A Blueprint for Telehealth Success for Skilled Nursing Facilities

April 13, 2020 - With a high-risk patient population and razor-thin business margins, skilled nursing facilities (SNFs) have been adopting telehealth platforms to reduce costly rehospitalizations and improve clinical outcomes and staff morale. And with the nation in the grip of the COVID-19 outbreak, the number of SNFs turning to connected health has soared. 

But it’s not as easy as buying a telemedicine cart, plugging it in, and watching it work. SNF administrators have to plan carefully by picking the right partner and technology and laying the necessary groundwork so that the system works as expected. One misstep could prove costly, perhaps even dangerous. 

“This is more than about just the technology,” says Brian Carpenter, National Medical Director of Telehospitalist Services for Sound Physicians. “It’s about getting ready for the clinical delivery changes that telemedicine will bring to your facility.” 

To integrate telehealth into the daily operations of a SNF, administrators should follow a checklist that addresses six primary issues. 

Select the Appropriate Telehealth Provider 

One of the most important aspects of integrating telehealth into an SNF is the partnership with a telehealth provider. SNF administrators and staff are already under a lot of stress, and telemedicine is designed to relieve that stress and improve care. The right provider can take as many of those tasks as possible off the table, giving administrators and staff the time they need to adapt to new workflows and build confidence in their abilities. 

SNFs need a telehealth provider that can offer on-demand services. That means having qualified and credentialed hospitalists on the other end of the telemedicine platform at a moment's notice, especially when a nurse is dealing with a patient in decline. 

"All this technology means nothing if there's not someone who's going to respond in a timely manner," says Carpenter, who suggests that SNF administrators do plenty of research before selecting a telehealth partner. 

Credentialing is a vital part of that research, as each state has its own telehealth rules. A telehealth provider has to have not only enough doctors on hand at all times to meet an SNF's needs but also the credentials for every doctor on the platform to practice in an SNF's home state. They also have to know what is and what isn't allowed in virtual care. 

“There’s technology that can support a SNF’s ability to have an audio-visual connection with a provider on the other end, but that’s not really what SNFs need,” Carpenter maintains. “They need a true telemedicine partner that’s going to provide a comprehensive program to them.” 

In looking for a telehealth partner, Carpenter advises that SNF staff should consider companies that are flexible and able to create workflows and services that are tailored to the facility or chain of facilities. 

They should also have good knowledge of coding and reimbursement laws as well as a willingness to work with a SNF to develop a sound and scalable business plan. 

Choose the Right Technology 

SNF staff are dealing with patients with increasingly complex care needs, so a telemedicine platform should focus on a workstation or mobile cart that, at the very least, includes real-time audio-visual capabilities and mHealth devices for capturing vital signs. Those devices are important because they give the hospitalist an accurate picture of the patient’s vital signs while freeing the nurse to perform other care duties. 

Since the most common and immediate use of telehealth services in a SNF is to evaluate a patient whose vital signs are deteriorating and is in danger of returning to a hospital, the platform has to have the equipment for rapid and remote diagnosis, including a wireless stethoscope. 

Carpenter emphasizes that integration with the SNF's electronic health record platform "is nice to have," but by no means vital. Most SNFs have simple EHR platforms that can exist side-by-side with telehealth and allow for access when needed to review vitals, medications, and diagnosis. 

Administrators might want more than just episodic emergency care. If so, they should have discussions with their telehealth partner about their flexibility to add additional services like remote patient monitor and/or chronic disease management. This could potentially mean that more technology is needed. But that complexity shouldn’t become a problem. 

“The technology has to be easy to learn and easy to use,” Carpenter stresses. 

Set Up the Right Infrastructure 

First and foremost, a SNF has to have reliable broadband connectivity to support telehealth and a backup plan for emergencies. Every patient room must be able to accommodate a telemedicine station that can provide clear, uninterrupted audio and video signals. 

"You need to make sure you have the bandwidth to support the technology," Carpenter notes. 

Administrators also need to be sure that the entire SNF is organized to handle new tasks online, not just the nurses who are talking with hospitalists. An advanced platform - or one that is personalized by SNF administrators - might integrate housekeeping and support services, issuing electronic messages to clean rooms, restock supplies, and perform other tasks as part of a remote patient monitoring or patient welcome program. Front office personnel will use an online registration process for new patients as well as those returning to the SNF from the hospital. 

Administrators will also need to establish protocols for how the telemedicine technology is used, moved around the facility, maintained, cleaned, and stored. 

Train Staff to Be Comfortable With Telehealth 

Before going live on a telehealth platform, a SNF has to be sure that staff know why, when, and how to use the technology. Administrators need to set time aside for training and several run-throughs, giving nurses a chance to use the technology in multiple scenarios, from an emergency to daily care. 

"Standard operating procedure can be thrown out the window when there's a crisis," states Carpenter. 

It's also important that administrators do more than just hand over the training manual and conduct drills. Staff support is a crucial and often overlooked aspect of telehealth adoption, and a lack of emotional investment could doom an otherwise adequate program. Administrators need to work alongside nurses to become familiar with the technology and processes, answering questions and removing barriers along the way. A good telehealth partner will help administrators navigate these change management tasks. 

Prepare for Workflow Changes 

A telehealth platform will improve clinical and operational outcomes by improving care delivery and management, and that sometimes means adjusting workflows. Staff need to be taught how SNF care pathways will change with the addition of telehealth and their responsibilities will evolve as a result of those new workflows. 

According to Carpenter, administrators should take the opportunity to review their current care pathways before introducing a telehealth program. This allows them to identify the current resources available and determine what resources or care pathways might be impacted by telehealth. Some workflows will need to be slightly altered, while others will need dramatic changes that require more time for design and training staff. 

"Many SNFs aren't 100-percent sure about all the tools they have on hand," he notes. In other words, administrators have to get a handle on what they’ve been doing before getting into what they’re capable of doing with a connected health platform. 

Whereas nurses traditionally have to contact the on-call doctor when a patient shows signs of declining, the conversation is markedly different on a telehealth platform. With telehealth, more patients will be treated at the SNF rather than sent to the hospital, meaning that nurses will assume more care management responsibilities. Guided by a telehospitalist on the other end of the telemedicine platform, they'll be more active in a patient's care. 

A very important capability that the telehealth provider must include is that the telehospitalist contact the ED physician to discuss the case, which often results in a plan to treat the patient in place instead of sending that patient to the ED. 

For those patients who still require admittance to a hospital, telehealth changes how that transfer occurs. Nurses and telehospitalists work closely to coordinate a transfer with the hospital, giving hospital staff a complete picture of the patent. This act could also aid in improving outcomes at the hospital. 

In addition, that telehealth platform is used when the patient is ready to return to the SNF, allowing nurses and telehospitalists to prepare sufficiently for care management. 

"Understanding what happens after the patient leaves the building is critical," Carpenter stresses. "That is rarely thought about." 

Telehealth benefits extend beyond emergency care to daily care. Backed by a telehealth platform, nurses will be able to do more to improve day-to-day outcomes, particularly in promoting health and 

wellness and managing remote patient monitoring and chronic care. They’ll need to know how to fit those services into their daily routine. 

Develop New Patient Engagement Guidelines 

A telehealth program will have a significant impact on how a SNF runs, giving administrators and staff new responsibilities and workflows. What's more, the program will also enable more meaningful interactions between staff, patients, and family and friends. 

Because a telemedicine platform gives nurses instant access to a doctor, it's also available to provide patients and their caregivers more timely responses to any questions or concerns they have. The byproduct is a more engaged and educated patient and improved care management. To that end, nurses have to know how to integrate a patient’s needs and questions into the telehealth workflow. 

“They don’t have to wait until the doctor comes into the building next week,” Carpenter points out. 

In addition, a telehealth platform can also improve care collaboration by bringing more people into the care loop. That might mean using a virtual platform for online conversations. Doing so brings together the patient, nurse, telehealth doctor, primary care doctors, specialists, and the patient's family, who may need to be looped in from the office or home. 

“It will elevate the care and improve the patient experience,” Carpenter asserts. 

As with any telehealth program, the key to success lies in personalizing the services to the specific setup and needs of the care provider. What may work in one place may not in another owing to a building's design or the technical capabilities of staff (among others). Administrators should expect to tweak the process — and the checklist — along the way. But they'll be better prepared to see that process through to the end.