Components for integrating telehealth into a health care program

1. Video platform
Successful integration of telehealth delivery depends on the quality and usability of the video conferencing platform. The criterion for selecting a platform is simplicity/ease of use for patients and staff.
Almost all platforms require the patient to download software or an app to their smartphone or tablet. Any vendor to a covered entity that creates, receives, maintains, or transmits protected health information must remain compliant with the specific institutional guidelines. It is possible to use Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, Skype, etc.
Telehealth can also be delivered via telephone in areas with unreliable Internet connections: the best platform may be as simple as the existing telephone service.

2. Video devices and connectivity
Video conferencing requires at least two devices equipped with front-facing cameras and adequate high-speed Internet or data connectivity. Hard-wired Internet connections, secured wifi, and satellite broadband can all support videoconferencing.

3. Training
Videoconferencing encounters are fundamentally different from the usual experience of patients and providers interacting in an office or a home setting. It is useful to schedule the initial encounter as a face-to-face visit in the clinic or home, while explaining that some or future encounters will be over videoconference.

Patient and family training
Once a patient/family agrees to participate, patient and family training can begin by telephone with an assessment of available connectivity, devices, and comfort with technology use.
The staff members in charge of video conferences should be selected for the following.
• Understanding the technology to be used.
• Patience, as occasional technological difficulties are inevitable, and the tech-literacy of patients vary.
• Clear (no jargon), slow, and detailed communication style.
• Familiarity with the psychological barriers about acquisition of new technology skills.

Care team member training
The staff must agree to use telehealth, and be educated on the benefits expected for both patients and the team. The training for staff must demonstrate the effectiveness of videoconferencing in establishing genuine presence. Techniques that take advantage for non-verbal communication:
• matching one’s image size to the patient’s
• awareness of body language within the frame
• maintaining eye contact
• controlling when you move in or out from the camera/patient

Effective training provides professionals with awareness of and attention to background, position, lighting, distracting background sounds, and the maintenance and focus on active listening. Additional tips for staff training include:
• dress appropriately and do not multitask
• create a professional or neutral background
• speak slowly and clearly, as audio/video can lag

During a home-based videoconference, staff should assess the visible home environment. They can ask to be shown where and how medications are organized, what the inside of the refrigerator looks like, or they can scan the room(s) for safety issues and other relevant elements of the home.

4. Situational assessment
Disabilities of speech, cognition, hearing, mental health, or impaired ability to manipulate the devices can all limit the use of videoconferencing, and staff presence in the home may be needed to fulfill goals of the encounter. An in-home, face-to-face visit should be used in the following circumstances.
• Initial complete assessment
• Physical exam for acute changes in condition
• Wound care
• Assessment of caregiving adequacy
• Precision tasks (i.e. helping to fill medication organizers)

When staff are physically present at the home visit, videoconferencing can be used to include others on the team. For example, a nurse staff member in the home can assess the patient’s wound and show it to a physician on the care team.

5. Patient and family encouragement
A videoconferencing encounter can be initiated by staff or by the patient themselves, a family member, or a caregiver. They should be encouraged to do so upon any change of condition or concern.

PREPARING FOR THE FIRST VISIT
Confirm that the device settings can support the platform, that programs/apps are downloaded successfully, and that communications are tested. Face-to-face testing and demonstration of the capabilities and benefits of synchronous videoconferencing prior to the first encounter will build the confidence of patients and families.

How to create a therapeutic telehealth environment:
• Choose a quiet, private space that has good lighting. When possible, choose a space with a neutral and organized background.
• Use a laptop or desktop computer whenever possible; avoid using a handheld smartphone.
• Look at the camera (not the electronic medical record) to ensure good eye contact and to foster rapport and trust.
• Staff should orient the patient view to where the staff member is sitting, and reassure the patient that the conversation is private; ask the patient to do the same.
• Multiple clinicians and/or family members can participate in the visit from separate locations.
• Ask for a tour of the patient’s home.
• Perform accurate medication reviews by having the patient hold up each medication to the camera.

See reference for more information.

Adapted from telehealth start-up guide - CAPC.ORG. Internet. Available at https://www.capc.org/documents/download/233/ Accessed on November 7, 2020.