RUNNING HEAD: WIRING IN HOSPICE CARE29

Wiring in Hospice Care: Implementing telehospice in our evolving healthcare systemMichael ThornConcordia University Wisconsin

AbstractWith the growing percentage of elderly people, hospice care will need to be widely accessible. A large percentage of people prefer to die in the comfort of their homes around those they love, not in the hospital. Currently, hospice care is universally offered to Medicare beneficiaries; however, this care remains largely underutilized, particularly in rural settings. The purpose of this paper is to identify the challenges facing the utilization of hospice in rural settings. It will also discuss how the use of telehealth technology can help bridge the wide gap of coverage in rural areas while still maintaining a holistic and palliative approach to caring for the dying patient. An analysis of evidence shows that applying telehealth in hospice care increases accessibility, decreases expenditures, convalesces communication, and still upholds the holistic approach of what hospice is founded upon. Therefore, this paper will provide recommendations to help pave the way to hospice accessibility in rural regions.

IntroductionPurposeHealthcare is a dynamic and ever-changing concept. Changes are made every day to increase safety, decrease costs, increase patient satisfaction, and increase efficiency. In the past, healthcare providers focused mainly on the hospital and clinic platform; however, in recent years the homecare and hospice aspect of the healthcare system has been given much greater attention. Many recent changes in our healthcare system focus on bringing the patient back to their home and maintaining independence, avoiding readmissions, and using the home as a holistic and palliative environment.Technology has engulfed our culture as well as our healthcare system. Health professionals have a long history of utilizing technology to enhance patients care, but these developments tended to stay within primary and tertiary care. With the expansion of telecommunications in the healthcare arena, we are starting to utilize it in home healthcare and in hospice care, where we can reach more patients in rural areas. Our culture has had a longtime tendency of trying to increase the life expectancy of our patients. With the baby boomers reaching retirement and the 65 and older age group dramatically increasing, a majority of our healthcare dollars will go towards this group through Medicare. With chronic issues such as heart failure and diabetes sequelae, we may see an increase in people needing hospice. As a culture, we tend to prolong the inevitable by not letting go of family members who have reached the end of their life. This results in the expenditure of millions of dollars in the United States on life-sustaining efforts. Many people see that hospice is an increasingly strong and crucial component of our healthcare system, but with the need to conserve costs, the decrease in reimbursement, and a decrease in geographical availability, hospice has been underutilized. Through the use of advanced telecommunications to increase access to hospice care, our healthcare system can provide holistic and palliative end-of-life care while decreasing costs.

Significance of telehospiceThe unification of hospice with the use of telecommunications is very important having been raised in a small farming community in Vermont where healthcare and hospice access is limited. Its been noted that too many cases where hospice cannot be accessed due to the terrain, limited availability of hospice agencies, and patients lack of awareness of hospice benefits. Since moving to Minnesota to start a nursing career, some time has been spent working per-diem at a hospice house. There are many patients from rural areas utilizing the hospice house because the hospice agencies do not offer services in the low- populated counties in southern Minnesota. Many of the families wish they could have their loved ones at home, but they must resort to the hospice house, which can be 2-3 hours away from their home. With the trend of trying to utilize more technology in healthcare to help improve patient clinical outcomes, increase efficacy, and decrease costs, it is important to utilize technology in ways where it does not replace the human touch, but to supplement it to provide more time with the patient. Hospice care lends itself to many different types of technology that can be used to help enhance care and nursing productivity. The goals of utilizing advanced telecommunications equipment and software in hospice care is to expand the availability of hospice, increase communication between families and hospice providers, and decrease costs but still maintain quality of care. The first part of this paper will explore the history of hospice care and the current limitations to access. The second part will introduce telehealth technology and explore telehospice as a potential solution to hospice underutilization.

Overview of Hospice

Definition and history Hospice has grown in awareness and utilization throughout the years, but the term actually sprouts from medieval times: The term hospice stems from the Latin word hospitium meaning guesthouse. During the medieval times, hospice was used to describe a place of shelter for weary and sick travelers returning from religious pilgrimages (What is Hospice, 2013). Today, hospice provides medications and palliative care, informs patients and family members about the dying process, and offers emotional and spiritual support.Historians believe that hospices started to become prominent around 1065. The crusading movement in the 1090s brought a bout of ill travelers that were close to death. In the early 1300s, the Knights Hospitaller of St John of Jerusalem opened the first hospice in Rhodes, meant to provide refuge for travelers and care for the ill and dying (What is Hospice, 2013). Hospices flourished between the 1300s and the 1800s but soon declined as religious institutions took over the role of hospice providers (Lewis, Milton & James, 2007). This resulted in nuns and monks taking in those who needed care and compassion during the end of their life. A more modern definition of hospice helps encapsulate the holistic nature of this core concept in medical and nursing care: Hospice is a care concept aiming to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure oriented treatments (Demiris, Oliver, & Courtney, 2006). This hospice care model carries on and resonates among hospice agencies.The modern hospice movement did not begin until the 1960s when Cicely Saunders, a registered nurse from England, established the first hospice house in London. Saunders was inspired to pursue the expansion of the hospice philosophy was when she was tending to the care for a dying Polish refugee. This helped coagulate her ideas about the need to provide compassionate end-of-life care and manage symptoms rather than treat diseases. Saunders then volunteered her time at the St. Lukes Home for the Dying Poor. This is where she became inspired to pursue a medical degree because she was told that she could have better influence on others as a physician. To help pave her work into other parts of the world, Saunders went to the United States to introduce her model of care. She went to Yale in 1963 where she lectured many professionals on hospice care, including social workers, medical students, chaplains, and nursing aides. Her establishing of Saint Christophers, a hospice house in London in 1963, was the first program of its kind that focused on using pain management modalities to care for people who were dying (What is Hospice, 2013). Because of her influence on healthcare professionals in the United States, Saunderss work inspired the foundation of the Connecticut Hospice in Branford, CT. Despite multiple legislative movements to help provide financial support to hospice programs, it wasnt until 1982 that Congress provided the Medicare Hospice Benefit (MHB) in the Tax Equity and Fiscal Responsibility Act. In 1986, Congress made the MHB permanent and hospice facilities were given a 10 percent increase in reimbursement rates (Hospice Care, 2013). In 1989 and 2001, Congress approved Medicare to increase reimbursement rates and also tied the reimbursement in conjunction with the hospital market basket (Hospice Care, 2013). This would allow the hospice reimbursements to be sustainable and not need an action of Congress to allow reasonable reimbursement that coincides with the market costs. It is important to understand that hospice care is an interdisciplinary team approach that involves a wide array of providers to help optimize the patients comfort and quality in the end of their life. Even though there are many licensed providers that can assist in the care of the hospice patient, the main provider in hospice care, at least a majority of the time, is the patients family members acting as caregivers. That is why support for the caregiver is essential to ensure burnout or emotional distress is minimized or phased out. Members of the hospice care team visit the home to help enhance the caregiving and help with specific specialized cares that need to be done and to provide education in the care of the patient or family member.

Current utilization of hospiceHospice care used to be viewed as giving up, but through campaigns by Medicare and increased public awareness, hospice has seen a recent surge of utilization: Between 2005 and 2009, the number of people receiving hospice care rose 30 percent to 1.56 million, according to the National Hospice and Palliative Care Organization. In fact, the Centers for Disease Control and Prevention estimate that more than 4 out of 10 deaths in the United States occur under the care of a hospice program (Utterback, 2011). Through public campaigning and the increase in awareness of Medicare benefits, the utilization of the MHB has greatly increased from in the past. Despite this increase in use, however, hospice care remains largely underutilized. In addition, hospice initiation is often put off until the very final stages of the patients life, when it is too late to reap the full benefits of holistic hospice care.Hospice is provided in a number of ways in the United States. Some hospice agencies have in-hospital hospice or hospice houses, where it may be easier to manage the care. But the majority of hospice utilization is done in the patients home. According to Parker Oliver, Demiris, Wittenberg- Lyles, and Porock (2009), nearly 75 percent of hospice services are delivered in the patients residence. Therefore, it is imperative that hospice agencies find ways to be efficient in seeing these patients on a routine basis, especially in the rural setting. It should be remembered that hospice care is not solely for the elderly population or those with Medicare benefits. In some cases, middle-aged people and even children suffering with terminal conditions opt to have hospice care versus traditional tertiary care. The initiation of hospice can be quite lengthy and extensive. In some states, hospice can only be initiated when two physicians sign that the patients life is limited to within 6 months and that the patient has refused to undergo the current curative methods to help battle the disease or condition or all other options of treatment have been exhausted. At this point in time, Medicare does not authorize that nurse practitioners can sign this certification. When the physicians have completed the referral, the MHB is initiated and any life-sustaining treatments are discontinued. Medicare will continue to pay for medications that aid in symptom and pain management, but Medicare usually denies payment authorization for any other treatment.

Limitations to accessAs with other types of healthcare, there are many limitations to hospice access that explain the underutilization of services. These limitations include the geographical location of hospice beneficiaries, financial reimbursements, late referrals, and difficulty in hospice staffing. All of these limitations can be addressed through the use of telehospice, which will be discussed in the second part of this paper.

Limitations due to geographical locationGeographical location greatly impacts access to hospice care services. Compared to urban and suburban areas, Americans in the rural communities tend to have higher rates of unemployment and are less likely to have health insurance coverage. This consequently makes these rural residents more prone to health disparities. Despite the greater need for care, rural residents have less access to healthcare providers because of their locations: Rural residents are more likely to have difficulty accessing a healthcare provider and are more likely to be uninsured or underinsured because they have less access to employer-based health insurance (Franckhauser, 2013). In a 2006 study, Virnig, Ma, Hartman, Moscovice, and Carlin found that while 100 percent of urban areas surveyed with a population of over one million were readily serviced by hospice, only 76 percent of rural areas had similar access. These numbers illustrate how living in a rural area can impede on access to hospice services. Part of this disparity is a result of the low population of people, which may make it difficult for a hospice agency to maintain itself financially. Paradoxically, a large number of rural residents are elderly people with Medicare benefitsthe population most likely to utilize hospice services.

Limitations due to financial reimbursementsAnother major hindrance to hospice access stems from the lack of Medicare reimbursements, which are often not enough for rural hospices to be sustainable. There is a discrepancy in reimbursements depending on where the agency is located: Medicare per diem rates for rural hospices are consistently lower than that of urban areas, because the hospice wage index attempts to adjust for the higher cost of living expenses in urban areas (Casey, 2005). However, the hospice wage index doesnt take into account the cost of traveling long distances to several different homes. According to Casey, approximately 80 percent of rural hospices rely on charitable donations, fundraising, and support from other companies and entities in the community to fiscally sustain a workable hospice agency. In the current state of the economy, hospices cannot rely on charities and nonprofits, since these entities are having financial trouble as well.

Limitations due to late referralsAnother issue that limits access to hospice and palliative care is referrals that are done at the last minute. Rather than focusing on quality of life, our culture tries to prolong life as long as possible through science and technology. This fight to preserve life and not cherish the last moments results in late referrals and underuse of hospice services because physicians, patients, and family members are reluctant to stop aggressive treatments. Because of this, patients either do not enter hospice in time, or they enter hospice but do not obtain optimal pain and symptom management before the end of their life. The sequelae of not controlling pain and symptoms is that some people can mistakenly view hospice as a process of suffering, but in fact, if properly utilized it can be a peaceful time with emotional and spiritual support from the nurses and hospice staff. Currently, more nurse practitioners are entering primary care in rural settings to help offset the vacancies of physicians. Unfortunately, this does not help offset the issue of late hospice referrals because nurse practitioners and physician assistants are not permitted to sign hospice referral forms. According to Franchenhouser (2013), this regulation is particularly troubling for rural communities: In many rural communities, the receiving rural primary care physician often relies heavily on a nurse practitioner or physician assistant, who is not permitted under the current rule to sign the F2F document, thus limiting the patients access to home healthcare and hospice. Not allowing nurse practitioners and physician assistants to fill out a hospice referral form or a face-to-face encounter form for in-home palliative care is a very significant problem that needs to be addressed. Nurse practitioners are more than capable of aiding in the transition of tertiary care to hospice care.

Limitations in staffingLastly, staffing becomes an issue within hospice and palliative care. Because of the fiscal tension and high patient turnover rates, keeping and retaining staff can be a problem that many hospices face both in the urban and rural agencies. Hospice care tends to be not very marketable to those looking for a nursing job because of the frequent fluctuation of patient census. Low patient census results in a large amount of downtime and mandatory time off, while a high influx of patients at the same time can cause a large amount of stress for hospice nurses. According to Casey (2005), Hospices serving rural areas, especially low-volume hospices and those with large service areas, face challenges recruiting and retaining staff and providing coverage 24 hours a day, seven days a week. Joint staffing between agencies has been introduced in certain regions of the country to help consolidate staff and resources, therefore decreasing costs and the need for a large staff of nurses.Staff burnout can be another contributing factor to limitations in hospice staffing. The combination of traveling long distances to patients homes in rural communities and constantly working with families during the grieving process can take a toll on the nurse, chaplain, and the social worker. There is a constant need to help comfort the patient and the caregiver. Although it can be rewarding and very fulfilling, staff burnout is always a possibility from the high stress of the job.With these evident issues that are plaguing the access to care there are solutions to these problems. We have used technology in every realm of healthcare but it hasnt been fully introduced in the care of patients in hospice. With the immense amount of evidence concluding that technology has improved lives, it has also been shown to improve pain and symptom management in patients in hospice as well. We will now explore how implementing telehealth into hospice care can break the many barriers that we see and give those who are at the end of life dignity, comfort, and peace of mind.

Overview of TelehospiceDefinition of telehealthTelehealth is a growing field of medicine and nursing that implements telecommunication technology into healthcare to help improve access, communication, and patient satisfaction; decrease costs; and maintain positive clinical outcomes. According to Demiris (2004), Telemedicine, defined as the use of advanced telecommunication technologies to bridge geographic distance and importance delivery of care, is perceived by many as a way to eliminate barriers to quality care at the end of life. Telehealth has been implemented in many different ways, including video conferencing, vital signs measurement, and educational platforms. With the variety of capabilities that telehealth poses for use, it is evident that it can be used to help supplement hospice care when the hospice nurse is not readily available.

Types of telehealth technologyThere is a wide array of technology used in telehealth, and each tries to meet the needs of the patient and staff in a different way. Not everything used in telehealth requires a massive machine that can do everything that is done in a hospital; it comes down to simplifying costs, optimizing clinical outcomes and patient satisfaction, and allowing access to healthcare.The most basic type of technology used in telehealth is the telephone. It is simple and has been used for many years, but it still falls within this category. In telehospice, basic telephones can be used to provide regular check-ins to see how the patient is doing, health status updates, medication reminders for caregivers, and emotional support. Another type of telehealth technology is an individual measurement device. These can be blood pressure machines, glucometers, or other measurement devices that allow hospice providers to gather crucial information between visits. Through telehealth, some of these machines use a wireless connection and are transmitted back to the hospice agency, where measurements are compiled into the patients Flowsheet. This allows providers to see graphical data and know what trends are occurring. Finally, the use of videophones is increasingly common in telehealth technology because of the audiovisual modality of the equipment. Other types of telehealth equipment rely on just audio communications through the telephone or the transmission of numbers, but the videophone makes everything more personal and allows the holistic approach of hospice care to continue in the patients home. The videophones enable the patients and the hospice providers to communicate with each other. It allows the hospice worker to get a general impression of what is going on with the patient and allows assessment to occur between regular visits. The older videophones used to be tabletop only, but with telehealth hardware becoming smaller and more mobile, modern videophones allow more mobility within the home, allowing the clinician to see the patient easier and to assess specific parts of the body. The videophones also allow a great avenue to help with education. Because the caregivers at home are somewhat isolated and are thrown into the role of being a nurse, they need help to know what is going on. Most of the duration during the home visit is focused on the patient and optimizing pain and symptom management, and the caregiver may not get the education and support they need. Being able to use a videophone to help demonstrate certain aspects of care, to have a face-to-face conversation about coping and anxiety, and just having someone to talk to during non-visit hours can be very beneficial for everyone in the team of care and for the patient.

Implementation in healthcareOutside of hospice care, Telehealth has been making a tremendous improvement in the home healthcare world. It has been proven to help increase clinical outcome core measures and to improve the quality of life among those with chronic health issues. In a 2000 study conducted by Johnson et al, researchers evaluated the utilization and the costs of implementing remote video conferencing in the homes of congestive heart failure patients. The patients were evaluated on their treatment plans, and researchers recorded meals, vital signs, activities, and medication adherence. They determined that money was saved during this study and that the technology improved access between routine nursing visits and did not impede on clinical outcomes (Johnson, Wheeler, Deuser, & Sousa, 2000). This study exemplifies how telehealth can save healthcare dollars without sacrificing quality.Another example of how audio-visual technology is utilized for chronic health conditions in the home setting is through asthma management. One system, called Home Asthma Telemonitoring (HAT), provides the patient and their family with ongoing education and asthma management through a web-based program (Wise et al, 2006). It helps provide the patient feedback on minimizing exacerbations in their asthma flare-ups and also helps identify barriers in self-care. This is important because an ongoing goal of health professionals is to find ways to decrease hospitalizations and exacerbations of chronic health conditions. Utilizing telehealth can help patients maintain autonomy and optimal well-being.

Benefits of telehospiceLike other forms of technology, many people want concrete quantitative data to support that the use of telehealth is valuable in healthcare, but that cannot always be provided. In hospice care, most of what is done cannot be shown through this method of research, and we have to rely on subjective data that is found through qualitative reasoning. One of the major benefits to using telehealth in hospice care is that it allows patients and providers to communicate visually outside of routine home visits. Human expression encompasses more than verbal communication, and much of what we express is through facial and body expressions. In a 2010 study, researchers explored whether participants could recognize emotions based on facial expressions via videophone conversations: The study found that nonverbal communication, such as facial expressions of emotion, proved the value of videophone contact for providing access to visual nonverbal emotional communication (Schmidt, Gentry, Monin, & Courtney, 2011). Further, the ability to see facial expressions through the use of videophones helps ensure greater understanding of the issues being addressed. Being able to identify the nonverbal cues and behavior is essential in a nursing-patient relationship; without it, certain needs, especially emotional needs, would go unmet and the holistic approach in hospice care would crumble. Being able to use videophones allows for better after hours access without diminishing face-to-face contact. Another benefit to the utilization of telehospice is that it helps relieve the caregivers stress and anxiety. As Kinsella (2013) noted, These caregivers are untrained, ordinary people who suddenly are thrust into a role of providing the same care that a team of professionals would have rendered in the hospital setting. Many, if not most, of these caregivers need regular and frequent contact. Sometimes these caregivers feel isolated and overwhelmed. Through the use of telehospice, the caregiver can have access to a nurse to help ease these concerns. Administering pain medications to their loved ones can be a particular source of stress and anxiety for caregivers who worry about administering too much or too little medication. In a 2006 study, researchers used videophones to communicate with the patient and the caregiver over concerns in pain management. The study found that the use of the videophones helped caregivers feel more comfortable giving pain medications, including evaluating when and how much medication is needed. The study also found that the visual communication provided by the videophone gave the caregiver greater comfort than talking over the phone (Oliver, Demiris, Day, Courtney, & Porock, 2006). Kinsella looked at 16 hospice programs that are operating the use of telehospice technology to serve their patients. These programs were using the equipment on a smaller scale and were using it solely for video conferencing and hospice education for the caregiver. She also investigated several other hospice agencies in which were using full scale workstations that had the ability to take vital signs and a more mobile camera to assess the patient from different angles versus a table top camera. Using telehospice to monitor a patient allows the provider to see what is happening in real time, rather than relying on the caregiver to communicate over the phone.Lastly, telehospice have been proven to be a time-saver in situations of acute need. One example given by Whitten (2003) was a patient who was in a remote part of Michigan where the caregiver stated that he had excruciating pain in his belly and he had not urinated for hours. In response, to help assess the patient, the hospice nurse had the caregiver take the videophone and scan it over the patient and found that the catheter in place had been kinked. The hospice nurse instructed over the videophone how to manage the catheter. This visit using telehospice saved a 100+ mile round trip and offered immediate pain relief for the patient. This story helps illustrate how telehospice can save money and time and offer immediate support when hospice nurses are far away.

Cost AnalysisBefore implementing telehealth into hospice care, cost analysis is imperative. With changes being made in the current healthcare sector, we want to ensure that the changes made will have a positive outcome financially. When it comes to implementing a new technology in a different realm of healthcare, some healthcare professionals can be skeptical. That is why it is important that we use evidence-based research to determine our future actions. A 2000 study conducted a cost analysis to determine whether the use of videophones for virtual visits sufficed the use of the technology. The researchers worked with two hospices in Michigan and Kansas and found that the overall costs were reduced without any negative impact on the patient or caregivers perception of care (Doolittle, 2000). In another study, an automated telephonic monitoring system was used with hypertensive patients to help ensure medication adherence and proper measuring of blood pressure. Again, the study did not show any differences in clinical outcomes, but it did find a reduction in costs and a modality of care that improves access to home healthcare (Demiris, Oliver, & Courtney, 2006). Even though this case is not related to hospice, it does illustrate that the telehealth concept can be utilized in the home of patients and decrease cost expenditures.

Current BarriersOne of major barriers within telehealth is information security and privacy. We live in an age where most information is transmitted electronically and the transmission of very private information needs to be highly secured and encrypted. The Health Insurance Portability and Protection Act (HIPPA) have specific regulations for the transmission of data over data networks. Given the extremely sensitive nature of medical data, ensuring this data is not hacked over the telecommunications infrastructure is crucial.Another concern is the telecommunications infrastructure for these rural areas. Urban populated areas have high-speed Internet access and better cell phone service. In the rural areas, these services become spotty and may not have full service. Cell phones sometimes drop in and out of connectivity and the Internet may not be fast enough to support Telehealth services. Some hospice providers express concern that some very rural areas lack basic telephone services, which are essential for Telehealth equipment to function. The third concern is the usability issue among elderly people or those with a lower socioeconomic status. The usability of this technology extends beyond age and into socioeconomic status (Demiris et al 2011). He references what is known as the digital divide, meaning, the gap in computer and internet access between population groups segmented by income, age, educational level, or other parameters (Demiris, Parker Oliver, & Wittenberg-Lyles, 2011). In a 2011 study comparing Internet usage between income levels, it was found that 58 percent of households earning more than $75,000 were likely to have sent an email in a typical day, compared to only 37 percent of households earning less than $30,000 a year (Demiris, Parker Oliver, & Wittenberg-Lyles, 2011). The study also found that only 52 percent of rural residents use the Internet, versus 77 percent of those who live in an urban setting (Demiris et al, 2011). Since a sizeable percentage of rural residents have limited usage of technology, this could impact the use of telehealth in rural settings; however, much of the equipment to be used in the hospice setting would be simplified for patients and caregivers. Much of the equipment developed for telehealth use is designed to make it highly usable for both healthcare professionals and patient caregivers. The most technical aspect of using the equipment is the setup, which includes connecting the equipment to a phone line, setting up the Wi-Fi, and logging into the network. If the healthcare professionals are able to navigate an EMR without difficulty, using the telehealth equipment should not be difficult. Healthcare professionals and caregivers are trained in the use of the telehealth equipment and technical support is always available.Another barrier to the utilization of Telehealth in hospice care is the concern that the Telehealth communication will inhibit and minimize human touch and the patient-provider relationship. Some critics believe that this technology will hamper the holistic approach in hospice care, since therapeutic touch is a very important aspect of this field of medicine. In fact, therapeutic touch has been found to be one of the highest-ranked hospice interventions in both effectiveness and frequency of use (Demiris, Oliver, & Courtney, 2006). Crucially, the intention of telehospice would not be to replace the hospice nurse experience, but to supplement the nursing care when the nurse cannot be present.

Caregiver acceptance and perceptionCaregiver acceptance needs to be noted when implementing this technology because it is ultimately affecting them. This technology is intended to enhance the caregivers ability to provide optimal care and reduce caregiver burden and anxiety. In a 2007 study, Demiris et all found that the videophones were accepted by the patient and the caregivers, and that the videophones reduced anxiety and increase quality of life. These findings are very positive because anxiety can encapsulate a caregiver and have effects both psychically and mentally on him or her. Having that visual contact with a healthcare professional can help relieve anxiety and actually induct comfort and calmness. One of the major negative perceptions, as stated earlier, was that there was concerns that this technology would automate and digitalize all care; but this is not true. According to Utterback (2011), [Telehealth devices] can give patients and their caregivers peace of mind during inevitable peaks and valleys of dealing with a life-limiting condition, which may bring new questions and concerns. With the ability to electronically check in on patients every day, clinicians can stay on top of symptom management issues. The device allows clinicians to evaluate the patient daily, receiving information about signs, symptoms, behaviors, and knowledge that can contribute critical information to the interdisciplinary team. Despite the information that can be learned about a patient using telehospice technology, this service should be viewed not as a replacement, but as a supplement to hands-on care. When bad weather sets in or if it is 3 a.m., the patients caregiver can utilize the technology when traveling becomes unlikely. Hospice has always been built on the foundation of holistic modality, and this technology cannot replace that modality of care. But with technology showing its benefits in the delivery of care, supplementing hospice care with basic telecommunication technology can actually help improve the holistic care model.In one study conducted by Whitten, Doolittle, and Mackert (2004), researchers interviewed 35 patients to get feedback on what they thought about the telehospice services and equipment. Only 26 percent of the patients described it as just a piece of equipment, while 63 percent viewed the telehospice equipment as a means for communicating. It is apparent that most people who encounter the equipment see it as a way for communicating more easily with their care team, rather than just another machine.

RecommendationsAs nurse practitioners, we are always trying to find innovative ways to help optimize care and reduce costs. Telehospice has the potential to bridge the gap in care that we see in rural areas, while making the most of healthcare dollars. This tool is important for nurses both in family practice and in the hospital, since both areas deal with hospice discussions and implementation. There are many ways nurse practitioners can help advance this modality of care in the healthcare system. First, more research needs to be conducted and presented to discover whether objective findings such as pain level and symptom management are managed well with telehospice. Most existing research has resulted in qualitative and subjective data, such as cost analysis and the perceptions of patients, caregivers, hospice nurses. While this data is necessary and helpful, further objective data would be greatly beneficial in quantifying the importance of telehealth in hospice care. Evidence-based practice is the foundation of what we do as nurse practitioners, and with more research we can better construct our practice and approach for our patients. Second, more education for nurse practitioners and registered nurses should encompass end-of-life patient care. Much of what we learn is about optimizing health and treating disease, but end-of-life issues receive very little focus. Most nurse practitioners will work within various family health clinics and inpatient settings, and there will come a point within these careers where the end-of-life topic will arise; however, current nursing education generally focuses on every stage of life from birth to the elderly but leaves out the last phase of life. More didactic and continuing education should be focused on end-of-life care, because the more we know about end-of-life care and hospice, the more comfortable we will be will it. Finally, nurse practitioners can help expand the utilization of and access to hospice by advocating for policy change. The current regulations only allow physicians to subsequently authorize hospice in the MHB. Nurse practitioners and physician assistants can work under the physician and help with the management and care of the patient, but they are not allowed to authorize the initiation of hospice care. This is a big problem, because many primary care providers in this country are nurse practitioners and physician assistants. Hospice care is underutilized in rural areas where nurse practitioners and physician assistants work, potentially because of the lack of physicians to authorize the care. Advocating for policy change to allow nurse practitioners to authorize the use of the MHB and sign the face-to-face encounter sheet for Medicare coverage is essential to increase access. This will subsequently increase access in rural areas, creating a forum of discussion for utilizing telehealth technology to help further increase access, optimize caregiver well being, and optimize symptom and pain management.

ConclusionIn conclusion, increasing the awareness and utilization of hospice and palliative care in our country is key. Many healthcare dollars and resources are spent trying to prolong life when they could be utilized elsewhere. By attempting to prolong the inevitable, we rely too much on quantity of years and not the quality of those years. By utilizing the technology that we have at hand in the hospice setting, the people we love and care for can have more comfortable end-of-life care within their own homes. With the expansion of the healthcare system and the reforming in certain aspects, healthcare providers need to understand that hospice care is not a way of giving up. Too many healthcare providers hesitate to introduce the idea of hospice care to their patients. If we as healthcare providers understand the importance of hospice care and are knowledgeable of the benefits of end-of-life care and how to support families through the process, we can be more assertive and comfortable with offering the idea. Lastly, we need to help promote the idea of utilizing telehospice technology, which is available and cost-effective to implement. Through reform, acceptance, training, and utilization, telehospice can make a difference in the healthcare system fiscally and improve patients quality of life, rather than fixating on the quantity of life.

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AuthorPurpose of ResearchSampleDesignConclusionScholarly Project Focus

Demiris (2004)

To assess receptiveness, how providers see it being useful, and concerns that prevent utilization

10: staff members from 5 Midwestern hospicesFocus groupProviders had positive attitudes towardAttitudes: Being able to identify the perspectives and perceptions of those using telehospice is vital for expansion. Finding barriers can help heave the split shut. Also knowing how to enhance it is important as well.

Carr et al (2008)

To evaluate use of telephone in a Palliative Care Advice Line155: Staff from 2 hospice programs in NortheastInterviews, focus groups, surveysTelephone advice line resolved specific clinical needs and provided supportUse: Depicts that using telecommunications and have a line open for questions can help offer an open communication line so issues can be resolved between visits.

Demiris, Oliver, Courtney (2007)

To evaluate videophones as a tool to decrease caregiver anxiety and improve caregiver quality of life

12: senior caregivers in two hospice programsOutcome measures STAI, CQLI-RCaregivers were satisfied. Anxiety and quality of life are possible clinical outcomesClinical Outcomes: More evidence that supports that telehospice can empower caregivers with support through telecommunications and still maintain quality care and lower costs.

Doolittle (2000)

Examine the expenses of providing telehospice and to compare with traditional hospice.3569: Staff from one hospice in Kansas/MissouriCost data analysisTelemedicine visits are less expensive than home visits.Cost: Signifies that even though technological equipment can be expensive, it the long run, it ends up being less expensive than home visits.

Hong et al (2009)

Evaluate the adaption of a PDA information system

3174: Hospice nurses in KoreaObservationPDA technology reduced nursing documentation time.

Use: Utilizing telecommunications by use of PDAs for documentation allows the nurse to be more efficient and allow more time to see the patient and time to get to the next patient

Johnson et al (2006)

To evaluate the use of remote video technology in the home healthcare setting is cost effective and still maintains quality.

212: newly referred patients referred for hospice care

102= intervention

110= controlQuasi-experimental study No differences were seen in quality indicators or satisfaction. The average cost for those using telehealth was $600 less than those who did not use it.Costs: Cost is a major component that needs to be investigated before implementing something of this magnitude. Its important to ensure that research has been conducted and has found concrete evidence before utilizing 1000s of healthcare dollars into a program.

Oliver et al (2006)Evaluate a telehospice intervention effect on anxiety and quality of life74: seniors and hospice staffInterviewsClinical outcomes assessed included Anxiety and Quality of LifeClinical Outcomes: This is very important because the anxiety of the caregiver can have a toll on the care of the patient. It is already a stressful situation and if we can give the resources to help curb the anxiety, we should use them

Parker Oliver et al. (2009)

Evaluate the use of a telehospice intervention on caregiver perception of pain143: Caregivers and staff in two hospital agenciesClinical assessment and interviews, observation Caregivers perception of pain medication was identified as the most sensitive measure.

Clinical Outcomes: Shows how supplementing standard hospice care can help improve anxiety and quality of care

Virnig et al (2006)To evaluate and find the areas in our country that lack hospice services

100% Medicare enrollees (hospice benefits) between 2000-2002Bayesian smoothing technique for data analysisIt was found that at least 98% are served in urban areas. 24% of ZIPs in our country are not served by hospice.Access: Knowing who doesnt have access is vital. If we know the underserved areas, we can funnel our attention to those areas where telehospice would be highly beneficial.

Whitten (2004)Describe how telehospice is used, why patients decline, and what patients like and do not like189: 1 hospice in MichiganSurvey, interviews, and nurse notesPatients had positive experience with the technologyPatient attitudes: Having a high incidence of positive patient feedback and acceptance proves that it should have a wide acceptances to help the patients in their houses