Shut Out of Nursing Facilities, a Post-Acute Mental Health Practice Pivots to Virtual on the Fly

When skilled nursing facilities went into lockdown in March to try to keep COVID-19 out of their buildings, group activities and all nonessential visitors and personnel were banned.

How nursing homes interpreted the definition of “essential” personnel could vary, but Executive Mental Health, a psychology practice based in Los Angeles that provides services to acute and post-acute facilities in California and Nevada, found that it didn’t always include psychologists.

The company, which was founded in 1996 by Dr. Ari Kalechstein, provides forensic and non-forensic mental health evaluations in both SNFs and acute care centers. Before COVID-19, Executive Mental Health serviced anywhere from 220 to 240 SNFs, though of that total, the company serviced 125 to 150 “on a more regular basis,” Kalechstein told SNN on August 13.

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But when the pandemic struck, the company had to find a way to convert its practice from an in-person model to a virtual one — in effect, pivoting to a telehealth model in a matter of weeks. The process involved finding a way to acclimate facility staff to using the new system, hiring device technicians, and driving around Los Angeles to secure iPads amid the first wave of pandemic-induced panic-buying.

Skilled Nursing News called Kalechstein on August 13 to talk about how the company was able to make the switch, and how it’s incorporating telehealth into its plans for the future.

When did you start looking seriously at converting to a telehealth model — and how long did it take to start putting the system together from scratch?

We started in mid-March, but when I think back, back in late January or early February, I remember reading about the city of Wuhan, China. That was a city of 10 million people, and they were quarantined. I remember talking to my wife about this, and some of my colleagues in my group and saying: “This sounds pretty serious.” At that point and time, there wasn’t a lot of discussion about COVID-19, or the implications that it would have, or the impact it would have on society at large.

Over the next few weeks, it became apparent that it was going to be an issue. So right around mid-March, we had to make a decision about what we were going to do as a company, and I would describe it as one of those existential decisions — because I had great fear that COVID-19 would sweep the nation. I didn’t realize that it would become the pandemic that it has, but I was concerned. So I spoke to my colleagues: How are we going to do this? How are we going to make this work?

The first thing we had to do was identify the hardware that we could utilize in order to make this happen. Our goal at that point in time was to identify hardware that was easily transportable, had a good battery life, and would not become a vector for disease transmission. So what we identified was Series 7 iPads with a relatively large screen, and we bought stands so that the iPad would be on the stand — and that patients would never actually touch it. We were trying to find equipment that was functional in a skilled nursing environment, that would adapt to the Wi-Fi that would be relatively safe, and be functional for the purpose that it was intended.

The next goal was to identify a particular program that could be utilized on the iPad and that would be easily accessible. It was called Doxy, and the point of the program was that it was easily accessible. We had one of our operations people take the iPads, program them so easily that you basically had to press one button to start the iPad and bring up the Doxy.

That was basically solving just the portion of what kind of hardware and software we would use to transition to a telehealth model. That doesn’t even account for the fact of how we had to figure out how to source all this equipment. What happened was — if you imagine back when the pandemic first hit, when people were panicked, if you imagine going to the grocery stores and seeing empty shelves when you’re looking to buy food, if that rings a bell, the same thing was happening with computer equipment.

I had gone to Best Buy as soon as I figured this out, and I said, “I’m just going to go there and I’m going to buy a bunch of iPads.”

They were limiting it to two. So part of our group’s mission was to figure out: How do we source these things?

Fortunately, I have a decent contract with AT&T, because they’re our mobile carrier, so I called around and I found an intrepid young woman who was eager to source iPads for us.

In the first several weeks following the onset of the pandemic and the shelter-in-place prohibitions, she was essentially driving around the city of Los Angeles, probably hundreds of miles, to get iPads in every single AT&T store she could lay her hands on. Then she brought them back to us, and I had a colleague in my group programming the iPads so they’d be ready. We’d set them up to fit with stands, and then ship them out to the various facilities that desired us to implement telemedicine techniques or telemedicine as an approach to providing patient care.

This was happening mid-March to April. There was an additional transition to it all. The SNFs, when President Trump talked about concerns related to the pandemic, one of the concerns was that he identified SNFs as ground zero for disease transmission if you will. So imagine these SNFs, they’re having to — in a very short time — figure out how to manage all these issues related to COVID-19. They have staff that are absolutely petrified regarding the possibility of becoming infected with the disease. They’re having to explain to family members why there will be no ingress and egress from the facilities.

One of our missions was to explain to the facilities: Look, we completely get the distress you’re experiencing, because my staff is experiencing it, too. And there can be no doubt that residents and patients you service are also experiencing that same distress, because in SNFs, people are there because they’re experiencing some sort of medical and/or mental state compromise.

The prevalence of depression and/or anxiety in skilled nursing facilities is relatively high, even under the best of circumstances. Then you consider the addition of COVID-19 as a risk factor for the onset of depression and anxiety, and it would make sense that even more people are going to be depressed or anxious.

Our goal was to explain to the facilities: We get you’re distressed, and we understand that and we’re here to help, and we can help by alleviating some of the emotional distress that the residents/patients at your facilities are experiencing.

We had to figure out how to move the iPads from room to room. What happened initially was that the facilities said: We can handle that. We’ll have somebody internally move it around. But no doubt you’re aware that facilities have experienced staffing shortages, so they were just up to their eyeballs in managing the day-to-day activities associated with patient care at the time of COVID-19.

What we proposed to facilities was this: We’re going to hire somebody, and we will have them move the iPad in the stand from room to room, and we identified that position as a device technician (DT)

The importance of the DT was to have a person in a facility who would take the iPad from room to room, but also serve as a concierge of telehealth services, if you will. So they don’t simply walk in, plunk down the iPad and turn it on and then the doctor appears. Their goal is to walk in, explain that a doctor is about to speak to them to make that person feel comfortable, to set it up so they can see the iPad, and make that introduction — so it’s more of a warm handoff, rather than a cold, two-second interface.

Did you ever run into concerns about that person going into the facility, given the nature of COVID-19 and the lockdowns facilities were under?

Yes, 100%. The first thing I told each of my staff members is this: First, if you’re concerned, you should be, because I am. The second is this: If anybody says they don’t want to go into a facility, then don’t. That’s perfectly fine. We completely support that. The third is: If you’re going to go in, I know the facilities will appreciate it. But we want to make sure that you have all the adequate PPE [personal protective equipment] to make sure you’re safe.

When we introduced staff and/or the DTs to the facility before they went, we provided our colleagues with the appropriate measures for ensuring that they stayed safe and disinfected, so that they themselves would not become vectors for disease transmission.

Fortunately, to the best of my knowledge, nobody’s been diagnosed as COVID-19 positive so far. So I thank our lucky stars that our staff have followed these directives, they’ve remained safe.

Do these technicians go to every facility you work with on the telehealth program? Or were there facilities that decided to handle it internally?

There are a number of facilities that have chosen to utilize an internal device technician, and we try to work with those facilities as best we can. We encourage them to use external DTs. What we have found is this: Some facilities have been terrific in terms of being able to provide an internal employee from within the facility to dedicate enough time for us to provide the services we would to at the facility, to see all of the patients.

In other instances, it’s been more difficult, and the DTs have been distracted. They are asked to perform multiple activities while providing these device technician services.

In that regard, what we’ve tried to explain to the facilities is: Look, if you want to have somebody internal you want to handle the device, we’ll pay them just to be dedicated to doing this work. Our goal is to ensure that we have uninterrupted service that we can provide to the residents so they can get the care they need. And we’re trying to be a good partner to the facility, so we’re trying to work within the constraints that the facility provides.

In terms of the infrastructure, does it all involve those L.A.-sourced iPads, or did any facilities have an existing setup for telehealth services that you could use without using your own equipment? Did that situation ever come up?

It did from time to time, but by and large, we sourced the material. There were some facilities that do have iPads. But from my perspective, the most prudent approach was to own iPads.

If we’re going to provide that service at the facility, I would rather not be encumbered by the issue of having to decide how we were going to share a particular device with other groups or other clinicians. It seemed more prudent, from my perspective, that we have a device dedicated to EMH clinicians.

As you were getting this program off the ground, were there any other obstacles or hurdles you encountered, besides sourcing the iPads?

The first issue you mentioned was the sourcing, and we did work that out. The second issue was, as the leader of a company, it was being able to talk to my colleagues and explain to them: There’s a pathway forward, and my goal is to keep you all employed and protect you in this time.

First, we had daily morning and afternoon Zoom calls with executive staff, and our field reps or liaisons and lead clinicians, so we could talk about the problems people were facing — so we could address those issues immediately. The second was we implemented what was affectionately known as fireside chats. The idea was: We had a conversation every week, just me talking about how we need to persevere as a team, that we have the technology and the know-how to work our way through this, that it’s a scary time, that everybody is concerned and that we as a team are going to support each other to work through the problems associated with the pandemic. My goal was to ensure that nobody gets laid off, and fortunately today, that’s not happened.

The other obstacles we experienced over time were the waves of the pandemic, and I’m not talking about whether we’re through this first wave of the pandemic or not, but over days or weeks, cases of COVID at different facilities would ebb and flow. So there would be times when facilities would shut down, or times when they would open up, or times when they would be more amenable to telehealth services than other times.

Our goal at that time was to determine: How do we pivot rapidly and effectively to ensure that clinicians have an adequate caseload, to ensure that they’re safe and to ensure that our people remain employed/

Looking ahead, do you think a telehealth model will be the new norm?

First and foremost — and I would say this with near 100% certainty — telehealth is here to stay. I believe that you cannot put that genie back in the bottle.

I think all things being equal, if it’s possible to provide face-to-face care, that’s always preferable. I think with telehealth, you do lose some of the interpersonal connection that a face-to-face treatment model provides. Having said that, I think there are so many benefits that are afforded by a telehealth model that to return to a strictly face-to-face model would be to ignore the benefits of a great technology.

For example, one of the things that we’ve been doing is we have acquired new partners or new facilities that are in relatively rural places where they struggle to get mental health care. I can imagine that even if the pandemic subsides, and a number of facilities are willing to return to a face-to-face model, those facilities won’t, because there’s no clinician there to service them anyways. That’s one instance in which I can see where telemedicine will remain a vital resource for SNFs.

Other aspects of telemedicine that I think are indispensable are the timeliness and efficiency of telemedicine techniques. Especially in more acute emergent situations, telemedicine is an amazing way to provide efficient, timely intervention.

For example, there was a concern a patient might require civil commitment — maybe they were a danger to themselves or some other person. Rather than having to wait hours or days for a clinician to conduct an examination face-to-face, telemedicine technology provides a medium to do quick and efficient and valid assessments of an individual’s mental state. This ensures facilities are intervening and providing the best possible care in the most timely manner. So I think telemedicine in that regard is incredibly helpful.

For your company, then, are you approaching facilities with this program as a feature?

Absolutely. We are approaching facilities and we are acquiring new partners. I foresee that telehealth is going to be instrumental in the growth of EMH — not only now but even after the pandemic subsides. I think that, for lack of a better description, telehealth is going to be part of the new normal. It’s going to be a method by which patient care can be effectively provided alongside the traditional face-to-face model.

So at present we are acquiring new facilities, and when life hopefully transitions back to a point in time where we can just walk into a facility — and who knows, we may not even have to wear a mask — facilities will be given the option of receiving direct, face-to-face care, with the understanding that there will be times where telehealth will be the most effective and efficient way to provide care on behalf of their patients. And it’s my perspective that most facilities are going to be receptive to that.

This interview has been condensed and edited for clarity.

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