Abstract
This research evaluated a project that provided video consultations between general practitioners (GPs) and residential aged care facilities (RACFs), with the aim of enabling faster access to medical care and avoidance of unnecessary hospital transfers. GPs were paid for video consultations at a rate equivalent to existing insurance reimbursement for supporting telehealth services. Evaluation data were gathered by direct observation at the project sites, semi-structured interviews and video call data from the technical network. Three pairs of general practices and RACFs were recruited to the project. 40 video consultations eligible for payment occurred over a 6 month period, three of which were judged to have avoided hospital attendance. The process development and change management aspects of the project required substantially more effort than was anticipated. This was due to problems with RACF technical infrastructure, the need for repeated training and awareness raising in RACFs, the challenge of establishing new clinical procedures, the short length of the project and broader difficulties in the relationships between GPs and RACFs. Video consulting between GPs and RACFs was clinically useful and avoided hospital attendance on a small scale, but further focus on process development is needed to embed this as a routine method of service delivery.
Introduction
Providing primary medical care to residents of nursing homes, also known as long-stay or residential aged care facilities (RACFs), has become increasingly difficult in Australia, to the point where it was recently described as “fundamentally broken.” 1 General practitioners (GPs) in Australia and elsewhere report that time pressure, the way GPs are remunerated for RACF attendance and increasing bureaucracy have made this work less attractive.2,3 A survey of RACFs in Australia found that over half reported difficulties accessing GP services for residents. 4 This problem contributes to a high rate of resident transfer to hospital emergency departments (EDs), together with the other factors of poor communication between clinical services, and staffing at RACFs not always being adequate to make decisions about treatment options, particularly after hours. 5 Transfer of RACF residents, who are frail, elderly and have multiple medical problems, to EDs is associated with adverse events and avoidable hospital admissions; therefore there is a pressing need to change the model of care delivery. 6
Using telemedicine to RACFs is one option to improve timely access to medical care. A systematic review reported most research in this area to be concerned with the delivery of specialist or allied health services, with only four studies about general practice; the overall quality of evidence was low, although feasibility and participant satisfaction were noted. 7 The few published studies of supplying primary medical care by telemedicine have shown that video consultations are useful for routine consultations and after-hours medical cover.8,9 Two studies have demonstrated reduced hospital admissions,10,11 although these were from the US and used rosters of specialist physicians to supply primary care, rather than the residents’ usual general practitioners.
In Australia, video consultations have been funded by Medicare (the universal health insurance system) since 2011; however, general practitioners are not rebated to deliver telehealth services, only to attend patients in person to support video consultations from medical specialists. Telehealth support activity by GPs in RACFs has been very low, 12 most likely because it is difficult to coordinate an in-person GP visit at the same time the specialist is available for a video consultation. If GPs themselves were funded to deliver care to RACFs via telehealth, this could supply one component of the new model of care that is needed.
This research evaluated a project that aimed to provide video consultations between general practitioners and residential aged care facilities, to see if it was possible to provide faster access to medical care and avoid unnecessary hospital transfers. Specifically, the evaluation assessed the technical, training, staffing and process issues that were found in the project, as well as the numbers and outcomes of the video consultations.
Methods
This study was approved by The University of Adelaide Human Research Ethics Committee. A description of the project inviting expressions of interest was sent to the general practices and RACFs in the northern Adelaide area. From these, the sites were first assessed for technical suitability, and then pairs of RACFs and general practices were recruited, in which the GPs were already supplying regular medical care to a sufficient number of residents to make it likely that video consultations would occur.
The technical visit at each site assessed ADSL (broadband) fixed lines, 3 G/4 G connectivity, wireless infrastructure, and mobility and placement requirements for equipment. At the general practices, videophones were attached to their existing ADSL lines, and at the RACFs both videophones and iPad minis utilising the RACF Wi-Fi networks were installed. The researchers made regular visits to the sites to encourage video consultations, conduct training, assist health care providers to develop processes and deal with problems. General practitioners were paid by this project for the video consultations at the same rate as the Medicare rebate for in-person attendance to support a specialist telehealth consultation.
The number of video calls was logged by the network exchange, and the number of video consultations with patients was determined by the payments requested and by interviews with GPs. Implementation issues were documented by the research team after training sessions, discussion with participants, and from direct observation of video consulting activity at the sites.
In the final month of the project, semi-structured interviews were conducted by the first and second authors, both of whom were experienced in qualitative research, with participating GPs, RACF staff members, and residents with sufficient cognitive capability to provide informed consent. The interviews were transcribed, entered into nVivo software and analysed thematically.13,14
Results
Recruitment
Eight RACF sites were assessed for initial suitability to enter the project. Two other RACFs showed interest until the short timeframe of the project was explained, at which point they declined participation. Of the eight sites, two had intractable technical issues and three sites could not be paired with a willing general practice, which left three pairs of sites in the project.
Technical assessment
Technical infrastructure at most RACFs was problematic. Two had very poor ADSL due to their distance from the nearest exchange, plus low 3 G/4 G signal strength, which excluded them from the project at the first hurdle. Generally, the RACFs had not installed connectivity with synchronous video communication in mind, but had purchased the lowest level of business-grade ADSL, which was used for email and internet access for all staff.
It was initially anticipated that consulting using videophones would be conducted in a designated room in each RACF, but early feedback from staff was that a mobile solution to see residents in their rooms would be essential, therefore iPad Minis were added. Wi-Fi signal strength was an issue due to distances between repeater stations, facility architecture, and metal firewalls in the roof. One facility began with good Wi-Fi and two others conducted upgrades during the project.
Process development
One brief training session was sufficient for each general practice, as the videophones were simple to operate, but at the RACFs about half the staff had low digital literacy and no experience with iPads. Up to four longer training sessions were required at each facility due to staff rosters and turnover. Senior staff also changed at each location during the project, requiring repeated management-level meetings and explanations of the project.
Initial visits to RACFs observed that staff forgot the location and password of the iPad, and did not charge it up or use the written instructions. Despite encouragement, the technical helpdesk was barely used, being called just twice in the course of the project. Participants were not sure how to organise a video consultation; on inquiry each site was waiting for the other to initiate. The project therefore devised a protocol which treated a video consultation like an in-person visit, with a time needing to be booked in advance, and this plus repeated hands-on training helped uptake commence.
Video communication
After the recruitment, site assessments, installation and commissioning of equipment was completed, six months of the project remained to conduct video consultations. 40 consultations that were eligible for payment were notified, although many more calls than this were logged by the video exchange. As calls were not recorded, the log did not distinguish between calls with or without patients. From provider interviews, one pair of sites used video calls two or three times a week for doctor-nurse discussions about patients. They reported this communication was better than telephone calls; for example, an RACF manager said: Dr [GP] can see body language from the nursing staff, so if the nursing staff disagrees with what he is saying he can see that and go, “Right, so you don’t agree with what’s happening, explain it a little bit further.”
Clinical uses
Video consultations were observed being used for a range of clinical conditions: firstly to assess and review visible signs such as pitting oedema, bruising, wounds, ulcers, feeding tube sites, skin cancer, skin infections and lacerations; secondly, to assess the overall condition of patients with agitation, generally unwell or following a fall. The main clinical issue identified as not suitable for video consultations was suspected pneumonia, when either physical examination by the doctor or sending the patient off‐site for a chest X‐ray was regarded as essential. Whilst peripheral devices such as electronic stethoscopes would have assisted in this case, they were not funded by the project.
Three of the 40 video consultations were judged by the GPs to have avoided hospital attendance. Two were cases of cellulitis in which GPs authorised intramuscular antibiotics via video consultation, and were able to see by repeat video call that the patients were improving, thus avoiding an admission for intravenous antibiotics. One patient had a video review after a fall, which determined that the patient did not need radiology or external assessment.
RACF staff interviews
Five interviews, including one group interview of three participants, were conducted with seven RACF staff. These averaged 19 minutes in length. Compiling the themes from these interviews showed that all seven participants expressed enthusiasm for the concept of telemedicine, six said they lacked awareness of the practical processes of organising a video consultation, four noted difficulties fitting telemedicine into a very busy working day and three reported initial discomfort with video communication which soon changed to a positive attitude with experience.
GP interviews
The four GPs who participated were interviewed for an average of 20 minutes each; two from the same practice were seen together and the remainder were interviewed individually. All were positive about the potential of video consultations, but also thought it had not been realised due to a lack of mutually agreed protocols. Most strikingly, three GPs wanted to cease or substantially reduce their work with RACFs. Encapsulating the heart of the issue from the GP perspective: “I want to pull out of aged care, not because of anything else, just paperwork, paperwork. You’ve got to do this, you’ve got to sign that. Crazy.” Within this context, they reported that trying to add video consultations to an already stressful environment was difficult.
Patient interviews
Most patients were unable to be interviewed, due to cognitive impairment, inability to speak English, or physical illness. Three individual interviews with patients, all of whom were very elderly, were obtained. These were only an average of 5 minutes in length, however all participants indicated that they were interested in and accepting of video consultations. One said, for example: “He [GP] got all the information and he’d seen my legs and everything on the screen and he give me an opinion. A great idea that.”
Discussion
Overall, it was very challenging to make video consultations a routine method of delivering general medical services to long term care facilities. Existing communications infrastructure was usually not suitable, with bandwidth being the greatest barrier. A similar project in the US attempted to set up a videoconferencing network to serve rural nursing homes, and did not achieve any video consultations after 19 months. 15 Our project was quite short term, involving only 6 months of clinical activity, which then had to conclude as the funding ceased, but it did accomplish some useful video consultations. The rate of billable consultations was low, averaging one a fortnight per GP/RACF pair, with 7.5% avoiding a hospital transfer, but if such a service was able to be scaled up there is potential to avoid both ED attendances and admissions.
The impression from GPs and RACF staff was that the telehealth project was a very small part of their working lives, and it suffered from inadequate time to become routine practice. Initiation stalled because each party was waiting for the other to define how this new option for communication would be used. If either experienced a difficulty, staff gave up and returned to usual practice rather than call the helpdesk. From the RACF point of view, using telehealth required additional effort without organisational or financial rewards, so uptake was driven by a small number of nurses who were enthusiastic about its value for residents. Hence it worked due to personal relationships rather than protocols, which is not a sustainable approach. One GP/RACF pair made the shift to routine use of video communication for case discussions, but not for patient consultations. The videophones were used almost exclusively for this purpose rather than the iPads. Perhaps the ease of simply dialling a number, the lower staff turnover at that site, plus the stronger relationship between the GP and RACF, facilitated this.
More broadly, it was apparent that the model of care between GPs and RACFs was not working well, and this impacted on the project. Fee-for-service seemed a poor fit for GPs to work with RACFs. On-site, GPs spent considerable time discussing patients with staff, and once off-site, they received a constant stream of requests for patient care, none of which were remunerated, and this was so regardless of whether the GP was physically visiting or attending by telehealth. This resulted in high levels of stress for the GPs and some dysfunction in the relationship between GPs and RACFs, with three GPs indicated that they would be reducing or entirely ceasing their RACF services. Ongoing reimbursement for video consultations by itself will not solve this problem, although adding a means of electronic data transfer to the video calls could make the extra work more efficient. To conclude, a solution that encompasses video consulting, but includes a new GP remuneration model, plus a longer time to bed down new processes, is recommended in order to make medical care delivery to RACFs more effective and realise the benefits of avoiding hospital transfer for residents.
Footnotes
Acknowledgements
The authors wish to thank the staff of the Northern Adelaide Medicare Local, the general practices and the aged care facilities who participated in and supported the research.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Australian Government through the Medicare Locals programme.