Renaissance in the Nursing Home During the COVID-19 Pandemic: Telemedicine Blooms in a Time of Crisis

Abstract

Prior to the pandemic, telemedicine was not well adopted in nursing facilities in the United States and was nearly non-existent in Hawaii. Many nursing facilities have since acknowledged its value due to the need for stricter infection control measures and reduction of exposure risk from face-to-face visits during the COVID-19 pandemic. To develop, implement, and assess a quality improvement project for a safe and effective telemedicine protocol in a high-volume, post-acute nursing home during the COVID-19 pandemic. Hale Nani Rehabilitation and Nursing Center (HNRC, an Avalon Health Care Group facility) is Hawaii’s largest skilled nursing facility with 288 beds and approximately 100 post-acute admissions and discharges per month. Five major medical groups (about 15-20 medical providers) and a wide array of consultants provide care here, with different and complex demands on facility staff. The COVID-19 pandemic spurred the rapid development and implementation of an innovative telemedicine protocol as a quality improvement project to sustain patient satisfaction, quality and access to care, and infection control. A needs assessment survey and internal focus groups directed process improvement. Project impact was measured by a retrospective pre-post survey of 7 questions to evaluate process improvement, attitudes, skills and perceptions with a 5-point Likert scale (5=strongly agree, 1=strongly disagree). Three additional qualitative questions assessed respondents’ views on the post-pandemic sustainability of telemedicine in the facility. The survey was completed by 22 respondents (8 medical providers and 14 HNRC staff). Scores from before and after implementation of the telemedicine protocol were compared using paired T-tests. Respondents expressed improvement in the perceived value of telemedicine (3.23 vs. 4.82, p < 0.0001); personal skill/efficiency with telemedicine visits (2.29 vs. 4.24, p < 0.0001); comfort level with telemedicine (2.29 vs. 4.45, p < 0.0001); and the scheduling process for telemedicine visits (2.27 vs. 3.91, p=0.0001). They expressed increased awareness of barriers and benefits of telemedicine (2.84 vs. 4.66, p < 0.0001) and improved leadership commitment (2.64 vs. 4.43, p < 0.0001). The weekly average number of telemedicine visits per respondent increased significantly after protocol implementation (6.48 vs. 25.61, p=0.002). Although not statistically significant, medical providers were more likely to wish to continue telemedicine post-pandemic compared to facility staff (75 % vs 43%, p=0.204), who expressed concerns about time commitment and workflow. With support of facility leadership, interdisciplinary team members and engagement of key stakeholders, we successfully implemented a complex telemedicine protocol in a high-volume, post-acute care skilled nursing facility during the COVID-19 pandemic, allowing patients to receive the care they needed.