Introduction Telemedicine use in nursing homes (NHs) expanded during the COVID-19 pandemic. The objectives of this study were to characterize plans to continue telemedicine among newly adopting NHs and identify factors limiting its use after COVID-19. Methods Key informants from 9 Wisconsin NHs that adopted telemedicine during COVID-19 were recruited. Semi-structured interviews and surveys were employed to identify participant perceptions about the value of telemedicine, implementation challenges encountered, and plans and barriers to sustaining its delivery after COVID-19. Directed content analysis and a deductive thematic approach using the Systems Engineering Initiative for Patient Safety (SEIPS) model was used during analyses. Quantitative and qualitative data were integrated to identify participant views on the value of telemedicine and the tools and work system enhancements needed to make telemedicine easier and more effective. Results All participating NHs indicated a preference to continue telemedicine after COVID-19. Urgent assessments of resident change-in-condition and cognitively based sub-specialty consultations were identified as the encounter types most amenable to telemedicine. Reductions in resident off-site encounters and minimization of resident therapy interruptions were identified as major benefits of telemedicine. Twelve work system enhancements needed to better sustain telemedicine were identified, including improvements to: 1) equipment/IT infrastructure; 2) scheduling; 3) information exchange; and 4) telemedicine facilitators. Discussion NHs that adopted telemedicine during COVID-19 wish to continue its use. However, interventions that enhance the integration of telemedicine into NH and off-site clinic work systems require changes to existing regulations and reimbursement models to sustain its utilization after COVID-19.

Nursing homes (NHs) have been at the frontline of the COVID-19 pandemic. 1,2 Despite representing <1% of the US population, NH residents account for nearly 33% of all COVID-19 deaths. 3 The Centers for Medicare & Medicaid Services implemented sweeping telemedicine regulatory relief in an effort to reduce COVID-19 spread in NHs. Telemedicine activity in US NHs has expanded dramatically 4 but has not been without its challenges. Herein, we report 12 recommendations to enhance and sustain telemedicine (Table 1) from a telemedicine adoption study, certified as quality improvement by the UW-Madison Health Sciences IRB.A convenience sample of NHs (n ¼ 9) in south-central Wisconsin were recruited based on geography (rural vs urban), ownership, and profit status. Each NH had newly adopted or significantly expanded telemedicine during the COVID-19 pandemic. Key informants (n ¼ 27) involved in the structure and conduct of telemedicine encounters were interviewed or surveyed including NH staff, long-term care advanced practice providers, and regional health care subspecialist providers.Study participants identified 5 technology enhancement needs, including (1) improvements to connectivity and bandwidth; (2) an increased supply of telemedicine devices; (3) availability of sound amplification devices; (4) availability of telehealth-ready stethoscopes, and (5) enhancements to video quality. During the QI project, Internet connectivity and bandwidth as well as TM device availability improved in all participating NHs, although technology bottlenecks remained a problem in several facilities after the project. The volume capabilities of the telemedicine devices employed in NHs was often inadequate, and participants identified secondary sound amplification devices as a critical need for encounters with hearing-impaired residents. Although many telemedicine encounters did not require a heart or lung examination, advanced practice provider participants noted that having a telehealth-ready stethoscope available would further alleviate the need for face-to-face encounters when encountered with a scheduling conflict or a facility outbreak. Some respondents noted

Background The use of telemedicine increased dramatically in nursing homes (NHs) during the COVID-19 pandemic. However, little is known about the actual process of conducting a telemedicine encounter in NHs. The objective of this study was to identify and document the work processes associated with different types of telemedicine encounters conducted in NHs during the COVID-19 pandemic. Methods A mixed methods convergent study was utilized. The study was conducted in a convenience sample of two NHs that had newly adopted telemedicine during the COVID-19 pandemic. Participants included NH staff and providers involved in telemedicine encounters conducted in the study NHs. The study involved semi-structured interviews and direct observation of telemedicine encounters and post-encounter interviews with staff and providers involved in telemedicine encounters observed by research staff. The semi-structured interviews were structured using the Systems Engineering Initiative for Patient Safety (SEIPS) model to collect information about telemedicine workflows. A structured checklist was utilized to document steps performed during direct observations of telemedicine encounters. Information from interviews and observations informed the creation of a process map of the NH telemedicine encounter. Results A total of 17 individuals participated in semi-structured interviews. Fifteen unique telemedicine encounters were observed. A total of 18 post-encounter interviews with 7 unique providers (15 interviews in total) and three NH staff were performed. A 9-step process map of the telemedicine encounter, along with two microprocess maps related to encounter preparation and activities within the telemedicine encounter, were created. Six main processes were identified: encounter planning, family or healthcare authority notification, pre-encounter preparation, pre-encounter huddle, conducting the encounter, and post-encounter follow-up. Conclusion The COVID-19 pandemic changed the delivery of care in NHs and increased reliance on telemedicine services in these facilities. Workflow mapping using the SEIPS model revealed that the NH telemedicine encounter is a complex multi-step process and identified weaknesses related to scheduling, electronic health record interoperability, pre-encounter planning, and post-encounter information exchange, which represent opportunities to improve and enhance the telemedicine encounter process in NHs. Given public acceptance of telemedicine as a care delivery model, expanding the use of telemedicine beyond the COVID-19 pandemic, especially for certain NH telemedicine encounters, could improve quality of care.

BPHCC staff successfully employed the protocol eight times from August 1999 to November 2000; this article describes the protocol and three representative cases.

Background: Suspicion of urinary tract infection (UTI) is the most common justification for prescribing antibiotics in nursing homes. More than half of antibiotic prescriptions for treatment of UTI in nursing homes are either unnecessary or inappropriate. Achieving a better understanding of the factors that underlie UTI treatment decisions is necessary to improve the quality of antibiotic prescribing in nursing homes. An ongoing hybrid type 2 effectiveness-implementation cluster randomized trial of a recently developed nursing home UTI recognition and management tool kit provided us with an opportunity to explore the influence of organizational, clinical, and staff attributes on UTI antibiotic prescribing practices in nursing homes. Methods: Data on antibiotic starts for suspected UTIs were collected in 29 nursing homes over a 9-month period. Antibiotic practices evaluated included total antibiotic starts per 1,000 resident days, % antibiotic starts with treatment duration >7 days, % antibiotic starts in which the initial antibiotic choice was a fluoroquinolone, and % antibiotic starts meeting UTI tool-kit criteria of appropriateness. Prior research and bivariate analyses were used to select clinical and organizational attributes as well as individual nursing staff-level retention rates for inclusion in a stepwise linear regression model for each antibiotic practice outcome. Results: In total, 602 UTI antibiotic events were evaluated. Four associations were identified for antibiotic starts including nursing home urine culture rate, ICP status, nonprofit and part-time LPN retention. Nursing homes with higher full-time LPN retention had a lower rate of antibiotic treatment duration >7 days. Full-time CNAs and part-time LPNs retention and for-profit status was associated with the proportion of fluoroquinolone antibiotic starts. No attributes influenced the proportion of antibiotic starts meeting appropriateness criteria (Fig. 1). Urine culture rates are driving overall nursing home antibiotic prescribing. Conclusions: Urine culture practices was strongly associated with UTI treatment rates in nursing homes. A variety of organizational characteristics were also associated with UTI treatment rates as well as other UTI antibiotic prescribing practices. Some of these associations appear paradoxical but may reflect increasing resident acuity and increased capacity to standardize practices through organizational centralization.Funding: Support for the project provided by the Wisconsin Partnership Program.Disclosures: None