NET ETRC C - Sum umme mer Web ebinar nar Ser eries es Se - - PowerPoint PPT Presentation

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

• r expand a Telehealth program reach success.

The TRC’s mandate from OAT is to assist health care

• rganizations, 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-
• rgan 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
• ften 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 Structured Communication Quality of Care Satisfaction Burden of family/PTSD/Anxiety Inappropriate use of ICU

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

• Dr. Menon:

: Prema ma.M .Meno enon@vtm n@vtmedne ednet.o t.org rg