Elizabeth A. Krupinski, PhD Arizona Telemedicine Program.

Elizabeth A. Krupinski, PhD

Arizona Telemedicine Program

Recipe for Success: Skill Sets Home TH◦Leadership Potential EquationCriteria Definition

Emotional Stability Tolerate stress & frustration, well adjusted, psychologically mature

Dominance Assertive, competitive, decisive

Enthusiasm Optimistic, energetic, flexible

Conscientious Self-disciplined/motivated, high standards excellence

Social boldness Spontaneous risk takers

Tough mindedness Practical, logical, to-the-point

Self-assurance Self-confident, resilient

Compulsiveness Socially aware, careful, abundant foresight

Recipe for Success: Skill Sets Home TH◦5-Factor Personality ModelFactor Definition

Conscientiousness Extent to which hard-working, organized, dependable

Emotional Stability Degree calm, cool, self-confident

Extraversion Extent assertive, positively interacts with others

Openness Creative & curious

Agreeableness Degree cooperative & warm to co-workers

Recipe for Success: Skill Sets Home TH◦VA Skill SetsCriteria Critical Ingredients

Skill Sets Clinical assessment, critical thinking, scientific process, communication, negotiation, collaboration, conflict resolution

Core Knowledge Organizational structure, community resources, team building, service delivery, psychosocial support

Personality Traits Flexible, adaptable, optimistic, resourceful, self-motivated, persistent, intuitive, advocate, leader, compassionate

Technical feasibility Provider & patient acceptance/satisfaction

Cost effectiveness Outcomes = equivalent or better than traditional

H.R. 6331. = 1/1/09, skilled nursing facilities, in-hospital dialysis centers & community mental health centers = originating sites for Medicare reimburse

COPD HH vs TN◦Pare et al. 2006◦7.5 vs 4.2 home visits 46.6 min vs 57.5 min

◦40% vs 5% hospitalizations 7.3 days vs 13.5 days

◦$2,779 vs $2,424 per patient over 6 mo

◦Attitudes overall positive

Diabetes◦Chumbler et al. 2005 with VA◦Pre vs post TH enrolment◦50% reduction hospitalizations◦11% reduction ER use◦3.0 fewer bed days of care◦Overall improvement QOL, pain reduction & social functioning

◦Other studies show HbA1C improvement

Acute infections Chronic respiratory failure Lung transplant recipients Stroke recovery Asthma self-management Cystic fibrosis Chronic heart failure Spinal cord injury PTSD & TBI Mental disabilities (schizophrenia,

Alzheimer’s) Pediatric, adult & geriatric populations

Cancer patients with ostomies being discharged earlier after surgery

Reduces time proficient in self-care Increases need for education & support visits by nurses after discharge

Distance & time can be considerable Shortage of nurses specializing in ostomy care

Achieving self-care is a process Nurses guide patients from dependence to independence

Start with total care & conclude with education & support

Telemedicine can serve a role in this process at all stages

28 patients with ostomies resulting from treatment for cancer◦14 HH =11 urostomy, 3 colostomy◦14 TH/HH = 7 urostomy, 7 colostomy◦LOS = 8.86 days HH; 8.36 days TH◦68% male, 32% female◦Mean age = 66.5 yrs (sd = 9.68)◦89% Caucasian, 7% Hispanic, 4% AfAm

HH TH

Bladder Cancer (64%) 1 7

Colorectal Cancer (28%) 3 5

Cervical/Ovarian Cancer (8%)

0 2

HH TH

Spouse (78%) 11 11

Daughter (11%)

2 1

Sister (4%) 1 0

Brother (3.5%)

0 1

Parent (3.5%) 0 1

HH TH

Education

Some College (55%) 8 8

Some High School (26%) 3 4

Grade School (19%) 3 2

Marital Status

Married (77%) 11 11

Widowed (4%) 1 0

Divorced (4%) 1 0

Never Married (14%) 1 3

Religion

Protestant (39%) 6 5

Catholic (25%) 4 3

Other (11%) 1 2

No Affiliation (25%) 3 4

No significant differences

Mean SD Range

HH 6.29 4.25 1 – 17

TH FTF 5.43 3.03 1 – 13

TH 3.57 1.28 2 - 6

Surgery: t = 0.304, p = 0.7632 Discharge: t = 0.170, p = 0.8666

Mean SD

HH Surgery 15.07 days 8.42

HH Discharge

6.79 days 7.49

TH Surgery 13.71 days 14.39

TH Discharge

6.14 days 12.04

Ostomy surgery explained = 100% Enterostromal nurse participated care =

96% Family of support during surgery = 100% Received United Ostomy Association

visitor during hospital stay = 38% Who helped adjust to surgery

◦Family = 36%◦Ostomy nurse = 36%◦Doctor or nurse = 22%◦Other = 6%

Agree HH

Agree Both

DisagreeHH

DisagreeBoth

NeutralHH

Neutral Both

Future hopeless 0% 15% 91% 77% 9% 8%

Take care self 70% 77% 30% 15% 0% 8%

Easily talk @ ostomy 100% 92% 0% 8% 0% 0%

Feel helpless 18% 8% 82% 84% 0% 8%

Activity limited 36% 38% 64% 62% 0% 0%

Feel angry 28% 30% 63% 62% 9% 8%

Prevents relationships

28% 24% 72% 76% 0% 0%

Odor 18% 31% 73% 61% 9% 8%

Look at stoma without depressed

82% 84% 18% 16% 0% 0%

Colostomy Significantly > Urostomy

Agree HH

Agree Both

DisagreeHH

DisagreeBoth

NeutralHH

Neutral Both

Dress same clothes 72% 54% 19% 38% 9% 8%

Avoid situations now 18% 34% 64% 66% 18% 0%

Ostomy is a disability 45% 38% 54% 55% 0% 8%

Travel is no problem 81% 77% 10% 8% 9% 15%

Physically active 45% 54% 55% 38% 0% 8%

Socially active 72% 62% 28% 30% 0% 8%

Sexually active 30% 18% 70% 82% 0% 0%

Sex relationship worse 55% 54% 45% 37% 0% 9%

Would visit other ostomy patients

45% 62% 28% 23% 27% 15%

HH TH Sig

Nurse understands problem

11% disagree 0% disagree

X2 p < 0.01

Comfortable with what nurse said about ostomy

11% disagree 0% disagree

X2 p < 0.01

Overall satisfaction 81% satisfied 93% satisfied

NS

Camera embarrassed

15% agree

TH care more accessible

100% agree

Prefer TH instead of waiting

87% agree

Prefer FTF 70% agree

TH as good as FTF 85% agree

HH TH

A) Mean # visits 6.29 5.43/3.57

B) Mean cost nursing visits $63 salary* + 0.34/mile

@ 12 miles

HH = sameTH =

$18.90**

C) Average cost pouches used $123.22/pt $70.73/pt

D) Final cost (A x B) $444.52 $377.31 HH$67.50 TH***

$444.81 total*Set fee for HH visit

**30 min 0.04/min airtime = $1.20 + $17.70 salary*** TH only vs HH t = 5.05 p = 0.0001

Pereira et al. IMEDIR in Spain

ICU filled with infoNeed to organize

Avera eICU (South Dakota; Pat Herr)

Avera eICU (South Dakota; Pat Herr)

Sutter Health eICU (CA; Teresa Rincon)◦Onsite intensivist coverage 12 hrs/day = $43,810

◦RN resource for APACHE & se[sis data collection = $11,700

◦Licensing fees for risk adjusted data collection = $1800

◦Total costs per bed onsite = $57,310◦Total costs per bed eICU = $42,000

Remote monitoring & wearable devices

Wellness & prevention devices Call-centers & automatic monitoring Smart homes Business-based programs All have TH Nursing component Need to be evaluated further for impact & health outcomes

Telenursing occurs on a variety of levels & in many environments

Clear cost & outcome benefits have been demonstrated

Opening avenues for reimbursement & new care settings

Providers & patients will continue to benefit from telenursing expansion

THANK YOU!