Implementation of Telemedicine Consultation to Assess Unplanned Transfers in Rural Long-Term Care Facilities, 2012-2015: A Pilot Study

Evolution of Telehealth Program to Meet Current Needs of Post-Acute and Long-Term Care Communities

This article describes a telehealth program initially created to reduce transfers to acute care from the nursing home and its evolution into a robust program that includes Behavioral Health, a Medical Director program, and telenursing.

Long-Term Adoption of Televisits in Nursing Homes During the COVID-19 Crisis and Following Up Into the Postpandemic Setting: Mixed Methods Study

BACKGROUND

There is growing evidence that telemedicine can improve the access to and quality of health care for nursing home residents. However, it is still unclear how to best manage and guide the implementation process to ensure long-term adoption, especially in the context of a decline in telemedicine use after the COVID-19 crisis.

OBJECTIVE

This study aims to identify and address major challenges for the implementation of televisits among residents in a nursing home, their caring nurses, and their treating general practitioners (GPs). It also evaluated the impact of televisits on the nurses' workload and their nursing practice.

METHODS

A telemedical system with integrated medical devices was introduced in 2 nursing homes and their cooperating GP offices in rural Germany. The implementation process was closely monitored from the initial decision to introduce telemedicine in November 2019 to its long-term routine use until March 2023. Regular evaluation was based on a mixed methods approach combining rigorous qualitative approaches with quantitative measurements.

RESULTS

In the first phase during the COVID-19 pandemic, both nursing homes achieved short-term adoption. In the postpandemic phase, an action-oriented approach made it possible to identify barriers and take control actions for long-term adoption. The implementation of asynchronous visits, strong leadership, and sustained training of the nurses were critical elements in achieving long-term implementation in 1 nursing home. The implementation led to enhanced clinical skills, higher professional recognition, and less psychological distress among the nursing staff. Televisits resulted in a modest increase in time demands for the nursing staff compared to organizing in-person home visits with the GPs.

CONCLUSIONS

Focusing on health care workflow and change management aspects depending on the individual setting is of utmost importance to achieve successful long-term implementation of telemedicine.

Internal Medicine Virtual Specialist Assessment Program Reduces Emergency Department Transfers from Long-Term Care

BACKGROUND

Transfers to emergency departments (EDs) from long-term care (LTC) can expose residents to care discontinuities and risks. Virtual platforms can increase the breadth of care available for residents within their facility, thus replacing transfers to EDs when safe and appropriate. The authors aimed to assess whether leveraging a virtual care platform at an LTC facility would reduce the number of transfers to EDs.

METHODS

Data on the number of transfers to EDs were collected from January 2019 to October 2021 at an LTC facility. In June 2020 the home began using a virtual care platform that allowed residents to speak with specialist physicians through video and receive management plans remotely. The authors evaluated the Internal Medicine Virtual Specialist Program (IMVSP) using a pre-post study design by comparing the number of transfers to EDs and the proportion of transfers resulting in hospital admission before and after program implementation. Unstructured phone interviews were conducted with employees at the home to understand their experiences.

RESULTS

The median number of transfers to EDs per month after program implementation showed a 13.0% reduction. The median proportion of these transfers resulting in hospital admission per month increased by 26.1%. Employees at the LTC home were satisfied with the program.

CONCLUSION

The IMVSP reduced transfers to EDs and allowed for a higher proportion of transfers that resulted in hospital admission. Early access to specialist care via virtual platforms has important implications for improving accessibility to high-quality care for LTC residents and reducing risks associated with transfers.

Telehealth technologies in care homes: a gap for dentistry?

BACKGROUND

Telehealth technologies are playing an increasing role in healthcare. This study aimed to review the literature relating to the use of telehealth technologies in care homes with a focus on teledentistry.

METHODS

Khangura et al.'s (Evidence summaries: the evolution of a rapid review approach. Syst Rev 2012;1:10) rapid review method included an electronic database search on Embase, PubMed, Web of Science and OpenGrey. Out of 1525 papers, 1108 titles and abstracts were screened, and 75 full texts assessed for eligibility. Risk of bias was assessed using the Mixed Methods Assessment Tool 2018.

RESULTS

Forty-seven papers (40 studies) from 10 countries, published 1997-2021, were included in the review, four studies related to teledentistry. Whilst some preferred in-person consultations, perceived benefits by stakeholders included reduced hospitalization rates (n = 14), cost-savings (n = 8) and high diagnostic accuracy (n = 7). Studies investigating teledentistry using intra-oral cameras reported that teleconsultations were feasible with potentially high diagnostic accuracy (n = 2), cost-savings (n = 1) and patient acceptability (n = 1).

CONCLUSION

There is limited published research on teledentistry, but wider telehealth research is applicable to teledentistry, with findings suggesting that telehealth technologies play a role in care homes consultations that are acceptable, cost-saving and with potential diagnostic accuracy. Further research is needed on the mode, utility and acceptability of teledentistry in care homes.

A randomized clinical trial of home telemonitoring in patients with advanced heart and lung diseases

BRIEF SUMMARY

The addition of home monitoring to an integrated care model in patients with advanced chronic heart/lung diseases decreases mortality, hospital and emergency admissions, improves functional status, HRQoL, and is cost-effective.

BACKGROUND

Telemonitoring is a promising implement for medicine, but its efficacy is unknown in patients with advanced heart and lung failure (AHLF).

OBJECTIVE

To determine the efficacy of a telemonitoring system added to coordinated clinical care in patients with AHLF.

DESIGN

Randomized phase 3 multicenter clinical trial with parallel groups in adult patients.

PARTICIPANTS

Five spanish centers including patients with AHLF at discharge or in out-patient clinics.

INTERVENTION

Patients were randomly assigned to receive a remote bio-parameters telemonitoring system (TELECARE) or best usual care (UCARE). TELECARE patients were provided with devices that collected symptoms and bio-parameters, and transferred them synchronously to a call-center, with a real-time health-care response.

MAIN MEASURES

Primary end point was the need of admissions/emergency room visits at 45, 90, 180 days. Secondary end points included health care requirements, mortality, functional assessment, health related quality of life (HRQoL), perceived satisfaction, and cost-efficacy.

RESULTS

510 patients were included (54.5% women, median age 76.5 years; 63.1% suffered heart failure, 13.9% lung failure, and 22.9% both conditions). Clinical and functional features were comparable in both arms. TELECARE globally needed less admissions with respect UCARE after 45 days of inclusion (35.4% vs. 46.9%, p < 0.05). This tendency was maintained in the subgroups of patients with multimorbidity (34.2% vs. 46.9%, p < 0.05), intermediate risk of mortality (36.5% vs. 51.1%, p < 0.05), and those included after hospital discharge (34.9% vs. 50.5%, p < 0.01). HRQoL significantly improved (TELECARE/UCARE EuroQol baseline of 56.2 ± 18.2/55.1 ± 19.7, p = 0.054, and 64 ± 19.9/56.3 ± 21.6; p < 0.01 at the end), and perceived satisfaction was also higher (6.77 ± 0.52 vs. 6.62 ± 0.81, p < 0.001; highest possible score = 7). A trend to mortality decrease was also observed (12.9% vs. 19.3%, p = 0.13). TELECARE was cost-efficacious (TELECARE/UCARE QALY 3.94 Euros/0.81Euros).

CONCLUSIONS

The addition of a telemonitoring system to an integrated care model in patients with AHLF decreases hospital and emergency admissions, improves functional status as well as HRQoL, and is cost-efficacious.

Wearable technology use in long-term care facilities for older adults: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to explore how wearable technology is being used to care for older adults in long-term care facilities.

INTRODUCTION

The use of digital health technologies to support care delivery in long-term care facilities for older adults has grown significantly in recent years, especially since the COVID-19 pandemic. Wearable technology refers to devices worn or attached to the body that can track a variety of health-related data, such as vital signs, falls, and sleep patterns. Despite the evidence that wearable devices are playing an increasing role in older adults' care, no review has been conducted on how wearable technology is being used in long-term care facilities.

INCLUSION CRITERIA

This review will consider studies that include people aged over 65, with any health condition or level of disability, who live in long-term care facilities. Primary and secondary studies using quantitative, qualitative, and mixed methods study designs will be included. Dissertations and policy documents will also be considered.

METHODS

Data sources will include comprehensive searches of electronic databases (MEDLINE, Embase, CINAHL, and Scopus), gray literature, and reference scanning of relevant studies. Two independent reviewers will screen titles, abstracts, and full texts of the selected studies. Data extraction will be performed using a tool developed by the researchers. Data will be mapped and analyzed. Descriptive frequencies and content analysis will be included, along with the tabulated results, which will be used to present the findings with regard to the review objectives.

REVIEW REGISTRATION

Open Science Framework https://osf.io/r9qtd.

The impact of the COVID-19 pandemic on transfers between long-term care and emergency departments across Alberta

BACKGROUND

Long-term care (LTC) was overwhelmingly impacted by COVID-19 and unnecessary transfer to emergency departments (ED) can have negative health outcomes. This study aimed to explore how the COVID-19 pandemic impacted LTC to ED transfers and hospitalizations, utilization of community paramedics and facilitated conversations between LTC and ED physicians during the first four waves of the pandemic in Alberta, Canada.

METHODS

In this retrospective population-based study, administrative databases were linked to identify episodes of care for LTC residents who resided in facilities in Alberta, Canada. This study included data from January 1, 2018 to December 31, 2021 to capture outcomes prior to the onset of the pandemic and across the first four waves. Individuals were included if they visited an emergency department, received care from a community paramedic or whose care involved a facilitated conversation between LTC and ED physicians during this time period.

RESULTS

Transfers to ED and hospitalizations from LTC have been gradually declining since 2018 with a sharp decline seen during wave 1 of the pandemic that was greatest in the lowest-priority triage classification (CTAS 5). Community paramedic visits were highest during the first two waves of the pandemic before declining in subsequent waves; facilitated calls between LTC and ED physicians increased during the waves.

CONCLUSIONS

There was a reduction in number of transfers from LTC to EDs and in hospitalizations during the first four waves of the pandemic. This was supported by increased conversations between LTC and ED physicians, but was not associated with increased community paramedic visits. Additional work is needed to explore how programs such as community paramedics and facilitated conversations between LTC and ED providers can help to reduce unnecessary transfers to hospital.

Implementation and evaluation of a nurse-led intervention to augment an existing residential aged care facility outreach service with a visual telehealth consultation: stepped-wedge cluster randomised controlled trial

BACKGROUND

Up to 75% of residents from residential aged care facilities (RACF) are transferred to emergency departments (ED) annually to access assessment and care for unplanned or acute health events. Emergency department presentations of RACF residents can be both expensive and risky, and many are unnecessary and preventable. Processes or triage systems to assess residents with a health event, prior to transfer, may reduce unnecessary ED transfer. The Aged Care Emergency (ACE) service is a nurse-led ED outreach service that provides telephone support to RACF nurses regarding residents' health events. This service is available Monday to Friday, 8am to 4 pm (ED ACE hours). The primary objective of this study was to assess whether the augmentation of the phone-based ED ACE service with the addition of a visual telehealth consultation (VTC) would reduce RACF rate of ED presentations compared to usual care. The secondary objectives were to 1) monitor presentations to ED within 48 h post VTC to detect any adverse events and 2) measure RACF staff perceptions of VTC useability and acceptability.

METHODS

This implementation study used a stepped wedge cluster randomised controlled trial design. Study settings were four public hospital EDs and 16 RACFs in two Local Health Districts. Each ED was linked to 4 RACFs with approximately 350 RACF beds, totalling 1435 beds across 16 participating RACFs. Facilities were randomised into eight clusters with each cluster comprising one ED and two RACFs.

RESULTS

A negative binomial regression demonstrated a 29% post-implementation reduction in the rate of ED presentations (per 100 RACF beds), within ED ACE hours (IRR [95% CI]: 0.71 [0.46, 1. 09]; p = 0.122). A 29% reduction, whilst not statistically significant, is still clinically important and impactful for residents and EDs. A post-hoc logistic regression demonstrated a statistically significant 69% reduction in the probability that an episode of care resulted in an ED presentation within ED ACE hours post-implementation compared to pre-implementation (OR [95% CI]: 0.31 [0.11, 0.87]; p = 0.025).

CONCLUSION

Findings have shown the positive impact of augmenting ACE with a VTC. Any reduction of resident presentations to a busy ED is beneficial to healthcare overall, but more so to the individual older person who can recover safely and comfortably in their own RACF.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ID ACTR N12619001692123) (02/12/2019) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378629andisReview=true.

The hospital care and outcomes of long-term care patients treated by paramedics during an emergency call: exploring the potential impact of 'treat-and-refer' pathways and community paramedicine

INTRODUCTION

Adults living in long-term care (LTC) are at increased risk of harm when transferred to the emergency department (ED), and programs targeting treatment on-site are increasing. We examined characteristics, clinical course, and disposition of LTC patients transported to the ED to examine the potential impact of alternative models of paramedic care for LTC patients.

METHODS

We conducted a health records review of paramedic and ED records between April 1, 2016, and March 31, 2017. We included emergency calls originating from LTC centers and patients transported to either ED campus of The Ottawa Hospital. We excluded scheduled or deferrable transfers, and patients with Canadian Triage and Acuity Scale of 1. We categorized patients into groups based on care they received in the ED. We calculated standardized differences to examine differences between groups.

RESULTS

We identified four groups: (1) patients requiring no treatment or diagnostics in the ED (7.9%); (2) patients receiving ED treatment within current paramedic directives and no diagnostics (3.2%); (3) patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and (4) patients requiring admission (34.1%).

CONCLUSION

This study found 7.9% of LTC patients transported to the ED did not receive diagnostics, medications, or treatment, and overall 11.1% of patients could have been treated by paramedics within current medical directives using 'treat-and-refer' pathways. This group could potentially expand utilizing community paramedics with expanded scopes of practice.

Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models

OBJECTIVES

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

Residential LTCFs in rural areas worldwide.

METHODS

The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary.

RESULTS

A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth.

CONCLUSIONS AND IMPLICATIONS

This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

Telemedicine vs Face-to-Face for Nursing Home Residents With Acute Presentations: A Noninferiority Study

OBJECTIVES

Telemedicine and face-to-face outreach services to nursing homes (NHs) have been used to reduce hospital utilization rates for acute presentations. However, how these modalities compare against each other is unclear. This article examines if the management of acute presentations in NHs with care involving telemedicine is noninferior to care delivered face-to-face.

DESIGN

A noninferiority study was conducted on a prospective cohort. Face-to-face intervention involved on-site assessment by a geriatrician and aged care clinical nurse specialist (CNS). Telemedicine intervention involved on-site assessment by an aged care CNS with telemedicine input by a geriatrician.

SETTING AND PARTICIPANTS

A total of 438 NH residents with acute presentations from 17 NHs between November 2021 and June 2022.

METHODS

Between-group differences in proportion of residents successfully managed on-site and mean number of encounters were evaluated using bootstrapped multiple linear regression; 95% CIs were compared against predefined noninferiority margins with noninferiority P values calculated.

RESULTS

In the adjusted models, care involving telemedicine demonstrated noninferiority in the difference in proportion of residents successfully managed on-site (95% CI lower limit -6.2% to -1.4% vs -10% noninferiority margin; P < .001 for noninferiority) but not in the difference in mean number of encounters (95% CI upper limit 1.42 to 1.50 encounters vs 1 encounter noninferiority margin; P = .7 for noninferiority).

CONCLUSIONS AND IMPLICATIONS

In our model of care, care that involved telemedicine was noninferior to care delivered face-to-face in managing NH residents with acute presentations on-site. However, additional encounters may be required. Application of telemedicine ought to be tailored to fit the needs and preferences of stakeholders.

Reducing unplanned hospital admissions from care homes: a systematic review

Background

Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost.

Objectives

Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings.

Data sources

We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked.

Methods

We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect.

Results

We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence.

Conclusions

Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation.

Limitations

Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible.

Future work

We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes.

Study registration

This study is registered as PROSPERO database CRD42021289418.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.

Perfil dos teleatendimentos realizados pelo núcleo telessaúde-Pará de 2018 a 2019

Introdução: O Programa Telessaúde desempenha seu papel na assistência à saúde, especialmente nas regiões que não possuem estrutura ou atendimento médico especializado no Brasil No Pará esse núcleo presta assistência aos 144 municípios do estado. Objetivo: Delinear o perfil dos atendimentos realizados no estado do Pará. Métodos: O desenho do estudo foi observacional, retrospectivo e quantitativo, com análise da base de dados do programa. A fonte consultada foi a plataforma do Telessaúde-Pará com as consultorias realizadas entre 2018 e 2019. Resultados: Verificou-se que, nesse período, 208 teleconsultorias foram realizadas. Médicos foram os profissionais que mais as solicitaram. Os especialistas que responderam às solicitações com maior frequência foram médicos de família e comunidade, neurologistas e dermatologistas. As dúvidas mais frequentes foram as relacionadas a tratamento farmacológico e diagnóstico. A utilização de teleconsultorias evitou potenciais encaminhamentos em 76,9% dos casos. Entre os profissionais que utilizaram a plataforma, mais de 90% afirmaram satisfação com o serviço. Conclusões: Os dados demonstram a importância do programa na resolubilidade da Atenção Primária à Saúde, muito embora ainda haja pouca adesão e subutilização pelos usuários.

Does telehealth influence the decision to transfer residents of residential aged care facilities to emergency departments? A scoping review

BACKGROUND

Emergency Departments (ED) can be crowded places and not ideal environments for Residential Aged Care Facilities (RACF) residents awaiting assessment. Assessment and care planning may be made available via telehealth thereby avoiding unnecessary transfer to ED, without compromising the quality of care for the older person. Telehealth is attractive addition to improving healthcare decision-making in RACFs.

OBJECTIVES

The aim of this scoping review is to explore the evidence around the use of telehealth and whether it influences the decision to transfer residents of RACF to ED.

METHODS

All peer reviewed literature that focused on RACFs, decision-making and assessment of residents using telehealth in real time, was included. All study designs, pilot studies and some systematic reviews were considered. Databases Medline, Embase and CINAHL were used in this search in June 2022. Search terms were a combination of the population: RACF residents, decision-making and assessments using telehealth, and or transfer to the ED. The search was assisted by a senior university research academic librarian/information specialist and reviewed by senior researchers. The PRISMA-ScR guidelines were used to report this study.

RESULTS

Of the 124 articles initially identified, 31 were eligible for inclusion for synthesis. The date range of the included studies was 2001 to 2022, with 15 published in the last five years. Critical appraisal was conducted using the Mixed Methods Appraisal Tool.

CONCLUSION

This scoping review has mapped evidence that telehealth has been widely used in multiple settings. The association between the use of telehealth with improved clinical outcomes highlights its potential utility in enhancing care delivery for an older population in RACFs. Telehealth has shown that it can improve the decision-making for residents in RACFS, but more robust research designs are needed.

IMPLICATIONS FOR PRACTICE

Using video/telehealth appears to improve RACF staff access to expert clinicians who can then assess and jointly plan care/management that can be provided in the resident's home. Knowledge and skills of RACF staff appear to be improved through joint assessment and decision-making with the use of video/telehealth access to expert clinicians.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Japan Geriatrics Society "Statement for the use of telemedicine in geriatric care: Telemedicine as a complement to in-person medical practice": Geriatric Medical Practice Committee consensus statement

Telemedicine has changed from a way to treat patients with limited access to hospitals to a necessary method of treatment for non-urgent conditions during the coronavirus disease 2019 pandemic. There are two styles of telemedicine, namely "hybrid medical care" and "gateway medical care," which take advantage of the characteristics of online medical care and might become important in the near future. During hybrid medical care, a patient and their primary care physician have face-to-face medical care while simultaneously being examined by a specialist physician through telemedicine, leading to an overall improvement in the level of local medical care and expansion in the number of treatable diseases. Gateway medical practice is a form of telemedicine used for patients who would otherwise refuse or not receive in-person medical care to engage in consultation with a physician. Telemedicine allows physicians to determine disease severity and triage patients, while reducing unnecessary home visits, emergency hospitalizations and the spread of infection. Telemedicine is less intense than in-person medical care, and allows for easier collaboration with other healthcare providers. However, telemedicine is not optimal for conditions requiring a definitive diagnosis and a comprehensive understanding of the patient's medical history. It is limited by the patient's ability to use telemedicine devices, and the risk of accidental treatments and fraud. The use of telemedicine might result in the development of new, online comprehensive geriatric assessment tools and technologies. Geriatr Gerontol Int 2022; 22: 913-916.

Nursing Home-Sensitive Hospitalizations and the Relevance of Telemedicine: A Scoping Review

The aging of society is increasing the number of hospitalizations of nursing home residents. Telemedicine might help reduce the frequency of these potentially risk-associated hospitalizations. This scoping review looked for evidence of a change in the rate of hospitalization and, if mentioned, any cost savings and/or staff acceptance of the use of telemedicine in a nursing home setting. To identify available evidence, the electronic databases PubMed, Livivo, EBSCO and JSTOR were searched (without time or regional constraints) for comparative primary research studies on this topic in peer-reviewed journals. A total of 1127 articles were retrieved and 923 titles and abstracts were screened, with 16 studies published between 2001 and 2022 being included. Telemedicine consultation reduced the hospitalization of nursing home residents in 14/16 and care costs in 8/11 articles. Staff satisfaction was mentioned positively in five studies. Most studies used telemedicine involving medical diagnostic technologies (10), (electronic) health records (9), specialists (9) and specialized nursing staff (11). Few studies had a higher level of evidence: only one randomized clinical trial was included. There is the need for high credibility studies, using guidelines on protocol and reporting, to better understand the hindering and facilitating factors of telemedicine provision in the healthcare of nursing home residents.

Exploring the implementation of an outreach specialist program for nursing home residents in Macao: A multisite, qualitative study

Background

The "Specialist Medical Outreach Project (SMOP)" involving inter-disciplinary hospital-based healthcare professionals is a government initiative that aims to provide integrative specialist care to high-risk residents at the nursing homes. However, research exploring the implementation and impact of SMOP is lacking. This study aimed to evidence the impact of SMOP on the quality of care at the nursing home and the key contextual determinants influencing SMOP outcomes.

Method

Semi-structured key informant audio-recorded face-to-face interviews were conducted with eight managers, six doctors, 28 nursing staff, and seven pharmacy staff at the nursing homes participating in the SMOP to collect insights about how SMOP was operated and performed, and the impact of SMOP as observed and expected. Participants were recruited with purposive sampling. A thematic analysis approach was employed and key themes were identified using open coding, grouping, and categorizing.

Results

Forty-nine interviews were conducted. Thematic analysis identified three principal themes: the overall perception about SMOP, the benefits as observed; and the areas of improvement. Together with the 10 subthemes, the results highlighted the expectations for SMOP to address the unmet needs and promote patient-centered care, and the benefits of SMOP in supporting effective use of resources for the nursing home, reducing the risks of adverse events for the residents, promoting communication and capacity building for the healthcare providers and facilitating efficient use of healthcare resources for the health system. Requests for more frequent visits by a larger inter-disciplinary specialist team were raised. Careful staff and workflow planning, and mechanisms for data-sharing and communication across care settings were deemed the most important actions for improvement.

Conclusion

It is a general perception that the SMOP is beneficial in enhancing the quality of care for high-risk residents in the nursing home in Macao. Cross-sector inter-disciplinary collaboration and efficient data-sharing and communication mechanism play a crucial role in ensuring the success of the program. A robust assessment framework to monitor and evaluate the cost-effectiveness of the program is yet to be developed.

Experiences of nurses working in RACFs and EDs utilising visual telehealth consultation to assess the need for RACF resident transfer to ED: A qualitative descriptive study

AIMS AND OBJECTIVES

This study aimed to explore whether an intervention using visual telehealth improves care outcomes for residents in residential aged care facilities during acute illness events from the perspective of the nurses from residential aged care facilities and emergency departments. The intervention was the addition of visual telehealth, to an already existing outreach service called Aged Care Emergency.

BACKGROUND

Older people who are residents of residential aged care facilities commonly experience potentially avoidable visits and hospitalisations. Adopting visual telehealth or telemedicine has emerged as a care transition solution across several domains in health care, including residential aged care.

METHOD

This study used an interpretive descriptive methodological approach and was part of a larger study called the PACE-IT project that implemented a visual telehealth assisted model of care in four emergency departments and 16 residential aged care facilities to prevent unnecessary resident presentations to emergency departments. We report findings from six focus groups that explored key issues relating to the experiences of emergency department and residential aged care nurses who participated in the PACE-IT project. This study adhered to COREQ research guidelines.

RESULTS

There were four overarching themes that emerged from the six focus groups; facilitated person centred care; built confidence, relationships and trust; enabled bidirectional communication that strengthens decision making, but there were issues with technology access, connectivity and usability between the acute care setting and the residential aged care facility.

RELEVANCE TO CLINICAL PRACTICE

Understanding the experiences of residential aged care facility and emergency nurses' experiences when using visual telehealth will better inform practice development in aged care, in particular enhancing decision making and increasing safe practices using telehealth. The knowledge gained in this study in terms of enhanced assessments for residents will provide policy makers with valuable insights for future health care planning and implementation of telehealth.

TRIAL REGISTRATION

ACTRN12619001692123.

There and back again: the shape of telemedicine in U.S. nursing homes following COVID-19

Introduction

Telemedicine use in nursing homes (NHs) expanded during the COVID-19 pandemic. The objectives of this study were to characterize plans to continue telemedicine among newly adopting NHs and identify factors limiting its use after COVID-19.

Methods

Key informants from 9 Wisconsin NHs that adopted telemedicine during COVID-19 were recruited. Semi-structured interviews and surveys were employed to identify participant perceptions about the value of telemedicine, implementation challenges encountered, and plans and barriers to sustaining its delivery after COVID-19. Directed content analysis and a deductive thematic approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model was used during analyses. Quantitative and qualitative data were integrated to identify participant views on the value of telemedicine and the tools and work system enhancements needed to make telemedicine easier and more effective.

Results

All participating NHs indicated a preference to continue telemedicine after COVID-19. Urgent assessments of resident change-in-condition and cognitively based sub-specialty consultations were identified as the encounter types most amenable to telemedicine. Reductions in resident off-site encounters and minimization of resident therapy interruptions were identified as major benefits of telemedicine. Twelve work system enhancements needed to better sustain telemedicine were identified, including improvements to: 1) equipment/IT infrastructure; 2) scheduling; 3) information exchange; and 4) telemedicine facilitators.

Discussion

NHs that adopted telemedicine during COVID-19 wish to continue its use. However, interventions that enhance the integration of telemedicine into NH and off-site clinic work systems require changes to existing regulations and reimbursement models to sustain its utilization after COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03046-y.

[Opportunities and challenges for the use of video consultations in nursing homes from the caregiver perspective: a qualitative pre-post study]

INTRODUCTION

The implementation of medical video consultations in nursing homes can support primary care in rural areas and counteract the shortage of physicians. So far, video consultations have been limited to pilot projects and have not yet been comprehensively implemented. The present study addresses potentials of video consultations and challenges that may arise during the implementation of medical video consultations.

METHODS

Twenty-one guided interviews (pre-implementation: n = 13; post-implementation: n = 8) were conducted with a total of 13 participants (physicians, nurses and medical technical assistants). The data was analyzed using qualitative content analysis. The results were contrasted in a pre-post analysis.

RESULTS

Almost all of the interviewees' expectations regarding video consultations described prior to implementation have been met: time savings, improved communication, reduction of information breaks and increase in the quality of care. After implementation, other unexpected advantages of telemedical care became apparent, such as the possibility of regular monitoring or the improved ability to plan routine visits without interrupting the daily schedule. At the same time, the implementation of video consultations is associated with the following challenges: defining responsibilities, acquiring experience in handling video consultation tools, providing for sufficient qualification and training, dealing with new billing modalities as well as missing links between nursing documentation and medical information systems.

DISCUSSION

Video consultations can improve health care routines in nursing homes, lead to a wider availability of medical services, and contribute to improving patient safety and the quality of care. However, various aspects and contextual factors need to be addressed when implementing video consultations. These include: implementation of technical requirements, initial training with test consultations, continuous interactive development of potential fields of application, and the definition of the respective responsibilities of caregivers, physicians and medical assistants.

Using video consultation technology between care homes and health and social care professionals: a scoping review and interview study during COVID-19 pandemic

Background

the COVID-19 pandemic disproportionately affected care home residents’ and staffs’ access to health care and advice. Health and social care professionals adapted rapidly to using video consultation (videoconferencing) technology without guidance. We sought to identify enablers and barriers to their use in supporting care home residents and staff.

Methods

a scoping review of the evidence on remote consultations between healthcare services and care homes. Interviews with English health and social care professionals about their experiences during the pandemic. Findings were synthesised using the non-adoption, abandonment, scale-up, spread, sustainability framework.

Results

18 papers were included in the review. Twelve interviews were completed. Documented enablers and barriers affecting the uptake and use of technology (e.g. reliable internet; reduced travelling) resonated with participants. Interviews demonstrated rapid, widespread technology adoption overcame barriers anticipated from the literature, often strengthening working relationships with care homes. Novel implementation issues included using multiple platforms and how resident data were managed. Healthcare professionals had access to more bespoke digital platforms than their social care counterparts. Participants alternated between platforms depending on individual context or what their organisation supported. All participants supported ongoing use of technologies to supplement in-person consultations.

Conclusions

the evidence on what needs to be in place for video consultations to work with care homes was partly confirmed. The pandemic context demolished many documented barriers to engagement and provided reassurance that residents’ assessments were possible. It exposed the need to study further differing resident requirements and investment in digital infrastructure for adequate information management between organisations.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study

BACKGROUND

Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously.

METHODS

In this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions.

RESULTS

There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively.

CONCLUSIONS

Video-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support.

TRIAL REGISTRATION

The larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.

Avaliação da satisfação e resolubilidade da plataforma telessaúde redes no estado do Pará, Brasil

Introdução: As tecnologias da informação modernizaram diversos ramos de atuação humana, inclusive a medicina. Nesse contexto, surge a telemedicina como um avanço das tecnologias de comunicação aplicadas nessa área. No Brasil, o Telessaúde é uma ferramenta da telemedicina a serviço da saúde pública e funciona com o propósito de elevar a resolubilidade da Atenção Primária à Saúde (APS). No Pará, Norte do Brasil, o núcleo Telessaúde presta assistência aos 144 municípios do estado. Objetivo: Avaliar a resolubilidade dos casos enviados por teleconsultorias e a satisfação dos profissionais solicitantes no Telessaúde Redes Núcleo Pará, de 2015 a 2019. Métodos: Foi realizado um estudo observacional, transversal e quantitativo de série histórica, no qual se consultou a plataforma Telessaúde para verificação dos dados sobre resolubilidade, satisfação profissional e status de utilização do serviço, com base em perguntas geradas automaticamente na plataforma. Resultados: Verificou-se que a resolubilidade variou ao longo dos anos com 45,6 a 70% de referenciamentos evitados, demonstrando-se relativamente pouco variável. Já a satisfação dos profissionais usuários demonstrou-se elevada, variando de 77,9 a 95,45%, estando os solicitantes majoritariamente “satisfeitos” ou “muito satisfeitos” com o serviço. Conclusões: Os dados sugerem a relevância do programa no que tange ao apoio à APS, com efeitos diversos na saúde pública.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

AIM

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life.

DESIGN

Systematic review, without meta-analysis, with vote counting based on direction of effect.

DATA SOURCES

Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies.

REVIEW METHODS

Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness.

RESULTS

Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result.

CONCLUSION

This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed.

IMPACT

The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Challenges in current nursing home care in rural Germany and how they can be reduced by telehealth - an exploratory qualitative pre-post study

Background

Telemedical care of nursing home residents in Germany, especially in rural areas, is limited to a few pilot projects and is rarely implemented as part of standard care. The possible merits of implementing video consultations in longer-term nursing care currently lack supporting evidence. In particular, there is little documentation of experiences and knowledge about the effects and potential benefits of the implementation in presently existing structures. The goal was to assess the effect of implementing medical video consultations into nursing home care addressing the following research questions:

How is medical care currently provided to nursing home residents, and where do problems in its implementation arise?

How can video consultations be used to reduce difficulties arising in everyday care?

How does implementation of video consultations impact day-to-day nursing home care delivery?

Methods

Twenty-one guided interviews (pre-implementation n = 13; post-implementation n = 8) were conducted with a total of 13 participants (physicians, nurses and medical technical assistants). Narratives were analysed using qualitative content analysis. The results were contrasted in a pre-post analysis.

Results

Challenges described by the participants before implementation included a requirement for additional organisational and administrative efforts, interruptions in the daily care routine or delayed treatments, and risk for loss of patient-relevant information due to process diversity. After implementation, communication was facilitated upon introduction of assigned time slots for video consultations. Clinical information was less likely to be lost, additional work was spared, and medication and therapeutic and assistive devices were provided more quickly.

Conclusions

Telehealth cannot replace physical, in-person visits, but does offer an alternative form of service delivery when properly integrated into existing structures. Our results suggest that the use of video consultations in nursing homes can reduce the burden and additional workload, and increase the efficiency of care provision for nursing home residents. Video consultations can complement in-person visits to nursing homes, especially to address the shortage of medical specialists in rural areas in Germany. To promote implementation and acceptance of video consultation in nursing homes, we need to increase awareness of its benefits and undertake further evaluation of video consultations in nursing home care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06950-y.

Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review

BACKGROUND

In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions.

METHODS

A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions.

CONCLUSION

There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Where Skilled Nursing Facility Residents Get Acute Care: Is the Emergency Department the Medical Home?

OBJECTIVES

This study aimed to characterize the distribution of acute care visits among Medicare beneficiaries receiving skilled nursing facility (SNF) services.

METHODS

We conducted a cross-sectional analysis of a 20% sample of continuously enrolled Medicare beneficiaries in the 2012 Chronic Condition Warehouse data set. Beneficiaries were grouped by the number of days of SNF services, and acute care visits were categorized as "before SNF," "during SNF," or "after SNF."

RESULTS

Among the 10,717,786 Medicare beneficiaries analyzed, 384,312 (3.6%) had at least one SNF stay.

DISCUSSION

Beneficiaries who received SNF services had a higher proportion of acute care visits made to emergency departments (EDs) than beneficiaries who did not receive SNF services. Also, a higher proportion of acute care visits were made to EDs by beneficiaries after a SNF stay in comparison to residents actively residing in a SNF. The acute care capabilities of SNFs and post-SNF transitions of care to the community setting are discussed.

Telemedicine and Telehealth in Nursing Homes: An Integrative Review

OBJECTIVES

Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes.

DESIGN

Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies.

SETTING AND PARTICIPANTS

Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families.

METHODS

PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020.

RESULTS

Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs.

CONCLUSIONS AND IMPLICATIONS

Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.

The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review

INTRODUCTION

Programs that seek to avoid emergency department (ED) visits from patients residing in long-term care facilities are increasing. We sought to identify existing programs where allied healthcare personnel are the primary providers of the intervention and, to evaluate their effectiveness and safety.

METHODS

We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. We reviewed 11,176 abstracts and included 22 studies in our narrative synthesis, which we grouped by intervention category.

RESULTS

We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Among studies measuring that outcome, 13/13 reported a decrease in ED visits, and 16/17 reported a decrease hospitalization in the intervention groups. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening.

CONCLUSION

We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. However, most studies were observational and few assessed patient safety. Many identified programs focused on increased primary care for patients, and interventions addressing acute care issues, such as community paramedics, deserve more study.

A multicenter randomized clinical trial to evaluate the efficacy of telemonitoring in patients with advanced heart and lung chronic failure. Study protocol for the ATLAN_TIC project

Background

Using technologies of information and communication (TICs) is emerging in medical assistance. TICs application for medical assistance is promising. Its applicability in advanced heart and/or respiratory failure is still controversial because studies have shown methodological weakness which could put in danger their conclusions. Our objective is to evaluate efficacy of the application of home monitoring biological parameters in a multi-level model of coordinated clinical care for patients with chronic diseases with advanced heart (HF) and/or respiratory failure (RF) in comparison with conventional clinical care.

Method

/Design: Multicentric, phase III, randomized, parallel groups, controlled clinical trial. Patients with advanced HF and/or RF were eligible to participate. Patients received medical assistance by a multi-level model of coordinated clinical care with or without home monitoring. Follow up was performed until 180 days after inclusion. Primary efficacy outcome was defined as the percentage of patients with hospitalization/emergency room visits. Secondary efficacy outcomes were hospital admissions, admissions to hospital emergencies and Primary Care Emergencies, number of days of hospital stay, total cost per patient in euros, mortality, change in functional status, quality of life, assistance and technology devices. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruits patients per arm is set at 255, a total of 510 patients.

Discussion

This trial could provide some knowledge about the real impact of home monitoring for patients with advanced HF and/or RF within a multi-level model of integrated care.

Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review

BACKGROUND

Disparities in healthcare access and delivery, caused by transportation and health workforce difficulties, negatively impact individuals living in rural areas. These challenges are especially prominent in older adults.

DESIGN

We systematically evaluated the feasibility, acceptability, and effectiveness in providing telemedicine (TMed), searching the English-language literature for studies (January 2012 to July 2018) in the following databases: Medline (PubMed); Cochrane Library (Wiley); Web of Science; CINAHL; EMBASE (Ovid); and PsycINFO (EBSCO).

PARTICIPANTS

Older adults (mean age = 65 years or older, and none were younger than 60 years).

INTERVENTIONS

Interventions consisted of live, synchronous, two-way videoconferencing communication in nonhospital settings. All medical interventions were included.

MEASUREMENTS

Quality assessment, using the Cochrane Collaboration's Risk-of-Bias Tool, was applied on all included articles, including a qualitative summary of all articles.

RESULTS

Of 6616 citations, we reviewed the full text of 1173 articles, excluding 1047 that did not meet criteria. Of the 17 randomized controlled trials, the United States was the country with the most trials (6 [35%]), with cohort sizes ranging from 3 to 844 (median = 35) participants. Risk of bias among included studies varied from low to high. Our qualitative analysis suggests that TMed can improve health outcomes in older adults and that it could be used in this population.

CONCLUSIONS

TMed is feasible and acceptable in delivering care to older adults. Research should focus on well-designed randomized trials to overcome the high degree of bias observed in our synthesis. Clinicians should consider using TMed in routine practice to overcome barriers of distance and access to care. J Am Geriatr Soc 67:1737-1749, 2019.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Cost analysis of implementing a telegeriatrics ecosystem with nursing homes: panel data analysis

Our study analyzed the economicimpact of a telegeriatrics programme on care of nursing homeresidents, from the healthcare system provider's perspective. Thisis a retrospective, archival data analysis of multiple data sourcesin 4 nursing homes of Singapore from 2010 to 2015. Individualsadmitted to nursing homes and have undergone telemedicineconsultations (N=859) from 2010 to 2015 were recruited. Weconducted a cost analysis of the programme by reviewing pasthospital admissions' and specialist outpatient clinic (SOC) visits'billing records, nurse training records, and key performanceindicators' reports. A significant relationship was observed betweenteleconsultations and SOC visit cost (β1 = -83.366, p-value<0.01) and between teleconsultations and inpatient cost (β1 =-470.971, p-value <0.05). Remote video consultations could reduceunnecessary SOC visits and hospital admissions, and thereforelead to cost savings. Training of nursing home nurses couldtranslate to cost savings as a result of decreased ED transfers.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: Protocol for a systematic review

AIM

To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life.

DESIGN

Systematic review and narrative synthesis.

METHODS

Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016.

DISCUSSION

Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes.

IMPACT

Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.

Nursing Home Provider Perceptions of Telemedicine for Providing Specialty Consults

BACKGROUND

Nursing homes (NHs) provide care to a complex patient population and face the ongoing challenge of meeting resident needs for specialty care. A NH telemedicine care model could improve access to remote specialty providers.

INTRODUCTION

Little is known about provider interest in telemedicine for specialty consults in the NH setting. The goal of this study was to survey a national sample of NH physicians and advanced practice providers to document their views on telemedicine for providing specialty consults in the NH.

MATERIALS AND METHODS

We surveyed physician and advanced practice providers who attended the 2016 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their likelihood of referral to and perceptions of a telemedicine program for providing specialty consults in the NH.

RESULTS

We received surveys from 524 of the 1,274 conference attendees for a 41.1% response rate. Respondents expressed confidence in the ability of telemedicine to fill existing service gaps and provide appropriate, timelier care. Providers showed the highest level of interest in telemedicine for dermatology, geriatric psychiatry, and infectious disease. Only 13% of respondents indicated that telemedicine was available for use in one of their facilities.

DISCUSSION

There appears to be unmet demand for telemedicine in NHs for providing specialty consults to residents.

CONCLUSIONS

The responses of NH providers suggest support for the concept of telemedicine as a modality of care that can be used to offer specialty consults to NH residents.

Hematopoietic cell transplantation: Training challenges and potential opportunities through networking and integration of modern technologies to the practice setting

Hematopoietic cell transplantation (HCT), particularly allogeneic HCT, is a complex and a high-risk procedure requiring expertise to manage potential treatment complications. Published data supports the value of quality management systems in improving post-transplant outcomes; however, there are no universally established, or agreed upon, criteria to assess adequacy of training of physicians, transplant or nontransplant, and supporting staff, among others. It is of paramount importance for transplant centers to identify the needed area(s) of expertise in order to seek appropriate training for their staff. Moreover, transplant physicians need to keep up-to-date with the rapidly occurring advances in the field. Outcomes of patients undergoing HCT are affected by various factors related to patient, disease, procedure, preventative, and supportive strategies, among others. Accordingly, availability of databases is necessary to collect information on these variables and use to benchmark future prospective clinical trials aiming at further improving clinical outcomes. Twinning with leading centers worldwide is helping to not only bridge the survival gap of patients diagnosed with cancer in the developing vis-à-vis the developed world, but eventually closing it. The advent of the World Wide Web and revolution in telecommunication has made access to information more readily available to various sectors including healthcare. Telemedicine is enabling healthcare delivery to remote and underserved geographic areas. In the setting of HCT, ensuring compliance to prescribed therapies and post-transplant surveillance are some areas where implementing telemedicine programs could fulfill an unmet need.