The key concepts to rapidly design and scale a tele-palliative care program: Q&A with Providence's Dr. Gregg VandeKieft

The coronavirus has forced healthcare organizations to rethink many processes so they can stem the spread of the disease and save resources while still delivering essential and compassionate care.

One of the big transitions is telehealth, which has skyrocketed in all areas, including palliative care. Gregg VandeKieft, MD, the associate medical director for the Providence Institute for Human Caring in Renton, Wash., is now conducting remote palliative care visits through Zoom with patients and families. He heads regional palliative care for Providence and has seen more televisits in palliative care over the past few weeks than in the last few years.

CMS has temporarily expanded the telehealth 1135 waiver to cover these visits and Providence now deploys remote patient monitoring via Twistle. Dr. VandeKieft predicts that tele-palliative care will become part of the palliative care landscape in the years to come.

Here, Dr. VandeKieft describes the transition to tele-palliative care for COVID-19 and non-COVID-19 patients and the important lessons learned from designing and rapidly scaling the program.

Question: What are the key steps to rapidly develop and scale the ability to have virtual palliative care visits?

Dr. Gregg VandeKieft: One of the most crucial steps is to develop a close collaboration between IT, telehealth and clinical experts, operations leads and administrative support staff within palliative care. Ideally, there would be coordination by a program manager or project manager, although many teams will not have those resources available. Designating a clinical champion or a few clinical champions to pilot virtual encounters will allow for debugging or beta testing prior to a broader role out.

Given the extensive experience care that has accumulated within tele-palliative care, utilizing training and lessons learned from established programs can help advance program development more rapidly. The Center to Advance Palliative Care and the California State University Shiley Institute for Palliative Care both offer an array of tele-palliative care resources.

Q: What are the key considerations for the IT team to make sure the providers and families can conduct these visits?

GV: IT needs to take into account the technological resources patients and families have on hand, as well as their comfort and skill in communicating via a virtual platform. Not everyone has broadband, laptops or smartphones. IT also needs to consider some patients will need language interpreters. And IT should know some patients may have communication, cognitive or functional impairments.

Q: From the palliative care specialist and caregiver's perspective, what are the most important things for them to do differently during the virtual visits versus in-person consultations?

GV: Palliative care teams need to be mindful of the different nature of "presence" across a virtual encounter. The ideal encounter is when both the clinician and the patient become unaware of the devices they are utilizing and fully focused on the other individual.

Q: What is the timing like for these visits for patients with COVID-19, as well as non-COVID-19 patients who need these services?

GV: The timing to arrange a visit can be days or more in advance for an outpatient visit, or arranged same day for inpatient visits and some outpatient visits. The length of an encounter is variable, but typically it is shorter than an in-person encounter due to a more focused conversation. Telephonic visits tend to be more succinct than video visits. In my limited experience, most telephonic visits were completed within 15 minutes and nearly all within 30 minutes.

Video visits have tended to run in the 15-30 minute range. I have not heard about substantial time differences between encounters with COVID-19 patients and non-C-19 patients. However, families of patients dying in the hospital of COVID-related illness have required more frequent contacts and often longer contacts related to visitation restrictions and the added emotional distress related to these restrictions. There is also increased communication required around discharge planning for COVID-positive patients, and given the distancing requirements for caregivers even for non-COVID-19 patients.

Q: What other advice do you have for smaller hospitals and systems that will need to implement these types of programs in the next few weeks?

GV: Appoint someone with a track record of successfully implementing programs or completing projects to be the point person. Start the process now with a "not if but when" mentality. Do all planning with an eye to what can/should be sustained after the COVID-19 pandemic passes. Borrow heavily from others who have gone before — there is no need for the wheel to be reinvented by each system or facility. Be open to unconventional approaches. Be sure everyone involved is acknowledged and genuinely appreciated as essential members of the team; we need collaborative teams right now far more than individual stars.

More articles on health IT:
How Northwell Health's CIO updated its EHR to manage surge of patients, additional beds
HCA, Google Cloud create COVID-19 data-sharing platform: 6 details
10 updates for CIOs during the COVID-19 pandemic

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