We have really become aware of the fact that family members aren't just ancillary people, they're actually core members of the patient's treatment team. And so globally we've seen shifts from highly restricted visitation hours for critically ill patients to more open ICUs where we hope family members and loved ones can be at the bedside as much as they would like.
Of course COVID is a highly infectious disease. And so we saw a complete reversal in those trends. During the first years of the pandemic, we unfortunately had to transition to entirely virtual communication or telecommunication with family members. This was a big setback.
At the onset of the pandemic we did not have the technological equipment necessary to enable that shift to tech enabled psychological services or the inclusion of family members in the care of the patient. What that meant was that we were relying on patient's personal technological equipment to facilitate those encounters. Now, the challenge with that is that not everyone has access to that type of technology. And on the family side, not everyone has access to that technology, either.
My hope or aspiration for the future is that what came about because of necessity will be refined into increased access.
Historically, perhaps some of our patients wouldn't be able to be with their loved ones because of work or perhaps childcare needs. And because we had the shift to telemedicine, it enabled them to now be more included in the care of their loved ones.
I think that the sky is the limit. I think we proceed with caution and pay attention to people's unique needs in these situations. But I would like to hope that COVID kicked the door open and pushed the envelope and something that we should have been doing a while ago.
Welcome to Find Empathy, a continuing education podcast for therapists, where we discuss the interaction between health and emotions. My name is Dr. Meghan Beier, a clinical psychologist who specializes in chronic illness and disability. Our current series is focused on using telepsychology to work with medical populations. While the topics, stories, and case studies are relevant for every therapist who uses telepsychology with medical populations, the topics covered were created specifically to meet the criteria needed to satisfy PSYPACT requirements for psychologists and American Psychological Association, the association of state and provincial psychology boards, and APA insurance trust telepsychology guidelines. I hope you enjoy this episode.
Welcome to our second series on the use of telepsychology with medical populations in today's podcast course, we'll be talking with two inpatient rehabilitation psychologists that utilize telepsychology technology, not only to help their patients, but also to keep family and support partners connected.
I will ask both of them to provide more in depth details about their work history. But in brief, we have Dr. Mayra Sanchez Gonzalez, an assistant professor at the Johns Hopkins department of physical medicine and rehabilitation who previously worked on the rehabilitation inpatient unit. And we have Dr. Megan Hosey, also an assistant professor at the Johns Hopkins department of physical medicine and rehabilitation, and she specializes in critical care and works on the medical ICU welcome Megan and Mayra.
Thanks! Glad to be here.
So I'm just gonna ask each of you to share a little bit about yourself and your background, as well as your role on the inpatient unit and Dr. Sanchez Gonzalez. I know that you've since moved off the inpatient unit and are doing mostly research now. So just describing kind of what your inpatient role was when you were working there. Let's start with Dr. Sanchez Gonzalez, can you share a little bit about yourself, your backgrounds and your role on the inpatient unit?
Absolutely. So I am a psychologist and I specialize in rehabilitation psychology. I was previously working at an inpatient rehabilitation unit where I was one of the lead psychologist for the patients there. My role there was to provide support for the patients, um, the patient's family system, as well as our team members in helping to ensure that we were, um, helping the patient to have the best outcomes, uh, during their recovery.
So happy to have you and Dr. Hosey, can you share a little bit about yourself, your background and your role on the inpatient unit?
Sure. So I am a clinical psychologist with fellowship training in rehabilitation psychology. I have worked on inpatient units since about 2010 and my career trajectory evolved to working in an inpatient intensive care unit. So my primary role is to meet with patients and their families while the patient is critically ill. That evolved a bit during the COVID pandemic, where we started to use telehealth and internet based communication to facilitate working with patients and families.
And just a follow up for you, Megan, what role do family members typically play on the medical ICU? Um, and how did that shift, I mean, you kind of hinted at this, but how did that shift once the units were shut down due to COVID concerns or even on the COVID units?
Yeah, really interesting paradigm shift has been happening in critical care medicine for about the past decade. We have really become aware of the fact that family members aren't just ancillary people.
They're actually core members of the patient's treatment team. And so globally we've seen shifts from highly restricted visitation hours for critically ill patients to more open ICUs where we hope family members and loved ones can be at the bedside as much as they would like. Um, we know that having BA family members at the bedside results in, um, reduced anxiety for patients, it actually re results in better mental health outcomes for family members as well.
And we're evolving to a space where we can help train family members on how to assist with providing care to our critically ill patients. And that comes with everything from reorientation during experiences of delirium for the patient anxiety management, as well as helping family members be informant about the patient's life before hospitalization and helping them help the patient engage more in their care.
So prior to the COVID pandemic, family members were increasingly being viewed as instrumental in patient recovery. Of course COVID is a highly infectious disease. And so we saw a complete reversal in those trends. During the first years of the pandemic, we unfortunately had to transition to entirely virtual, uh, communication or telecommunication with family members. This was a big setback.
Right. So it sounds like, you know, there was some benefits to being able to stay in contact, but a lot of those critical roles that the family members were playing really ended with the COVID pandemic, where they, they were limited.
That's exactly right. Yep.
I'm gonna shift over to, to Mayra and I wanted to hear a little bit of what is the day in the life for you on the inpatient unit pre COVID without the use of telepsychology and then how did that shift, how did things change, when COVID hit and you had to quickly shift to using telepsychology?
So pre COVID my day consisted of getting there in the morning, reviewing, um, medical chart records and, you know, being familiar with where, if there are any new patients on our unit. How are the patients doing the ones that have been with us for a while and determining who are the patients that we're gonna meet with, uh, depending on the concerns that may be going on.
So usually what that entails is meeting with the patient, uh, completing an initial psychosocial evaluation to identify any challenges and facilitators in their recovery. So following that initial intervention, we are usually going to do one of two things. We may decide that the patient may benefit from close follow up.
At which point we are going to continue meeting with the patient because the length of a stay of our patients is so, uh, short on average, about 12 days or so, interventions are very short term and highly targeted. So this may include interventions to enhance their engagement in their rehabilitation therapies, um, enhance their adherence to provider recommendations, pain management. Perhaps we're gonna be targeting modifications in health behavior.
Now, if we determine that the patient was coping and adjusting well during the initial evaluation, we're gonna do more of a distant, uh, or a follow up at a distance. So this means that we're gonna still be aware of what's going on with our patients, by talking to the different team members who are familiar with that patient.
And we're going to intervene if at any point, anything changes with their coping and adjustment. So usually, you know, this would mean that in, in, in rehabilitation care, Patient's support system is highly involved or historically has been highly involved because there's a lot of planning that happens for when the patient is ready to go onto the next level of care, which hopefully that means home, but can also mean many other scenarios.
So pre COVID, you know, they were also very highly involved. That meant that families needed to be in the unit and they would receive training on how to help their loved one. Once they went to the next level of care and how to support 'em during their recovery. After COVID that changed as well. Very similar to what, um, Megan was saying because of the visitor restrictions to ensure that everyone was being kept safe.
That meant that, you know, family training, for example, one of the many things that happened during their care had to be done differently. So that meant many cases engaging the family with the use of technology to be able to still get that training.
So both of you described some initial hurdles or really some big hurdles actually with family involvement. What were some of the biggest challenges or hurdles when using that telepsychology that technology to try and keep family members involved and how did you try to overcome those?
So I think some of the biggest challenges that we faced with the switch to telemedicine was that at the onset of the pandemic, we did not have the infrastructure, the telemedicine infrastructure that would really support such a major shift that happened within the health system.
So that meant that, you know, we did not have, for example, in our unit, perhaps the technological equipment necessary to enable that shift to tech enabled psychological services or the inclusion of family members in the care of the patient. So very specifically at the onset of COVID where I was working, you know, we did not have the, the tablets, for example, that would facilitate that encounter.
So what that meant was that we were relying on patients' personal technological equipment with their personal cell phones to facilitate those encounters. Now, the challenge with that is that not everyone has access to that type of technology. And on the family side, not everyone has access to that technology either.
So it meant that we needed to somehow figure out how to provide that access in a way that was equitable for all of our patients. Once we were able to overcome that, at least on the unit, on the patients side, we were able to get the devices necessary to, to enable that shift to telemedicine. But now the next challenge from my perspective became the lack of, uh, software that would enable those encounters.
So initially, you know, we did not have the video platforms, for example, or ways of securely communicating with, with patients in the inpatient unit, especially we had strict restrictions on, you know, who was able to see the patient. So that created a lot of challenges too, because we had to figure out what was the way in which we were gonna facilitate that encounter.
Now, during the states of emergency, we did have a little bit more leniency on the software platforms that we were able to utilize to facilitate that access. But that still, you know, was not, uh, uh, perfect. And I think it created many challenges for many of our families, who, again, because of many reasons do not have access to that type of, of technology.
On the other hand, though, I do want to highlight that it facilitated the inclusion of family members or just support system for many of our patients. Historically, perhaps some of our patients wouldn't be able to be with their loved ones because of work or perhaps childcare needs. And because we had the shift to telemedicine, it enabled them to now be more included in the care of their loved ones.
For some of our patients, perhaps their families were not in state or were not in a accessible geographic location. So it did create a lot of access for some of our family in support systems, but I also want to acknowledge that it created some barriers and challenges for other support systems.
And so there's so many pros and cons there.
So you said that you were, you were using tablets as a means of communication. What were some of the software programs that we're using to provide video, uh, interactions and now kind of where have things progressed? Cuz I imagine that as we've gotten better with this, or I know as we've gotten better with this we've chosen software that is, uh, more HIPAA compliant or has some protections in place.
Yeah. So initially because of the, um, state of emergencies and some of, of, of the. The, the wanting to support this major shift to telemedicine, you know, we were able to use, um, other software that were not HIPAA compliant. So for example, we could use, uh, phone applications such as WhatsApp, or perhaps FaceTime, um, Skype in the inpatient unit though, we were quickly able to adopt zoom, which do has some, um, protections for, for the patient.
So in the inpatient unit, we were able to use that throughout the continuum of care. I think, you know, what you were able to use was a little bit different because it meant that the patient had to know how to use that software, which is mm-hmm , you know, another barrier, but initially at least for us, we were able to adapt, uh, the use of, of zoom, um, when facilitating those encounters.
Wonderful. Now I'm gonna switch over to Dr. Hosey. You had shared some of the concerns with switching to telemedicine in the sense that, you know, family members were not able to be as involved on the ICU unit as they were previously. Can you talk a little bit about those along with other challenges in terms of implementing technology and what are some of the ways that you've tried to overcome those barriers?
With regard to the first part, yeah, we were not allowed to have patients, family members in the intensive care unit at all for at least six months during the beginning of the pandemic. And so for lots of reasons, that was stressful.
Just to give people context, what that looked like for a lot of family members was dropping their loved one off at the emergency department, receiving a phone call from a physician or a loved one. Being informed that their loved one was about to be intubated or to receive more in depth care. And then perhaps not seeing them for weeks or months at a time mm-hmm . So this is very intense. And you can imagine that the other things that, that involves is sort of waiting by the phone for care providers at the hospital, to be able to call with updates, being really concerned about the vulnerability of their patient during that time. And then finally, when patients are transitioning to home, it can be really confusing for family members who haven't been able to be at the bedside because they haven't been there to witness the invasiveness of the procedures, the depths of the delirium or cognitive impairment that the patient might have experienced or even know how many medications or why the patient has been on. And so it also deeply affects the patient's transition back to home. You know, why is my loved one so weak after they were able to do so much prior to coming home? Without the witnessing of, you know, prolonged bedrest and things like this. And so those are really some of the hardships I think of not having loved ones consistently at the bedside.
When the pandemic started, I think that there was a lot of concern about PPE. Which providers should be prioritized? Who should be allowed to go in the room? Um, of course, all of this before we understood how severe or not severe the, the first variant of the, of the virus were. And so for a little while I trialed seeing the patients virtually.
So for example, at, at the Hopkins ICU, there's a lot of heterogeneity across hospitals and in equipment as Mayra was sort of telling us. Um, we had iPads in every room with access to zoom and I could attempt to zoom with our patients, but for those who were intubated, those who had any type of confusion, this was really not an optimal way to go.
Um, it was very difficult to communicate virtually, and also it was additional time taken out of our nurses, techs, or other care providers day when they were already so busy. Really everyone was doing multiple new jobs now in the wake of COVID, we weren't just doing our typical job. Everybody was asked to sort of pitch in and do more.
And so for that reason, I decided that seeing patients virtually from my desk was not going to work. And so I did work with teams and administrators to ensure that I wasn't taking up valuable PPE and decided to work directly at the bedside with the patient. And again, I just provide all of this as context so that people might know what types of conversations you would have in these similar situations.
So once in the room, again, I think similar barriers that might or might have experienced. So ensuring that family members at home have access to proper technology.
One of the things I really learned along the way was coaching families about what they might expect to see in their loved one before hopping on with them. So letting them know, or reminding them that their loved one was intubated, letting them know that perhaps that they were sedated and letting them know what they would probably see in the room were really important things to do. I think, to just set those virtual visits up for success.
I think other things that helped were having a meeting time for the family so that they could have as many people on as they wanted and sort of doing the work of getting to know the patient through the family ahead of the visit.
And so what I usually do at the bedside with family members is, um, include them in an interview. So I can know the history of the patient. Of course, that might include things like pathology, like previous cognitive impairment, previous mood or mental health disorders. But I think most importantly, learning who that person is prior to being hospitalized.
What do they love to do? Who are their most important people? What did their usual day look like? Were they working? In school? Those types of things. And so that when we do finally have that virtual family visit, everyone is on the same page. So I think those were some of the barriers or sort of patient centered things I thought about while working via telehealth at that time.
Those are so helpful. I'm wondering also about what are some of the unique needs or considerations that you had to think about in terms of using technology in the ICU and I'm thinking infection control or patients who are so critically ill, maybe not being able to hold the technology or the tablet. Um, how did you handle those types of situations?
Yeah, that's a really important point and highlights part of the importance of multidisciplinary care in all of these settings. And so in terms of infection control, we are very lucky and privileged and grateful that each bed in the ICU had access to an iPad that gets locked inside of this box that has a handle.
So that is something that we can wipe down after each use and between patients coming in and out of that room. So, um, that was the patients to use some of the infection control that becomes a barrier is that many of us were in, um, masks, so N95, which a lot of people are accustomed to, or what we call PAPR hoods. So these are face shields connected to a HEPA filter, and both of these had their own types of barrier. So the person. Uh, you know, many of us are now used to masks where it might be harder to see or hear what somebody is telling you. Um, and for the patient that can be very alarming, um, to be working with a person who is in PPE, especially if they were hospitalized quickly and aren't really sure where they're waking up. It also makes it harder for them to understand. And the other side of the, of the televisit, it's also a little bit harder for families to hear and understand what's going on. So we're sort of shouting through the gear and fighting to be heard back through the gear. Um, so that's part of the infection control piece.
So, um, patients who are critically ill might have dexterity problems, are likely not able to set up the meeting visit themselves. And that's for a number of reasons. First patients who have been in bed for long periods of time may have critical illness myopathy. So that's weakness or sort of, uh, change in muscle from consistent bedrest.
Sadly, a lot of our patients at that stage, the early stage of the pandemic were in restraints so that they don't, um, self extubate. So those would be difficulties withholding. And so we worked together with our colleagues in occupational therapy who created foam, wedge cushions, and, um, adaptive. Uh, devices that would let us prop the tablet up either at the bedside table or in the patient's lap so that they could see the family members and the family members could then see them back.
Um, so you're right. It, there are a lot of in the moment work around that we, as a team would do together to sort of overcome all kinds of barriers. It does involve with a lot of innate problem solving to sort of get there.
I love that you use that multidisciplinary team to, to come up with a solution to some of those barriers.
I'm gonna switch back over to Dr. Sanchez Gonzalez and ask similar a similar question. I imagine that you didn't have that since you didn't even have the tablets on the unit to begin with that you didn't have those same infection control options to begin with. How was that handled on the inpatient unit for the rehab department?
Yeah, initially there, we just faced an problem amount of challenges. So initially, because at least with, with psychology, we were able to provide the care via telemedicine, which I just wanna mention that was not the case for some of our other colleagues, um, in, within rehabilitation services. So for psychology we're able to do so.
And because initially we were relying on, um, patient's own devices. We didn't have to do a lot of that infections control, because we were simply going into the patient room and just letting them know that, you know, how we were gonna connect. However, there were many of our patients, we did have barriers on accessing or knowing like how to set up zoom and many times, because we had to download it on their phones.
We did end up, you know, having to handle their devices. So at that time we did, uh, had access to ways in which we could disinfect, uh, and the reasons to do so. So it was great that we could, you know, be able to go and, uh, disinfect everything after we had touched it. But we had to have very clear, uh, sort of guidelines on how we were going to do that.
So going into the room, if we were gonna handle the device, you know, disinfecting that ourselves, uh, and making sure that we were handling that, uh, appropriately. So it really relied on it. It really meant that the providers were doing. That kind of work. Once we were able to get some technological equipment, we were able to have initially at least some access to some tablets, but because we did not have enough, that meant that we needed to, you know, be using the same one throughout the day.
So it was going into different patient rooms and, you know, being handled by different people. So again, that also created a responsibility for us to ensure that we were disinfecting that and making sure that we were, uh, handling that in a appropriate way. So it was really on the providers, uh, to do that at each encounter.
This was throughout the day. So I think after a while, we were just, you know, good with our routine, our cleaning routine. Cause we were seeing patients throughout the day. So that was good. Later on. We were able to get resources to where EV every patient could be assigned a tablet. And that was great because that meant that the patient would have access to their own device throughout the, you know, throughout their stay.
And, and that was very, very helpful. And of course, the, the cleaning at that point in infection control at that point was to ensure that the device was appropriately handling clean, you know, after the patient was discharged and ready to be used by a new patient.
I imagine that connecting with administration to, to share the challenges of needing more technology, um, needing more resources, also checking in with maybe infection control or nursing, or the medical staff on how to properly clean things. These were all things that you had to do before you started implementing the use of the technology.
Um, at least on our unit, you know, there was a lot of advocacy and just bringing up those concerns to people in positions, to be able to make decisions, to help patients and providers, to ensure that everyone was getting equitable access to care.
So it did involve letting people know that about the barriers and challenges that we were facing in advocating, you know, for those resources, which at our institution, as Megan has mentioned, I think we're privileged in many ways. So we had a good response by our institution, which, you know, I think it really differs, uh, based on people where people are located in the type of resources that they have access to.
So at least on our end, I feel. They were mostly responsive. And then of course it took a lot of, you know, time to ensure, like you're saying that we're having conversations with the providers and team members and departments that we need to talk to to ensure that we are actually handling all the equipment and in, in appropriate way.
And that we're ensuring, you know, the safety of our patients and, um, our team members.
Yes. You've mentioned equitable care a few times. And so I wanna switch gears a little bit or shift our focus. You know, many of our patients who come to Johns Hopkins and I'm sure this is true in many other hospitals.
Are either non-English speaking or they, or their family members have limited English proficiency, um, or would benefit from the support of an interpreter. That adds an extra layer right. Of challenge, or maybe, um, an extra layer of consideration when you're using technology like this. So how is that handled on the inpatient unit and how did that change when you implemented the use of telemedicine or telepsychology?
Yeah, this is such an important question. And again, I just wanna start by acknowledging that at the institution where I work, we have incredible access to language services, which I do not believe is a representation of the reality of many health institutions. So I think it's important that we keep that framework in mind.
As you know, I go on to answering that question. So typically in, in, within my institution and, you know, uh, in my unit, we could get pre COVID access to, uh, language services in, in one of three ways. So we could have in request an in person provider to come to the, to the room or, or to the unit to help us, um, interpret for, with the patient.
We could also request someone via video or someone, uh, via phone. So the standard of practice is that we include an interpreter at every encounter in which the patients preferred language is non, is not English. And the provider is not officially certified to provide services in that language. Even if the provider and the patient do speak the same language, at least in our institution, which is not the case for all institutions, our providers need to be certified to provide that service in that language. So if they're not, we must always include an interpreter.
So the shift to using telemedicine meant that for the most part, we couldn't really rely on in person on the in person option because at least at the very beginning, you know, we were trying to make sure that we were keeping everyone safe. So we were relying more on telephone or video options.
Unfortunately, there is no real easy way to include interpreters during telemedicine appointments, in many of the platforms that were used for telemedicine, especially during those emergency declarations. You know, we, we have waivers to use other platforms, uh, that were not HIPAA compliant. However, there is no easy way of then including an interpreter in those platforms.
So, you know, providers really had to be creative on how to include interpreters. And this might have included, you know, having an interpreter on the phone line while you were on the video with the, with the patient. But of course you can imagine the significant challenges of doing so that way. For example, this was not an option where when we needed American sign language interpretation.
So, you know, a lot of different situations where we had to think of how are we gonna ensure that we're still providing this care for this patient? Again, at my institution, we're very fortunate that we can also schedule interpreters interpreters via video to be included during appointments. But again, this is not the case for every institution. And it also is not a perfect solution because in order to be able to access that platform and include the interpreter, it requires some support for the patient prior to, right? So the patient needs to understand how we're going to use the technology and the fact that we're going to use the technology to facilitate this encounter.
So if there is no support staff to provide those instructions to the patient in their preferred language, then that also creates barriers on how are we going to then help them access that.
So, you know, in my practice, I work with Spanish speakers. And even though I can provide language-concordant care, which is not, you know, the, the norm. Many of my patients were still facing barriers prior to meeting with me, because they did not have access to really understanding how to sign up for, for the platform or all the instructions were not available, you know, in, in Spanish, the support staff and the staff, um, in their care team, you know, may not speak the language. Our patients may have low technological literacy.
In fact, many of our patients did not speak Spanish or, or whatever other language, you know, um, they were able to, I mean, did not read. So that also created some challenges on how we were gonna communicate if we chose to, you know, communicating written language. So I think the, the takeaway for me in that is that although telemedicine and the switch to it did create so much access for so many vulnerable populations.
I think we need to be, uh, Careful not to believe that that access was equitable. Because even those communities are very diverse. And while some of our patients might have been able to get increased access, that was not the story for everyone. And when you have intersecting identities, such as, you know, individuals speaking another language, or as you were talking with Megan earlier about individuals who may not be able to, you know, hold a tablet, you know, you still need to have access to adaptive equipment.
You still need to have access to other resources that are then going to create that equitable access to telemedicine. Um, so I think it's important to remember those points.
Those are such powerful reminders and something all of us really need to keep in mind as we're thinking about this. I mean, there's a lot of enthusiasm around tele psychology and telemedicine, and there are, as you said, some benefits to it, but we also really need to keep in mind these barriers and not jump both feet in without having a good solution to provide equitable care. So thank you so much for highlighting all of those pieces.
Dr. Hosey, do you have any additional pieces to add in terms of how you on the ICU have utilized technology or barriers that you saw and how you overcame them with individuals or family members who either were non-English speaking had low English literacy or needed the use of an interpreter?
I mean, I think Dr. Sanchez Gonzalez is like a world leader in thinking about these things. So I just definitely wanna echo all of the facilitators and barriers that she mentioned. I'll also just reiterate that people who are hospitalized and are not primary English speakers have an added set of barriers that I think can really make being in the hospital harder.
I will say that early in the pandemic, we saw a disproportionate number of people from Hispanic and Latinx communities in the critical care unit, and in the acute care hospital. And that was because of disproportionate risk to infection. For example, we had multiple patients in the CR in the intensive care unit who were working in meat or fruit packing plants, where the rest of us might have been given access to PPE or allowed to shelter at home. These are folks who continue to go into work, who are reminded that if they didn't come to work, they would lose their jobs or worse would be reported to authorities. And so continue to work while being infected. And then, um, subsequently hospitalized.
You can imagine that then being hospitalized in a place where you don't speak the language where people are wearing PPE, where you're being given invasive medical treatments without full access to understanding or explanation about what's happening to you can be terrifying. And you can imagine that without some kind of debriefing, without some kind of explicit mention of care or what folks have been through, those are people who will have worsening access to care as they go home.
Basically, you know, concerned about returning, due to um, any myriad number of barriers, like billing, like being exposed to, um, punitive governmental actions or worse returning to a place where they were concerned that at some levels they were vulnerable to harm or things like being experimented on were themes that we heard not infrequently.
So I wanna, you know, talk about the telehealth piece, and also just sort of amplify that these are our folks who we should be proactively reaching out to in multiple formats in the wake of the pandemic, because of their unique challenges during hospitalization. And I, I think that those are folks who will need new ways of follow up, including, but not limited to telehealth.
Such important points that both of you have brought up, uh, in terms of vulnerable populations that we might be seeing on the inpatient units in ICU.
So my understanding is that there were challenges along the continuum of care when COVID hit. And when we switched to using technology and telemedicine, um, when patients moved from ICU to inpatient to outpatient, I just wondered if you could share some of those challenges that you witnessed and maybe how we as psychologists or hospital systems can address or overcome some of those challenges.
Yeah. So, I mean, I think that some of the biggest barrier was that like, as we mentioned, variable or heterogeneous access to telehealth. Um, we did have patients who had, you know, fairly regular access to family members, for example, in the intensive care unit. Um, but then may step down to ward where they have less access because there maybe fewer iPads or, or fewer nurses with the time to help them get set up with that.
Um, and then finally, I think. One of the things that we saw and were somewhat concerned about, but folks in our postacute COVID team tried to work on were access to telehealth, once people got home, for the continuation of their care. So folks who had computer access, some knowledge about how things like zoom work or, or how the electronic medical records work, um, might have had better access to outpatient visits with their physician than some other, uh, previous ICU patients.
For example, we did not have a packed clinic or a routine structure for outpatient, uh, follow up after ICU prior to COVID. However, you can imagine that if people don't have familiarity or technical access, that that's a gap where often family members were catching patients, at home with limited understanding of their new acquired impairments, um, limited understanding of what medical needs they would go forward. And so there is a little bit of a trench there for people who don't have, um, better access to technology.
Dr. Sanchez Gonzalez, can you speak to that question of any challenges that you witnessed with the continuum of care?
Yeah. Um, very similar to, uh, what Dr. Hosey was mentioning, you know, I think like on the inpatient side again, um, the, the access to the technology and the barriers that she had already mentioned on the inclusion of support systems definitely applied to our, um, inpatient rehab units as well.
And the, sort of the expectations that, you know, family members had for what their loved ones were able or not able to do, which is something that Dr. Hosey mentioned in, you know, happening in the ICU. And I think also within our inpatient rehab unit. So one of the things that we do when we're, you know, planning a discharge is providing recommendations on the services and support that the patient will need to be successful in their next level of care.
And many times, because family support was not present and the use of technology did not provide a clear picture of how their loved one was doing. Sometimes there were a mismatch between what the family or the support system belief needed to happen, uh, after they were discharged from our unit, and what our team members were recommending. So that was really difficult.
Another challenge that they faced now, um, When, when, if they needed to be discharged, for example, to another level of care in a, in a different facility, in a nursing home, or if they needed to have support in a subacute, uh, rehab facility that also created a lot of challenges because families knew that the access to technology was also gonna be a challenge there. And, you know, again, visit visitation restrictions were also happening in those contexts. So it created a lot of distress for families and patients. So I think it really highlighted the importance of patient provider communication and how to ensure that we were doing that in the context of telemedicine, uh, and included everyone, including everyone that was important and making sure that we were being clear and that we were also acknowledging and answering the questions of the support system for the patient.
Now at the outpatient setting, I think those challenges extended to what Dr. Hosey already mentioned, you know? We know that most people do have access to, for example, smartphones, you know, um, generally speaking. But we know that there are disparities in who has access, uh, for example, uh, in other type of, uh, technology that would enable, um, access to the care.
So not everyone had access to internet at home. Or not everyone had access to a laptop. Or not everyone had access to the support system that would help them to access the telemedicine care once they were at home. And, and we as an institution did not perhaps have all the resources and support to then really facilitate that, that access.
So I think in the outpatient setting, it did end up requiring a lot of time from providers to ensure that their patients knew how to get on the platforms, knew what to expect of those first encounters. And also knew that the care they were getting, you know, was still good care. Despite it being in, you know, via telemedicine, which was, I think, a concern that we hadn't really highlighted, but I think some of our patients did have that concern.
So it sounds like a lot of what both of you are describing is problem solving ahead of time. What are some of the barriers that our patients might be running into and talking about that openly, honestly, and maybe even setting some time aside or letting our patients know that, you know, initial sessions might be spent on making sure that we can get this technology to work and then we'll dive into the work.
So it's, it's really being aware that you might have to spend some time helping them get, uh, used to different technology or, or used to using different platforms. And we have two more questions. One is on incorporating students. So both of you work with our psychology fellows who, um, are on the inpatient units with you.
Sometimes they're working hand in hand or side by side with you, sometimes they're on the units independently. And so I wondered if you could speak to any of the challenges that arose with using technology or incorporating students into the use of technology and how you overcame any of those challenges that arose.
Yeah. So just to put a little bit of context out there. So in that, you know, where I was working, we usually work with, uh, psychology fellows and also with psychology, uh, externs. So the externs at least, you know, During that first year where things were really uncertain and because of the restrictions, um, and safety precautions taken by our institution, that meant that psychology externs, uh, were not able to be on site with us, so they were working fully remotely.
The challenge for, with, with psychology externs was that many times this was your first experience working in a medical setting, an inpatient setting, uh, specifically, or, you know, their first time working with, with a rehabilitation population. So when you're, when this is your first time and you know, the setting of your work requires that you work closely with other team members, it can create a big disconnection on how you feel in regards to your position in the team.
So I think that was one of the biggest challenges, sort of that sense of feeling connected to the team, uh, when working with their patients to make sure that they were all in the same plan and that they could collaborate with them to, you know, improve patient outcomes. I think the other challenge was just, you know, getting a sense of what it was truly like to work in an inpatient unit and in rehab unit, for those that did not have prior experience doing so fully, virtually looked very different than if they would've been in person.
So some of the ways that we overcame those challenges for the extras was really focusing on creating a plan where we were going to help feel included in all activities. So that meant, you know, having a clear schedule of what was gonna happen during the day, what was expected, ensuring that they had links to, uh, join all of our, uh, meetings with the rest of our team members, ensuring that, you know, they still were able to talk to other team members via secure, uh, messaging.
And, and that was really good. So a lot of leveraging technology to ensure that, you know, they felt included. That they really felt like they knew what was happening. And ultimately that we could, you know, support patient outcomes.
At the fellow side initially, they also were working fully remotely, but eventually as things improved, we were able to have the fellows working with us in the inpatient unit. So it was really a combination of how things look like because we had externs working fully from home. We have fellows working in the inpatient unit and still providing telemedicine within the unit. So that meant, you know, the patient was in the room and the fellow might have been in their office providing that care or a combination.
And then me as a provider, um, being also in the unit. So it was a combination of some of us being there in person, other people being fully remotely. And I think the main takeaway from that is that it just took a lot of coordination amongst ourselves in really understanding the, the use of technology.
Leveraging technology, not just for telemedicine, but even, you know, for our training programs. And we were able to, uh, do some great things with it, like for students and for training purposes, you know, we were able to join, um, some of our other units for some didactic experiences, which, you know, perhaps before we would've been able to do it, we were just not doing it as actively.
So I think because technology got really put on the forefront, uh, we were thinking more on how to leverage that for training, um, in supervision. So I think at the end of the day, you know, really a lot of training around patient confidentiality in telemedicine, and also a lot of conversations on how to include trainees in different inpatient activities.
As I had previously mentioned, And also in making them aware and having conversations about, you know, the, the diverse challenges that we may face when working with our populations and how to address those.
Such good information and so many wonderful tips there for, uh, psychologists who work with trainees.
Dr. Hosey, did you have anything to add?
Just a couple things because Mayra already did such a good job. um, covering that. So my experience with trainees, uh, during the pandemic were to get to work with two of our fellows. And so, um, when the pandemic hit in March 2020, I was paired with Dr. Eva Keatley and she and I worked on two inpatient units.
So our, our inpatient rehab units here at Hopkins, the regular one. And then we also set up, um, a second inpatient rehab unit specifically for PA COVID patients, recovering after critical illness. And so the instrumental tips that I can give you are that, um, first of all, our trainees are remarkably resourceful.
Dr. Keatley, I think you'll probably be talking with her in a different part of the podcast, but Dr. Keatley engineered a remote cognitive battery that we administered via telehealth with our patients. Again, this was because in the early stages of the pandemic, we put a priority on safety and asked our fellows and externs to stay home and work remotely with the patient. So Dr. Keeley developed this remote battery. She worked with the team to identify a point person who wound up being our patient liaison on the inpatient rehab unit, who would go in and set up an iPad as well as a speaker so that the patients could meet with Dr. Keatley virtually as part of their inpatient rehab schedule.
So Dr. Keatley really took ownership of a lot of that in the pandemic, did a fantastic job. The feedback from our patients was that during those really isolating stages of the pandemic, to have somebody to talk to and know that their mental health and wellbeing were checked on was critically important.
And Dr. Nmezi was, uh, also our inpatient fellow who worked with me in the MICU again from home. Dr. Nmezi took the lead on calling several of our family members to do the work that we mentioned earlier, which was gather patient history, gather understanding of the families, knowledge about what was happening to the patient on the inpatient rehab unit, educate family on what they might see from a mental and cognitive health perspective. When their loved one came home. And then sort of prep them for a later virtual bedside visit with the patient.
In addition to that, Dr. Nmezi took on creating patient handouts and, uh, did a lot of extra backup work to sort of keep things moving in a, uh, helpful direction for our patients and families. And so I just wanna double down and shout out how much ownership they took and how helpful they were in those stages when given the reins to be able to do so.
I think those were the instrumental parts. The supportive parts of supervision in these situations, I think are also important to highlight. So first the pandemic was, I mean, I keep using the word stressor, but I feel like that's a bit of an understatement for what we all faced. As we went into isolation, quarantine.
Our trainees were often moved from one place to Baltimore. And so they didn't have high familiarity with folks who were here or with the, um, city, for example. Um, that's already a challenge, but then to go into isolation, be working in a completely new format with completely new supervisors. This was a very tall order.
And so I think the hope is that some of the emotional support would be routine check-ins to ask, not just about the technical aspects of patient intakes and follow ups, but how that was for that, that trainee to hear about what hospitalization is like for patients and family members. To do the extra checking on if the trainees felt like they had all the resources they need and to figure out how to problem solve, not just for the patients and family members, but for themselves when they had less access to their usual coping, just like we all did.
And so rarely did our, our trainees need a lot of in depth help, but I do think that all of us just sort of reaching across the tech divide to do the extra double check about how we're faring and knowing that there's somebody who cares on the end of the other end of the, the zoom call or, or the supervision line is, is really important.
Thank you for highlighting that piece of it. And, and yes, we will hear from Dr. Keatley. She's gonna talk about that cognitive battery that she put together. One final question. Thank you both for all of the time and energy you've put into helping, um, with this project and educating about technology on the inpatient unit, you've highlighted some challenges around the use of technology.
And so I'd love for both of you just to share quickly now that we've started to shift away from strict requirements that we saw at the beginning of the pandemic. And as we move kind of into the future, do you see any role for telepsychology or the use of technology on the ICU or the inpatient unit? If not, why?
And if so, why, or if you think maybe there's more research needed before we really full, fully roll this out. I'd love to hear about that.
There are again, facilitators and barriers and pros and cons. Of course, the use of telehealth, my hope or aspiration for the future is that what came about because of necessity will be refined into increased access for lots of people.
And so, uh, I will tell you just anecdotally to have family members who, again, because of, of distance or time be able to be a part of the patient's care, um, I think will be something that will be helpful well into the future. I think that building spaces for psychologists on, for example, rural hospital teams might be something that we should all be thinking about in the future. Especially as our mental health professionals are looked to more and more to help patients cope with medical conditions or medical symptoms.
And finally, I really, you know, thinking very futuristically, we've seen early major benefits of things like virtual reality and video gaming for inpatients. And so with increased access to technology, things like iPads and additional software, I would love to see how we can continue incorporating novel ways of intervening to support the patient's mental health and abilities to cope with symptoms.
So for example, we've seen, uh, patients with severe pain due to burns benefits, significantly from VR in inpatient rehab units and inpatient burn teams. I think that the sky is the limit. I think we proceed with caution, and pay attention to people's unique needs in these situations, but I would like to hope that COVID ticks the door open and pushed the envelope in something that we should have been doing a while ago.
Wonderful. Thank you so much, Dr. Hosey and Dr. Sanchez Gonzalez, I'll give you the final word. Any thoughts about whether you think there's still a role for technology on the inpatient unit and if so, what does that look like for you?
Absolutely. I believe there is absolutely role for technology in the inpatient unit for all of the amazing reasons that Megan already highlighted. And I will finish by saying when we're thinking of providing equitable care again, Megan already highlighted some of these reasons. But I think another reason too, is that, you know, we're thinking about providing services to PA, to patients who haven't had access to them historically.
And this can look in other locations, geographic locations, where psychological services are not available. So. As Megan highlighted, this could really, you know, facilitate that. But I would also argue even, you know, access within our own hospital systems. Uh, for example, I know Megan and I work closely on, you know, providing care for Spanish speakers when they were in the ICU, even though I was in the, um, rehab unit.
So I think we can really leverage telemedicine to increase the access to language-concordant care, which we know is so important in improving patient outcomes. So yes, I, I absolutely believe there is so much that we can do to fine tune the use of technology in inpatient care.
Thank you both so much for all of your wisdom, your experience, and also all of the great tips that you shared today for psychologists who are working on the inpatient unit.
I just wanna thank you again for your time and, and expertise. And I look forward to working with both of you in the future.
Thank you.
Thank you for your work, Megan.
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