The nursing profession has seen many changes in the 21st century and continues to find new and innovative ways of delivering care. Along with changes in the way health care is delivered come changes in the way providers are reimbursed as well as the reimbursement rate. No matter what end of the healthcare system you are on, it is safe to say that times are challenging.
With the greying of the nation and the healthcare system in its current state of ill health, something has to give. Is telehealth the cure? Can this healthcare delivery method take the place of face-to-face medical care? What role does the registered nurse play in the delivery of such care especially when dealing with the most vulnerable patients, those with Alzheimer’s disease and other dementias?
The aging population continues to grow and it is no secret that people are living longer thanks to innovations in healthcare and chronic disease management. Science however has yet to discover long-term management of brain disorders such as Alzheimer’s disease and other dementias. The term dementia is an umbrella term that is used to describe a disease or condition that affects the brain’s ability to function properly.1 Dementia is a debilitating disease which robs victims of their memory and eventually the ability to complete simple tasks like dressing and eating, tasks most of us take for granted. People with dementia (PWD) progress to the end stage of the disease over years and often need 24-hour care by the time they reach the mid to final stages. “By 2025, the number of people age 65 and older with Alzheimer’s disease is estimated to reach 7.1 million-a 40 percent increase from the 5.1 million age 65 and older affected in 2015.”1
The Price of Dementia
The cost of caring for a PWD is great. “Total payments in 2015 (in 2015 dollars) for all individuals with Alzheimer’s disease and other dementias are estimated at $226 billion.”1 Preventing hospital visits could potentially save millions in healthcare dollars every year. Health care services such as ambulances, emergency rooms, hospital stays, skilled nursing facilities, and home health care are used more by PWD than those without and even more so by people with both chronic diseases and dementia.1 “With changes in the healthcare delivery and reduced hospital lengths of stay over the past decade, family caregivers are serving increasingly as health care extenders.
This reality must not be underestimated when incorporating technology into the home settings of adults with severe disabilities. Without the incorporation and education of family caregivers, adherence with treatment regimens and long-term recovery from severe disability may be compromised.”2 This is an important statement. Family caregivers are rarely educated in healthcare or the special needs of the PWD making caregiver strain a very likely outcome and the potential for neglect and abuse a real concern.
Telehealth
“Telehealth is the use of technology to deliver health care, health information or health education at a distance.”3 Can telehealth serve as an option to help keep those suffering with dementia in their homes longer by assisting caregivers with the day-to-day challenges of caring for a loved one with dementia? One way telehealth could be utilized in the care of the PWD and their caregivers is by having registered nurses available 24 hours a day and 7 days a week to take phone calls or engage in video chats. The nurse would answer questions about care including but not limited to, behavior changes, signs and symptoms of dehydration and or infection, cardiac distress, or neurological changes. During the telephone interview the nurse uses a series of algorithms and protocols to assist in the construction of recommendations for the caller.4
Nurses would be assigned to specific families so that a nurse-client relationship can be built. This enhances trust and would likely allow for a more thorough head to toe assessment over the phone via the caregiver. The nurse gets to know the caregiver as well as the patient. After the assessment information is collected the nurse can advise on the next step to take. A call to a doctor may be most appropriate or perhaps a visit to an emergency department, or the situation may call for recommendations to treat at home. “The majority of people taking care of a PWD in the home, usually family members, felt very much alone in their battle. After the diagnosis of dementia in their loved one they felt abandoned by the physician and needed someone to help them navigate the system and for support in their daily struggles.”6 In addition to clinical assessment and recommendations the nurse could offer emotional support. Caring for a PWD puts a strain on the emotional health of the caregiver and having someone to just listen can be invaluable.
Challenges in Telehealth
There are however some pitfalls to this type of nursing care delivery with some more obvious than others. First, nurses would need special training on how to elicit a thorough assessment through a caregiver over the phone. This is not always easily done. Caregivers will need to buy into this type of healthcare delivery and change their habits of visiting the emergency department with slight changes in condition. In order to video chat the caregiver must be fluent in the use of this type of technology and have the means to support it. Still the biggest problem lies in reimbursement. Who will pay for this service? If insurance companies would look at this service as preventative treatment by keeping people out of hospitals, and nursing homes maybe they would see the vital need for this service and authorize payment.
Future of Long-term care
As a long-term care nurse for my entire career I have seen the changes in the industry over the years. Gone are the days of entering a long-term care facility because you are old and need some assistance with activities of daily living. Today, the majority of residents in long-term care facilities are in the mid-to-late stages of dementia. Most have behavior issues and or need total care. There comes a time when it is no longer possible for a loved one to care for a PWD at home and when this happens they often turn to nursing home placement as an alternative. In 2012 the United States had a total of 1,646,302 certified nursing home beds.5 Nursing home placement will likely become increasingly difficult to find due to over-crowding. Caregivers will need an alternative to long-term care placement and telehealth could be the answer.
References
1. Alzheimer’s Association. Alzheimer’s disease facts and figures.
https://www.alz.org/facts/downloads/facts_figures 2015.pdf. Published 2015. Accessed May 26,2015
2. Forducey PG, Glueckauf RL, Bergquist TF, Maheu MM, Yutsis M.
Psychol Serv. 2012 May;9(2):144-62. doi: 10.1037/a0028112.
3. United States Department of Health and Human Service. Telehealth. http://www.hrsa.gov/ruralhealth/about/telehealth/ Accessed June 5, 2015
4. Jones M, Hendricks J, Cope V. Toward an Understanding of Caring in the Context of Telenursing. International Journal For Human Caring [serial online]. March 2012;16(1):7-15. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 1, 2015.
5. Henry J. Kaiser Family Foundation. Overview of nursing facility capacity, financing, and ownership in the United States in 2011. http://kff.org/medicaid/fact-sheet/overview-of-nursing-facility-capacity-financing-and-ownership-in-the-united-states-in-2011/ Accessed on May, 27 2015
6. DiZazzo-Miller, R, Pociask, FD, Samuel, P. Understanding resource needs of persons with dementia and their caregivers. Michigan Family Review, 171-20.
http://quod.lib.umich.edu/m/mfr/4919087.0017.102/–understanding-resource-needs-of-persons-with-dementia?rgn=main;view=fulltext;q1=dementia. Published 2013. Accessed June 1, 2015
Linda Kaufman, RN, is a long-term care nurse and a current RN-BSN student at St. Joseph’s College of Maine.
