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Video & Telephone appointments for New Rheumatology Referrals
We have started offering new routine rheumatology referrals either telephone or video appointments. Consultants were somewhat nervous about video and telephone appts for new patients who they have obviously never seen before. Building rapport, interpreting subtle body language, language barriers and the patient feeling they have been properly assessed were all concerns but the major concern has been the lack of being able to undertake a physical examination.
All our referrals are triaged by a clinician to determine if a routine or urgent appt is required. Consultants have then reviewed patients who have been booked for a routine appt to ensure they are appropriate for a telephone or online consultation
Patients have then been contacted by phone and asked if they would like a video (using Attend Anywhere) or telephone appointment. At this assessment we also explore whether there is a language barrier. We have tried to encourage video appts, but if patients do not have access to the technology or are not keen then a telephone appt is offered. We have designed an FAQ for patients which is emailed to the patient along with the instructions about how to login to Attend Anywhere.
We are collating information about outcomes and have 3 weeks of data. So far 44 patients have been seen.
-18 patients had an on-line consultation, 26 telephone consultation (7 patients who had a telephone appt had requested an online but Attend Anywhere was down)
-6 patients need to be brought back for a further face-to-face appointment, 12 require a further routine follow-up appointment & 11 patients results of further investigations are awaited before a decision is made about further follow-up
-15 have been discharged
Patients complete a feedback questionnaire about their online appointment which we will analyse in due course.
What is needed to sustain the change?
At this time we recognise that patients are grateful to have an appointment and we are mindful about how many patients we can safely see face-to-face and maintain safe social distancing. However, we have been surprised how positive the response has been from patients and that many patients have been able to be assessed and discharged and we are considering whether there is a role for seeing some patients
The importance of selecting appropriate patients for a remote consultation is paramount and also explaining to patients what this will entail and ensuring that patients are comfortable with this type of appointment.
There also needs to be a "safety-net" in place to be able to bring patients in for a face-to-face appt quickly if needed. So to look to sustain this change there needs to e careful review of clinic templates and more clinician time invested in the triage process
What is your region?
North West
We have done some of this, ie referrals should be being triaged (temp stop as Cons reallocated to a ward). Initial 'validation' has actually created additional work, with difficulty allocating time to do it, and at least one unhappy patient who was validated as not needing F/U (this was in their clinic letter) - pt refused to be discharged.
The majority of patients I have telephoned - if new, need a face to face appointment to be able to examine them. I have not been able to discharge any new patients from a telephone appointment, have discharged 1 F/U - who should not have been on for F/U anyway as had already been discharged. Others all deferred and will reappear in 3-4 month or some changed to patient initiated follow up. So there is a OPD bulge to come.
Of follow ups - several have needed F2F - but have refused inc some with vasculitis / lupus flares. Others have needed medication escalation as RA / PsA not controlled - but have been too scared to do so. Several, inc new RA patients, only willing to accept steroids - which stores up issues for future side effects / bone protection etc.
Others have not been able to explain their symptoms well enough to be able to manage them remotely eg one was very confused between a surgical and the Rhematology issue - the surgical issue could not be solved by Rheum, the only other information gained was how severe the pain was in hands - but they were unable to say where / describe if swollen / understand the explanation of results, this was not an elderly person. F2F was arranged.
I suspect there will be area variations ie those working with patients who are fluent in medical terminology / highly educated will possibly find it easier to do telephone / video consultations. For those areas with patients who have less medical knowledge / ability to explain symptomatology / ability to take in medical explanations (not neccessarily due to speaking a different language) - this is really difficult.
Personally - I feel as if I am not able to manage my patients properly / failing to manage their diseases. And I am very concerned re the lupus / vasculitis patients that have not been seen (by their choice) despite giving symptoms suggestive of flares starting.
The only benefit I have found was in patients who could be discharged after results - but even after phoning them - I still have to do a letter, so it actually increased the work as otherwise I would just have done a letter.
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As a therapy service, we are completing subjective assessments over the telephone and giving advice based on the patients reporting of their symptoms. Where required, we are offering follow up appointments via AccuRx.
This is limiting in some ways as a number of patients are against downloading the Whereby App onto their smart phone or are unable to.
Generally we feel as though we are getting better information from our patients than face to face as their attention is firmly on the telephone consultation, however, the consultations take approximately 40 mins for a new patient.
We have been enabled to work from home 4 days out of 5, visiting the department one day a week to maintain social distancing.
In general, we have been able to complete full courses of treatment over the telephone and discharge patients. This set up enables patients to take a much better attitude to self management and we feel that they are more open to this than when they attend the department.
Patients report that remote appointments make it easier for them to avoid missing work, that it is much more efficient use of their time, that they are not arriving tired and in pain from the stress of the journey and attempts to park.
Where children are concerned, particularly those with diagnoses of ASD, Anxiety, sleep disorders in addition to their rheumatological/ MSK condition, it is of great benefit to see them in their own environment. This makes it easier for us to agree courses of treatment that fit in with their interests and minimise conflict with their parents/ guardians.
Some patients choose not to answer the telephone where the call is NO caller ID. We are using our own mobiles to contact patients. Where there is no facility to leave a message we have had to develop new attendance policy. We will contact the patient during hteir appointment time, once again and then sent an SMS and a letter. If no contact for 2 weeks they are discharged from the service.
F2F is not offered at this time for this client group.
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Status labels added: Integration Of Resources, Investment In Technology, Pathway Redesign, Patient Activation, Patient Selection, Screening, Triage, Video Consulting, Virtual Consulting, Horizon 2
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Status labels added: Health & Wellbeing, Home Working / Remote Working, Shared Decision Making, Telephone Consulting
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Status labels removed: Health & Wellbeing, Home Working / Remote Working, Integration Of Resources, Investment In Technology, Pathway Redesign, Patient Activation, Patient Selection, Screening, Shared Decision Making, Telephone Consulting, Triage, Video Consulting, Virtual Consulting
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