Best Practices for Using Telehealth in Hospice and Palliative Care

Michelle Webb, DNP, RN, BC-CHPCA; Susan Lysaght Hurley, PhD, GNP-BC; Jennifer Gentry, DNP, ANP-BC, GNP, ACHPN; Melanie Brown, LCSW; Cynthia Ayoub, BSN, RN, BC-CHPCA

Disclosures

Journal of Hospice and Palliative Nursing. 2021;23(3):277-285. 

In This Article

Why Best Practices?

Best practices in health care are "those practices that have shown evidence of effectiveness in improving population health when implemented in a real-life setting and are likely to be replicable in other settings."[32] (p157) The emphasis is on real-life evaluation of practices with a focus on organizational contextual and implementation factors as compared with practices tested through an experimental design. Given the rapid expansion of telehealth in hospice and palliative care during the COVID-19 pandemic, new research opportunities are expected to emerge that will advance the supportive evidence for specific practices and clinical effectiveness of this method of care delivery. In the interim, written best practices are an essential way to identify and disseminate essential telehealth care activities, overcome common implementation factors, and eliminate some of the previously mentioned contextual barriers faced by hospice and palliative care providers who provide inpatient and community-based telehealth services.

Well-defined best practices can be used to provide the instruction clinicians need to develop competence and skill with this mode of health care delivery, thereby addressing a commonly identified barrier to the successful adoption of telehealth. The accelerated use of telehealth creates an ancillary need to develop tools to assist the novice clinician in selecting the most appropriate technology to conduct virtual visits. In areas where technology access provides multiple options for telehealth delivery, support for clinical decision-making is essential. Following the established plan of care is fundamental to the process; however, best practices, decision trees, and algorithms may provide additional guidance for selection of the best technology to be used and guidance on the optimal way to use it to provide person-centered telehealth care.

During COVID-19, hospice and palliative care professional organizations and clinicians have published tips and guidelines for incorporating telehealth into existing hospice and palliative care practices.[6,33–35] This article provides best practice recommendations based on an extensive review of the existing evidence and multiple years of provider experience. The proposed best practices can be used to promote the delivery of high-quality, person-centered telehealth care and can be adapted (or customized) according to the unique organizational needs and established infrastructure of diverse hospice and palliative care providers.

Best Practices for Hospice and Palliative Telehealth

Principles to guide the development of best practices are elucidated in this article that are based on an extensive review of the existing literature on the use of telehealth in hospice, palliative care, and other medical specialties and the clinical expertise of the authors who directly provide or direct the provision of telehealth services in their respective organizations. The consensus opinions of the authors reflect nearly 20 years of total experience providing and/or directing telehealth services of varied scope by interdisciplinary team members. While the majority of telehealth visits have been performed by nursing professionals (advance practice registered nurses and registered nurses) in the organizations represented by the authors, telehealth visits have also been provided by all members of the interdisciplinary team (chaplains, music therapists, physicians, social workers), reflecting a breadth and depth of experience with providing virtual care to persons needing hospice and palliative care.

Six principles should be applied when developing best hospice and palliative care telehealth best practices:

  1. Benchmark the work of experienced providers of telehealth in hospice and palliative care.

  2. Develop best practices that reflect the integration of clinical expertise, patient values, and the use of the best available evidence.[32,36]

  3. Develop best practices for each type of telehealth service/intervention provided as indicated (ie, virtual visit, phone call, remote patient monitoring).

  4. Organize best practice interventions around what will be done before, during, and after the telehealth intervention.

  5. Include guidance in the best practice on both the task and process functions of the telehealth intervention:
    • selection of the appropriate technology to be used to provide telehealth services;
    • management of the technology used to perform the visit to promote the delivery of an effective, efficient visit;
    • management of the intrapersonal/interpersonal aspects of the telehealth intervention to ensure a caring "presence" is conveyed throughout the intervention;[37–40]
    • planning and coordination of care to be delivered before, during, and after the telehealth intervention; and
    • documentation of care and services delivered to ensure that reimbursement for any billable services can occur.

  6. Incorporate principles of person-centered care into the best practice.[41–43]

Application of these principles is illustrated in sample best practices included as Table 1, Table 2 and Table 3. Table 1 is a Quick Reference Guide for novice telehealth providers of all disciplines performing hospice or palliative care visits in the community setting. Table 2 is an example of a best practice for an audio-only (phone) visit used by nurses performing primary palliative care in the hospital. Table 3 outlines best practices for performing a "virtual visit." This guide was developed and used primarily for hospice visits in multiple settings including long-term care facilities, assisted living facilities, group homes, and private homes. Table 4 includes a crosswalk to the six principles demonstrating how the principles were and can be applied to develop best practices.

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