnership installed equipment in five additional facilities.

Did It Work?

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Results

Early results suggest the program has meaningfully reduced the need for ED transports. During the first year of operation, 20 telemedicine consults took place. In 10 instances, the ED physician concluded that the patient did not need to come to the ED. Prior to implementation of this program, all 20 patients likely would have been transported to the ED.

Evidence Rating (What is this?)

Suggestive: The evidence consists of a review of 20 telemedicine consults that took place in the first year after program implementation, with a focus on whether the patient required transport to the ED.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Obtaining stakeholder support: Dr. Janiak met with representatives of the telemedicine partnership and nursing home company to explain the potential cost savings and reductions in patient stress that could result from the program. He also met with all ED physicians at the Georgia Health Medical Center to ensure that he had their support as well.
  • Establishing central credentialing: To provide consultations, all participating ED physicians had to be designated as nursing home staff. Fulfilling this requirement in Georgia required submission of forms to the state’s Central Credentialing Program.
  • Developing protocol for consultations: Dr. Janiak met with all ED staff to develop and discuss the protocol for performing telemedicine consultations. As a result of this process, they decided to have nursing home staff call the communications center at the Medical College of Georgia Health Center, which would then contact the ED physician on duty.
  • Visiting each nursing home: Dr. Janiak met with the nursing director and nursing home managers to explain the program and its benefits.
  • Training nursing home staff: In most instances, the charge nurse at the facility took initial and ongoing responsibility for teaching staff how to use the telemedicine equipment. The ED medical director also makes himself available to provide instruction during inservice sessions for new employees.

Resources Used and Skills Needed

  • Staffing: The program generally requires no new staff, as existing staff within the nursing home and ED integrate the program into their everyday job responsibilities. Dr. Janiak spent some time upfront developing the program and continues to promote it.
  • Costs: Each telemedicine unit costs $20,000. (The participating nursing homes did not pay for this equipment; see Funding Sources section for more details.) Each nursing home pays approximately $400 per month for the T1 line. Capital costs are now less than $1000 per facility (updated October 2013).
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Funding Sources

Centers for Medicare and Medicaid Services
Third-party payers generally provide reimbursement for the telemedicine consultations. The Partnership for Telehealth paid for the 10 telemedicine units with funds from the state.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Review insurance billing policies: States may have different rules regarding reimbursement for telemedicine consultations. Therefore, would-be adopters should review state regulations that might affect billing.
  • Identify ED and nursing home champions: Champions can help to win the support of key stakeholders, including ED physicians and nursing home physicians and staff. To that end, identify potential champions in each setting and explain the benefits of the program for their respective organizations.
  • Provide staff incentives: Nursing home management should provide incentives for nurses to learn about and use telemedicine consultations. Incentives could include paying for continuing medical education and providing employee recognition awards.

Sustaining This Innovation

  • Affordable, accessible equipment: The personal computer that is part of the current telemedicine unit does not have video capabilities, thus the use of the camera and need for a separate room for consultations. However, with advances in computer technology, physicians are finding they can perform consultations using portable computers that have video capabilities, which are less expensive than the telemedicine units currently in use.
  • Document outcomes: As previously mentioned, unnecessary transports to EDs are stressful to elderly patients and very costly. Therefore, program implementers can document program outcomes by comparing equipment and usage costs and the cost of transport for patients who do not require hospitalization to the savings realized when patients are not sent to the ED.
  • Maintain relations with nursing home leaders: Would-be adopters should maintain regular communications by phone and in person with nursing home leaders. Dr. Janiak hosts telemedicine conference calls with participating nursing homes every other month to discuss the program, including any barriers to obtaining telemedicine consults.
  • Educate and train nursing home staff: To maximize program benefits, nursing home physicians and nurses must be periodically reminded about when and how to obtain an ED consult.

More Information

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Contact the Innovator

Bruce Janiak, MD, FACEP, FAAP
Professor of Emergency Medicine
Georgia Health Sciences University
1120 15th Street
Augusta, GA 30912
Phone: (706) 721-7144
E-mail: bjaniak@georgiahealth.edu

Innovator Disclosures

Dr. Janiak has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

An article about the telemedicine program is available at: http://smhs.gwu.edu/urgentmatters/news
/innovations-using-telemedicine-link-nursing-homes-emergency-department.

Footnotes

1 Janiak B. Innovations: using telemedicine to link nursing homes to the emergency department. Urgent Matters E-Newsletter. 2010 Jul/Aug;7(4). Available at: http://smhs.gwu.edu/urgentmatters/news
/innovations-using-telemedicine-link-nursing-homes-emergency-department.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 28, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 03, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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