Telemedicine Reduces Emergency Room Visits for Dementia Patients

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Dr. Nathaniel Chin: I'm Dr. Nathaniel Chin and you're listening to Dementia Matters, a podcast about Alzheimer's disease. Dementia Matters is a production of the Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners on the latest news on Alzheimer's disease research and caregiver strategies. Thanks for joining us.

Dementia Matters is on location in Los Angeles, California for the Alzheimer's Association International Conference, the world's largest gathering dedicated to the scientific study of dementia. Today's guest on Dementia Matters is someone I work with on a regular basis back in Madison, Wisconsin; but our paths typically cross late at night in the emergency room, hardly a place to sit down and record a podcast. Today, without any patient responsibilities, I can sit down with Dr. Manish Shah and discuss what I think is a fascinating topic: dementia patients in the emergency room. Dr. Shah is a professor of Emergency Medicine at the University of Wisconsin School of Medicine and Public Health and the John and Tashia Morgridge Chair of Emergency Medicine Research. Dr. Shah, welcome to Dementia Matters.

Dr. Manish Shah: Thanks Nate. It's great being here.

Chin: If you don't mind starting by explaining your role as an emergency room doctor and how you became interested in improving care for patients with dementia who visit the ER.

Shah: I love the emergency department. I get to take care of patients who come in with a symptom and figure out what's going on. It's really the forefront of medicine in the sense of - I have to figure out in a very time-limited fashion what's going on with them, because they need treatment quickly. I don't know what's going to come in one minute to the next. Someone that's got a little bit of ADHD and a little bit of hyperactivity, it's perfect for me. The thing that became really evident to me years ago was that a bigger and bigger proportion of our patients are older adults, and realizing even more so that these patients frequently have some sort of cognitive issue. Twenty years ago there was very little research on this and being able to be part of that generation of researchers that are starting to dive into this I say: how do we take care of these folks better, do what's right for them given their goals of their life, the problems that they run into, their family's concerns? It's just incredibly fulfilling and a lot of fun.

Chin: The emergency room is typically thought of as an acute care, acute medicine place, but what you're suggesting and proposing here is that there is a really important need for emergency rooms and emergency room doctors in this whole spectrum of care for people with dementia.

Shah: The way I think about what we do in the emergency department is that we are a diagnostic center, more than just purely an acute care center. We get patients who have something wrong, they feel something is abnormal and we need to figure out what the cause is. The cause may be sometimes more social, it may be behavioral, it may be medical, it may be an adverse drug reaction to a medication that their physician started, but that all comes together in one place and allows us to do the right thing for the patient. There is a paper that we wrote a few years back; then we called ourselves the front porch to the hospital, because everyone's got to come up onto the porch. We'll take a look at them and try to figure it out and then we'll either send them on their way or bring them into the house.

Chin: I like that and I was actually about to use the expression frontline, because the ER is a frontline for healthcare. You're also one of the main access points that many people use in receiving health, particularly people with dementia.

Shah: That's a really good point. The challenge is that most healthcare services are only available Monday through Friday. The question then becomes: how do you get care to these folks at times when they need it? Not everything happens Monday through Friday between eight o'clock and four o'clock, and even if it did, people's clinic schedules are full. How do you get in and seen? Or if you have any functional limitations or you're not driving anymore, how do you even get to the clinic?

Chin: Some of your research was highlighted this week at the conference, and you've been getting national press for your work that has shown telemedicine programs can decrease emergency department use by people with dementia. Can you tell us more about this?

Shah: Absolutely. It really springboards on what we were just talking about. We know it's tough for patients with dementia to get acute illness care. They start having a symptom, they may call their family member, may call to get in to be seen. But between challenges in getting an appointment, challenges in getting to the doctor's office, it becomes really difficult for them at times, which is why we see that they come to the emergency department more frequently than people without dementia. While we are really good at taking care of patients in the emergency department, we also know it's pretty stressful for them in the emergency department. It's an unfamiliar place, it's loud, it's noisy, there's a lot of things going on. The question that we have been asking for a few years now and I think a lot of people have been talking about is, with all this modern technology that we have, can we use telemedicine and take care of these folks in their home? Take care of them in an environment that they are more comfortable in and maybe decrease visits to the emergency department so that they're happier, their family members are happier, and it becomes a win-win situation. We had some funding a few years ago and we implemented what we call high-intensity telemedicine for older adults that live in independent and assisted living. We found in that study that there was an 18% reduction in ED utilization across the board if you had access to telemedicine services. I'll talk about what high-intensity telemedicine is in a minute. For this study, we actually took another look at that data and said, what happened if the person had dementia? Forty-nine percent of the patients in our study had dementia, so we had quite a number of people we could actually look at that. What we found is that for the group that had access to our high-intensity telemedicine, there was a 24% reduction in ED utilization as compared to the control group that didn't have access to that telemedicine service.

Chin: That's incredible. As someone who works with you down in the ER, but then who also works in a memory clinic and sees the patients after the ER visit, that has a significant improvement in their quality of life because the ER, as you said, is not necessarily a place where you want to be. 

Shah: It really surprised us that it was such a huge reduction. We thought we'd see a reduction, I didn't think it'd be 24%. It made us happy to see it because what drove this research to begin with was a couple people I saw in the emergency department that got sent in from their assisted living facility because they had a bruise on their arm. They came in in the middle of the evening, they got cared for, went home and it was pretty efficient and quick. They were in and out in less than a couple hours, but still that was such a burden on them. It was horrible to see. This is the type of thing that telemedicine could take care of. Now, the caveat I should talk about is - what is our high-intensity telemedicine? The telemedicine I think most people are used to now is really just video conferencing. A lot of insurance plans have that. I know the UW staff and faculty, we have that as part of our insurance plan, but basically it's just teleconferencing. It's basically facetime or Skype or whatever. We took it to another level. We realize that older adults are on a lot of medications, have a lot of issues, and may have trouble navigating a computer or other devices. What we did is we said, what if we take a technician, someone that would go to the patient side to facilitate this visit? So that's what we did. We had someone that was basically an EMT or a nurse's aide who went to the patient's side when they needed to be evaluated to facilitate the visit. They could do a medication reconciliation, they could collect the history, they could do a blood pressure and check the heart rate. Then we gave them some cool tools to work with. We gave them a digital stethoscope, so they could capture the heart sounds or the lung sounds or the bowel sounds. We gave them a video camera, if the patients said their neck hurt, they would have them move their head and videotape it to show what it looked like. We gave them a digital camera, not so special, but if they had a rash they could take a picture of it. We then also gave them a 12-lead electrocardiogram, because you could do it on a laptop computer now so they could get that electrocardiogram. We taught them how to draw blood. They could get blood samples for us if we needed to do some advanced testing. We made this technician a really capable resource who would pull all the information together, and then connect up to the physician who was the telemedicine provider, or nurse practitioners and PA's also, and they would video conference with the patient if it was appropriate. They would video conference with a patient and their family members at the same time if needed, and come up with a plan and figure it out and address it.

Chin: Wow. Were you able to get feedback from the participants who are also patients in this? I would imagine they had positive things to say.

Shah: Yeah, we published that from our main group a few years ago and basically everyone loved it. I mean, who wouldn't? You don't have to leave your house, someone comes, takes care of everything and the communication is really good and gets reinforced by the technician that's there. Everyone loved it. The staff loved it. The patients love it. The family members loved it. It was an easy win from that standpoint.

Chin: Now that you've found a framework that seems effective in improving care for people with dementia, keeping them home instead of sending them on an unnecessary trip to the ER, which could actually exacerbate their condition and also add unnecessary expense and pressure on the health care system; how does a program like this get implemented in emergency rooms across the country?

Shah: I think that question is a really important one because I would argue that this is not an emergency department program as much as it's a health system program, right? This is something a very large assisted or independent living facility could offer. This is something a health system could offer across the board and link people up to eliminate needing to go to the emergency department. There are a number of places around the country that are starting to do it, not this high-intensity model necessarily, but at least at a video conferencing low level. It just helps increase the capability of the overall health system. There are a number of companies out there that have started coming together that are offering very similar services to nursing homes, assisted living facilities and what not. I don't believe we have any in Madison. I know that one of the groups we worked with back in Rochester, New York where we actually did this work before I came to Madison were planning on going into the business to do it. I don't know what's happened to that. I think that as health systems think about this, they can implement it and get significant efficiencies of scale and really roll it out in a community with significant benefit.

Chin: This is just one example of health care researchers like yourself identifying ways to improve care for our patients. This is something that we all want to see happen of course, but this is your specialty in particular. You recently joined the Wisconsin Alzheimer's Disease Research Center as an investigator to do just that, identify better ways to treat patients with Alzheimer's disease and help health care facilities adopt those best practices. You're doing this as the co-leader of our center's new Care Research Program. I know this is young in its development, if you could just tell us a little bit about this initiative.

Shah: I was really honored Dr. Asthana and Dr. Kind asked me to join in and help them with this initiative. It's really particularly exciting, because I believe this is the first one in the country to really focus in on the care research side of things. The Care Research Program really is going to look at a couple of things; one is really to build infrastructure and support for other people that want to do research in this area. We're reaching out to a number of community groups, community collaborators, others within the university and the university system to help be that resource so that we can increase the amount of care research that occurs with patients with dementia at UW. That piece I think is a key foundational component of this. Another piece that's being worked on is linking the data. We have so much data on so many people. We've got cohorts of people that have agreed to participate within the Alzheimer's Disease Research Center. How do we link together their care experiences, their care that's going on, to the various testing that occurs as part of our overall ADRC? That's another piece that we'll be working on over the years to come. It's super exciting. It's super fun to do. I think that the potential is enormous in terms of improving how we care for folks in our communities.

Chin: Well, we're excited to have you. Especially someone in a different discipline. I think this speaks to the importance of multidisciplinary, transdisciplinary research and clinical care. Someone from emergency medicine working with geriatrics, who would've thought it? But it seems to make the most sense now that we're in this. What are some of your other care projects that you're working on that focused on dementia patients or elderly patients in the emergency room?

Shah: Probably the other big area I've spent much of my career working on is thinking about how we use our EMTs and paramedics in the community to support people in the community. There have been a lot of projects, some of which I've done, that have looked at this for older adults in general. We're working to start thinking about how we can use these paramedics and EMTs to support people with dementia who live in the community. Particularly some of them in underserved communities, whether it's more rural or more urban, could be that resource for family members, caregivers, and the patients throughout the entire spectrum of disease. It's fun being able to innovate and think of ideas that people haven't in the past. Given the serious needs around dementia, and given the incredible skills that these paramedics and EMTs have it's just a natural synergy there. I'll tell you in talking to them, they are incredibly excited about having these new roles and being able to continue in their important community role they always have.

Chin: I think it's important to emphasize that your type of research has direct human implications. You are researching people. That's why it's a human study. The benefits are seen by your research participants.

Shah: That's why I love doing what I do.

Chin: I'm going to end by putting you on the spot because a lot of our listeners, they range anywhere from 18 to a hundred, but we're all wondering how we should be best prepared to go to the ER. Is there any advice you can give any of us, if we get sick enough that we need to go to the ER, is there something that we should be doing in advance to prepare us for the most successful ER visit?

Shah: Gosh, that's a great question. I think that the number one thing would be to know what medications you're taking. If you've missed some of the doses, that's fine. Just know it and let us know. Medications particularly, because some people are on so many medications, are one thing that we often struggle with. The electronic medical record theoretically solves that problem. Unfortunately, it sometimes actually makes it more complicated because every medicine you've ever been on isn't there. Then we're trying to find out what you're actually taking. If there's anything I'm going to say it's know your medications and which ones you've actually been taking. I understand if you don't want to bring them in, they're expensive, but at least bring in the list for us.

Chin: That's wonderful and thank you again for being on Dementia Matters.

Shah: Thanks Nate.

Chin: Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health and the Geriatric Research Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private, university, state and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers. This episode was produced by Rebecca Wasieleski and edited by Bashir Aden. Our musical jingle is "Cases to Rest" by Blue Dot Sessions. Check out our website at adrc.wisc.edu. You can also follow us on Twitter and Facebook. If you have any questions or comments, email us at dementiamatters@medicine.wisc.edu. Thanks for listening.