Buzz around virtual nursing is building. As telehealth sheds its COVID skin, the virtual care technology is entering a new phase of growth helping health systems advance acute care models to mitigate hospital workforce challenges.
In a recent interview with Commercial Integrator editor-in-chief Dan Ferrisi, Caregility President and COO Mike Brandofino addressed the rise of inpatient virtual care and, more specifically, virtual nursing.
“We lost a lot of nurses during COVID who retired, can no longer work, or just decided they didn’t want to [do it] anymore and we don’t have enough nurses coming in so there’s a huge shortage,” said Brandofino. “Virtual care is being used now to augment that.”
Nursing shortages during the pandemic led to labor cost inflation as hospitals battled for scarce resources. Recent CNBC coverage revealed that the “average pay for travel nurses was $150 an hour in early 2022, which analysts say tempted more nurses to leave staff jobs, increasing turnover and exacerbating shortages.”
That pay rate is three times higher than the national average for full-time staff nurses.
Virtual nursing offers health systems an alternative to expensive contract nurses that not only acts as a force multiplier for care teams but also enhances care collaboration and improves patient and clinician experience.
How Virtual Nursing Can Help Solve Many Workforce Shortage Woes
Healthcare IT News
Virtual care pioneer and Caregility Chief Nursing Officer Wendy Deibert, EMBA, BSN, RN, recently sat down with Healthcare IT News editor Bill Siwicki to offer a deep dive into the benefits of a hybrid approach to nursing that employs telehealth.
Virtual nursing programs are typically campus-based and staffed internally but can also be supported by third-party clinical services or a combination of the two. Workflows vary from campus to campus.
“Some organizations use virtual nurses for patient admissions and assessments or discharge education,” shared Deibert. “Others implement more comprehensive 24/7 patient surveillance and deterioration management programs. The fact that there is no one universal approach is really the beauty of telenursing. Programs can and should be tailored depending on your health system’s specific needs.”
Deibert noted that multiple organizations are actively working with stakeholders within the nursing community to develop virtual nurse certification programs to help establish standards for programs.
Virtual Nursing Programs Adapting to Organizational Needs
HealthTech Magazine
Meanwhile, organizations like Mary Washington Healthcare are forging their own path as early adopters of virtual nursing.
HealthTech Magazine editor Teta Alim highlighted the health system’s journey into virtual nursing in coverage of the 2023 American Telemedicine Association conference. Debra Marinari, Associate Vice President of Hospital Operations at Mary Washington Healthcare’s Stafford Hospital, and Heidi Steiner, MD, Clinical Program Manager at Caregility, were on site to share insight into the nursing workflows the hospital is working to virtualize, including admission assessment, plan of care, patient education, and discharge, to name a few.
Mary Washington Healthcare deployed an Inpatient Virtual Engagement solution to support its new virtual nursing program. According to Marinari, the leadership team will assess nurse engagement, patient satisfaction, the rate of nurse turnover, quality and safety metrics, and readmissions to measure program success.
Experts Weigh in on the Joys and Woes of Virtual Nursing
The Atlanta-Journal Constitution
Given the elevated rates of nurse attrition during and since the pandemic, many care teams are onboarding new hires who have limited field experience. As Atlanta Journal-Constitution writer Hunter Boyce shared, another benefit of virtual nursing is its ability to connect new nurses with experienced remote nurse resources who can help guide and mentor them. That secondary line of clinical reinforcement boots confidence for care team members, improving clinician experience and increasing the likelihood of retention.
As Walsh University nicely sums it up:
“The impact of technology on nursing practice cannot be overstated. When nursing technology takes over time-consuming routine processes, streamlining communication and delivering accurate diagnoses and personalized treatment plans, NPs are freed up to do the work that only humans can: providing one-on-one, compassionate care.”
Virtual Nursing for Post-Acute and Transitional Care
Virtual nursing programs continue to make headway as health systems look for new solutions to the ongoing staffing crisis. Many of the virtual workflows sprouting up in inpatient departments have applicability in post-acute and transitional care, as well, where the impact of workforce shortages is also being felt.
Here is a look into how virtual nursing can support transitional care management, home care, population health, post-acute care, and hospital-at-home models.
Transitional Care Management
A patient’s discharge signals the start of a 30-day period where Medicare pays for services to help the patient transition from inpatient services to a community-based setting. Patients are typically moved to either a home, long-term care, or assisted living facility.
Many of the processes to prepare patients for care transitions can be fielded virtually. Providers are required to contact the patient within two business days of discharge, followed by a face-to-face visit within 14 calendar days of discharge for moderate-complexity patients and within 7 days for high-complexity patients. Supportive services provided by a virtual nurse can include:
Coordinate follow-up visits, durable medical equipment delivery, etc.
Educate the patient and/or caregiver on self-care, activities of daily living, etc.
Support adherence to the treatment plan, including medication management
Provide access to community resources and assist with care navigation
Home Health
Traditionally, care has been delivered in person when patients transition to a home setting.
Hybrid “tele-home” care models are emerging where a home care nurse may see a patient in person on the first visit and then virtually after that unless hands-on nursing care is required (i.e., dressing changes, wound vac care, etc.) or in-person visits are deemed necessary.
If practitioner-ordered virtual visits are incorporated as part of the patient’s Plan of Care (POC), the virtual visit must address specific patient needs identified in the comprehensive assessment and incorporate interventions and measurable outcomes identified in the POC.
Many home health agencies provide patients with Bluetooth or wireless devices such as pulse oximeters, blood pressure cuffs, glucose monitors, and scales connected to a tablet. This allows virtual nurses to track patients more frequently, between formal visits, to catch trends and head off deterioration before resulting in an ED visit. A home care aide acting as a telepresenter for the virtual nurse can also be used for virtual nurse visits.
In a study of nearly 1,400 patients with 314 patients belonging to a hybrid model, there was a significant reduction in hospitalizations in both the 30- and 60-day time period for those in the hybrid model. This patient group also demonstrated better clinical outcomes across a variety of measures.
Population Health & Chronic Disease Management
Chronic diseases continue to plague approximately 46% of Americans, with almost 30 million people living with five or more chronic diseases. Leveraging virtual care can dramatically improve outcomes for patients living with difficult-to-manage chronic illnesses.
Employing virtual nursing to support chronic disease management increases patient adherence to their POC. It also provides a quick and easy way to connect with their care team more often for early intervention to prevent unnecessary trips to the ED or hospital.
Remote Patient Monitoring
Remote patient monitoring (RPM) helps achieve chronic disease management goals while reducing patient travel costs and infection risk. Conditions that are appropriate for RMP include hypertension, diabetes, cardiovascular heart disease, COPD, and asthma. RPM tools are sent to the patient’s home and may include scales, digital stethoscopes, blood pressure monitors, pulse oximeters, blood glucose meters, and questionnaires.
Use cases reimbursed by Medicare include remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate, set-up and patient education for equipment use, and treatment management services.
Knowing how to manage risk alerts is a key to success and guides the actions and interventions of the virtual nurse. In this way, patients are informed of self-care interventions, thus improving and reinforcing what they need to know the next time. In addition, alerts from remote monitoring devices help the virtual nurse monitor the maximum number of patients.
Skilled Nursing Facility & Long-Term Post-Acute Care
Telehealth can address over 50% of resident cases typically sent to the hospital, potentially avoiding readmission. To qualify for Medicare coverage, there must be a “qualifying event” that includes a three-night hospital stay that requires skilled nursing or rehabilitation for at least one hour daily, five days a week. Medicare SNF benefits last 100 days without a new qualifying event.
Post-acute workflows that can be performed virtually include:
Provider virtual visits: SNF patients are typically seen by a nursing home provider on admission, then monthly for the first 90 days and every 60 days after, or as concerns present.
Specialty virtual visits: Specialists can be brought in virtually, avoiding patient transport needs.
Ancillary visits: Virtual visits with pastoral care, hospice, family, and friends.
Continuous virtual observation or tele-sitting: Patients at high risk for falls or other safety concerns can be observed continuously and redirected.
Virtual Nursing: Admission, discharge, care planning, chart review, and assessment can be fielded virtually to offset some of the administrative burdens of bedside nursing staff.
Long-term care (LTC) facilities can utilize the same workflows, albeit at a lower frequency given lower patient acuity. LTC facilities provide long-term custodial care that is typically paid for byeither Medicaid, personal finances, or long-term care insurance.The use of a telepresenter is especially helpful within both populations.
Long-Term Acute Care Hospitals
Patients moving to a Long-Term Acute Care Hospital (LTACH) require direct skilled nursing care and have complex medical needs such as ventilator weaning and or complex wound care that can’t be met at a lower level of care. Patients are typically transferred from a hospital’s ICU to an LTACH.
LTACHs must maintain an average length of stay greater than 25 days. For optimal reimbursement, it’s imperative that the acute care hospital discharge patients to the LTACH as soon as feasibly appropriate. Every extra day spent in an ICU instead of the LTACH hinders LTACH reimbursement by minimizing LTACH length-of-stay (LOS), increasing costs and LOS for the acute care hospital.
Like other post-acute inpatient facilities, virtual workflows can support a multitude of use cases. Virtual observation can be more broadly used to support workflows beyond fall and safety monitoring by unlicensed personnel. Ventilator-dependent and other complex patients at high risk for deterioration or readmission can be observed continuously or rounded on more frequently by a virtual nurse.
These workflows can help to interrupt deterioration requiring hospital readmission, decrease adverse events, and keep the LTACH’s LOS intact by treating patients in place.
Hospital at Home
The Hospital at Home (HaH) care model has shown promise for reducing cost, improving outcomes, and enhancing the patient experience. HaH offers hospitals more flexibility to care for patients in the comfort of their own home.
Programs vary based on hospital capacity and patient population needs, but may include:
Medium-acuity patients who need hospital care but are considered stable enough for home
Patients with defined treatment protocols such as pneumonia, COPD, diabetes, etc.
A combination of in-person visits, virtual visits, and continuous biometric monitoring
Diagnostic studies (electrocardiograms, echocardiograms, X-rays), treatments (oxygen therapy, IV fluids, IV antibiotics, and other medications) and services (respiratory therapy, pharmacy, virtual nursing)
The combination of in-person and virtual nursing visits provides patients with 24/7 access to care. If necessary, the patient can visit the acute hospital for treatments that cannot be provided in the home (i.e., CT scan, MRI, etc.). The patient is discharged when stable.
Conclusion
When we think about keeping patients out of high-cost care settings and preventing unnecessary use of the ED and inpatient settings, virtual nurses are key players. They can advise multiple patients during their shift, provide timely care, perform competent assessments, document results in the EMR, and guide patients to the most appropriate level of care.
Nurse triage and advanced practice nurses do what they can to alleviate the pressure on providers who are in short supply and overtaxed. By providing sound care advice to patients on-demand, any time of the day or night, virtual nurses enable physicians to direct their expertise to patients who are high-risk, have chronic diseases, or are in the most fragile condition.
As health systems seek to meet the new demands of today’s healthcare environment, virtual nursing has become a hot topic. Here we address some of the most frequently asked questions about telenursing.
What is virtual nursing?
Virtual nursing is a hybrid care model that partners bedside staff with an experienced virtual nurse resource who works from a centralized hub and helps guide and support care for assigned patients.
Should virtual nursing be staffed internally or outsourced?
Virtual nursing programs are typically staffed internally, but hybrid or outsourced models can provide relief when clinical team resources are limited. Virtual nursing programs seek to support bedside staff, not replace them. In any staffing model, building trust between bedside and virtual staff is one of the most important factors in the success of virtual nursing programs.
What makes a good virtual nurse?
Seasoned nurses with extensive bedside experience are ideal candidates for virtual nursing. Virtual nurses should be assertive yet personable, good at multi-tasking, and comfortable with technology. They should also be good problem-solvers with high emotional intelligence who are adept at picking up on nonverbal cues. Prior experience at the health system or facility will likely be more important than telehealth experience, which is one reason unit managers may encourage bedside nurses who are burned out, seeking a change, or considering retirement to consider a telenursing role.
What virtual nursing programs do most hospitals begin with?
Hospitals and health systems typically start with virtual nursing programs that take time-consuming work off the plate of bedside nurses, such as admissions and discharges. Providing relief to bedside staff early on helps to establish trust and buy-in around hybrid care models. Medication second signature and blood product verification are also relatively easy programs to stand up. Tele-sitting is another workflow many health systems begin with, as it often poses the most immediate ROI.
What staffing ratio is recommended for a virtual nursing program?
Ratios will vary depending on the responsibilities being fielded by the virtual nurse. If the virtual nurse is only doing admissions and discharges, they could take over an entire facility or multiple facilities. When telemonitoring with a clinical decision support tool, virtual nurses may monitor hundreds of patients. 30 to 50 patient beds per virtual nurse is typical of other programs. Time studies can help you determine the average time needed to complete specific tasks and inform your strategy. Consider peak usage times when evaluating staffing ratios, as needs can vary greatly from shift to shift.
What KPIs help assess the value of virtual nursing programs?
Efficiency gains are typically assessed to quantify the impact of virtual nursing programs. Conduct time studies pre- and post-implementation to determine time saved by transitioning processes to virtual workflows and the subsequent labor cost savings. Improvements to clinical measures such as patient falls, patient falls with injury, and average length of stay are other metrics to assess program value.
Want to learn more? Check out these on-demand webinar resources:
The U.S. will grapple with a critical nursing shortage for at least the remainder of the decade. Thus, health systems are now looking for ways to more efficiently ensure that patient needs are met, while recruiting and retaining qualified clinical staff. Many successful health systems are turning to telenursing to supplement and enhance traditional bedside care.
Across the country, healthcare organizations are experiencing difficulty recruiting, higher labor costs, and increased staff burnout. In a 2021 letter to HHS Secretary Xavier Becerra, the American Nurses Association noted that states were challenged by unfilled positions and failure to recruit enough replacements. Louisiana reported 6,000 unfilled positions even prior to the Delta variant, Tennessee had 1,000 fewer nurses than when the pandemic started, Mississippi lost 2,000 nurses between January and August that year, and Texas recruited 2,500 nurses outside the state but still did not meet its staffing need. These shortages feed on themselves, since working in a chronically-understaffed setting takes its toll.
In the first quarter of 2021, 36% of hospitals experienced an RN vacancy rate above 10%, according to the NSI National Health Care Retention & RN Staffing Report. RN turnover in 2020 was 19%, about three points higher than in 2019. Unsurprisingly, burnout is a big reason that almost half of nurses are changing roles, reducing hours, becoming “travelers,” and retiring. Conservatively, one-third of nurses reported being “burned out” or “very burned out” in 2021. This shortage of nurses and other qualified staff is increasing hospital and health system costs by $24 billion per year, averaging $17 million in additional costs for a 500-bed facility.
Approaching the shortage: a series of stop-gaps
Some health systems use travel nurses as a stop-gap to help staff more shifts. This does not actually solve the problem, though, as added expenses limit the long-term sustainability of this approach. Other hospitals are increasing their patient-to-nurse ratios, with some facilities relying on patient care techs and nursing aides to ease the burden. Unfortunately, thousands of qualified would-be nurses have been turned away from nursing schools due to shortages of faculty, clinical sites, classroom space, preceptors, and financial support.
While schools implement strategies that enable them to add student capacity, health systems must find ways to do more with less, without sacrificing care quality. With declining margins due to the pandemic, it is all the more difficult to simply hire more aides, even presuming they are available.
Besides actual procedures and hands-on care, bedside nursing includes charting, consulting with team members, accessing supplies, coordinating with other departments, and speaking with family members and friends. However, given the understaffing on many floors and unit, patients often interact with a variety of care team members on each shift. This fragmentation in turn makes it more difficult for patients and their visitors to decipher “who’s who,” and to bring forward important concerns.
Dividing to conquer
The pandemic accelerated acceptance of telehealth, along with more comfort with wearables, Bluetooth-enabled physical assessment, and virtual monitoring from patients, clinicians, and healthcare systems.
Incorporating telehealth programs within acute care facilities allows floor nurses to cover more ground. Virtual patient observation, for example, can support a number of goals, from greater patient safety to an improved patient experience.
Patients have long complained about the sleep deprivation caused by clinicians entering the room, along with the background noise from nurses’ stations and hallways. In addition to the discomfort and disorientation that interrupted rest entails, when a series of staff intrusions occur with no prior warning nor way to ask questions, the patient can easily feel like an “object,” with little control over the situation — not an ideal environment for healing.
With on-demand access to nurses and supporting care team members, patients can have their questions answered remotely, allowing floor staff to be notified and physically intervene only when needed; thus systems have seen their room entry needs, often with attendant needs for PPE or other precautions, significantly reduced.
With some basic concerns addressed by virtual nurses, the floor nurses can also cultivate an improved relationship with patients, providing more concentrated time for in-person care to focus on their needs. This is obviously a more desirable situation for a high-performing bedside nurse.
The best solutions are those that address a number of pain points, and virtual patient observation is gaining traction as a core workflow. Facilities have learned that consistent monitoring and early intervention, as is facilitated by virtual observers, can reduce wandering, falls, self-harm, and visitor security incidents.
Health systems can also reduce labor expenses by leveraging virtual infrastructure. For example, one 900-bed hospital reported a $3 million annual unbudgeted expense for bedside sitters alone. Furthermore, just one hospital-related fall injury can cost up to $30,000 (not to mention legal and reputational exposure).
Telenursing: more efficient delegation and workflows
Collaboration among virtual and on-site nurses can enable floor staff to spend more value-added time with patients at the bedside. Telenurses with “eyes on the patient” can address tasks such as admission and discharge planning, medication reconciliation, patient and family education, and some student/trainee preceptorship. Meanwhile, floor nurses can focus on the tasks requiring hands-on skills and in-person availability, including supervision of aides and less experienced staff.
Tele-nurses can train, mentor, back up and otherwise support bedside nurses, coaching them through unfamiliar tasks or procedures, while also being available for advice and counsel. Of course, they can also coordinate communication in urgent and emergent situations, and can instantly activate alarms on the floor.
Thus, telenursing does not solve the nursing shortage, but it can support optimal outcomes of care, staff development, retention, and morale — with fewer RN FTEs.
Download Caregility’s latest eBook to discover how virtual workflows can streamline bedside care and improve patient and clinician experience. The eBook includes tele-nursing use case examples, staffing model best practices, and guidelines for implementation.
Spotlight on National Nurses Month: Caregility Supports ANF’s “Reimagining Nursing Initiative”
Nurses are an indispensable part of U.S. healthcare delivery. Standing on the front line of patient engagement and at the crux of care coordination, RNs have long served as the backbone of the medical industry, helping to keep healthcare consumers, their loved ones, and clinical staff in step in their shared pursuit of improved patient health.
During National Nurses Month each May, these care team members are formally recognized and celebrated for their ongoing commitment and contributions. The hardship experienced by many nurses during the COVID-19 response over the past two years serves as a particularly salient reminder of the sacrifices that are frequently required of these vital resources. As our nation emerges from the pandemic to confront a national nursing shortage and unprecedented rates of clinician burnout, many organizations aligned to the field of healthcare are amplifying efforts to identify new ways to better support our RNs.
It is in the spirit of that mission that Caregility has teamed up with the American Nurses Foundation (ANF). As the philanthropic arm of the American Nurses Association (ANA), ANF’s vision is to “achieve a healthy world through the power of nursing.” Relying on the generosity of donors to help achieve and expand this mission, the Foundation funds “bold thinkers to pilot and evaluate new ideas that accelerate widespread transformation in nursing.” The ANF’s Reimagining Nursing Initiative focuses on three core pilot program areas:
Practice-Ready Nurse Graduates
Technology-Enabled Nursing Practice
Direct-Reimbursement Nursing Practice Models
To support the ANF’s cause and honor National Nurses Month 2022, Caregility donated $3,000 to the Foundation’s Technology-Enabled Nursing Practice program, which supports the design and implementation of technology-based tactics and tools that meaningfully enhance the practice of nursing. The program’s emphasis on nurses as key drivers of effective healthcare IT design echoes Caregility’s core development principles for telehealth.
“Like the ANF, we recognize the fundamental role that nurses play in successfully reimagining healthcare,” said Caregility SVP of Clinical Solutions Wendy Deibert. “We’ve seen first-hand the tremendous positive impact that our own clinical leadership team has had on virtual care program design, so we see tremendous value in ANF’s efforts to similarly advance nurse involvement in digital transformation.”
Donations from Caregility and others will fund as many as 11 innovative pilot programs that will receive three-year grants totaling a combined $15 million.
“The American Nurses Foundation is extremely grateful for Caregility’s recent contribution to The Reimagining Nursing Initiative in honor of National Nurses Month,” said a spokesperson on behalf of ANF. “This gift will enable the Foundation to fund innovative pilot programs designed to create and implement cutting-edge, technology-based tools and strategies that will significantly enhance the practice of nursing.”
The donation was made as part of the Caregility Cares program, honoring members of the medical community who go above and beyond to bring relief to others. Learn more about the Caregility Cares Essential Worker Scholarship and Frontline Worker Recognition Programs here.
Looking for virtual workflow relief to reduce pressure on your nursing staff? Contact us today to see how Caregility can help.
