Using Telemedicine to Reach Isolated Patients

Understanding Obstacles to Healthcare Access  

Patient access is one of the universal markers of a great healthcare system, along with value and care experience. It’s also one of the toughest to achieve—and an important application of telemedicine. 

Anyone without access to care is considered an isolated patient, whether the reason for isolation is temporary or permanent. (This is not to be confused with medical isolation, where isolation is necessary to prevent the spread of disease.) 

Reduce Patient Isolation
Both temporary and permanent obstacles contribute to patient isolation 

The obstacles that prevent people from accessing care can be categorized into four types: socio-demographic, geographic, systemic, and crisis-based. The first three types are permanent, while crisis-based obstacles are temporary. 

Socio-Demographic Obstacles 

  • Limited understanding of care sites. Many people simply do not have the know-how to access healthcare. Either public awareness programs have failed them, or they don’t have the right support system to properly advise them on the actions they need to take. 
  • Lack of transportation to go to the healthcare facility. Having or arranging transportation, either private or public, is a major issue when it comes to accessing healthcare. There are people who do not have a car, do not have any public transport near them, and do not have the means to arrange transportation. 
  • Inability to reach out to mental health patients. Almost two-thirds of patients with a mental health diagnosis are not actually receiving treatment. There is still great stigma associated with getting help in these situations.
  • Increasing immobility with age. This one is straightforward and compounds the isolation caused by the obstacles identified above. Many older people experience a decline in physical and cognitive functions. This makes it harder for them to move from place to place. Apart from the initial challenge of getting to a care site, there is the additional challenge of being alone when transitioned from one setting to another. 

Geographic Obstacles 

 For many patients, geography is a significant barrier. In rural areas far from the nearest metropolitan centre, health problems are compounded by a lack of healthcare resources and limited access to transportation. A crisis can leave patients feeling far more isolated than in urban areas. 

Systemic Obstacles

  • Scarce appointment availability. Physician’s offices may not have hours that are convenient for all patients. Moreover, many physicians and staff have a heavy workload.
  • Shortage of physicians. There is a general shortage of physicians right now, and this problem is expected to get worse in the coming decade.

Crisis-Based Obstacles 

  • Natural calamities. When there is a natural disaster like a hurricane or flood, some areas can lose health access coverage via loss of communication lines or transportation.
  • Infectious spread. In the case of a virus outbreak like the COVID-19 pandemic, patients may be unable to access healthcare, not because they cannot make the trip but because medical isolation is preferred to contain the spread of the disease. 

The Role of Telemedicine 

Telemedicine is the virtual communications aspect of telehealth that helps to overcome the various obstacles to care, usually through video conferencing between patients and physicians. Its definition can be extended to communication between patients and other members of the care team as well, including caregivers and family members for added care coordination and emotional support, respectively.  

Drivers Moderators and Solutions of Patient Isolation

Access to Healthcare Professionals 

Teleconsultation allows people with financial or age-related limitations to access healthcare without having to set foot outside their door. This saves them transportation costs and is generally more convenient, especially if they have mobility issues. In times of crisis, even patients in urban centres can feel disconnected, but the role of telemedicine is magnified if the patient lives in a geographically isolated area.

Whether they live in rural or urban areas, if patients are not educated on care sites, a teleconsultation can be a great first point of contact to clarify where they should access care. In fact, it’s wise to include telehealth in any patient education strategy. 

Teletherapy is used on a regular basis to reach mental health patients who might otherwise miss in-person appointments. In times of crisis, when their access to healthcare is temporarily severed, virtual communication technology allows these patients to continue their therapy sessions and stay connected to fight off loneliness. 

Telemedicine also alleviates systemic limitations by helping healthcare professionals see patients more efficiently. Thus, a smaller number of physicians can tend to a larger number of patients, directly addressing the shortage of physicians. Virtual platforms also allow physicians to offer more flexible hours by removing the typical overhead costs of running a facility. 

Access to Family and Friends

Finally, telemedicine helps to address isolation factors that go beyond access to healthcare professionals: connection with family and friends. After they are admitted to a facility, or when they are transferred from one setting to another, it’s important for patients to keep in touch with their loved ones. And it’s also a great psychological boost for family and friends to be kept in the loop on the patient’s care. 

The word televisitation is used to describe instances when the family cannot physically be at the bedside of a patient in lockdown, and instead use virtual communications to interact with them. Televisitation can also be used to maintain contact with seniors in potentially lonely long-term care situations such as nursing homes and assisted living facilities.

Whatever the specifics of the situation, creating a regular communication schedule via virtual conferencing goes a long way to reducing the sense of social isolation and providing necessary psychological and emotional support.

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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