Telehealth in a Long-Term Care Facility

Using Telehealth in Long-Term Care Facility: an Experience from Thailand

Nahathai Wongpakaran, MD, FRCPsychT, Issaren Nantasen, MD, Narawit Krungvong, MD, Tinakon Wongpakaran, MD, FRCPsychT, Yupapan Siri-ai, BSc, MEd, Pairada Varnado, BSc, MSc
Department of Psychiatry, Faculty of Medicine, Chiang Mai University

Introduction 

During the COVID-19 pandemic, every sector of healthcare service needs to adjust itself to the “new normal” to maintain adequate and proper services to patients. As physical distance policy is one of the effective methods to reduce COVID-19 transmission, long-term care (LTC) facilities for older people are also largely affected. We would like to share our experience in using telehealth care during the COVID-19 spike at our LTC Facility in Chiang Mai, Thailand.

LTC Facility 

The Thammapakorn Social Welfare Development Center for Older Persons is a provincial LTC home, funded by the government and is 15 min away from Maharaj Nakorn Chiang Mai, Faculty of Medicine, Chiang Mai University. We, as one of a multidisciplinary team, comprising geriatric psychiatrists and psychiatry residents, occupational therapists, psychologists, pharmacist, gerontologist, and nurses, have been providing mental health (MH) services and education to staff and patients at this LTC home on a monthly basis since 2010. Since the government has legislated by emergency decree and declared public policies, as of March 2020, such as work-from-home, strict shelter-in-place and physical distancing, the hospital decided to hold the usual health services delivery to the facility. Our team, therefore, uses “telehealth” to provide virtual health care services to the residents and to continue with education and training to staff and caregivers.  

Team Preparation 

Staff, equipment and broadcasting facility preparation is the first step. The staff come from two teams, the hospital’s MH team and the LTC Facility team. The hospital’s team, including a geriatric psychiatrist and psychiatric residents, provide interviewing, examining, diagnoses, treatment planning, and prescribing. When a patient needs an immediate evaluation, physicians will provide a prompt investigation, intervention, or even transfer to the hospital. A clinical psychologist (and students) and an OT (and students) provide non-pharmacologic group treatment while a gerontologist offers individual counseling for the patients. The nurses from the Health Promotion and Disease Prevention play an important role in case managing and coordinating among team members. A pharmacist checks with rationale drug use, adverse drug reaction, and adherence. 

On the LTC home side, the staff comprises social workers, nurses, an occupational therapist, and caregivers. Patients who can mobilize are queued while the immobilized ones are waiting at their beds. The patients were assessed for vital signs, brief cognitive tests (e.g., MoCA, MMSE), the Geriatric Depression Scale, and functional assessment beforehand. 

Software/application and Device Preparation 

The team uses Zoom® to deliver the telehealth services via computers, tablets, and smartphones due to its convenience in breaking into multiple rooms. 

Activities at the LTC Home  

The team members maintain the activities as usual, i.e., began with a 1-hour new case conference, which is an interprofessional team meeting. The nurse and the social worker at the LTC home prepare and present the case. Discussion about the resident’s conditions is held by everyone to formulate a diagnosis and treatment plan.

After the case conference, each staff made a virtual visit with each patient in the breakout rooms. Psychiatry residents interview the patients and notify the geriatric psychiatrist staff at the main room to confirm with the diagnoses and, finally, plan for the management.

The broadcasting space was set up in each individual’s office using personal computers and a hospital computer, which is able to access the patients’ data through the hospital server. While on the other side, staff and patients at the LTC facility connected to the telehealth program and broadcasted from a private space, i.e., meeting room, patients’ beds. It was conducted a one-on-one, face-to-face basis. The same principle and process of approach as the usual face-to-face visit was employed despite using the virtual visit. The approach for each patient ended by lab investigating, prescribing medication, and scheduling the next appointment.

The holistic care concept and multidisciplinary care were also provided as usual, i.e., the occupational group therapy for cognitively intact residents and the cognitive training/rehabilitation group activities for residents with mild and major neurocognitive disorders. The total time spent on each visit is 3.5 hours on a monthly basis. 

Benefits of Telehealth 

Telehealth created an auspicious impact on MH care during the outbreak of COVID-19 due to the reasons stated below. 

1. The team could maintain MH services to the LTC home. No incidence of depression was observed pertinent to social isolation.
2. Up until July 2020, no transmission of COVID-19 occurred among our team members, the case managers, or LTC residents and caregivers. This Telehealth method clearly demonstrates the efficacy of physical distancing.
3. Telehealth also benefits calling team meetings concerning a crucial situation. It provides team members a convenient and quick access to an urgent summons. For example, in June 2020, a completed suicide case was found at this LTC home. An urgent meeting was set up for a Morbid and Mortal Conference a few days later. Online meeting can overcome the fear of confrontation and reduces conflicts among team members. 

Challenges 

Although providing telehealth services is a very promising strategy during the “new normal” era, some challenges need to be dealt with.  

1. Even though keeping distance cannot hold MH professionals back from providing services, physicians are limited in assessing by physical examination, which at times necessary to diagnose a condition or illness or to evaluate any adverse effects of psychiatric medications. We had one case with altered consciousness and debilitating weakness. The patient was brought to the hospital for a laboratory investigation and then received a diagnosis of hypokalemia and was properly treated at the hospital. This example demonstrates that acting upon the suspicious signs and symptoms should be warranted. Limitation of two-dimensional assessment of telehealth should be highly considered, while other alternative backup interventions should be promptly made available.
2. Visual sight and hearing problems are common among seniors. Some patients can poorly observe therapists through a tiny monitor. Moreover, some cannot hear properly from the devices’ speakers. The barrier also has limited capacity to be adjusted for higher quality communication. 
3. Difficulty is encountered using the technology.  Some team members were unfamiliar with such technology and struggled using these platforms, e.g., difficulty in sharing the presentation, splitting groups or moving between rooms, or even connecting or reconnecting the internet. Nonetheless, the difficulties can be overcome by practicing and supervising. Maintaining a stable internet connection is the crux of the matter. An alternative backup network may probably be the best policy.  
4. Confidentiality. Confidentiality is one of the core values of medical ethics and may be a highly sensitive issue for patients with mental illnesses. Our team is tremendously focused and concerned about this issue. Every healthcare provider and related personnel need to pre-register before joining the meeting and would be provided with the password to access the meeting. The team members endeavor their best to ensure reliable confidentiality using the most trusted platforms recommended by the university and encouraging members to practice medical ethics. 

 In conclusion, telehealth services at LTC home provide knowledge and experience. Benefits, limitations, and difficulties have been investigated, yielding improved telehealth services. This type of service may help establish guidelines and create a model for future practice in geriatric telemental health settings in Thailand.