The Folly of Unforeseen Consequences: Let’s Talk About Telehealth

4 thoughts on “The Folly of Unforeseen Consequences: Let’s Talk About Telehealth”

  1. Rebecca
    As a Palliative NP that semi-retired I re-engaged in my work through Telehealth.. Yes, in rural communities you have to choose those that are able and comfortable in using telehealth (or computer technology) So at this point, I get the patient with more “urgent” pain and symptom management needs that are willing to do this via “remote” telemedicine. I must say that I at first was reluctant if I would be able to do the more intense conversations, but after several new patient visits, I have learned that visual contact promotes the contact needed to establish a personal relationship. Currently, I am following several patients that are in need of more intense symptom management as my colleague is less comfortable titrating narcotics to manage pain

  2. Great points, as I mentioned, we had increased deaths on service when telehealth was all we had. Major barriers including the patient who would never admit to decline, can’t hear well enough for a phone call, doesn’t know what a computer or smartphone is, or just never answered the phone. I did find it helpful to extend our reach for those relatively stable for an extended period of time, ice and snow storms, and was grateful I could get credit for some lengthy phone calls and coordination with patients in-between visits. Prior to telehealth I would have had to do this on my own time and not be credited for a visit. One day my car broke down and it was all I had. Another time, I was recovering from COVID but not cleared for visits. Winter weather is always a problem. Telehealth also was preferable when families were self isolating for COVID and could wait for an in person visit. During staffing shortages many patients could only receive telehealth while the arduous hiring process grinded on.
    As a very large national practice we have employees who contact patients and explain the services. Unfortunately, they also have scripted responses to rebuttals and seem like telemarketers. I felt like telehealth was used a business opportunity to get patients on service that normally wouldn’t want or accept a home visit. Unfortunately, some never relented and had to discharged later when they refused home visits and were declining and not allowing care. Others agreed only to get off the phone and then screamed at the nurse practitioner calling in for the initial visit. While helpful to extend our reach it does have its limitations.

  3. As a social worker for a palliative care organization serving rural areas via telehealth (yes, when in doubt, call a social worker!) I have been amazed at the impact we have on people suffering with all of the challenges that come with having a complex or life-limiting illness. We help in countless ways with needs both physical and socio-emotional. We are reaching people who would otherwise not have access to palliative care, or if they did the burden of accessing it in person would be nearly insurmountable. We also serve as a defacto hospice provider when there is no licensed agency serving their address. Is it perfect? No, but then healthcare rarely is.

    What I do see is that we make a very positive difference in the lives of our patients. We approach our work with a commitment and integrity that allows us to truly connect (yes, that’s possible using Zoom), to dig in and understand their story, and to partner with them to provide not only symptom management and coordination of care, but also access to income, housing, food, transportation and other basic needs that must be met in order to even approach living well with illness.

    Concerns about large organizations cutting corners or providing scripted and impersonal care are valid. It happens in brick and mortar settings every day. Telehealth is not the issue. People and their priorities are the issue. There is always a way to be more “efficient” while hiding the less effective and less person centered result. So please do more research, with the goal of improving telehealth delivery not eliminating it. There are millions of people needing care, all with different needs and stories, and each one deserves whole person care until the very end.

  4. Thank you for this thoughtful and spot-on analysis. My perspective is from the family caregiver side.

    A total telehealth model also lets companies get around license-based regulations—at least that’s how it was in our state before covid. We discovered this after we had an abusive experience with a telehealth-based palliative provider. The state investigator told us that since the company hadn’t actually provided any hands-on in-home doctor visits or nursing care, and the company was insisting they were just a “care coordinator” that occasionally provided prescriptions and such, the company didn’t need to be licensed as a hospice or home health agency. And since they weren’t a licensed entity, they fell through a regulatory crack beyond reach.

    But that wasn’t how the very expensive (well north of $1,000/month) enrollment had been sold to us. They’d sent a couple of nurses to the house to enroll my family member, and made it sound like it would be Hospice Lite, with nursing visits and medical support. After we signed the contract, we never saw those nurses again, neither in real life, nor virtually. The nurses we did eventually see were provided not by them, but via a referral to an over-burdened home health agency, which was billed to Medicare. The home health agency didn’t want to be on the case, because they said they were for rehabilitation, and my family member obviously had end-stage disease and was better suited to hospice. (Our area’s only hospice had recently discharged my family member, which is why we’d turned to the palliative care company. We were desperate for medical support.)

    Our “palliative care” experience was harrowing and traumatic, involving financial malfeasance and more, too much to go into here. Pull back the green curtain, and there wasn’t much care behind the facade.

    Telehealth has been hugely helpful to us in other ways, with other providers. I’m very grateful the option now exists for some situations. But after our experience, I’ve come to view the telehealth-based palliative care industry with great skepticism.

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