July/August 2021

Technology Improves Hospice Care
By Michele Deppe
Today’s Geriatric Medicine
Vol. 14 No. 4 P. 14

Telehospice care helps meet the needs of terminally ill patients.

Many health care providers have used computers for charting and other simple tasks at their patients’ bedside for years, and hospice is no exception. Articles and studies have documented telehospice practices for more than a decade.

But with the arrival of a public health emergency in 2020, hospice staff members were facing new challenges that could only be solved with an increase in technology. On one side of the equation, patients, families, and caregivers were reluctant to be exposed to visitors who may be carrying the coronavirus. Conversely, health care environments’ restrictions created a problem: Clinicians desiring to follow up with their patients were often prohibited from entering facilities during a lockdown. Yet, according to Medicare-certified hospice protocols, patients must be seen regularly—for some patients, that means daily—and be able to reach staff 24 hours a day, seven days a week.

“I think that what would’ve normally taken many hospices five or 10 years to implement has happened over the last year, out of necessity,” says Lori Bishop, MHA, BSN, RN, CHPN, vice president of palliative and advanced care for the National Hospice and Palliative Care Organization. “Because of COVID, we have a widespread adoption of telehealth across health care, and that has probably been one of the best things to come out of this challenging time.”

The Medicare Hospice Benefit affords patients four levels of care depending on patient needs, including routine hospice care, with regular visits at the patient’s home; continuous home care, where care is provided between eight and 24 hours a day to manage pain and other acute symptoms at home; inpatient respite care, where patients receive around-the-clock care in a facility to give the caregiver in the home a break; and general inpatient care, also in a facility setting with patients receiving daily visits and registered nursing available 24 hours a day.

Bishop describes hospice care as a “beautiful benefit, the Cadillac of services.” She says that hospice is based on a holistic approach because it offers care of both the patient and family and views them as a one unit. Hospices are required to provide an interdisciplinary care. Another unique aspect, Bishop says, one that honors the grassroots of hospice, is that the hospices are required to provide trained volunteers for at least 5% of the patients’ care. The bulk of hospice care is provided in the patients’ homes. Telehospice enhances the ability for the team to communicate and collaborate in providing hospice care to seriously ill individuals and their families.

Coming Up to Speed
Many hospices conducted technology-based visits prior to COVID-19 with great success; still there are many hospices that only began to rely on technology as a response to the pandemic, says Theresa Forster, vice president for hospice policy for the National Association for Home Care & Hospice. Hospices are finding that technology-based visits can be an invaluable tool, she says, adding that the association believes that vulnerable populations will likely continue to have fears about admitting caregivers to their homes for some time. “We have heard that patients, as well as providers, have found such visits to be useful and appropriate. We hope that [the Centers for Medicare & Medicaid Services] will clarify that such visits are permissible under normal circumstances where appropriate,” Forster says.

“I had never completed a telehealth visit prior to COVID-19,” says Katarina Marinzel, MSN, FNP-C, a nurse practitioner with Chesapeake Supportive Care, a palliative care organization. She’s been in a nurse practitioner role for just over a year and previously worked as a hospice admission nurse for four years. Just as with any situation, Marinzel says, there are benefits and challenges to providing health care from this platform. “On a positive side, it helps to ensure the safety of some of our most vulnerable populations,” Marinzel says. “While we are getting tested routinely and are provided with appropriate personal protective equipment, we might be in a nursing home where COVID-19 is present or see a home care patient with respiratory symptoms and are unsure of the underlying etiology. Then our next scheduled patient may be geriatric or immunocompromised. It is very reassuring to a lot of our patients to still have face-to-face routine access to our team members without having the risk of potential exposure.”

Another employee of Chesapeake Supportive Care says that telehealth is new to her as well. “Before COVID-19, I would phone family members to let them know when I would be visiting, but everything else was done in person,” says Genevieve Lightfoot-Taylor, MSN, CFNP, ACHPN, who has been working in hospice since 1998. Now, Lightfoot-Taylor uses many apps and recalls how quickly she had to come up to speed. In the evenings after work, Lightfoot-Taylor would learn how to use the different platforms and practice with family members. “You have to be confident that you know what you’re doing while speaking to patients and their families. There’s no time to fumble around and learn on the job,” she says. Lightfoot-Taylor has been surprised at how many of her older patients were already comfortable using the FaceTime function on their iPhones. She’s also utilizing DocuSign for forms, and her other primary apps include Medici, Zoom, and a medical platform called Doximity. She stresses that she allows the patient and family to dictate which app is used, and that you can send the link to as many people as are involved, which helps ensure continuity of care for the patient.

Marinzel has been using multiple telehealth technology as well. “A lot of patients do not want to download an additional app, but most are familiar with and have used Zoom before, so I find a lot of patients request to use that platform,” she says. “We use Zoom for other health care issues, and it is [available in a version that’s] HIPAA compliant.” However, Marinzel has encountered a number of patients and families who will request a telehealth visit but then have difficulties using the technology or have a poor internet connection, and she resorts to having a phone appointment instead. She says her preference is to conduct appointments in person. “I have found that my telehealth appointments, on average, have a shorter duration,” Marinzel says. “I also feel patients are not as willing to discuss their barriers to care or concerns.”

Are Telehospice Visits Effective?
The provision of hospice services via telecommunications technology varies depending on the service provided and the mode in use, Forster says. In many instances, she says, the hospice staff member will use audio-visual enabled technology, which allows for direct observation of a patient. In such cases, visits are very similar to in-person visits. In cases where a telephone call is used, the clinician will rely more heavily on the patient’s responses. Forster says those visits may require working with other staff members to clarify the patient’s condition.

Virtual visits can work very well when hospice patients are in facilities, but they can also be the most difficult, based on staffing issues. “As an NP, I am usually completing a face-to-face evaluation for hospice patients when I am using telehealth,” Marinzel explains. “When the hospice nurse is present, these visits can be quick, effective, and thorough. When a nurse is not present—because the staff at these facilities are very busy—then the appointments feel rushed.”

Bishop’s daughter is a hospice social worker based on the East Coast who was skeptical about using technology to conduct patient visits. Initially, she increased the frequency of visits to meet the needs of her patients and noted that televisits take as long or longer than visits conducted in person. However, Bishop’s daughter saw that both her efficiency in addressing all of the necessary concerns and the patients’ level of trust in the process improved rapidly. “My daughter was surprised how valuable and impactful those visits were for the patient and family,” Bishop says. “Patients and staff became comfortable with the vehicle of using technology for a visit. She was amazed by the rapport established with the patient and how much care and concern can come through a telephone call.”

Previously employed by Sutter Health’s Advanced Illness Management program in Northern California, Bishop and her coworkers relied on telephone case management to support a large volume of seriously ill patients. When patient satisfaction surveys were conducted, Bishop was surprised by how impactful those telephone visits had been. “People even mentioned their nurses by name, even though they hadn’t met them in person,” she says. Those visits, she emphasizes, as with telehospice, are scheduled and patients and their families rely on them. They plan that time to be together. “It’s very reassuring for the individual receiving care,” Bishop says. “They come to know that you are only a phone call away.”

The conversations conducted via phone or video conferencing proceed like a regular in-person visit, Bishop explains, with pertinent information gathered and typed into the patient’s chart. There is no actual (digital) recording of the visit, just as you wouldn’t make a video or audio recording of an in-person visit.

Lightfoot-Taylor also feels that having a nurse present with the patient helps facilitate a good visit. “But you can be very thorough,” she says. “I accumulate as much information as possible by reviewing the chart. If someone who is with the patient knows how to take vitals, then I request that they do so and share them with me. I ask the patient a lot of questions and often ask them to do a small task; for example, I’ll ask if I can watch them stand up and see whether they’re able to take a few steps. Using the camera function with the flashlight, I’m able to look into the patient’s ears, eyes, and mouth. I’m intently observing the patient and listening during the televisit, and it is very much like being there in person.”

Is Technology-Based Hospice Appropriate for Everyone?
Forster says that the use of telecommunications technology to conduct hospice visits is appropriate for many patients. Still, the critical element is that the hospice staff member can meet the care goals for the visit as laid out in the plan of care. If that is not possible, the staff member must conduct an in-person visit to ensure meeting the patient’s full care needs.

The hardest part about telehealth, Marinzel says, has been having challenging conversations or end-of-life conversations through a computer screen. “As a palliative care hospice provider, I am used to holding the hands of my patients and their loved ones,” she says, “And it is very difficult not to be a source of physical comfort for them as an illness progression is coming to an end.”

Bishop says 35% of patients are enrolled in hospice care for seven days or fewer. “If you’re admitting someone to hospice who is truly imminently dying, then technology is not going to be an appropriate tool,” Bishop says. “Telehospice may supplement your in-person visits, perhaps to support the family as they go through the process.” There are some people who simply don’t want anything to do with technology, Bishop says, so telehospice visits are not appropriate for them. “What we’ve also found on the flip side is true, that some people feel a much greater sense of control. Instead of having a number of different people in their home, they actually prefer a televisit, giving them more control over their environment and who is in it.”

The Future of Telehospice
Clinicians have various opinions about whether hospice will continue to rely heavily on technology. “I don’t think telehealth will be used in the near future as much as it is now,” Marinzel says. “However, I still think telehealth has multiple benefits and serves many of our patients well, so I hope it is a tool we can continue to use when appropriate.”

It’s important to note, Foster says, that technology is not a replacement for in-person visits. Telemedicine can play an essential role in hospice care where appropriate, but hospice care will remain a very high-touch benefit, and with good reason.

Lightfoot-Taylor misses the hands-on approach with her patients but is confident that telehealth will continue. “COVID-19 won’t really go away, any more than the flu has ever left,” she surmises. “But when it’s more under control, I think we’ll continue to use telehealth because, let’s face it, the increased efficiency generates income for insurance companies and facilities. Instead of driving from place to place all day to see each patient, visits can be done via technology every half hour.”

It’s important to realize telehospice is not an all-or-nothing scenario, Bishop says. She suggests thinking of telehealth as another tool in your clinician toolbox. It should be offered, and, when used appropriately, it can help improve access and timely responsiveness. “Telehospice won’t replace all in-person visits, but it can certainly complement them. It has a place in hospice care, as it does in all of health care.”

— Michele Deppe is a freelance writer based in upstate South Carolina.