Virtual and Telehealth Recommendations

Whether for telehealth appointments or for virtual connection during hospitalizations and long-term care, access to technology has the potential to greatly increase family and care partner engagement with the healthcare team. In order to meet patient needs and involve care partners effectively, healthcare leaders must ensure that technology doesn’t become a social determinant of health. Patients must have access to equipment and technology and should be engaged in developing work flows and policies surrounding the deployment of these technologies and tools.

While hospitals and long-term care facilities work toward making telehealth and virtual engagement available in new ways, it is important to prioritize the work based on what is meaningful for patients and care partners and what is feasible for healthcare organizations. Patients and caregivers have an interest in participating in conversations about virtual and telehealth and contributing to the development of policies and practices that improve health outcomes and the patient experience.
With these principles in mind, we advocate for the following:

Focus on Equity
Telehealth and enabling technology must be available to all.
Technology has the capacity to bridge distances, but without careful collaboration, broadband and smart device access can become barriers rather than bridges. As we transition our healthcare system to include virtual and telehealth encounters, it is important to consider disparities that exist in the larger community, such as broadband access and access to smart devices. The unique technology needs of specific communities should also be considered and included in plans to facilitate telehealth. A focus on equity for telehealth must include family caregivers and adequate preparation for visits and contacts using technology.
Telehealth has the potential to mediate other barriers to healthcare like geographic restrictions and transportation costs, making healthcare access easier for families. The evolution of telehealth can allow collaboration with multiple providers and specialists and home monitoring of chronic conditions, which can create cost effective solutions to traditional barriers.
A mother of twins who spent time in the NICU during the height of the pandemic in New York City describes how virtual connections made a difference for her family. “The virtual visit has been a game changer! When I was first given this option, I thought I wouldn’t need it. However, I went back to work so I couldn’t see my twins as often as I would like. On top of that, my husband and I decided to go less often due to the pandemic. The decision was upsetting, but for their safety and ours during the peak of the pandemic, we thought it would be best if we visited less. Virtual visits allowed us to see them and provided us comfort to see that they were doing okay. Additionally, the team often wanted to do family meetings, so this helped tremendously. We both didn’t have to take off work to go to the family meeting or spend money on parking, so it all worked out.”

Telehealth Funding
Telehealth reimbursement expanded during the COVID emergency must be made permanent.
Telehealth visits have the potential to keep patients connected to care when external circumstances make in-person appointments difficult. Telehealth has created new avenues to access healthcare, but these avenues will only remain open if reimbursements are in place, for all payors. In addition to reimbursement, capital funding should include infrastructure for telehealth and virtual options for patients, both inpatient and outpatient. All payors should be required to reimburse health systems for these services at a level that matches rates for in-person visits. Without such parity, health systems will be dis-incentivized to promote this useful, person-centered approach. Further phone-only visits, often the preference of patients and, in some cases, the only technology tool available, should be reimbursed at the same rate as video visits. Again, honoring patients’ preferences and assuring equity should be the fundamental drivers for this policy discussion.

At Hennepin Healthcare in Minneapolis, one elderly patient reported high marks for her phone-only encounters with her provider, much preferring them to the inconvenience of an in-person visit. “I have a flip phone and that’s all my doctor and I need to have a good conversation about my health needs. It is much better than having to find transportation to come downtown for my numerous health issues, and I don’t much care for video. I get everything I need from the phone visit.”

Care Partner Engagement in Inpatient Units and Nursing Homes
The concept of care partners and their critical role must be fully integrated into healthcare.
When possible, feasible and safe, care partners should be permitted at the bedside 24/7. However, when this is not an option, efforts to engage care partners should include virtual connection. Facilitating daily connection between patients and their care partners should be a stated goal for inpatient and long-term care settings.

To facilitate family updates during hospitalization, and even for telehealth visits, contact information for care partners should be included visually in the patient space, such as on a white board, as well as in the patient’s electronic medical record, so this information is easily accessed during rounds, change of shift, or times when the patient’s condition changes. Access to smart devices during rounding can help the healthcare team facilitate these contacts more easily.
The electronic medical record can also be used to indicate whether care partners have or need a smart device, what time of day is best for updates, and the care partner’s primary language, so interpreter services can be engaged as needed. Staff members or volunteers might be responsible for ensuring this information is captured in the medical record.
Along with daily contact between patients and their care partners, care partners should be notified if changes in the care plan or clinical status occur. Inpatient units and long-term care facilities might work with patients and care partners to co-design a summary of what they want and need to know each day.

Ideally, however, nothing matches in-person visitation and the presence of a loved one at the bedside to help with care and healing. Rick Evans, Chief Experience Officer at NewYork-Presbyterian Hospital and co-chair of the Patient Experience Policy Forum, believes hospitals can use what we have learned about COVID-19 to develop more informed policy decisions about visitation.
“We know a lot more now than we did last spring. We know what PPE to wear, and we have treatment options that we didn’t have in the past. Perhaps there are opportunities to be less restrictive since we know now what’s safer. Maybe we can allow for more ancillary supports in the hospital, like volunteers, because we know more,” he says.

Technology at the Bedside
Technological means for connection that were improvised during the COVID emergency must be rationalized and become a permanent part of the healthcare workflow.

Standards for the length of use of smart devices at the bedside should be established based on the availability of devices and patient needs. Infection control standards for cleaning smart devices should be defined, but the discussion about bedside technology use goes far beyond infection control. Protecting the privacy of patients, while respecting the boundaries of the healthcare space, are essential conversations when engaging patients and families virtually, with special consideration of cultural differences that can affect virtual engagement.

Rick Evans adds, “In the past when I’ve thought of iPads at the bedside, I would have said the hardest thing about them was infection control. That would be tenth on my list now. The primary concerns I have now are who’s using it and how is it used. Before COVID, we never talked about having an iPad in the room and the privacy of the patient in the next bed or whether it was acceptable to leave a device 24/7 in a patient room. What are the legal questions that we need to think through about that?”
More conversation is needed about engaging caregivers when a family member cannot consent. New platforms for patient communication are under development, which may address the issues of patient consent and privacy during hospital stays. The constellation of issues, including broadband, equity, cultural differences, staff rights, privacy, and confidentiality, are real issues that organizations should clarify going forward.

Dr. Michael Bennick, a physician at Yale New Haven Hospital and member of the Patient Experience Policy Forum, summarizes that, “Both in COVID and when we’re not in COVID, we always want to create bridges that connect patients and families with professional caregivers. There are times when things stand in the way of that, like distance, like language, like physical disability or physical challenge.”

In inpatient and long-term care settings, organizations should ensure technology is easy to use, from the devices and platforms themselves to physical supports like stands or mounts that can help patients access and use smart devices, regardless of physical ability. User-friendly, HIPAA-secure platforms should be selected, and patients and care partners should be oriented to the platforms. Having staff or volunteers available to assist and troubleshoot the use of the technology and telehealth platforms is an important step in institutionalizing the technology supports patients might need. Ideally, a designated responsible individual would lead and organize the efforts to ensure connectivity.

Fostering family connections via technology requires additional resources particularly for patients with limited English proficiency (LEP). Given the disproportionate number of hospitalized patients who are from minority populations with LEP, it is essential that interpreter services are adequately resourced to assure equitable access to technology when patients need bedside assistance. Additionally, facilitating telehealth visits for LEP patients requires extra resources, as well, and must be prioritized.
Inpatient units, ambulatory practices, and long-term nursing care facilities should facilitate daily virtual connection between patients and care partners, making sure that smart devices are available. Many institutions have created successful partnerships with local organizations that provide smart devices and hotspots or donate data minutes for patient and family communication with the care team. In addition to the devices and secure platforms for virtual contact, interpreter services must be available, based on patient and family needs.

According to Dr. Bennick, “We need to remove physical barriers, we need to remove language barriers, we need to remove distance barriers, and then we need to remove emotional barriers.”

Other Thoughtful Supports for Families
Families should be connected to peer-to-peer supports such as grief and loss groups, especially for those who have experienced trauma due to the loss of loved ones with whom they were unable to be physically present at end of life. Patient and family advisory councils should be engaged to co-design supports for families. Online portals can be promoted for information sharing with families and caregivers as well.

Caring for Healthcare Providers
Potential benefits of virtual connection for the care team should also be considered and reinforced.
Healthcare professionals can use virtual connection to continue to foster the trust that usually comes from being present at the bedside; this can be beneficial for both the patient and the hospital caregiver. As healthcare leaders focus on wellness systems both for the patient and the hospital caregiver, they should encourage and support healthy communication as a tool in preventing burnout.
Dr. Bennick reflects on the experiences of healthcare providers, saying, “To have so many of your patients die on your services is an overwhelming phenomenon, and we don’t do well with talking about deeply held feelings. We need to be taught anew how to do that, and how to communicate effectively. We need to ensure that connections are bridged between patients, their families, and the professional caregivers.”

Patients, caregivers and families need these connections to experience the best of virtual and telehealth contacts.

• Summary of patient and family recommendations:
• Advocate for universal telehealth reimbursement and broadband equity
• Provide daily connections between patients and care partners
• Select reliable, HIPAA-compliant technology that is easy to use
• Understand the unique needs of diverse communities
• Provide thoughtful supports for families

References
“Ensuring The Growth Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care, ” Health Affairs Blog, May 8, 2020. DOI: 10.1377/hblog20200505.591306
Adam Licurse, Kelly Fanning ,Karl Laskowski and Adam Landman. Balancing Virtual and In-Person Health Care. Harvard Business Review. November 17, 2020. https://hbr.org/2020/11/balancing-virtual-and-in-person-health-care
Telehealth and Health Disparities. Content last reviewed August 2020. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/reports/issue-briefs/teledx-5.html
Telemedicine and the COVID-19 Pandemic, Lessons for the Future
Rashid Bashshur, Charles R. Doarn, Julio M. Frenk, Joseph C. Kvedar, and James O. Woolliscroft
Telemedicine and e-Health 2020 26:5, 571-573
Virtual Visit Appointment Guides. PFCC Partners PFA Network.
https://pfccpartners.com/wp-content/uploads/2020/04/Virtual-Visit-Patient-Guide_FNL.pdf
https://pfccpartners.com/wp-content/uploads/2020/05/Virtual-Visit-Patient-Guide_Spanish.pdf

The Patient Experience Policy Forum (PXPF), supported by The Beryl Institute, is a broad-based and diverse coalition of patients, family members, caregivers, and health care professionals uniquely led by a balanced board of patient/family partners and senior patient experience leaders. Our purpose and commitment is to advocate for and help shape policy at the national and local levels on issues that directly affect patient and family experience and elevate the human experience in health care. We do so through convening policy forums, educating policy makers, sponsoring advocacy events, providing communication updates, and publishing calls to action.