NET ETRC C - Sum umme mer Web ebinar nar Ser eries es Se Septem ember ber 23, , 2014 www.netrc.org
Andrew Solomon, MPH - Project Manager Danielle Louder – Program Manager; Co-PI Dr. Terry Rabinowitz, DDS, MD – Co-PI Judy Amour, MA – Telemedicine Grants Administrator Mike Edwards, PhD – Consultant: Research/Evaluation
• Federally funded through HRSA/ORHP • TRC Grant Program established 2006 TRCs have extensive telehealth program experience • • 12 Regional TRCs • 2 National TRCs • Telehealth Technical Assistance Center (TTAC) • National TRC - Policy
All TRCs are committed to helping anyone who wishes to establish or expand a Telehealth program reach success. The TRC’s mandate from OAT is to assist health care organizations, health care networks, and health care providers in the implementation of cost-effective Telehealth programs to serve rural and medically underserved areas and populations www.telehealthresourcecenters.org
• Nuts and Bolts of Implementation • Program Design • Clinical Protocols and Best Practices • Workflow • Reimbursement Policies • Equipment Selection • Funding and Sustaining Your Program • Specific Clinical Applications • Telepsychiatry, Behavioral Health, Palliative Care, Pediatric Critical Care and Teleneurology • Connections with Peers Nationally • Reimbursement and Other Policy Issues • Training related to Telemedicine
“I have no financial relationships with a commercial entity producing healthcare-related products and/or services relevant to the content I am presenting”
Outline • Introduction – End of life care – Utilization – Communication – Quality of care • Pilot study • Clinicians’ perceptions of telemedicine • Trial of Telemedicine for Family Conferences • Ongoing research • Conclusions
End of life issues in critically ill • Certain diagnoses (i.e. end stage liver disease, multi- organ failure, metastatic cancer with organ failure) are associated with poor outcomes • ICU physicians are able to assess severity of illness and prognosis well Resche-Rigon, M. et al Crit Care Med, 2006 McKeown, A. et al J Palliat Med, 2011
Utilization of ICU • 50% of hospitalized deaths and 20% of U.S. deaths occur during or after an ICU stay • End of life care consumes 10-12% of all healthcare expenditures Angus DC et al Crit Care Med 2004 Pronovost et al Crit Care Med 2001
Communication • Many patients who are aware of their prognosis would then prefer to die at or near home • Factors associated with congruence with patient wishes include: physician support, hospice enrollment, family support and adequate symptom control Bell CL, et al J Pain Symptom Manage, 2010 Gyllenhammar, E. et al Support Care Cancer, 2003
Communication in ICU • Family members often view communication with clinicians even more important than clinical skills • Half of families of ICU patients do not sufficiently understand information about patients’ diagnoses, prognoses or treatments after family conferences • Efforts to improve communication during family conferences have yielded increased family satisfaction scores. • Among these efforts- structured approaches to conducting conferences has been found useful Stapleton et al Crit Care Med 2006 Hickey et al Heart Lung 1990 Azoulay et all Crit Care Me 2000
Communication • Many physicians wait to begin conversations about treatment preferences until no further treatments available • High quality and structured communication improves psychological outcomes Buss MK, J Palliat Med 2005 Keating NL, Cancer 2010 Baile WF, Oncologist 200
Quality of care • Critically ill patients with high risk of imminent death are often transferred to tertiary care centers primarily for end of life care • Long distance transfers increase burden on family members and loved ones • Decreased perception of quality of death and dying and have increased PTSD and GAD • Dying patients prefer to die at home McKeown et al Journal of Palliative Medicine 2011 Ligtenberg JJ et al Crit Care 2005 Bell CL et al J Pain Symptom Management 2010
Special Subgroup: Transferring Patients • Critically ill patients transferring to tertiary ICUs from smaller outlying community hospitals • Increased risk of death • Increased adverse events • Do not receive this form of communication until AFTER they have transferred, sometimes days into their critical illness Waydhas C, Crit Care 1999
Putting it all together Critically ill patient Inappropriate use of ICU Structured Communication Quality of Care Burden of family/PTSD/Anxiety Satisfaction
Outline • Introduction • Pilot study • Clinicians’ perceptions of telemedicine • Trial of Telemedicine for Family Conferences • Ongoing research • Conclusions
Pilot Study • Use telemedicine to conduct family conferences • Pilot study for one year • Retrospective data
Telemedicine as a palliative care/MICU tool for family conferences 12/08-12/09 12 conferences Limitations: Technical Inadequate clinician coverage Not universally reimbursed Fear of alteration in perception Of local physician role and loss Of value of phys-pt relationship Menon, P et al. Am J Hosp Pall Med May 2014 Epub
Outline • Introduction • Pilot study • Clinicians’ perceptions of telemedicine • Trial of Telemedicine for Family Conferences • Ongoing research • Conclusions
Clinicians’ Perceptions • Created an educational video for the Fletcher Allen Rural Palliative Care Network – http://you tube/gzlDUI1TChE • After watching the video, participants (RN’s and MD’s) filled out open -ended questionnaires
Clinicians’ Perceptions • Benefits – Satisfaction – Knowledge – Communication • Barriers – Time – Perception – Technology – Logistics
Outline • Introduction • Pilot study • Clinicians’ perceptions of telemedicine • Trial of Telemedicine for Family Conferences • Ongoing research • Conclusions
Research Project • Specific Aim 1: To assess feasibility of telemedicine as a setting for early family conferences • Specific Aim 2: To gather experiential data from participants in these family conferences
Study Design • Prospective qualitative study • Inclusion criteria- – Transferring or accepting physician initiated – Critically ill patient with high risk of death • Conference is audio and video taped • Follow up phone interviews and questionnaires – PTSD/GAD/QOC
Trial of telemedicine • Quantitative data – Time from call to conference – Total time of conference – Number of participants • Qualitative data – Experience of participants with telemedicine family conferences
Results • 8/2011-8/2012 • 14 requests • 5/14 (35.7%) completed conferences • Average time from initial call to conference: 1 hour 35 minutes • Average time to conduct conference: 15 minutes
Summary of Demographics • Age: 70.7 years • Male: 78.5% • Transfers: 42.8% • Mortality: 85.7%
Conclusions • Technically feasible • Less time than expected • Family members and physicians responding favorably regarding the experience • Preliminary data confirms that palliative care communication is NOT occurring early • Barriers: Identifying conferences early, consent from family
Outline • Introduction • Pilot study • Clinicians’ perceptions of telemedicine • Trial of Telemedicine for Family Conferences • Ongoing research • Conclusions
New Study- Part 2 • Prospective-non-randomized outcomes study • Refined the telemedicine intervention • Compare outcomes of patients and families who receive the TM intervention to outcomes of those who do not • Intervention performed by one person • Recruitment starts NOW!!!
Outline • Introduction • Pilot study • Clinicians’ perceptions of telemedicine • Trial of Telemedicine for Family Conferences • Ongoing research • Conclusions
Conclusions • Telemedicine can be used to conduct family conferences • It takes less time than expected • Participants responding favorably • No data yet regarding clinical outcomes
To speak with a member of the NETRC Team about your program, please contact our office. Our team will first identify your specific needs and then connect you with an expert that is best suited to assist you. Toll-free: free: 1-800 800-379-2021 Emai ail: l: net etrc@m @mcd cdph ph.org .org You can also visit t us on the web: www.ne netr trc.org c.org Dr. Menon: Dr : Prema ma.M .Meno enon@vtm n@vtmedne ednet.o t.org rg
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