Telegeriatrics

A Pilot Project to Reduce Unnecessary Hospital Admissions of Nursing Home

Residents in Singapore

H. J. Toh

, Chia J.

, E. Koh

, K. Lam

, G. C. Magpantay

, C. M. De Leon

, J. A. Low

gericare@north, AHS programme office, Khoo Teck Puat Hospital, Singapore, Singapore

Ageing-In-Place, AHS Programme Office, Khoo Teck Puat Hospital, Singapore, Singapore

Department of Geriatric Medicine and Palliative Care, Khoo Teck Puat Hospital, Singapore, Singapore

Keywords: Telemedicine, Telecommunications, Healthcare, Hospitalizations, Nursing Home, Nursing Home Residents,

Community Care.

Abstract: Geriatric specialists have been scarce in Singapore and this has drawn attention to a rising need in providing

quality care for the ageing society. Access to geriatric care could decrease nursing home to acute hospital

transfers, thus improving residents’ quality of life. A pilot project implemented by an acute hospital in

Singapore aims to use videoconferencing systems to improve access to geriatric specialist care for nursing

homes and thereby reduce unnecessary acute hospital admissions. We aim to assess the impact of the level

of engagement with Telegeriatrics has on nursing home to hospital transfer rates. Two nursing homes were

recruited from December 2010 to March 2014. A total of 379 telemedicine consultation episodes were

conducted over this period. Hospital admission rates were monitored over a 2-year period and compared

against the nursing home’s level of engagement with Telegeriatrics. The more-engaged nursing home

reported a significant decrease of 29% in hospital admission rates. In contrast, the less-engaged nursing

home only reported a 6% decrease. The findings show a reduction in hospital admission rate for both

nursing homes. When the two nursing homes were compared, the nursing home that was more engaged with

Telegeriatrics had a lower rate of unnecessary hospital admission. Telegeriatrics has the potential to reduce

unnecessary hospitalisation frequently experienced by nursing home residents. Furthermore, a decrease in

hospital readmission rates enables hospital beds to be better utilised, reduces medical spending and relieves

residents’ distress.

1 INTRODUCTION

Older people often require complex healthcare

treatment which may include hospitalizations.

However, several studies have shown that a large

percentage of people aged 65 years and above were

sent to hospitals for potentially preventable

conditions (Kim, et al., 2001; Wolff et al., 2002).

Singapore faces a rapidly ageing population and

a greater prevalence of chronic diseases (Cheah and

Heng, 2001; Cheah, 2001). Frequent hospitalizations

of nursing home (NH) residents is a growing

concern in Singapore as they result in increased

healthcare costs, hospital-acquired infections,

complications and morbidities. Furthermore, the

hospitalizations exert pressure to the healthcare

system’s problem of severe bed crunch (Tan, 2013).

Therefore, interventions involving frail NH residents

are needed to reduce unnecessary hospital

admissions while improving quality of care.

The specialized field of geriatrics has improved

diagnosis and treatment of common geriatric

problems such as falls (Tinetti et al., 1994), urinary

incontinence

, and delirium (Inouye, 1999). In order

to develop comprehensive care plans for frail elderly,

geriatricians also address social issues like economic

and demographic issues, lifestyle choices, social

isolation, and caregiver stress. Assessing and

considering these factors into an integrated plan of

care result in reduced rates of hospitalization, with

some studies suggesting a reduction in medical care

spending (Day and Rasmussen, 2004; Ellis et al.,

2011).

Currently, care of NH residents is largely

provided by the nursing staff and supplemented by

occasional visits by general practitioner. Lack of

J. Toh H., J. C., Koh E., Lam K., C. Magpantay G., M. De Leon C. and A. Low J..

Telegeriatrics - A Pilot Project to Reduce Unnecessary Hospital Admissions of Nursing Home Residents in Singapore.

DOI: 10.5220/0005436800910096

In Proceedings of the 1st International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AgeingWell-

2015), pages 91-96

ISBN: 978-989-758-102-1

 2015 SCITEPRESS (Science and Technology Publications, Lda.)

geriatric specialist care has led to sub-optimal care

and potentially preventable NH to acute hospital

transfers (Ouslander et al., 2009).

Videoconferencing is a possible method to

provide telemedicine (Moehr et al., 2005; Casavant

et al., 2014) and tele-education (Graham, 2002;

Pedley, 2003). Telegeriatrics is an acute hospital’s

initiative to extend care from the acute hospital to

the NHs in the northern part of Singapore. Initiated

in December 2010, Telegeriatrics enabled the acute

hospital to deliver geriatric medical care to two

partnering NHs via videoconferencing. The aim of

this intervention is to promote early identification of

potential medical problems in NH residents so that

appropriate and timely medical interventions can be

carried out. Early medical interventions can reduce

the deterioration of medical conditions and non-

urgent use of emergency departments. In order to

achieve this aim, two main approaches are used in

Telegeriatrics: telemedicine consultation and

Telegeriatrics Nurse Training Course (TNTC).

Telemedicine consultation is a live, interactive

video technology that allows the NH nurse and

resident to communicate with the geriatrician

remotely. TNTC is a 9-months course that aims to

enhance the knowledge and skills of NH nurses to

carry out telemedicine-specific duties and improve

the management of medical conditions. Activities

that are necessary for the proper governance of NHs,

for example, multidisciplinary meetings and

mortality audits, are conducted regularly through the

videoconferencing system.

This study was conducted to assess whether

increased level of engagement with Telegeriatrics

translates to lower hospital admissions.

2 METHODS

2.1 Ethics Approval

Ethics approval was obtained from the National

Healthcare Group Domain Specific Review Board

(DSRB).

2.2 Recruitment & Setting

Over the study period from December 2010 to

March 2014, two non-profit NHs agreed to

participate in the study. They were selected as they

had existing partnership with the acute hospital.

NH1 began its partnership with the acute hospital

in December 2010 while NH2 joined in April 2012.

During the study period, both NHs were not

involved in any other interventions related to

reducing residents’ hospital admissions.

2.3 Telemedicine Consultation

The technology involved in this project included

software, hardware, and infrastructure setups. The

equipments used for carrying out two-way

videoconferencing included a high-resolution

camera and high-definition video monitor installed

in the acute hospital and the two NHs. These

equipments were mounted on a portable trolley

enabling telemedicine consultations at different

locations. For example, residents on wheelchairs

arewere wheeled to the consultation room while bed-

bound residents will have telemedicine consultations

by their beds.

Before consultation, the TNTC-trained nurse

identifies residents requiring specialist care for

consultation. During consultation, the nurse presents

the residents to the geriatrician, and conducts basic

clinical assessments on the residents. The

geriatrician discusses the medical problems with the

nurse and recommends a treatment plan. The

telemedicine consultation is documented in a

telemedicine consultation form. After consultation,

the form is endorsed by the geriatrician and emailed

to the NH so that the nurses can follow up with the

treatment plan. The form is then filed in the

resident’s case notes.

2.4 Continuous Nurse Training &

Education

Before telemedicine consultations can be carried out,

selected registered nurses from the NHs have to

undergo the TNTC to equip them with the necessary

skills and knowledge. This course is conducted by

the acute hospital’s clinical educators. The TNTC

includes early identification of changes in residents’

medical condition; presenting and documenting

residents’ case history in a systematic way; and

management of basic medical conditions.

In addition, as a part of continuing nursing

education, multidisciplinary meetings were held

among the geriatrician, the TNTC-trained nurses,

and other healthcare professionals. The purpose is to

promote discussions and knowledge-sharing on the

diagnostics and treatment aspects of resident care,

allowing for collective, evidence-based

recommendations, for better resident management.

In a mortality audit session, the geriatrician and

the nurses review deaths of particular residents to

identify and evaluate deficiencies of care in

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e-Health

practices, and make recommendations for

improvement.

2.5 Data Collection

We measured and compared the hospital admission

rate of two NHs from December 2010 to

March 2014. The hospital admission rate was

measured at two points: before joining Telegeriatrics

and 2 years after joining Telegeriatrics.

Hospitalization rates were obtained from the

monthly data sent by the NHs to the acute hospital.

Other data including demographics, health data and

consultation details were collected from the Resident

Assessment form (RAF), resident case notes and

telemedicine consultation form.

2.6 Statistical Analyses

Factors that affect the NH’s extent of engagement

with Telegeriatrics include number of scheduled and

ad-hoc telemedicine consultations, multidisciplinary

meetings and mortality audits. We defined the NH

with the higher number of telemedicine-related

activities as “more-engaged”, and the other NH as

“less-engaged”.

In examining NH residents’ hospitalizations, a

comparison of hospital admission rates before and

during intervention was conducted. Univariate

analysis was performed to study the differences

between the more-engaged and the less-engaged NH.

We also investigated whether the factors that

influenced the level of engagement with

telemedicine had any impact on the NH’s hospital

admission rates.

Data was analyzed using SPSS version 22.0 for

Windows (SPSS Inc., Chicago, IL, USA).

3 RESULTS

A total of 379 episodes of telemedicine consultation

were conducted for 198 unique residents during the

study period. The average consultation time per

resident is 22 minutes (range 5-75 minutes). In 90%

of the consultations, the resident had multiple

comorbidities. Polypharmacy was present in 35% of

the consultations. Recent history of admission

(within the last 6 months) was present in 34%. The

demography of residents who have undergone

telemedicine consultation is summarised in Table 1.

The average age of residents of the two NHs

requiring specialist telemedicine consultations was

75 years (range 15-103), with 78% aged 65 years

Table 1: Demography of residents (N = 198).

Characteristic

NH1

(N=101)

NH2

(N=97)

Gender

Female

65 (64%) 38 (39%)

Race

Chinese

87 (86%) 69 (71%)

Malay

5 (5%) 12 (12%)

Indian

4 (3%) 16 (16%)

Others

5 (5%) 0 (0%)

Functional Category

0 (0%) 1 (1%)

3 (4%) 5 (5%)

III

46 (45%) 49 (51%)

52 (51%) 42 (43%)

and older. Their average length of stay in the NH

was 35 months (range 1-275). Majority were

Chinese, and almost all belonged to the functional

category III and IV. NH residents’ physical,

psychological, social and emotional needs are

assessed using the RAF and classified into 4

functional categories from I to IV. Those in category

I are the least dependent on others for care while

category IV residents are fully dependent on others

for care.

Table 2: Factors affecting the level of Telegeriatrics

engagement.

Factors

NH1 NH2

Scheduled consultations 72 52

Ad-hoc consultations 17 8

Residents seen at

scheduled consultations

207 147

Residents seen at

ad-hoc consultations

17 8

Multidisciplinary meetings 18 3

Cases reviewed during

multidisciplinary meetings

37 4

Mortality audits 15 7

Cases reviewed during

mortality audits

39 12

Table 2 presents the factors affecting the NH’s

engagement level with Telegeriatrics. NH1 carried

out more telemedicine-related activities when

compared to NH2. Significant differences were

found in factors such as the number of scheduled

telemedicine consultation sessions, residents who

have undergone telemedicine consultation and cases

reviewed during multidisciplinary meetings.

The presenting complaints that led to

telemedicine consultations are presented in Table 3.

The overall ranking of presenting complaints

reveals that dementia-related behavioural problems

Telegeriatrics-APilotProjecttoReduceUnnecessaryHospitalAdmissionsofNursingHomeResidentsinSingapore

Table 3: Most common presenting complaints referred for

telemedicine consultations.

NH1

Presenting

Symptom (%)

NH2

Presenting

Symptom (%)

Behavioural problem (32) Behavioural problem (27)

Medication review (18) Medication review (14)

Skin lesion / rash (8) Management review (8)

Fever (6) Oedema (7)

Poor appetite (4) Skin lesion / rash (6)

were perceived by the nurses to be the most

unmanageable. It was the top presenting problem

referred for specialist telemedicine consultations.

The next most frequently referred presenting

problem by the NHs was medication review. In a

study conducted in NHs in Singapore (Mamun,

2004), a high prevalence of polypharmacy and

inappropriate medication use is observed in the NHs.

The current practice of medication use in the NHs

may lead to adverse drug reactions and interactions.

Review of medication on a timely basis is therefore

a good practice for the geriatricians to adopt to

reduce polypharmacy (Walsh and Cussen 2010;

Finkers et al., 2007).

Skin-related problems such as rashes and

cellulitis were also referred by the NHs for

consultations. The other common presenting

complaints were different for the two NHs. NH1

prioritized fever and poor appetite as concerns which

required specialist consultation, while the NH2 tend

to seek consultations for a follow-up review of

previous management and oedema.

The most common diagnoses made by the

geriatricians during telemedicine consultations are

shown in Table 4.

Table 4: Most common category of primary diagnoses in

telemedicine consultations.

NH1

Diagnosis

Category (%)

NH2

Diagnosis

Category (%)

General (31) General (26)

Neurologic (23) Psychiatric (19)

Skin rash (17) Infectious (17)

Psychiatric (13) Neurologic (12)

Neoplastic (7) Skin rash (7)

The most common category of primary diagnoses

made in telemedicine consultations for both NHs

was general (mainly poor appetite, muscular pain,

constipation, and nausea).

The other common diagnoses were neurologic-

related (mainly vascular dementia and Alzheimer’s

disease), psychiatric-related (mainly depression and

anxiety) and skin rash. Other conditions in the NHs

were more commonly diagnosed as infectious-

related (mainly cellulitis, infected wound and

pressure ulcer), and neoplastic (mainly metastatic

lung cancer).

Figure 1: Average monthly rate of hospitalizations per

100,000 resident days.

The average monthly hospitalization rate for NH1

before joining Telegeriatrics was 144 per 100,000

resident-days (Figure 1). At two years after joining

Telegeriatrics, the hospitalization rate had

significantly decreased by 29%. In NH2, a 6%

decrease in hospitalization rate was observed 2 years

after joining Telegeriatrics (P>0.01).

4 DISCUSSION

NH1 is categorized as “more-engaged” as it had a

higher number of telemedicine-related activities, and

NH2 as “less-engaged”.

We observed a statistically significant effect with

the use of telemedicine on hospitalization rates in

the more-engaged NH. Similarly, in a study

where

the 4 more-engaged skilled nursing facilities were

compared with 2 less-engaged ones, a significant

decline was found in the hospitalization rate of the

more-engaged facilities. The hospitalization rate for

non-engaged facilities was very similar to that of the

control facilities. Hence, it is likely that if NHs were

to be less engaged in the intervention, they appear to

perform like NHs which were never exposed to the

intervention.

Telemedicine may contribute towards achieving

the goal of improving clinical care. Its potential role

in addressing issues arising from an ageing

population, chronic conditions and rising healthcare

costs has been emphasized by the European

healthcare community

(European Commission,

2009). Studies have demonstrated that the use of

telemedicine in accessing care improves quality of

patient monitoring, and reduces hospitalizations and

144

190

102

178

More-Engaged NH Less-Engaged NH

Rate of hospitalizations per

100,000 resident days

Pre-Intervention During-Intervention

ICT4AgeingWell2015-InternationalConferenceonInformationandCommunicationTechnologiesforAgeingWelland

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emergency department visits (Smart, 2011; Vander

Werf, 2004; Taylor et al. 2014). A study conducted

by the U.S. Department of Veteran Affairs (VA) on

281 patients with chronic illnesses demonstrated a

significant reduction in emergency department visits

and hospitalizations. Furthermore, there were high

levels of patient satisfaction and improved

perceptions of physical health (McLean et al., 2012).

The two NHs were scheduled for a weekly

consultation session and a bi-weekly session of

multidisciplinary meeting and mortality audit during

the study period. There was no restriction to the

number of cases that can be referred to the

geriatrician for each of these sessions. The less-

engaged NH referred fewer cases to each session

and during the last 3 months of the study period,

there was no telemedicine consultation session due

to cancellation initiated by the NH. However, the

more-engaged NH carried out consultations as per

normal. Also, shortly after the start of Telegeriatrics,

the less-engaged NH experienced a change in

management and three TNTC-trained nurses

resigned. The new management was not actively

engaged in Telegeriatrics. For the more-engaged NH,

there was no management and nurse turnover over

the course of Telegeriatrics. Many struggling

telemedicine programme innovators did not realize

that technology implementation is a social process

and requires the personnel in following through the

programme. The presence of a leader who can

manage day-to-day operations and encourage staff

acceptance is the key to achieve desired changes in

practice and targeted outcomes

. A study showed

that the leading reason for successful adoption of

telemedicine was that the support team had actively

identified barriers and found ways to address them

(Ellis et al., 2001). The programme champions

devoted time and effort in garnering resources for

consistent improvement and innovation, and

encouraging staff adoption (Chaiyachati et al., 2014).

The results of this study must be interpreted with

care because of its small sample size and lack of

randomization. However, this study provided

preliminary results from a comparison between a

more-engaged NH and a less-engaged NH. Hence, it

can be tested more rigorously with enrollment of

larger, randomized and more diverse sample of NHs.

Also, a control NH that did not receive telemedicine

consultations or received face-to-face consultations

was not included.

This study did not include unmeasured

confounding factors that could influence the level of

engagement of the NHs with Telegeriatrics. Thus,

the differences in hospitalizations observed between

more- and less-engaged facilities may not be of

significance, after adjusting for these unmeasured

factors.

Also, in this study, reduced hospitalizations were

regarded as the primary positive outcome of the

Telegeriatrics. Other telemedicine-related outcomes

such as the health-related quality of life and

functional status, and resident satisfaction with care

were not measured.

5 CONCLUSIONS

This pilot project showed promise for reducing

unnecessary hospital admissions among NH

residents. The early identification of clinical issues

and access to specialist support provided alternatives

to hospital care. By doing so, it could potentially

contain costs while optimizing resident outcomes.

It is observed from this study that increased

engagement with telemedicine could be fundamental

in preventing unnecessary hospitalizations. Savings

from hospitalizations were only apparent in the NH

that had a greater usage of telemedicine (Grabowski

and O’Malley, 2014). The intervention, even when

made available to the NH, does not guarantee the

NH staff’s active involvement. Telemedicine

providers will have to put in further efforts to

encourage engagement from the NHs. The

successful adoption of technological-related

interventions was reported to be generally due to

continuous support and comprehensive guidance

from the management (Moehr et al., 2006; Murray et

al., 2011). A team of skilled and knowledgeable NH

staff who work effectively together is crucial to

sustain the operations of using telemedicine, in order

to manage current and future influences.

Further work would be to measure the quality

outcome indicators, in order to better comprehend

the intrinsic value of distance support. These

indicators should measure mortality, cost savings,

and user satisfaction with the programme. Further

research is needed to qualitatively look into how the

NH users perceived Telegeriatrics and the barriers

that they face, which could potentially affect the

NH’s engagement level with Telegeriatrics.

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