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COVID19 Using telehealth for Memory Clinic consultations advice sheet

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During the COVID19 pandemic many memory clinic services had to cease face to face consultations and move their services to phone consultations and telehealth. This fact sheet is not an exhaustive resource but provides some initial general advice for practitioners using telehealth to facilitate consultations and assessments of clients with dementia and cognitive decline.

What is telehealth?

Telehealth consultations encompass a wide range of remote communication types including, telephone and videoconference platforms. The International Organisation for Standardisation defines Telehealth as the ‘use of telecommunication techniques for the purpose of providing telemedicine, medical education, and health education over a distance’ [1].

Generally, the use of ‘health direct’ is endorsed as a secure, Medicare-compliant platform to provide telehealth service: https://about.healthdirect.gov.au/video-call

In case your assessment service does not have access to this platform yet, the Australian Government’s Department of Health lists Zoom, Skype, FaceTime, Duo, GoToMeeting as possible Medicare-compliant alternatives.

Caution! Free versions of these platforms may not satisfy privacy laws. Clients should be informed about possible privacy issues prior to the assessment or consultation.

See the end of this factsheet for a list of useful resources and references, including links to webinars and Australian guidelines

Tips for a successful telehealth consultation

These tips are general advice, however, tips marked with the ADNeT brain  indicate suggestions that are particularly important to improve communications with people living with dementia or other cognitive impairment.

Advantages of using telehealth include

  • Client is in a familiar home environment
  • There is evidence of increased family participation
  • Ease of reaching clients in remote/rural areas, or in this case safely reaching vulnerable clients in a pandemic
  • Outcomes are often the same as traditional face to face interactions [2]
  • Some well recognised face-to-face screening cognitive tests have similar validity when conducted via videoconference e.g. Mini-Mental State Examination (MMSE) [3]

Before you begin consultations by telehealth:

  • Determine and test the options you have available to you – Are they secure? Do they provide confidentiality? Do they work?
  • What is your backup plan if the consult fails mid-way?
  • Check your equipment i.e. mobile phone is charged, webcam, headphones and microphone are available and in good working order and that you have adequate internet access
  • Does your professional indemnity policy allow you to do telehealth? [2, 4]
  • Practice a video call with someone who is off-site and request feedback

Important considerations for a video call

  • Ensure a simple visual background with good contrast
    • eg., no bookshelves, wallpaper or pictures on the wall
  • Minimise background noise
    • eg., typing on keyboard, air-conditioner, music, phone on silent, a quiet room such as your consultation room. If others are around, put a do not disturb sign on the door
  • Minimise your body movements
  • Enhance facial animation, an increase of 10% has been shown to improve communication
  • Ensure good lighting so the person can see your facial expressions well
    • Enough light on your face and background with less light
    • eg., window in your background would reduce light on your face – facial expressions difficult to see
  • Communicate what you are going to do, before you do it
    • eg., I am now going to look at my notes because the client has a limited view of your situation
  • Look directly at the camera not the screen (looking directly at the client)
  • Determine if you have access to a technician or ‘help desk’ [4]
  • Ensure you have a telephone number as a back-up plan

Setting up a consultation

  • If available designate a person to schedule the telehealth consultations to save time and maximise success of the call. This could be the practice receptionist.
  • Determine which type of call the client is able to participate in i.e. videoconference, voice only call (this will depend on computer literacy and availability of hardware)
  • Confirm terms of the interaction with the client
    • eg. client cannot be driving, suggest consultation occurs in a quiet place with good lighting with no other distractions, client not to record or reproduce the session, client should not type other things [4]
  • If the client has a cognitive impairment, would it be preferable to have a second person accompany them during the consult? e.g. carer or family member
  • What about language barriers? Is an interpreter required?
  • What is your plan for the consultation?
    • Prepare outline of the session
    • Prepare test material if required, including electronic versions of any material to be screen shared
  • Send forms and suitable non-copyrighted material via registered post or encrypted email (when client can print) before the assessment. Mark envelope “not to be opened until the appointment” to avoid practice effects
  • Caution! Test material of most neuropsychological tests cannot be sent to the client. Always double check licence requirement!

During the consultation

  • Plan extra time in the beginning to familiarise the client/ family with the technology [4]
  • Ensure client has prepared material that might be needed for assessments
    • eg. ADAS-Cog: paper, envelope, marker pen
    • normal pen or pencil is difficult to see via webcam – marker pen is a better option
  • Identify yourself and obtain informed consent to continue the consultation using the media platform https://www.australiandementianetwork.org.au/wp-content/uploads/2020/04/Telehealth-advice_Generic-Informed-Consent-for-Telehealth-Services_April2020.docx
  • Confirm the clients’ physical location and who else is present
  • Determine if they are recording or storing the session on their computer.
    • RACGP advises that ‘patients are not authorised to make their own recordings of a video consultation’, and that ‘clinicians should be mindful of their own privacy in relation to the risk of video recordings being redistributed in the public domain without their consent.’ [4]
  • At the beginning of the consultation briefly reiterate the terms of the interaction (i.e. no driving, quiet area etc.)
  • For people with dementia or other cognitive impairment speak clearly, keep questions simple, give a longer than usual time for the person to respond [5]
  • At the end of the consultation you could ask clients to hold up any writing or drawings they have done. These can be captured via screenshot. Ask them to mail the originals back in the post or send via email.

Documenting the conversation

In addition to your usual clinic notes include a section referring to the consult as a teleconference:

  • Who was present and how the interaction proceeded, where the client was located, consent to undertake the consultation, rationale for using telehealth instead of face-to-face consult
  • Do you need to make a still or video record during the call?
    • NOTE: for recording of still or video images written consent should be obtained from the client – perhaps this can be obtained via email before the consult? [3]
  • Existence and location of any recordings you made, e.g. Mini Mental State Examination (MMSE), Rowland Universal Dementia Assessment Scale (RUDAS), Geriatric Depression Scale (GDS) [4, 6]

Billing

Medicare billing FAQs, MBS items and specific advice regarding using telehealth for consultations during the COVID19 pandemic is available from the Australian Government Department of Health website. This website is regularly updated: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TempBB

References

  1. Standardisation, I.O.f., Health informatics-Telehealth services–Quality planning guidelines, in ISO/TS 13131:2014. 2014, ISO.
  2. Cullum, M., G. Gioia, and K. Podell, Taking neuropsychology out of the office: Extending our practice through telehealth technology, in Neuropsychology in Transition, 39th Annual Conference. 2019: San Diego, California.
  3. Cullum, M., et al., Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment. Journal of the International Neuropsychological Society : JINS, 2014. 20(10): p. 1028-1033.
  4. The Royal Australian College of General Practitioners, Telehealth video consultations guide. 2019, RACGP: East Melbourne, Victoria.
  5. Dementia Australia Let’s talk: Good communication tips for talking with people with dementia. 2018.
  6. Westphal, A., Cognitive Dementia and Memory Service Best Practice Guidelines: Service Guidelines for Victorian Cognitive Dementia and Memory Services. 2013, State of Victoria, Department of Health. p. 1 – 129.

Resources and websites

 

Download this advice sheet as a PDF here