Home visits by family doctors are key to patient-centred care, as emphasized by Dr Ian McWhinney in his textbook of family medicine.1 However, there are challenges to upholding this principle, which include more patients without primary care clinicians, an aging population with increasingly complex care needs, and practitioner time constraints due to administrative burdens.2-4
With an increasing need to support people aging at home, reducing dependence on institutional long-term care is crucial, especially for those residing in assisted-living communities5; patients in these homes are typically medically complex and require attendant care.
A founding principle of family medicine, as defined by Dr McWhinney, is that family physicians assess patients in their homes.1 This provides an essential service for patients in community-based assisted living. Yet physicians are constrained by time and bringing these patients to their offices creates logistical burdens of transportation costs, scheduling challenges, and attendant care.
This case study outlines a potential solution using mobile telemedicine digital health technology to perform virtual assessments simulating a face-to-face examination. This model of care is unique because of mobile integrated diagnostic peripherals embedded into the circle of care. This solution may simplify physicians’ workflows and reduce travel burdens for patients. Moreover, this case reconciles the foundational principles of family medicine and patient-centred care within the digital health ecosystem and reduces health care inequity. Sustainable fee codes, technical support required to train staff, accreditation, and competency training could make this model of care feasible for family physicians.
Case
This case details a digital health workflow that extends the capabilities of video assessments by integrating a digital stethoscope, otoscope, and pulse oximeter into video calls using a telemedicine kit and the AGNES Connect virtual care platform. AGNES is certified by the Health Insurance Portability and Accountability Act and the Personal Information Protection and Electronic Documents Act and allows physicians to remotely operate examination tools that are applied to patients by trained support staff at the patient’s bedside (Figure 1).
Figure 1.Digital equipment
The study’s initial phase involved co-designing clinical workflows with patients, caregivers, and clinicians. Medical directives and a triage flowchart (Figure 2) were created for the care team to use at the selected test site. Triaging was no different than for a face-to-face physician assessment, and once a need was determined, the mobile kit could be dispatched to the home in preparation for the physician’s virtual visit. The 75-year-old test patient had a history of cognitive delay, paraplegia, epilepsy, hypertension, and dyslipidemia. The patient was bedridden and used a wheelchair. On virtual assessment, the patient appeared fatigued but not acutely distressed. Using digital peripherals that support staff operated at the bedside, the physician was able to remotely perform a respiratory examination.
Figure 2.Virtual clinic visit flowchart
Auscultation examination results revealed bibasilar inspiratory crackles. No signs of upper airway obstruction or acute confusion were noted. A chest x-ray scan was not done due to limited value in this context. In older adults with frailty, clinical findings such as localized crackles, fevers, and staff-observed decline often provide sufficient diagnostic clarity to initiate empiric therapy for suspected lower respiratory tract infection. The patient was clinically diagnosed with probable community-acquired pneumonia and started on oral amoxicillin 50 mg 3 times daily for 7 days. For the following 72 hours, staff reported improved alertness, appetite, and respiratory symptoms. No escalation of care was needed, nor was a face-to-face visit.
Discussion
This case illustrates the potential for virtual house calls to minimize care burdens and enhance patient care. Integrating digital technologies into house calls supports patient care and aligns with proposals for new patient-centric care models.6 However, the standard of care for using digital technologies in home visits needs redefinition, as this is an evolving field of research.7
There are barriers to this model being feasible in a publicly funded health care system, such as a need for sustainable funding for using this technology. Ontario’s schedule of benefits, the A900 fee code for complex patient house calls, is only payable when rendered in person.8 This implies the need for face-to-face examination, which would need to be modified to allow for an equivalent virtual fee code. Pragmatic clinical trials should be conducted to compare this model against current standards to capture patient, provider, and economic outcomes. Internet connectivity requirements (minimum of 25 Mbps in this case), staff digital competency, and funding to accredit staff in this training are other potential barriers.
Telemedicine programs are evolving across Canada, and we believe this case is the first in Canadian literature that describes serving a patient in an assisted-living community. Commercial providers have integrated platforms focused on inpatient hospitals or community pharmacies.9,10 While commercial platforms like TytoCare serve individual home users and Teladoc focuses on clinic connections, we can find no published literature describing mobile telemedicine systems specifically designed for community-based assisted-living populations with embedded care team support.9-14 Telemedicine tools have also been useful when providing care to remote Indigenous communities, which is an example of its use for serving populations who are marginalized.15-17
The patient in this case study had an existing longitudinal relationship with their family physician and the circle of care was maintained with trusted staff. Allied health care staff were essential in providing patient-centred care in this model. Future studies should capture patient and provider satisfaction.
This case demonstrates the ability to bypass time constraints, transportation burdens, and other challenges associated with traditional housecalls to assisted-living residences. This model of care offers enhanced comfort, accessibility, and patient safety for this population. Ultimately, a program like this could support critical pillars of patient-centred care, especially within the current strained primary care landscape.
Data were collected on traditional face-to-face assessments requiring transport out of home (Table 1). Overlap staff costs were included if coverage was needed to replace staff leaving to accompany a patient. These data suggest that performing medical visits virtually is beneficial in reducing costs of out-of-home assessments. This successful outcome supports the clinical utility and safety of assisted virtual house calls in managing high-risk patients.
Transportation costs
Conclusion
Using home-based, mobile telemedicine tools for select groups of patients who are marginalized may lessen the digital divide, improve primary access, and support patient-centred care and its foundational principles.
Acknowledgment
This article was partially funded by a student research grant for Sahara Rosha from the Institute for Earth and Space Exploration at Western University in London, Ont.
Notes
Editor’s key points
▸ Virtual house calls support a founding McWhinney principle of family medicine using digital health technology.
▸ This case demonstrates a way to bypass the challenges of serving community-based assisted living populations by leveraging digital technologies.
▸ Further study and sustainable public funding are needed, including fee codes that can decrease the digital divide for marginalized populations.
Points de repère du rédacteur
▸ Les visites à domicile soutiennent un principe fondamental de la médecine familiale selon McWhinney à l’aide de la technologie numérique en santé.
▸ Ce cas démontre une manière d’éviter les défis de desservir les populations bénéficiaires de l’aide à l’autonomie dans la communauté en misant sur les technologies numériques.
▸ Une étude plus approfondie et un financement public durable seront nécessaires, y compris des codes de facturation pouvant combler le fossé numérique pour les populations marginalisées.
Footnotes
Competing interests
Dr Keith Thompson is Chief Medical Officer for NuraLogix Corporation and is a telemedicine provider for Rocket Doctor.
This article has been peer reviewed.
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