Health systems across the country are launching telemedicine programs aimed at improving the nurse's workload, but both value and sustainability are hard to pin down.

Editor's note: This article appears in the October-December 2023 edition of HealthLeaders magazine.

Virtual nursing is all the rage these days, with health systems across the country launching telemedicine-based programs aimed at helping their beleaguered nurses. But with no clear-cut path to ROI, executives are uncertain whether the programs can be sustainable.

Each hospital is approaching the issue from a different direction, ranging from basic telesitter programs targeting patient monitoring and fall prevention to platforms that support new nurses to more complex telenursing platforms that combine monitoring with administrative functions.

At the Medical University of South Carolina (MUSC) in Charleston, officials tested a virtual nursing service about a year ago, says Emily Warr, MSN, RN, administrator for the health system's Center for Telehealth. That program was geared toward helping new nurses learn the ropes.

Not long afterward, the program was shut down.

"We learned from that endeavor that it's not enough," Warr says. "It has to be much more complex and bring more value."

So MUSC pivoted, creating a platform designed not only to remotely monitor patients in their rooms but help with administrative tasks, from charting in the EMR to onboarding and discharges. That program will debut soon in four of the health system's rural hospitals, where the nursing ranks are especially strained.

"Bedside nurses spend way too much time in documentation," Warr says. The new program, she says, assigns those tasks to the virtual nurse, who can sit in a room in another part of the hospital and handle EMR documentation for several patients. It adds another set of expert eyes to the details that make up the patient record, while freeing up the bedside nurse to focus on hands-on duties and interactions that improve care management.

Warr says a virtual nursing program will only succeed if it addresses multiple pain points.

"This program can't just focus on workforce economics or quality [of care]," she says. "One is not enough. There has to be a quality component. We've got to impact patient care."

Warr says the biggest challenge to standing up a telenursing program is the CEO.

"They see this as an additional expense until proven otherwise," she says.

That's a common refrain in many health systems, as health system decision-makers struggle to balance new ideas and technology against a perilous bottom line.

'Things Are Changing Too Fast'

At a recent HealthLeaders Teams Exchange in Nashville, clinical and financial executives from several health systems across the country came together to discuss the challenges they face in sustaining a workforce. Virtual nursing was one of the hot topics of conversation, with nearly everyone agreeing they'll have fewer nurses in five years and nearly three quarters saying they've launched such programs to address that problem.

But they aren't going to wait long to see value.

"Things are changing too fast," says Meg Scheaffel, BSN, RN, MBA, MHA, NEA-BC, vice president and chief nurse officer at Baptist Health Louisville. "Anything beyond 18 months [is now considered] long-term planning."

[See also: Can Virtual Nursing Help Hospitals Address Workforce Challenges?]

Telesitting, telenursing, and virtual nursing programs saw a dramatic increase during the pandemic, when hospital leadership sought to reduce contact between infected patients and their staff to curb the spread of the virus. In time, those hospitals using the platform saw benefits ranging from reduced stress on nurses to improved clinical outcomes through more consistent monitoring, resulting in more efficient room turnover, improved patient discharge rates, and better patient satisfaction scores.

And they're seeing a lot of potential in the platform, especially as health systems look to address the changing nature of the hospital stay.

"With inpatient virtual care, it opens up a lot of doors," says Colleen Mallozzi, MBA, RN, senior vice president and chief nursing informatics officer at Jefferson Health, which recently launched its Virtual Nursing Program after a trial run earlier this year involving nearly 400 patients.

"The virtual nurse can do anything except physical touch," adds Laura Gartner, DNP, MS, RN, RN-BC, NEA-BC, an associate chief nursing information officer and division director of clinical informatics at the Philadelphia health system.

Jefferson Health is launching its virtual nursing program after a four-month pilot in two units and will be watching a wide range of benchmarks that include patient length of stay, patient satisfaction, patient flow (including transfers), nurse turnover and overtime, and documentation compliance. The program will be incorporated into the wall-mounted television unit in each room, a familiar form factor for many in-patient telehealth programs.

"We want our nurses to be doing what they should be doing, which is caring for patients," says Gartner.

But a nurse can't physically be in a patient's room at all times, and with fewer nurses that time spent in the room is even smaller. Jefferson Health's program puts a nurse virtually in each room at all times, accessible through the wall-mounted TV, giving patients the comfort of knowing there's someone looking in on them and answering their questions when needed.

"It's an evolving landscape," says Mallozzi, noting the program is separate from Jefferson's 10-year-old telesitting program, which focuses solely on monitoring and safety care and has shown value in reducing patient falls.

Starting Small and Scaling Up

To be fair, telesitting, whose roots trace back to the practice of using volunteers (sometimes retired nurses) to sit with patients with behavioral health concerns or at risk of falling, has proven its value, with studies finding it reduces patient falls and self-harm and can save hospitals hundreds of thousands of dollars a year in associated costs. But those programs don't address nursing workflow or stress issues. Telesitting can be incorporated into a virtual nursing program, but it can't be stood up as a telenursing service.

Farther south, Valley Health went live with its virtual nursing program in May. The six-hospital network, serving parts of Virginia, West Virginia, and Maryland, partnered with Teladoc Health to launch a pilot in one hospital, with plans to expand soon.

"We started this way, beginning with a traditional med-surg unit, so that we would have lots of options," says Theresa Trivette, DNP, RN, CENP, the health system's chief nursing officer. "Each unit is going to have its own culture and needs … so we need to begin slowly and let our nurses [help us to] build out this model together."

Trivette says the health system saw the value of an inpatient telemedicine platform during the pandemic, and officials wanted to find a way to keep that going after COVID. Not surprisingly, executives jumped on the idea of using the platform to support nurses.

"They're getting tired, and many are considering retirement," she says. "We thought about how we could keep them in care delivery longer."

Trivette says the program focuses more on care management, with administrators inviting nurses to map out the platform and prioritize what they do in the patient's room. And while some nurses initially saw this as an intrusion that affected their job responsibilities, she says, the attitudes turned positive as the program was fleshed out to address their stresses.

She says the platform has become popular with patients (especially seniors) who just want someone to chat with each day and has led to a 20% jump in patient experience scores. In addition, it has boosted staff morale and engagement, which in turn will improve care management and coordination.

"We're focusing on supporting the whole care team, not necessarily plugging a pain point," Trivette says. "How do we help our nurses in all aspects of care delivery?

At the HealthLeaders Exchange, much of the focus around virtual nursing was on hard results, such as clinical and administrative outcomes that translate into savings. At Mount Sinai South Nassau, for example, Senior Vice President and Chief Nursing Officer Stacey Conklin, MSN, RN-BC, MHCDS, NE-BC, is working side-by-side with John Pohlman, CPA, the hospital's chief financial officer and senior vice president of finance, to make sure virtual nursing outcomes align with financial considerations.

That might include reduced patient length of stay, which improves patient satisfaction scores as well as the room turnover rate. Or the extra pair of eyes on the EMR could not only cut down on documentation time but reduce errors, improving not only the coding and billing process but clinical outcomes.

"You have to have your CFO at the table," noted Helene Burns, DNP, RN, NEA-BC, senior vice president and chief nursing officer at Jefferson Health New Jersey. "We have to think about where we invest our dollars."

The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at https://www.linkedin.com/company/healthleaders-exchange/. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com.

Health Systems like Essentia Health are using specially trained EMS teams to help recently discharged patients and those with chronic care needs stay out of the hospital.

One of the biggest care gaps occurs when the patient leaves the hospital. The care team can send along instructions for care management, send texts or emails or make phone calls, even schedule follow-up care, but there's no guarantee those directions will be followed.

At Essentia Health, those patients are now getting house calls from paramedics.

The 14-hospital health system covering parts of Minnesota, Wisconsin, and North Dakota has been using community paramedicine since 2014, and has seen reductions of almost 60% in 30-day readmissions, with ED visits and hospitalizations cut in half up to three months after discharge. Brendan Krupich, the health system's community paramedic program manager, says the program has reduced costly ED and rehospitalization costs while helping patients with ongoing and acute chronic conditions improve their health and wellness at home.

"They have a continuity of care that they didn't have before," he says. "We're seeing them at home now instead of [the emergency room] and helping them to stay there."

Community paramedicine programs, part of an array of outpatient services known as mobile integrated health programs, change the paradigm of providers waiting around for patients to come to them. Most health systems with MIH programs identify patients as high-risk returnees (sometimes called "frequent flyers") and schedule visits to the home after those patients have been discharged.

Healthcare organizations across the country have been launching community paramedicine programs to reduce ED and clinic traffic, cut down on hospital admissions, and take pressure off 911 services and EMS departments swamped with unnecessary or preventable calls. They're also taking aim at soaring care management costs for Medicaid and Medicare Advantage populations, many of who either avoid healthcare visits and preventive health services or wait until it's an emergency. A 2009 Institute of Medicine study indicated roughly $750 billion was being spent on preventable services, amounting to about 30% of the nation's total healthcare costs for that year.

"We were seeing a lot of people who just waited too long" to connect with their care team after leaving the hospital, Krupich says. Some, he says, are too stubborn to seek additional care, while others don’t think their concerns are serious enough to warrant a phone call or trip to the doctor. In today's economy, the sting of another medical bill hangs over the household.

Krupich launched his program with a one-year state grant, aiming to cut 30-day readmissions in half. Patients were identified through the EMR, and scheduled for home visits from specially trained paramedics who are employed by the health system (some programs use their own paramedics, while a majority work with local EMS and ambulance departments).

"We really needed to get buy-in from home health [agencies], and that took a while," he says. "We weren't replacing what they were doing."

In fact, MIH and community paramedicine programs can supplement home health services. They also can be used in acute care at home programs, fulfilling that in-person link and giving patients a personal connection to their care management plans. The goal is to connect patients to their care plans in a more meaningful way, encouraging them to follow doctor's orders and embrace healthy habits.

Krupich says his community paramedics go into a patient's home focused on emphasizing such things as medication adherence, exercise, and nutrition. While there, they can also identify and perhaps address social determinants of health, as well as connect the patient with community health and social services resources, including behavioral healthcare.

"Honestly, that's a large part of what we're doing now," he says. "We can't claim all the successes, as there are a lot of moving parts in this."

Krupich says the program is well-received by patients and providers alike because it reinforces the human touch in healthcare, giving the health system an opportunity to get more acquainted with the people they see so often in the ED. The key, he says, is training EMS staff to make those connections and understand what patients need at home.

“I refer to them as a bit of a Swiss Army Knife,” Chris Anderson, MD, Essentia's EMS medical director, said in an August 2023 news release issued by the health system. “Their skill sets are broad and they often work under the radar because their patients interact with practitioners less frequently once the community paramedic establishes a relationship.”

"Essentia's community paramedics play an indispensable role in reducing cost of care by decreasing ED and hospital admissions," Anderson added. “Our community paramedics often develop lasting relationships with their patients, which allows patients to better understand and participate in their own care."

The challenge sustaining these efforts, Krupich says, is funding. Essentia Health has received grants to keep the community paramedicine program going, targeting expensive benchmarks for certain chronic care populations like those living with diabetes. The Centers for Medicare & Medicaid Services (CMS) does not reimburse health systems for community paramedicine visits, and recently ended a pandemic-era alternate payment model that would have reimbursed for some programs that divert care from the ED.

But the tide is shifting, as more health systems look to reduce unnecessary expenses in the ED and focus on making hospital beds available for those who need to be treated in a hospital. Krupich says the Essentia Health program has reduced unnecessary hospitalizations and readmissions, and some payers, such as Blue Cross Blue Shield, are taking notice.

"We are moving forward," he says. "I see us taking more of a proactive approach to EMS services. We've been so reactive for so long and haven't done anything to fix it."

Joneigh Khaldun, MD, MPH, FACEP, sees the national pharmacy chain as an integral part of a new healthcare ecosystem that uses data and technology to overcome barriers to care.

Editor's note: This article appears in the October-December 2023 edition of HealthLeaders magazine.

CVS Health's first-ever chief health equity officer says the national pharmacy chain is placing itself at the front of the health equity movement because it has the name-brand recognition to help underserved communities.

"People see us as a trusted brand," says Joneigh Khaldun, MD, MPH, FACEP, who also serves as vice president of the Rhode Island–based company, which includes among its many subsidiaries CVS Pharmacy, MinuteClinic, CVS Caremark, Aetna, Osco Drug, and Oak Street Health. "Nowadays people are more likely to go to their neighborhood pharmacists than a primary care provider."

Khaldun, who joined CVS Health in late 2021 and is also an Emergency Department physician for the Detroit-based Henry Ford Health System, has the background to address health equity. Prior to joining CVS Health, she was Michigan's chief medical executive and chief deputy director for health for the state's Health and Human Services Department, where she oversaw public health, Medicaid, behavioral health, and aging services. She also spearheaded Michigan Gov. Gretchen Witmer's COVID-19 response strategy and was appointed in 2021 to President Joseph Biden's COVID-19 Health Equity Task Force.

Khaldun says health equity is a long-standing issue, affecting underserved populations long before COVID-19 cast a spotlight on the topic. But with the glare of public perception came a new interest in addressing the issue with innovative technologies and strategies.

Health equity "has become a buzzword, but health disparities aren't new at all," she says. "What is exciting is the energy around addressing the root causes. The entire healthcare ecosystem has changed, and it has given us new opportunities" to level the playing field for consumers who have problems accessing the care they need.

Part of that change comes from the expansion of the healthcare marketplace, and the introduction of new and more diversified participants, such as Amazon, Microsoft, Google, Walmart, Walgreens, and CVS Health. Traditional healthcare organizations are working hard to stay competitive, often by using consumer-friendly technology and strategies to keep their patients.

Khaldun won't talk about whether CVS Health is competing with or partnering with health systems, but she does say the CVS network can address one aspect of health inequity: Lack of trust in the healthcare industry. Underserved populations often feel disenfranchised from local health systems due to barriers in accessing care. Having them access care through CVS Health helps to break down those barriers and put more faith in healthcare providers, she says.

Khaldun has a three-pronged approach to addressing health inequity: Empowering people to take charge of their own care, using data to identify each person's unique healthcare journey, and using technology to take action. Consumers often encounter care gaps, she says, when they don't have the data they need to make the right healthcare decisions.

"To understand the disparities and inequities, you have to have the right information," she says. "That’s what we can do."

Khaldun also says virtual care "is going to be an important part of our healthcare ecosystem," enabling CVS Health to link consumers to the care providers they need to see no matter where they're based. That will go a long way toward breaching the barriers to care caused by lack of access, she says, and open the door for new opportunities in care management.

[See also: Should a Pharmacist Be Allowed to Deliver Primary Care Services?]

Not lost in the equation is the impact that pharmacies can have on care delivery. Advocates say pharmacists can and should play a more active role in care management because they often have access to the data needed to link consumers to effective treatments and are often the best resource to address an ineffective treatment or identify new care plans.

"That's why CVS Health is certainly a healthcare innovation company," she says. "Pharmacists have an incredibly important role to play in this."

The New Hampshire health system is using a virtual health program to train rural providers to handle difficult births, while also plugging in a robust telemedicine network to offer on-demand access to specialists.

Rural hospitals are closing their labor and delivery (L&D) units at alarming rates, forcing more expectant parents to give birth in an ill-prepared emergency room or other location, like the back of an ambulance.

At New Hampshire's Dartmouth Health, officials are combining virtual learning and a hub-and-spoke telemedicine platform to address difficult and emergency births. This includes STONE (Simulation Training for Obstetric and Neonatal Emergencies) training delivered on a virtual platform to rural healthcare providers such as emergency department personnel and paramedics, as well as an around-the-clock Tele-ED platform offering on-demand access to specialists to assist in emergency births.

"Sometimes babies come fast," Kevin Curtis, MD, MS, medical director of connected care and the Center of Telehealth at Dartmouth-Hitchcock Medical Center, said during a presentation at the Northeast Telehealth Resource Center's annual meeting this month in Nashua, New Hampshire.

In New Hampshire, 11 of 27 hospitals, or 40% of the state's hospitals, have shut down their L&D units since 2011. All but one are in areas designated by the U.S. Health Resources and Services Administration (HRSA) as rural service areas. Nationwide, 217 hospitals have closed their L&D departments, creating more maternity care deserts, where access to services is strained.

Many rural hospitals are closing L&D units because of the cost of staffing and keeping open a unit that doesn't see a lot of activity over the course of a year, but the consequences are dire, especially for expectant parents experiencing a difficult birth, requiring a C-section, or needing immediate care by neonatal intensivists. On top of that, most rural EMS units and emergency departments don't have quick access to those specialists. The result is an increase in difficult births and a resulting surge in babies and mothers experiencing health problems, including death.

That's true in New Hampshire, a decidedly rural state in northern New England with one teaching hospital (Dartmouth-Hitchcock Medical Center) and a network of smaller hospitals and clinics overseeing a population of roughly 1.4 million. Aside from lack of access, residents also must contend with rough terrain and snowy winters, making travel difficult.

The lack of resources for pregnant families "is projected to get worse, and it's happening all over the country," says Curtis. "We're seeing these [complicated births] more often, and even bedside teams are asking for our help."

Dartmouth Health's answer is two-fold. Using a one-year HRSA grant, the health system created a virtual STONE program, and has seen more than 120 rural providers and EMS personnel go through the program so far. The program gives providers the education they need to handle difficult births and uses simulation to guide those providers through various scenarios.

Beyond training rural providers to handle difficult births, Curtis and Patricia Lanter, MD, MS, associate professor of emergency medicine at Dartmouth-Hitchcock's Geisel School of Medicine and associate program director of the emergency medicine residency program, saw an opportunity to integrate the health system's robust telehealth network. Dartmouth Health Connected Care, which launched 11 years ago, now offers eight different telemedicine services across the state through its hub at Dartmouth-Hitchcock Medical Center in Lebanon, including TeleEmergency care at 13 hospital EDs and TeleICN (neonatal intensive care) services at 11 sites.

Through the Lebanon hospital, the health system's telehealth team can connect providers in distant and remote locations with ED doctors or OB-GYN or TeleICN specialists to handle difficult births and resulting in care for both the mother and baby.

Lanter says rural healthcare providers "are scared to death" of having to handle complicated births and are eager to have experts on a real-time audio-visual platform helping them. It's also important, she says, to have those specialists on hand to help providers when something goes wrong, such as the death of a baby or mother.

Curtis says the Tele-ED program has assisted in roughly five OB emergencies since the program was launched in May, while the TeleICN platform has been called in, on average, five times a month to help with infant care. And he expects those types of emergencies to become more frequent and complicated as rural healthcare sites struggle to stay open and difficult pregnancies and births increase.

But while the program is no doubt saving lives, it's also expensive. Curtis says the price tag to keep the hub manned 24 hours a day every day is prohibitive, particularly in a region where there aren't that many emergencies.

"TeleEmergency [care] still isn't pervasive at all in this country," he says.

Curtis and Lanter say they'll look for ways to make the STONE program sustainable. As for the Tele-ED platform, Curtis says that will remain open, as it's part of the health system's core mission. They charge a subscription rate to each hospital in the network, he says, but that doesn't cover the overall costs.

"It's very expensive," he says. "We couldn’t offer a break-even price because no one could afford it."