Virtualizing Care for Patients During the COVID-19 Crisis

The nature of the COVID-19 virus — novel and highly transmittable — changed the paradigm for the delivery of care in unexpected ways. The Office of Patient Experience (OPE), a team dedicated to delivering compassionate, person-centered care at every step of the clinical encounter, had to act nimbly to adapt to a new era of care during the COVID-19 crisis.

“It was essential that we continue to enable the things we believe in, the things that are fundamental to who we are as an organization,” says Adrienne Boissy, MD, MA, Chief Experience Officer at Cleveland Clinic.

Much of this work involved virtualizing parts of the patient experience during a pandemic. They had already developed empathic communication tips for virtual visits. But developing virtual models of care — particularly for end of life patients — means upending expectations on all sides. Dr. Boissy points to the following selected examples where the team used technology to enable virtualized care in new, meaningful ways.

Facilitating virtual visitation with family

Managing disease prevention led to visitor restrictions at Cleveland Clinic. Recognizing the significance of facilitating connections with family and loved ones, OPE partnered with the Information Technology Division and the Nursing Institute to form the Enterprise Virtual Visit team. The collaborative group worked to facilitate online family visitation for admitted patients at Cleveland Clinic locations in Ohio and Florida. Through this initiative, the team deployed more than 500 shared iPad devices to 363 nursing units across 20 locations in Northeast Ohio and Florida. In addition to providing the equipment, the team worked with patients to use apps they were comfortable with or, in other cases, developed training guides to help patients navigate new or unfamiliar technology.

Grétchen Hebert, Program Coordinator in OPE, remarks, “The virtual visitation program offers an amazing connection between patients and loved ones — whether it’s simply to check-in and chat, give family members the chance to see each other for the first time in weeks or provide closure before a loved one passes.”

In one instance, a patient reached out to the team writing, “Because of your kindness and efforts, I was able to see my wife for the first time in 11 days. I can’t begin to describe how good it feels to see her again! She looks as beautiful as the day we met over 40 years ago!”

Leveraging technology for end-of-life planning

Within OPE, the Center for End of Life, led by Silvia Perez-Protto, MD, MS, had been working for years on integrating best-in-class resources for advance care planning conversations with patients, capture of advance directive (AD) documents in electronic health records (EHR), and many other efforts, often in collaboration with Cleveland Clinic’s Center for Excellence in Healthcare Communication (CEHC) and Palliative Care. Shared resources from the Conversation Project and Ariadne Labs, as well as the adoption of the Pause, were early successes. When working with IT and clinical teams on the patient engagement tool Care Companion, OPE integrated empathic, humanizing language to the digital tool, as well as an opportunity for the patient or caregiver to discuss advance care planning.

“What was most surprising to me is that during COVID-19, it wasn’t just patients fearing for their own lives, but also our caregivers — doctors and nurses — who wanted to talk about their wishes, complete ADs, and make sure their families were taken care of,” says Dr. Perez-Protto. “If patients using the Epic tool opted to talk about end-of-life planning, spiritual care jumped in to help facilitate these crucial conversations.”

Drs. Perez-Protto and Boissy also worked on a collective COVID-19 white paper Death, Grief, and Funerals in the COVID Age to describe the transformation of end-of-life care and rituals during the pandemic.

For admitted patients with COVID-19, care teams were able to access ADs, inpatient EHRs, lead discussions with OPE conversation guides around end-of-life decision-making and potential resource allocation, and help patients connect virtually with family do to so. They even explored remote notaries, and after taking her own initiative, one of the ombudsmen became officially certified.

“The goal was to do everything to make advance care planning accessible and straightforward, and help patients — and our own people — think through the unimaginable conversation they may need to have with their loved ones,” says Dr. Boissy.

Virtualizing spiritual care

Spiritual care has always been available 24/7 to patients and caregivers at Cleveland Clinic. Thanks to the leadership of Rev. Amy Greene, DMin, Director of the Center for Spiritual Care, and Stephanie Bayer, the Spiritual Care team was experimenting with virtualized services before the pandemic. “We knew spiritual care was a precious resource that we wanted to scale for the enterprise,” reflects Dr. Boissy, noting that she wasn’t surprised that the team successfully transitioned their model during the crisis.

“Just before COVID-19 hit, I remember one of our chaplains telling me how he (Rev. Brent A. Raitz) had led a funeral for a patient from California over the phone…and then I knew they could do anything,” recalls Dr. Boissy. In another instance, Rev. Nancy Lynch conducted a virtual baptism for a baby undergoing major surgery with 20 family members. “‘A big deal for the little guy’ she told me,” says Dr. Boissy.

Chaplain visits for COVID-19 patients remained available 24/7 by virtual visit or by phone. And that old-fashioned phone went a long way. After a long conversation with a patient, Rev. Brian Shields described one encounter as magic. “I call it magic because neither the patient nor I knew that a genuine connection would be made, but here it was over the phone on a Friday evening during the coronavirus pandemic.”

And it wasn’t just the patient or chaplain who benefitted. Spiritual Care also debriefed the caregivers on COVID-19 units, assisted with resources on managing grief with the Office of Caregiver Experience, and offered healing services to make sure our caregivers were cared for. The need for spiritual care in end-of-life circumstances hasn’t changed, but the pandemic did drive less traditional, albeit no less effective, modalities for its delivery.

“Even in virtualizing something as deeply personal as spiritual care, we want people to feel that we are still here for them in the same ways we always have been,” remarks Dr. Boissy.

A new approach to ombudsman services

The Ombudsman Office had to immediately figure out how to work from home — and yet still be available to caregivers and patients as they had always been. Part of the challenge was equipping them to get the access they needed from home. But services were maintained to support caregivers in distress and patients. Limiting visitation was incredibly difficult but necessary for the organization to keep safety the priority. The ombudsman stood at the front lines communicating this to patients and also made themselves available by phone anytime or in person when needed. They developed scripting for the screeners and observed many sites to learn how best to support the labor pool. They assisted in crafting language with CEHC when someone didn’t want to wear a mask (consistent with the Communicate with H.E.A.R.T® model) and continued behavioral contracts wherever appropriate.

Lessons learned and what’s ahead

Developing new modalities for care was not without challenges. Events and projects were changing daily, which can be disorienting. But there were some tactics that enabled the team to quickly adapt to these changes.

Collaborative framework. A collaborative framework among OPE, Information Technology Division and clinical care teams was established prior to the onset of COVID-19, making the implementation of these efforts more seamless and scalable.

Meaningful communication. The nature of the disease catalyzed action around the global need for empathy, something the teams already knew well. Teams changed the cadence of communication to brief daily huddle calls, organizing around “mission moments” to remind each other about the importance of the work, a best practice shared by Kelly Hancock, DNP, Chief Nursing Officer at Cleveland Clinic.

Caregiver and patient recognition. The team also embraced virtual and in-person leadership rounding and created caregiver and patient recognition in Hero Huddles, an addition to the tiered daily huddle wherein names are passed through each tier and an executive makes a personal phone call expressing gratitude for our heroes.

Embracing a new culture. Since there was no roadmap, embracing a culture of jumping in to help wherever it was needed became a big part of daily operations.

A new normal for patient experience

The COVID-19 pandemic has undeniably altered the landscape of healthcare — in some ways that have yet to be fully understood.

For both patients and caregivers, virtualizing services added a dimension of depth and richness to the overall patient experience. COVID-19 has taught us a few things, according to Dr. Boissy. We can create empathic digital tools — the interface is irrelevant. We can take the caring we have always had for patients and scale it. We can also better care for our own caregivers. She hopes that patient experience never goes back to equate with only HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores and instead realizes its full potential in organizations to humanize the care for everyone.

Dr. Boissy reflects, “Think about what we know of suffering — it does not discriminate. It is the great equalizer. It knows no boundaries — no walls, no device, no stature, no titles, no time, no viruses, no diseases. But from suffering grows the limitless and tsunami forces of empathy and love. And that’s where the real magic comes in.”