Example Final Project Report submitted by grantee




Section A:  Project Outcomes
Information on project outcomes identified at the start of the project

Project Outcome: Has it been achieved:  YES
Using telemedicine technology, improve end-of-life care for clients in Kansas and Michigan. 
Evidence/Next Steps: Improvement in end-of-life care for patients in Michigan was evident through multiple sources of data. Though utilization and data collection were lower in Kansas, there was also evidence that the use of telemedicine technologies improved the end-of-life care for patients there. Perhaps the most obvious evidence of telemedicine's impact on end-of-life patients came from talking to the patients during structured interviews and through caregiver focus groups. When interviewing patients, it was clear that they greatly appreciated the telehospice services. It gave them a sense of comfort, knowing they had the extra contact with hospice services if they should need it. A number of patients also mentioned that their family members felt more comfortable knowing that they had access to telehospice. Caregivers also discussed additional support available to them through telehospice. Both patients and caregivers expressed the desire for additional services to be made available via the telehospice system. There were a range of anecdotes that illustrated the benefits of telehospice service. In one case, a rural patient who was encountering extreme pain when his catheter tube was kinked. A nurse on telehospice system saw the problem and was able to help his caregiver unkink the tube. It saved the patient an hour or more of pain while a nurse would have been en route to his house. Utilization and chart data in Michigan also provided evidence that the outcome objective was obtained. The telehealth chart notes demonstrated that telehospice was used routinely to check on patients and perform physical assessments. In over half of the Michigan telehospice visits, no follow-up activity or visit was required. Also worth noting was the fact that in almost one-third of all telehospice visits, more than two parties participated. This system enable caregivers and multiple team providers to participate in the same visit, an indicator of high quality care.
 
Information on additional outcomes not identified at the start of the project

Additional Outcome: 1. Telehospice allowed for multiple parties to participate in a patient visit. 2. Telehospice equipment makes a dramtic impact on a dying patients end-of-life experience when used by an out-of-town or out-of-state family member or friend. 3. Timing is a critical issue for the introduction of a telemedicine service for this population. 4. There is significant long-term potential for a wide range of hospice services to be delivered via telehospice. 5. Rural needs related to distance and time have a significant impact on the utilization of telehospice. 6. Telehospice has great potential for use in other contexts such as nursing homes or the hospital. 7. Providers are the most significant barrier to telehospice dissemination. 
Evidence: 1. Telehealth chart notes indicate that in 30% of the televisits in Michigan, more than two participants were present during the televisit. 2. Utilization data indicate that telehsopice units were used by Michigan patient family members residing in Alaska, Hawaii, New Mexico, Arizon, North Carolina and throughout Michigan. When patients passed away, family members always returned units to agency in a timely fashion. 3. Data collected from decline surveys demonstrated that one quarter of the Michigan patients declining participation in the study cited reasons related to timing (i.e., they felt overwhelmed at the time the system was offered). 4. Content analysis of almost 600 random hospice patient charts indicated that for 65% of all activities, telehospice could have been substituted for an onsite visit. 5. Utilization data in Michigan indicate that even though there are higher numbers of urban patients enrolled in hospice, only 55% of all telehospice patients resided in urban areas. More importantly, only 45% of all televists were conducted with urban patients and 55% were conducted with the rural patients. 6. This project design excluded patients not living at home. Yet, in Michigan, more than 70% of decline forms were initiated by nurses because the patient did not meet study design criteria such as living at home. 7. Data from pre- and post- provider surveys in Michigan indicated that providers have a pre-conceived notion regarding telehospice that does significantly change over time. Providers who embrace this solution early on account for almost all utilization.  



Section B:  Project Accomplishments
The accomplishments of the project

The project's most significant accomplishment or achievement
  The project's most significant accomplishment was proving the efficacy of telehospice use in the field. It was evident that patients both enjoy the telehospice calls and feel an increased sense of comfort at having telehospice services at their disposal. Potential cost savings were also evident, as there were instances where a problem was solved via the telehospice service that would have traditionally required a nurse to drive to patients' homes. This saved the hospice providers both the cost of the nurses' time in driving to patients' homes, and savings in gas money. As mentioned above, there were problems solved via telehospice that traditionally would have required a nurse to visit a patient's home. This has the benefit of improving patient care, showing that telehospice works in real world settings.
Changes in the way in which end-users performed their jobs or carried out their activities
  The work functions of providers who embraced telehospice changed considerably with the introduction of telehospice services. Active telehsopice users supplemented and replaced onsite vists with patients. Some performed a televisit prior to an onsite visit to determine any special equipment or supplies that might be worth bringing to the traditional visit. A variety of examples emerged that demonstrate how telehsopice providers incorporated the system into their delivery strategies. In one case, the caregiver of a patient in an urban setting called Hospice of Michigan extremely anxious because her husband was bleeding from the neck, and she did not know what to do. A nurse instructed her to get the telehospice unit, and that nurse instructed the caregiver about what she should be doing while another nurse was en route to the patient’s home. The caregiver’s anxiety level decreased upon seeing the nurse’s face, and the caregiver was on the phone while waiting for the nurse to arrive at their home. Additionally, the nurses involved were able to communicate findings with one another via the telehospice units. Telehospice presented a new opportunity for teamwork among providers - one provider talking to the patient via telehospice while another was en route to the patient's home to solve a problem in person. In one case, a nurse received a call from her patient that was complaining of upper chest, neck, and arm pain. The patient had a cardiac history and could have been having spinal cord compression due to his terminal illness. The nurse got on the telehospice unit while another nurse was sent to his home. Using the telehospice equipment, the nurse could see the patient and that he was not appropriately following her instructions to relieve his pain. She then instructed him on what he was doing wrong, and how he could correctly work to relieve his pain. She stayed on the telehospice call with the patient until a nurse arrived at the patient’s home, and the two nurses used the telehospice units to consult about the patient’s care.
The impact of the project on the community at large
  The telehospice project had a significant impact on the community; particuarly rural communities where the entire area was familiar with the service and its advantages. Below are two anecdotes that illustrate some of the ways telehospice was used to make a difference in the lives of those who took part in the project. "Perhaps the most touching story of the telehospice project was when a unit was installed in a nursing home for a forty-year-old patient who had a five-year-old daughter that lived seventy-five miles away. The patient was only able to see her daughter every two weeks, until a telehospice unit was installed in her daughter’s home. The day the patient was being instructed how to use the unit happened to be the daughter’s sixth birthday, and her daughter brought all her presents to the camera and was able to share the day with her mother. The patient was crying, saying, 'You have no idea what you’ve given me. For me to be able to see my daughter every day is something no words could ever express.' For two weeks the patient was able to see her daughter at least every day through telehospice, helping her with homework and sharing stories. The patient improved emotionally in her final weeks as she was satisfied and fulfilled. She died two weeks later. Telehospice presented a unique opportunity to provide this patient with true quality end of life care." "A golfer on the PGA Senior Tour, Allen Doyle, was touring a Hospice of Michigan building in Detroit. A telehospice patient near Alpena lived in a golf course community and had been an avid golfer his entire life, before his illness prevented him from playing. Allen made a telehospice call to this patient, and it meant the world for the patient to talk with Doyle face to face using the telehospice equipment. The patient talked about that call many times before his death." Telehehospice has also been used to connect patients and caregivers to distant family located around the country, including Alaska, Hawaii, Florida, New Mexico, Arizona, and North Carolina. This is another way telehospice has worked to improve the lives of those involved with the project. Finally, telehospice improved the care of rural patients who traditionally had to wait longer periods of time for a provider could reach their house. With telehospice these rural patients can receive care immediately, a great improvement in the care of a traditionally underserved population.
A description of unanticipated problems that resulted from the project
  The most significant unanticipated problem related to the telehospice project may have been the difficulty in getting the providers themselves to buy into the program. The project simply never really got off the ground at some sites in Kansas, due mainly to a lack of buy-in from the providers and/or their managers. In Michigan, project planners never successfully acieved deployment in the Extended Coverage group at Hospice of Michigan. The people in charge of Extended Coverage chose not to make use of telehospice in many cases, despite the efforts of the research team to encourage its use a benficial tool for the Extended Coverage team. There were instances when telehospice could have improved the care of patients who called in to Extended Coverage after hours care, but it was not frequently used. This lack of provider support was due to both turnover in the management of Extended Coverage and a general lack of interest from the management of Extended Coverage. Overall, the challenge of universal provider buy-in was the real unanticipated problem, as getting the patients to support and use telehospice services was relatively straightforward. Some providers immediately saw the advantages of telehospice and used frequently. Many others did not want to be bothered with what they perceived to extra work.

The number of individuals who have benefitted (directly and indirectly) from TOP-related equipment or resources since the beginning of the project

  End Users Other Beneficiaries
Number in human service settings
Number in cultural settings
Number in government agencies
Number in public safety settings
Number in educational settings
Number in health care settings 325  150 
Other end users/other (specify):
    Family members located in distant states
15 
Total number of direct and indirect beneficiaries 340  150 



Section C:  Project Expansion
Information on the expansion of the project

Has the project expanded to serve additional end users in locations or organizations beyond those targeted in the TOP proposal:  Yes 

A description of the (1) scope of the expansion; (2) the number/characteristics of additional end users being served; (3) the funding sources for their expansion; and (4) the approximate dollar amount or value of any additional equipment or resources that were leveraged by your project as part of the expansion.
  Hospice of Michigan has obtained an additional $60,000 (from an SBC Foundation grant and private donations)to purchase more equipment for service expansion. All of these funds were obtained due to success from TIIAP telehospice project.



Section D:  Spin-Off Activities
Information on spin-off activities from the project

Has the TOP project generated any spin-off activities?  Yes 

A description of any spin-off activities and the additional services that are being provided.
  A statewide proposal has been submitted to expand telehsopice across the entire state of Michigan. Word on funding is still pending.



Section E:  Partnerships
Information on project partners

Describe how your project partnership worked? 
  The partnership between Michigan State University and Hospice of Michigan was extremely successful. Both organizations displayed significant dedication and devotion to the project and a high level of mutual trust was established early in the project. Open and frequent communication was a key strategy. Project personnel from MSU and HOM met every Monday without excpetion at 2:00 to go over key issues. In addition, the project coordinator at HOM was required to send a weekly email to all telehsopice offices in Michigan reporting on their level of activity that week and significant events. Periodic visits were made to all telehospice sites and periodic project updates were provided to staff at all participating offices. Personnel from MSU and HOM jointly presented study findings to conferences and local meetings and are currently collaborating on joint publications. Both MSU and HOM are actively looking for opportunities for future collaboration regarding telehospice research. MSU participants provide ongoing support as HOM obtains donations for future telehospice service expansion. HOM should be considered one of the premier telehospice providers in the nation. The relationship between KU Medical Center and its partners did not prove to be as fruitful. After making a commitment to participate in the project, the urban arm of Hospice Inc. and Kansas City Hospice both pulled out of the project.



Section F:  Lessons Learned
Information on the lessons learned from the project

The most significant barrier or obstacle that the project had to overcome 
  Hospice providers make or break the successful use of telehospice. Nurses, social workers, and other providers are the primary gatekeepers to the use of telehospice services for patients. We know that patients are comfortable receiving services via telehospice, yet this can only happen if their provider will use this innovation. Pre and post survey data informed us that experience does not have the impact we had hoped to see. Providers have pre-conceived notions about whether they want to use this technology or not, and watching others successfully employ this technology does not appear to sway those with little enthusiasm for telehospice. This has significant implications for how hospice organizations should launch and employ telehospice services in the future.
A description of any lessons that the project has learned that would be of use to future TOP projects
  Strongly consider timing and endusers. Telehospice was adopted more readily and demonstrated a more significant contribution for rural patients as compared to urban patients. Providers in rural hospice offices in both states identified applications and benefits more readily than their urban counterparts. Even though there are delivery challenges in urban areas, the sheer distance to reach rural patients dominates as the most important benefit of telehospice. Also, it is important to carefully time when a patient is offered telehospice. A great number of patient refusals for telehospice are directly attributable to feelings of being overwhelmed when patient is first being enrolled into hospice care. This is an extremely sensitive event, often when patients and caregivers are accepting the inevitability of death. Many patients are better prepared to consider telehospice a week or two into their hospice enrollment.
A recommendation that future projects replicate/adapt the TOP-related approach used by your project (YES/NO)
  Yes
A description of any lessons or advice that your would pass on to projects that are replicating/adapting this approach
  The academic/private organization approach was extremely important, particularly in Michigan. MSU researchers designed and evaluated the project. However, the project was carried out in an unrelated organization. The objectivity brought to the evaluation of this endeavor proved to be crucial. MSU was able to be candid and honest in its assessment of what really worked and what didn't. Most importantly, MSU was unable to inappropriately influence, adjust, or frame results from this project. This is an important element missing from many telemedicine projects that implement and evaluate within the same organization. Both MSU and HOM greatly benefitted from the university/private organization partnership.



Section G:  Impact of the TOP Grant
Impact of the grant on the organization and community(s) served

The most likely outcome of the project if it did not received Federal funds through the TOP program
  The activity would probably never been implemented.
How the absence of TOP funding would have affected the range of services offered by the project
 
How the absence of TOP funding would have affected the scale of the project
 
How the absence of TOP funding would have affected the implementation schedule of your project
 
Specific examples of how the support provided through the TOP program impacted the scope, scale, and success of your project
  The funding through the TOP program made it possible to purchase the actual equipment used to provide telehospice services in Michigan and Kansas. Most importantly, however, was that TOP funding enabled objective personnel to evaluate the project. These evaluation personnel, housed at universities, have a self interest in disseminating the results of the project. Thus papers and conference presentations will occur for several years post project completion. While it is possible other funding could have been found, it is unlikely that the project would have been able to support nearly so many patients or allow for data collection and dissemination.



Section H:  Future Plans
Information on future plans for project

The current status of the project
  In full operation. 

  Factors
  Mechanical obsolescence (equipment became inoperable, unreliable, worn out)
  Technological obsolescence (faster, more accurate, better alternatives became available)
  Personnel changes (project staff who were most interested are no longer involved)
  Insufficient funding available for maintenance of project-related activities
  Loss of partners or failure of partnerships
  Lack of community support
  Too costly to maintain/sustain
  Policy barriers (specify):  False

The future plans are envisioned for the project
  In Kansas, telehospice services will continue in the rural communities that participated in the project. No activity is planned for the prior urban paritipants. In Michigan, Hospice of Michigan has obtained $60,000 in funding to expand the service within its own agency. These funds came from SBC Foundation funding and private donations. Michigan State University, in parntership with Hospice of Michigan, Hospice of SW Michigan, and a hospice agency located in Michigan's Upper Peninsula, has submitted a proposal to launch telehospice across the entire state of Michigan. Funding notification is still pending. 



Section I:  Other
Additional topics or areas not previously addressed

  This project has been exceptionally well received, particularly in Michigan. Perhaps the most telling evidence of a telemedicine project is its sustainability post grant funding. Telehospice is an integral service within HOM and will continue through internal funding and support. Perhaps one question missing from this closeout survey concerns new areas of service or reseacrh that became evident from this project. In our case, it has become evident that telehospice needs to be explored as an option for hospice caregivers, in addition to hospice patients. In Michigan, project participants have become policy activitis in search of strategies to widen services for hospice caregivers. In an ideal world, it would be nice to see a mechanism between NTIA and other federal agencies such as NIH so that ideas could be forwarded regarding important outcomes-based research that should follow TOP projects.



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