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Telemedicine and Telehealth in Nursing Homes: An Integrative Review

Objectives Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes. Design Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies. Setting and Participants Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families. Methods PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020. Results Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs. Conclusions and Implications Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.

Telehealth and telemedicine are a potential tool for scaling caregiving capacity and business efficiency for NHs. In the United States, 39% of NHs currently use some form of telehealth or telemedicine, 3 whereas 76% of acute care hospitals use telemedicine and telehealth. 7 The use of these technologies has become even more salient recently as NHs have been in the spotlight as a result of the emergence of coronavirus 2019 . NH residents are among the most at-risk groups for COVID-19 fatality. 8 This combined with stringent infection control practices such as lockdowns, and other concerns such as staffing and availability of specialty care, presents an even greater impetus for exploring telemedicine and telehealth as modalities in the NH setting. 9 One recent approach to COVID-19 used telemedicine and remote monitoring to treat residents in place, resulting in lower hospitalizations and mortality compared with other NHs. 10 Moreover, there have been increasing calls to focus research on the use of technology to enhance care in NHs and other settings from the National Institutes of Health, the IMPACT Collaboratory, Health Resources and Services Administration, and others both previous to and in response to the pandemic. 11e14 Therefore, it is important to synthesize the most recent literature to provide groundwork for the future design, implementation, and expansion of telehealth services in NHs.
Previous systematic reviews have explored the use of technology in the care of older adults with chronic conditions, persons living with dementia in supportive environments, ambulatory care, and in longterm care settings. 15e18 Another international review focused on assistive technology, alarms, and surveillance technology. 16 Outcomes in the reviews were generally positive, though most call for further research. Overall, a gap was found in published reviews of NH telemedicine and technology studies from 2014 to 2020. Given the pace of technology development, a re-evaluation of the current evidence is needed.
The purpose of this integrative review is therefore to evaluate and appraise the outcomes of recent primary research involving telemedicine and telehealth in NHs. This integrative review adds to the knowledge base by evaluating and synthesizing recent studies and will conclude with recommendations for practice and future research.

Methods
Whittemore and Knafl's 19 methodology was used as the framework for this integrative review. Studies capturing clinician, patient, and family feedback on the technology's usability and user experience were analyzed within the context of the Technology Acceptance Model. 20

Search Strategy
Medline via PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycNET, and the Journal Storage (JSTOR) were searched for relevant articles. A medical librarian was consulted for the search strategy. A combination of the terms remote patient monitoring, telehealth, telecare, telemonitoring, telemedicine, videoconferencing, skilled nursing facilit*, SNF, long-term care, LTC, and nursing home were searched using Boolean logic in these databases. In PubMed, the medical subject heading (MeSH) terms Skilled Nursing Facilities, Nursing Homes, and Telemedicine were used, including their automatic explosion functionality to include a larger array of articles. CINAHL major headings Nursing Homesþ and Telehealthþ, as well as Embase subject terms exp telehealth/and *nursing home found additional articles.

Inclusion and Exclusion Criteria
The search included studies in the English language published from January 2014 through October 2020. Because of limited results specific to the United States, international studies were included. Primary quantitative and qualitative studies using telemedicine and telehealth were included. Studies were required to involve NH clinicians or NHs as the primary setting. Exclusion criteria omitted conference abstracts, magazine articles, and protocol proposals. Patientfacing mHealth applications (ie, no direct interactions with clinicians) were excluded.

Search Results
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram is shown in Figure 1. 21 A total of 933 results were screened by study title. Fifty-six were included for full-text review. A final sample of 16 articles meeting inclusion and exclusion criteria were kept for data extraction and evaluation. A Cochrane Systematic Review of telemedicine's effects on health outcomes was referenced but only included studies published before 2013. 6

Data Evaluation
The final sample of 16 empirical studies in this integrative review included randomized controlled trials (n ¼ 3), nonrandomized experimental studies (n ¼ 4), cohort studies (n ¼ 2), cross-sectional studies (n ¼ 3), mixed methods (n ¼ 2), and qualitative studies (n ¼ 2). Joanna Briggs Institute Checklists aided evaluation of the rigor of experimental and cross-sectional studies (Supplementary Table 1). 22 The Critical Appraisal Skills Programme Qualitative Checklist was used to appraise the qualitative studies (Supplementary Table 2). 23 Appraisal of a quality improvement study was completed with the Revised Standards for Quality Improvement Reporting Excellence tool.

Data Analysis
A constant comparative method was undertaken to discover patterns, themes, variations, and relationships. 19 Table 1 summarizes extracted data by purpose, study design, technology used, and main findings. Because of the variety present in the research studies, a table organizing studies by focus, intervention details, roles involved, and demographics was used to discover common elements (see Table 2).

Results
The NH settings included locations in Canada, France, Italy, Australia, Singapore, and the United States. NH settings were not reliably described for each study, but those that reported spanned across rural, suburban, and urban settings (Table 2). Studies involved patient, family members, and clinician participants.

Telemedicine and Telehealth Processes
Studies varied in regard to patient populations, technology used, and scheduling of telehealth services. Four studies focused on telemedicine consultations with geriatricians 9,26,27,30,31 ; another presented telemedicine services delivered by neurologists and psychologists. 37 Palliative care specialists trialed video consultations with patients living with dementia. 39 A quality improvement study implemented a telemedicine group practice offering numerous specialists, 29 and another implemented asynchronous messages between NH providers and 100 consulting specialty groups. 28 The remaining studies enabled access to heart failure, musculoskeletal, and wound care specialists. 24,32,35 Eight studies implemented video capabilities only, whereas 3 studies used Bluetooth stethoscopes for remote auscultation. 29,35,37 The scheduling of telemedicine was varied. In 2 studies, persons living with dementia received weekly 37 or monthly 36 counseling.
Other programs scheduled geriatrician consults individually as needed. 26,31 Another held biweekly 120-minute case-based teleconsultations where 3 to 4 cases were reviewed between NH providers and specialists at a medical center. 27 RPM studies undertook varied approaches. Subacute patients collected their own daily weights, pulse oximetry, heart rate, and blood pressure readings in anticipation of discharging to home with the same wireless equipment. 35 The same study deployed multiparameter continuous monitoring patches, point-of-care lab testing, and video visits with heart failure specialists. De Luca et al 37 deployed Bluetooth blood pressure cuffs and pulse oximeters to collect vitals 3 times a week, sending data to a remote-monitored dashboard to supplement the monitoring provided within the NH. Another study used sensors to detect urinary incontinence episodes and display data on a telemonitoring application. 38 An activity monitor was trialed with persons living with dementia. 36 Clinical Outcomes

Patient-level outcomes
Patients experienced improved self-report measures as well as objective improvements in blood pressure and incontinence. In a study combining psychiatric teleconsultations with remote monitoring, persons living with dementia showed improvement in Geriatric Depression Scale, Brief Psychiatric Rating Scale, and quality of life measurements. 37 Another study combined telemedicine counseling with activity and heart rate monitoring and found that persons living with dementia achieved 92% of the care management program's wellness goals, 89% of behavioral goals, and 82% of cognitive goals. 36 In facilities with access to geropsychiatric specialists via telemedicine, persons living with dementia were 75% less likely to be physically restrained, 17% less likely to be prescribed antipsychotic medications, and 23% less likely to develop a urinary tract infection than similar residents in control facilities. 27 Clinically significant results were found in reductions in hospitalizations and improved time to intervention. 35 A 10-point decrease in systolic blood pressure (P < .001) and heart rate (P ¼ .02) was found in an RPM intervention group. 37 This improvement indicated that telehealth provider collaboration with NH staff improved patient care. In a store-and-forward study, telehealth wound care was found to be noninferior to in-person care in relation to wound healing, while incurring substantial cost benefits. 32      Provider-level outcomes One study found NH providers to be enthusiastic regarding telemedicine's ability to fill service gaps, and were most likely to use telemedicine for dermatology and geriatric psychiatry consults. 40 In another, specialist recommendations were more likely to be followed if residents were at risk for depression [odds ratio (OR) ¼ 8.00, P ¼ .04] and in cases where the geriatrician was providing medical advice such as a decision to transfer to the hospital (OR ¼ 17.97, P ¼ .04). 26 There was a trend toward shortened time to new medication orders and new diagnoses of atrial fibrillation and pneumonia, 35 though results were not statistically significant. Asynchronous consults, in which NH providers sent written questions to specialists, found that 60% resulted in a new course of action and 30% of requests were resolved without the need for a face-to-face visit. 28 Increased telemedicine use was associated with decisions to treat residents in place, as telemedicine consultants deemed potential transfers unnecessary. 29 Results of this study are harmonious with qualitative work indicating that telemedicine may help address lack of on-site medical expertise and communication challenges. 34 NH nurses reported that on-call physicians often do not trust nurse assessments, and the use of video may validate their assessment and prevent a transfer to a hospital. 34 In an example of a perceived lack of parity between telemedicine and face-to-face care, a wound care study concluded that strengthening a primary team would be more advantageous than implementing a multidisciplinary team over telemedicine. 36

Facility-level outcomes
Reductions in preventable ED and hospital transfers was a common outcome in 5 of the studies. In one multisite telemedicine consultation program, reductions in hospitalizations were clinically and statistically significant using a derived categorical variable indicating high and low engagement. 33 Staff in high-engagement facilities used the after-hours and weekend telemedicine support program more frequently. The decrease in hospitalizations was 8.4% lower at high-engagement than low-engagement facilities. 33 Another report found a clinically significant absolute risk reduction of 6.51% and a relative risk reduction of 27.24% in hospital readmissions. 35 Admission to a health care service was higher in the control group than in the experimental group (c 2 ¼ 3.96, P < .05). 37 Over a period of 3 years, 500 potential transfers were deemed unnecessary within 20 NH pilot telemedicine sites. 29 Conversely, a remote wound care team study found that the mean ED visit rate was 1.3 times larger during the intervention period, though this result was not statistically significant. 32 Billing claims, medical record data, and facility reporting were used to track outcomes in 2 studies. 33,35 Savings to the Centers for Medicare & Medicaid Services were frequently reported. One afterhours and weekend telemedicine service cost $30,000 per NH annually. 33 The study found that a 170-bed NH with 180 hospitalizations per year saw a reduction of 15 hospitalizations per year, and generated a net Medicare savings of $120,000. 33 By another measure, 500 avoided transfers over a 3-year program prevented more than $5 million in admission-related charges. 29 The other 2 studies calculated savings and costs on a per-resident level. Itemized direct care cost savings from wound care nurse practitioners accumulated to Can$649 per Canadian resident, though the authors flagged uncertainties in their calculation. 32 One study's continuous monitoring and other telehealth equipment cost $1386 per patient, with hospital savings of $9234, though the analysis was not provided. 35 Clinician, Family, and Resident Perspectives Feedback from clinicians, families, and residents was collected in several studies (Tables 3 and 4). NH providers responded that they   would be most likely to use telemedicine for dermatology, geriatric psychiatry, infectious disease, cardiology, and neurology consults. 25 NH staff who did not use telemedicine opined that it would be a powerful tool to influence medical decision making. 34 Palliative care specialists and NH physicians, nurses, personal support workers, and rehabilitative therapists' knowledge of using palliative care (r ¼ 0.565, P ¼ .018), confidence in using palliative telemedicine (r ¼ 0.673, P ¼ .003), and overall telemedicine acceptance (r ¼ 0.698, P ¼ .002) was positively correlated with an increased number of videoconferences. 39 More frequent usage seemed to improve satisfaction with the modality. Two studies collected feedback from NH residents directly, who reported their experiences as positive. 24,35 Family perspectives were explored in 3 of the articles. 24,34,35 Family members considered telemedicine visits advantageous if they resulted in quicker access to a provider or resulted in more frequent visits. 34,39 There was also agreement that families would benefit from joining consultations through videoconferencing. 24,34

Facilitators and Barriers
Clinician-identified facilitators to telehealth implementation included having adequate technical support, integration into the electronic health record, and strong facility leadership. 24,28,32,39 Perceived benefits included improved timeliness of resident's care, elevated productivity, improved access to specialist advice, increased connection opportunities between NH nurses and providers, and subjective gains from involving families in care. 25,28,31,34 Resident-and family-identified facilitators included being able to see a provider sooner, high-quality audio and video, and functionality to allow family participation during visits. 24,34,39 Clinician-identified barriers included poor audio quality, missing functionality, technical difficulties slowing time to connect, time required to clean and charge devices, reimbursement challenges, and lack of workforce allocation for telemedicine. 24,25,31,32,36,39 Residents and families noted barriers as charging devices, preferences for inperson visits, and difficulties in connecting to Wi-Fi or cellular broadband. 35,39 Discussion This integrative review of 16 international studies illustrates the modes in which telemedicine and telehealth potentially expand access, cover gaps in care, improve resident outcomes, reduce unnecessary trips to the hospital, and generate cost savings for NHs. Throughout the studies, there is consensus in benefits to patient care, and enthusiasm or at least curiosity for its use from providers, residents, and family. In no study was there unequivocal evidence that telemedicine or telehealth negatively affected resident outcomes or presented an excessive cost burden.
This appraisal finds wide methodologic heterogeneity and low generalizability because of small sample sizes with poorly described characteristics, and study designs that fail to collect or report sufficient intervention data. These aspects impair the ability to construct overarching evidence-based recommendations and highlight the need for conducting future research with more comprehensive and consistent study designs.
Geriatric, wound care, psychiatric, and palliative specialist teleconsults were found most effective in this review. Some NH clinicians preferred in-person wound care nurse practitioners and palliative care providers over telemedicine providers. 32,39 Results suggests that telemedicine enables rapid specialist consultations and allows on-call NH providers to evaluate residents from home. Similarly, ED telemedicine research programs found reductions in unnecessary transfers and that 18% to 66% of teleconsultations influenced patient diagnosis or management. 41 Limited qualitative work explores telemedicine and telehealth in the NH setting. This scarcity may be due to the technologies' relatively recent emergence in the NH setting. Qualitative research emphasizes the experiences of residents, clinicians, and other users, which is beneficial to technology developers improving the usability and utility of systems. Although limited in this setting, in other settings, patients Audio qualitydunable to hear each other (Perri et al 14 ) Result demonstrability Majority of providers in the study said they were willing to use telemedicine again (Perri et al 14 ) Clinicians initially feared dehumanization of medicine, but did not report this after 2 y of use (  and caregivers have highly rated telehealth's impact on information sharing, consumer focus, and overall satisfaction. 40 However, given the NH setting's unique nature, future work is needed to better understand these issues. Difficulties related to staff turnover introduce training issues that impair the consistent implementation of telehealth interventions. 32 Despite such issues, there appear to be numerous opportunities for telehealth and telemedicine in NH settings, especially given the relatively low rollout and operational costs. According to the survey data included in this integrative review, participants are generally enthusiastic toward the use of telemedicine and telehealth in NHs.
The results of the present review are consistent with the Society for Post-Acute and Long-Term Care Medicine's standards document that guides NHs on the use of telemedicine to evaluate and manage changes of condition for residents. 42 Reductions in hospitalizations and emergency visits in particular are further supported by this review. This review adds new perspectives on remote monitoring in NHs and potential new metrics such as reductions in restraint use.
An earlier systematic review of telemedicine services for residents in NHs from 1990 to 2013 found that dermatology, geriatrics, psychiatry, and other specialties were successfully delivered via telemedicine while also showing economic savings. 17 This review extends this prior work's findings as our included studies also found financially and clinically efficacious results with asynchronous dermatology teleconsultations, 35 geriatric specialist teleconsultations, 24,28,30,37 and psychiatric care delivered over telemedicine. 37 COVID-19 has brought new difficulties as NH residents are at high risk because of resident age, comorbidities, and proximity to other residents and staff. 9 Visitation restrictions meant to limit potential contagion from unnecessary in-person contact created a push for telehealth to enable family visitation, mental health services, and allow remote assessments by specialists. Hospital COVID-19 programs indicate that telemedicine helps preserve personal protective equipment, limits exposures bidirectionally, encourages fast triage, and allows a specialist group to service multiple facilities. 43 A COVID-19 collaborative model between an academic hospital and NH enabled telemedicine consultations, infection advisory consultations, and nursing liaisons to prevent or limit outbreaks. 44

Limitations of the Included Studies
Overall, there was a general lack of rigorous experimental study designs. Studies using a historical group for comparison lacked matching procedures or propensity scores, which results in a risk of a study's internal validity due to selection bias. A large number of studies used author-developed surveys, which present risks of measurement bias. In other cases, advanced statistical methods may have given more robust results by for example using Poisson regression models for the analysis of count data and multiple hospitalizations. This would have permitted predictions around the effectiveness of the intervention. 45 No studies in this sample used a theoretical framework to guide their approach. Sampling strategies frequently were not described. Baseline characteristics of samples were poorly described, with few consistently captured demographic, psychometric, and physiological measures. This limited the analysis of person-level differences between groups. Inclusion of these data could help to identify disparities related to rurality, socioeconomics, or language barriers. Sample sizes were frequently small, with one study reporting results from a single orthopedic surgeon. 24 Most studies involved a small number of sites, thus limiting generalizability. Others involved multiple co-occurring treatments (eg, RPM, telemedicine, point-ofcare testing) but lacked representation as independently measured covariates. A full critical analysis may be reviewed in Supplementary  Tables 1 and 2.

Limitations of this Review
Encouraging telepharmacy, teledentistry, and telerehabilitation studies exist in NH settings but were out of scope for this review because of its focus on the medical-nursing nexus of telemedicine. This review used the ONC's definition of telehealth and did not include surveillance technology, passive monitoring, and robotics, though these are promising areas of research. 16,46 Videoconferencing for connection between NH residents and family was not included. Telehealth support of family caregivers of persons living with dementia in residential care was not included, though interesting work is ongoing in this area. 47

Implications Practice
Stakeholders may choose to implement a pilot program to validate telehealth's suitability for their NH. Quality improvement outcomes such as number of unnecessary hospital transfers, satisfaction surveys, and changes in selected clinical measures may be the most appropriate outcomes to track. 42 Further, technology implementations are more readily accepted when they are interoperable with existing system architecture. 48 Geriatric psychiatry and dermatology teleconsultations specialties can be effectively delivered through telemedicine. 25e27,32 Other work suggests after-hours telemedicine services help facilities maintain census and decrease patient transportation costs. 49 Research NH resident perceptions of telemedicine are absent from recent literature. Only 1 study used a patient-focused questionnaire. 35 Community-based studies eliciting feedback from older participants indicated that telehealth was well-received. 50 Similar studies may be undertaken in NHs. Furthermore, given the small size of many of the studies, performing embedded pragmatic clinical trials of those technologies with an underlying evidence base could provide more generalizable outcomes as well as information on effective implementation methods and intervention fidelity. Qualitative research could illuminate specifications for types of alerts that may be most beneficially triggered from RPM-collected data for NH residents.

Conclusions and Implications
This integrative review presents a comprehensive synthesis of empirical evidence regarding the state of the science on telemedicine and telehealth in NHs. There is evidence that telemedicine and telehealth may improve outcomes for patients, staff, and administrators in NHs, provide broader full-time coverage, and decrease costs. Telemedicine may help reduce the exposure to COVID-19 in NHs and decrease unnecessary hospitalizations. As may be expected, certain kinds of diagnostic support are better suited to remote settings than others. The research is far from comprehensive, indicating that this is a nascent field for future investigations into the implementation and adoption of these technologies. Did not use regression to compare independent variables such as respondent demographics with dependent survey result variables Findings did not include characteristics such as whether respondents were in resource-poor communities or rural and urban settings Some potential sources of bias not described such as potential for nonresponse bias (continued on next page) Reasons for GP nonadherence not reported

Supplementary
The abstract and discussion describe study as cohort study, but the methods section describes it as cross-sectional study Authors describe their higher percentage of GP adherence due to "good relationship between GP and geriatrician" but this is not measured or elsewhere described Gordon et al, 2016 27 Strengths Clear description of problem and purpose