Virtual patient care – the COVID-19 silver lining
In today’s digital society, it should be common place to talk to your doctor or attend a clinic appointment from the safety and comfort of home. Yet in health care, virtual technology has been virtually lacking. Until now.
Across St. Joseph’s Health Care London, teams are rapidly and creatively taking advantage of what they see as the COVID-19 silver lining – the impetus to fast forward and more optimally capture the benefits of virtual or remote patient care.
In April, 50-60 percent of all registered visits at St. Joseph’s were virtual, a jump from about five per cent pre-pandemic. The daily average is currently about 1,000 virtual visits compared to about 200 a day pre-pandemic.
“Our response to COVID-19 has helped us refocus our priorities to ensure our patients, many of whom have special health needs, keep connected with their health care team,” says Dr. Sarah Jarmain, Co-Chair of St. Joseph’s Quality Council and a member of the team implementing virtual care across St. Joseph’s.
The organization is just at the beginning of this journey, says Glen Kearns, Integrated Vice President, Diagnostic Services and Chief Information Officer. “We will continue to engage patients and clinicians in planning and how we evolve and adapt to this new way of providing service to some patient populations."
Without leaving home, many St. Joseph’s patients are receiving care, education and therapy through various virtual technologies. They include phone-based counselling and assessments, Ontario Telemedicine Network and a customized version of Cisco Webex appointments, online resources, e-newsletters, and more. All are being tapped with excellent results and appreciative feedback, “which tells us this is a model of care we must pursue post COVID-19,” adds Dr. Jarmain.
This doesn’t minimize the struggle of those patients we haven’t been able to be see during the pandemic, says Dr. Jarmain, “but what teams have been able to do very quickly has been remarkable.”
Virtual mental health care for veterans
One unique population is veterans. Psychiatrist Dr. Don Richardson is Medical Director of St. Joseph’s Operational Stress Injury Clinic (OSI Clinic), a program that provides mental health supports for veterans, Canadian Forces members and the RCMP. He has seen benefits of the OCS Clinic’s team of psychiatrists, psychologists, social workers and nurses in their London, Toronto and Hamilton sites incorporating virtual care into daily practice during the pandemic.
“Most of my patients have responded well to the use of both high-tech, secure, videoconferencing and the low-tech, but reliable, telephone for appointments,” says Dr. Richardson. “It’s been an important tool in ensuring we can continue to provide our patients care at a time when they are under added stress from the pandemic created by job loss, financial worries, family strain and increased isolation.”
Involving family caregivers in therapy is also enhanced when care is delivered virtually as caregivers can participate in sessions or be close at hand to answer questions and provide insight into the patient and family’s needs.
While research shows psychotherapy and mental health symptom management are effective through virtual care, Dr. Richardson admits there are challenges.
“Establishing trust with patients is key to providing effective treatment, something that’s harder to do virtually,” says Dr. Richardson. “As clinicians, most of our training and experience is in face-to-face assessment and treatment. When using videoconferencing, the quality might not always be clear, or if delivering care by phone, we have to rely on more subtle clues to what’s going on with the patient such as changes to their voice. That’s difficult to do, especially with a new patient.”
For mental health patients, it may also be difficult to transition back to face-to-face therapy once social isolation restrictions have lifted. Accessing care virtually may reinforce avoidance behaviours typical to someone with mental illness such as post-traumatic stress disorder and anxiety. Sometimes, coming for therapy is the only time that patient leaves their house in a week.
"Emergence of virtual care is something physicians have been asking about for years. COVID provided the impetus to finally make it happen. While it is not without enormous effort on the part of our leaders at all levels, the rapidity with which we have been able to transform some forms of care, and provide care where it is needed, provides us with examples that perhaps we can enact change more quickly than we traditionally have done in health care. Virtual care is not appropriate in every circumstance, but it will emerge as a new tool in the service of patients."
Making it work
It sounds easy – connect, focus, link or dial. In reality, virtual care comes with a host of both technical and process challenges.
“Adopting virtual patient care into our physician practices isn’t as easy as opening a video chat or picking up the phone,” cautions Dr. Jarmain. “There are a lot of new processes and nuances our teams need to be mindful of such as patient privacy, technology requirements and what type of care they should or should not be providing remotely.”
In April, The Canadian Medical Association posted resources on their website to support physicians in navigating the virtual patient care world. Their tips include how to establish a “webside manner” and what should and shouldn’t be assessed and treated virtually.
“There are some patient care needs that are not safe to assess or treat virtually, such as chest pain, shortness of breath and neurological symptoms,” says Dr. Jarmain.
St. Joseph’s recently launched a guide for physicians to help them understand the virtual care technologies available to them, although there are still bumps to iron out. Dr. Richardson has tips for health care providers diving into the virtual care world:
- Ensure there is a good video connection.
- Test and be familiar with the technology.
- Have two ways of connecting with the patient, for example by video and by phone, in case there are issues with the technology being used.
- Have the patients address available when talking to them in case of an emergency.
- If providing mental health care, establish rules ahead of time with the patient, such as ensuring they are in an appropriate state when connecting with you. Explain they should treat the session as if they were coming to your office.
- Ask the patient if they need help setting up the technology and facilitate help.
- Understand that use of technology to receive care may cause patients anxiety. Be patient and flexible.
- Remind patients that web-based counselling is only as confidential as their surroundings. Ask patients to make sure they are in a private, quiet place away from family and pets, as appropriate.
When talking about upsetting issues, it is easier for someone to leave or end the session (it only takes the touch of a button), and harder for the clinician to be sure that the individual is okay or safe. Ask the patient to provide a signal if they need a time out for any reason and to be clear about what they need.
Embracing the opportunities
Staff and physicians at St. Joseph’s are not only embracing the opportunities to incorporate virtual technology in care, they are excelling.
“There has been outstanding dedication and ingenuity by staff and physicians in finding new ways to serve patients at this unprecedented time,” says Tom Janzen, Integrated Chief Medical Information Officer for St. Joseph’s. “And we will be stronger for it.”
While not all patients are having their needs met remotely, there are many highlights of virtual patient care at St. Joseph’s:
- Rehabilitation: Patient therapy programs in the Rehabilitation Program at Parkwood Institute Main Building are being delivered through videoconference.
- Stroke: The Community Stroke Rehabilitation Team and Comprehensive Outpatient Rehabilitation Program are visiting patients and their caregivers through videoconferencing. Patients are progressing with their rehab using face-to-face virtual appointments, participating in group sessions and receiving stroke prevention education from the comfort of their homes.
- Endocrinology: The Diabetes Education Centre, diabetes and osteoporosis clinics, with few exceptions, have moved to a full virtual care model.
- Cardiac rehab: The Cardiac Rehabilitation and Secondary Prevention Program team, including rehab trainers, dietitians, nurses, psychologist, social worker and cardiologists, are engaging with patients through interactive telephone coaching sessions, telemedicine, video technology and a variety of online education resources.
- Adolescent psychiatry: Teen outpatients in the Adolescent Psychiatry Program at Parkwood Institute Mental Health Care Building who are experiencing serious mental health challenges are receiving dialectical behaviour therapy (DBT) from their mental health care team through a secure Webex platform. DBT is an evidence-based model of therapy that helps people learn and use new skills and strategies to better cope with stress, regulate emotions, and improve relationships with others.
- Pain management: In the Pain Management Program, each physician has moved their practice to phone or videoconferencing visits, as have the allied health team, including nurses, psychologists, occupational therapists, physical therapists, a social worker, and clinical pharmacist. Virtual group sessions, e-newsletters and email support are among other new ways pain management patients are accessing care. The program has also joined with other pain programs that make up the Ontario Chronic Pain Network to create and offer a weekly schedule of webinars for patients across Ontario to help them cope with pain during COVID-19.
- Inpatient programs - veterans, geriatrics, complex care and rehabilitation: At Parkwood Institute Main Building, patients, residents and their family members are finding comfort in virtual visits via video calls. Members of interdisciplinary teams provide support by partnering with individual families to facilitate – arranging schedules, booking a laptop or iPad and sitting with the patient/resident to make the calls. Seeing the delight, relief, laughter and tender moments exchanged between patients, residents and families has been uplifting for staff to witness.
- Allergy: The Allergy and Immunology Program for allergy and asthma patients have moved almost entirely to a virtual model of care. Patients are seen via telephone and videoconferencing to ensure continuity of care while also leveraging the relationship with primary care physicians to maintain treatments. One physician is participating with colleagues across Canada in virtual food challenges to help ensure the window of opportunity of food introduction isn’t missed in young children. Missing the window can increase the risk of food allergy in a susceptible child.
- Chronic obstructive lung disease: The COPD and Pulmonary Rehabilitation Program team, including respiratory therapists, rehab trainers, dietitian, social worker, nurse practitioner, and respirologists, are providing continued care and programming using interactive telephone coaching sessions, telemedicine, and weekly email communications to patients that include video technology. The nurse educator has begun group education by telephone, which allows for continued group interaction and support. A group virtual exercise program has also launched via WebEx.
- Long-term care: At Mount Hope Centre for Long Term Care, residents are experiencing virtual entertainment to stay engaged and entertained. Live music is happening via Skype, which is also connecting residents with loved ones thanks to staff who enable these important interactions.
- Pet therapy: Therapeutic recreation staff at Parkwood Institute Main Building are ensuring patients can still enjoy their weekly pet therapy through virtual visits with their favourite St. John Ambulance therapy dogs. The dogs provide a sense of normalcy, comfort and excitement to their week.
- Hand and upper limb: Physicians and therapists in the Roth McFarlane Hand and Upper Limb Centre are assessing and consulting with patients virtually using video and phone. Through video, therapists are able to see patient movements, limitations and restrictions and recommend care they can do at home to continue mobility and healing.
- Ear, nose and throat: To move care forward, Otolaryngology - Head and Neck Surgery runs a clinic virtually three times a week, where patients are triaged and seen through videoconferencing.