Videoconferencing Between Hospital Clinicians and Nursing Home Staff Lowers Use of Physical Restraint, Antipsychotics in Patients with Dementia

Project ECHO-AGE helps caregivers better manage behavioral challenges associated with dementia

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BOSTON – Nursing homes in the United States care for increasing numbers of people with dementia, yet many lack access to geriatric psychiatrists, behavioral neurologists and other specialists who may help manage symptoms associated with dementia, including behavioral issues. As a result, nursing home staff may resort to physical restraints or antipsychotic medications to manage behavioral challenges, which can significantly compromise a patient’s health, autonomy and dignity.

A new study, led by clinician researchers at Beth Israel Deaconess Medical Center (BIDMC) and Hebrew SeniorLife and published online in the Journal of the American Medical Directors Association, has found that use of video consultation technology that brings together nursing home staff and hospital-based clinical experts was associated with significant reductions in the use of physical restraints and antipsychotic medication among patients with dementia. Researchers found that patients in the facilities involved in the study were 75 percent less likely to be physically restrained and 17 percent less likely to be prescribed antipsychotic medications.

“There is a two-pronged issue facing nursing homes in the United States: shortages of geriatricians, behavioral neurologists and geriatric psychiatrists and a lack of proximity of community nursing homes to larger medical facilities with specialists,” said corresponding author Stephen Gordon, MD, MBA, a geriatrician in the Division of Gerontology at BIDMC and at Hebrew SeniorLife. “Video conference technology can bring academic medical center specialists and nursing home staff together in a collaborative effort to care for patients with dementia.”

“The data show that video conference technology can, indeed, have a significant impact on how often patients are physically restrained or given antipsychotic medications,” he added. “It’s clear that by working together clinicians and nursing home staff can notably improve patients’ health and quality of life.”

In 2012, BIDMC clinicians implemented Project ECHO-AGE, a case-based, video consultation program aimed to extend needed geriatric specialty care for patients with dementia from the hospital into community-based nursing homes. ECHO-AGE was adapted from a model of care known as the Extension for Community Healthcare Outcomes (ECHO) Project, which was originally developed by Sanjeev Aurora, MD, of the University of New Mexico to manage hepatitis C in rural parts of that state. BIDMC clinicians launched Project ECHO-AGE in the hopes that enhanced collaboration between care providers would improve the quality of care for people with dementia in the community.

Project ECHO-AGE uses video consultation technology to facilitate bi-weekly conversations between teams of front line nursing home staff and a team of clinical experts at BIDMC, including a geriatrician facilitator, geropsychiatrist, behavioral neurologist and a social worker. During each 120-minute videoconference, the interdisciplinary teams discuss and offer recommendations for three or four patient cases. The discussion may include didactic sessions and reviews of individual treatment plans.

With the goal of assessing the impact of Project ECHO-AGE, the researchers used a matched cohort of 11 nursing homes in Massachusetts and Maine. The facilities were matched with two other similar facilities based on facility size, non-profit or for-profit status, region, affiliation with a larger nursing home chain, staff rating and overall quality rating.

“We found that nursing home facilities that participated in Project ECHO-AGE saw a significant reduction in the use of physical restraints and antipsychotic medication among patients with dementia,” said study senior author, Lewis A. Lipsitz, MD, Chief of the Division of Gerontology at BIDMC and Director of the Institute for Aging Research at Hebrew SeniorLife. “These significant reductions also imply a potential decrease in adverse events such as falls, fractures and hospitalizations. As a result, further study of ECHO-AGE is warranted for the continued improvement of geriatric care management and lower health care costs.”

Additional authors include Alyssa B. Dufour, PhD, BIDMC, Harvard Medical School, Institute for Aging Research at Hebrew SeniorLife; Sara M. Monti, EdM, BIDMC; Melissa L.P. Mattison, MD, BIDMC and Harvard Medical School; Angela G. Catic, MD, BIDMC; and Cindy P. Thomas, PhD, Schneider Institutes for Health Policy at Brandeis University.