The COVID-19 pandemic disrupted every single industry and sector of society, with very obvious repercussions for healthcare systems. For hospice care, which is based on compassionate, person-centered care, social distancing restrictions and the requirement to wear PPE meant staff had to get very creative to continue providing the reassuring care their patients needed.
At Heart to Heart Hospice, which cares for patients across Indiana, Michigan and Texas, the technology they began implementing a few years previously as part of their digital journey helped to overcome many of these challenges.
Russ Abercrombie, Chief Information Officer, explains what the first few days were like after the pandemic was declared: "A very serious communication gap was created when the COVID pandemic was declared. It was critical that our care teams remained in contact with their patients and family members and also the staff needed to stay in contact with each other for coordination of care. Within days we procured a video conference solution for each office and deployed the mobile client to over 1800 mobile devices. Additionally, people still needed hospice services, so admissions were made virtually for the first time, and with the CMS 1135 Waiver, telehealth services were allowed, which enabled Heart to Heart’s psychosocial and spiritual care staff members , as well as bereavement support, to remain available.”
The electronic medical record (EMR) also required very quick, specific updates to accommodate changes coming out of CMS.
“It was a challenge that I could never have imagined”, says Abercrombie, but all the hard work we did for the digital transformation really began to pay off.”
Holistic, person-centered care
Modern-day hospice care aims to enable patients who have a terminal illness to be comfortable and as pain-free as possible when they are nearing the end of their lives, allowing them to enjoy the time they have left with their family and friends. More than being a "place" where people are cared for, hospice care is about ensuring all the patient’s needs are met - whether physical, emotional, mental or spiritual. "We meet the patient wherever they are, even if that's under a bridge or at a homeless shelter", explains Heather Lumsdon, Chief Clinical Officer. "We are, in a sense, a hospital without walls."
Lumsdon cites the example of a 39-year-old woman who had terminal breast cancer. Towards the end of her life, she had a lot of difficulty swallowing the medication she needed to keep her pain under control. She was also barely able to move around, to the point where she couldn't change her position in bed. But the hospice's clinical team realised that she was still able to move her thumb, so she was given an IV pump which allowed her to keep her pain under control on her terms.
"When you're in a hospital, you usually don't get that choice," Lumsdon says. "Her family watched her pass away with no pain. There is such a thing as a good death, and it can be beautiful, and it can be peaceful. That's what hospice care is about - literally living well till the very last breath."
It's a common misconception that a hospice is a place where people go to die, but this view is gradually changing. "Here in the US, from the early to mid-2000s, there were around 750,000 people receiving hospice care, now it's more like one and a half million. So definitely there's been a change," Lumsdon says. "When our clinicians identify an unmet need, whether physical or emotional, and refer a patient to the hospice, what we hear over and over again is, "I wish I'd known about this sooner".
There is a natural fear surrounding what a hospice is, but Lumsdon explains that it doesn't have to be this way. "I think that to accept what the hospice is, is to have to face all the things that you've been fighting against, whether you're the patient or the family member. People develop these coping mechanisms like, "well, the cancer hasn't spread yet, so we're still okay". Accepting hospice care unwinds all the coping, and you have to reconcile that there is an end, and it's on the horizon."
"Once you accept that and you embrace the concept of living life every day to the fullest, there's this huge sense of relief," she says. "If we changed the word "hospice" to "relief", maybe more people would see it for what it is."
The US healthcare system is currently undergoing huge changes with value-based reimbursement models and the introduction of patient risk stratification which directly ties into palliative and hospice care. "Hospice, because of the palliative care component, is now being invited to join the care continuum to assist in the care of the seriously ill patient population," Abercrombie says. "This is exciting, because we have a chance to positively affect a seriously ill person’s life by providing palliative care long before hospice services are needed with the expectation of improving their quality of life.
“Short term acute care facilities in addition to provider groups have been using electronic medical records (EMRs) for many years now" Abercrombie says, "The reason for the digital transformation began with Kelly Mitchell, CEO of Heart to Heart Hospice. Kelly saw a need for us to have an EMR so we could join the care continuum on a technological level.“
Abercrombie was hired in 2016 when the hospice began its digital transformation. "We had to start at the very bottom," he says. "The entire infrastructure had to be replaced to support the business and technology vision Kelly had. "Throughout 2016, we replaced the network and re-platformed the data center with enterprise-class core switching, data storage, and a high availability VMware environment. At that time, we were about 29 sites, but by the end of this year, we'll be a little over 50. So we had to build a scalable, flexible, secure infrastructure to be able to support the growth of the company." “The IT Support group, led by David Spitzer, Vice President of Infrastructure and Support, did an amazing job.”
“We selected Homecare Homebase as our EMR partner and began implementing the system in January 2017. The project took an entire year and was led by Patrick McPherson, Vice President of IT-EMR. This was a huge under-taking and with Patrick’s leadership, the team met the challenge.”
Abercrombie emphasises that implementing an EMR and all the ancillary systems is a clinical project first and foremost and cannot happen without a close relationship between the IT and clinical teams. "They know how to care for patients; they know what is needed," he says. "And obviously, we know the technical side and project management. So this was a very close partnership."
While the aim of the hospice is to go digital, there is still a substantial amount of paperwork required, so a document management system was acquired. "Our partner for that is Forcura," Abercrombie says. "They also provide secure texting and secure video services and provide a mechanism for legal consents to be executed electronically. They've been an excellent partner for us.”
"Over the last four years, we implemented a total of eight systems", he adds. A few of them are: Nuance Medical One for physician dictation, traditional dictation for remote patient recertification that automatically flows to Forcura, analytic capabilities, internal communication tools, and Muse-Medalogix AI. ”Technology to improve lives
Muse-Medalogix AI system is the latest system Heart to Heart has adopted. "Muse is an artificial intelligence system that provides a window into the EMR", Abercrombie explains. "One of the large culture changes that happens when you replace paper with an EMR is that all the spreadsheets and three-ring binders’ people used all of a sudden disappeared. All that information is on the computer now, and to get to it; we trained constantly and developed a sundry of tools and dashboards for the agency staff to manage their census. But the Muse AI system has been transformational for us - you can quickly see where your patient resides, how many visits have been made and scheduled, diagnosis, vitals, and many other data points needed for daily patient care."
The system even has a patient level trending chart, which includes nursing notes from past visits, to enable the nursing manager to build a better picture of why the patient might be in decline. "It's been instrumental in enabling the care teams to get their arms around the data and then to turn that into care", Abercrombie says.
The AI capabilities provided by Muse have been particularly important in this respect. "Part of our mission is to be present [with the patient] at the most important time," Lumsdon says. "Muse allows nurses to focus on where the patient is today, and it alerts our team if their condition changes. Coming from an old-fashioned paper world, I used to carry binders around when I was on call, containing a list of patients, their addresses and their medication. Now I can use my laptop or tablet to go into a chart in real-time and to see what's going on with the patient."
"This also helps us to see any changes happening that we need to discuss as a team and if we need to increase our services. It's really helped us to see a patient's trajectory - each illness process has its own trajectory, and Muse helps you to map this out over time," Lumsdon says.
The ability to chart the progression of an illness is perhaps even more important in palliative care than primary services, for instance, because there is no second chance to get the care right. "A patient may be with us for four months. If we miss that patient's transitioning and we weren't there at the end, there is no do-over," Lumsdom says.
"Guided by the data, we've actually seen our visits go up in the last three to seven days of a person’s life. When we look at our performance compared to other hospice providers, we have more visits, and that typically translates to better care because we're there at the end of the patient's life," she adds.
"Nurses don't work in hospice care because they want to do a lot of paperwork, they do it because they want to be at the bedside" Seeley Avery, VP of Marketing and Education, says. "Behind the scenes, we can use technology systems or processes to increase that bedside time and those conversations. That's what feeds the souls of nurses, and anything other than that can be very frustrating."
The EMR has vastly increased the amount of time nurses can spend at the bedside. "They used to spend so much time doing paperwork", Avery adds. "Once you're trained in how to use the EMR, it's so much easier. We'd hear of nurses who, after tucking their kids into bed, would then have several hours' worth of documentation to write up. Now they can document it into one system before they leave the hospice patient and then go home and get back to their lives. If it improves their lives, that improves their care and employee satisfaction, and it's just this whole upward spiral."
"It's been a huge ride," Abercrombie says of the last four years. "I won't say smooth, but with a clear, direct partnership with the clinical team and Heather, it's been really enjoyable and rewarding. We've had some hard times changing the culture, but we are here to care for the patients and their families. We do that by providing stable, flexible, secure technology that works consistently. We don't want staff to worry about whether their tablet is going to boot up or a system is not available. Ultimately it's all about the patient."
- Heart to Heart HospiceDigital Transformation