Helping Your Adult Patients With Overt HE Through Telehealth Transcript

Helping Your Adult Patients With Overt HE Through Telehealth

Host: Christina J. Hanson, FNP, South Denver Gastroenterology
Featuring Sharon Magalona, FNP-BC, Reddy GI Associates

Welcome to Clinical Conversations: Helping Your Adult Patients With Overt Hepatic Encephalopathy Through Telehealth

Christina Hanson and Sharon Magalona received payment from Salix Pharmaceuticals for their testimonies.

Christina: Hello, and thanks for tuning in to Clinical Conversations. I’m Christina Hanson. We’re going to be talking about telehealth, and how you can continue to care for your adult patients with overt hepatic encephalopathy, or HE, using virtual appointments. With me to talk about this is Nurse Practitioner Sharon Magalona. Thanks for being here, Sharon.

Sharon: Thanks, Christina. It’s great to be here.

Christina: As many of us have seen, the COVID-19 pandemic drastically altered how we provide regular care to our patients with chronic liver disease. What types of changes did your practice have to make to adjust?

Sharon: Initially, we identified our patients at high risk for hospital admission, which includes patients with liver cirrhosis and HE. We sent emails to schedule monthly virtual check-ins to make sure they were doing okay and ensure we weren’t missing anything at this point in time. We also involved their caregiver in these appointments to get their perspective.

Christina: There is a crucial need for clinicians to adapt to this virtual environment so that we can continue to provide quality care to our patients. Can you talk a little bit more about how your practice has adapted patient care?

Sharon: To continue managing HE through early recognition, we have had to make a number of changes to how we provide care to our patients. A number of interventions could potentially improve outcomes in patients with cirrhosis. For example, for many patients, we are prioritizing proactive care—like the monthly check-ins I mentioned, with the goal of helping decrease avoidable emergency department or urgent care visits and reduce the need for elective procedures. Clinicians may be able to help reduce the burden of cirrhotic complications through proactive coordination between different providers, sharing information and resources, and offering secondary services like vaccinations, nutritional counseling, and substance use disorder therapy.

Christina: In our practice, we have transitioned many patients with cirrhosis to telehealth. Though telehealth quickly became essential to providing care during the pandemic, its usefulness really extends far beyond its role as a substitute for clinic visits during physical distancing.

Sharon: Absolutely, telehealth has become an important tool that allows for remote monitoring, focused education, caregiver support, and early intervention to help ensure patients are adhering to their care plan and medication schedule. Telehealth has been associated with multiple patient-centered benefits that may help improve access to specialty care, identify patients at risk for rehospitalization, and decrease costs involved in traveling to the clinic. Where I am in Arizona, some of my patients live very far from our office, so making it to an in-office appointment can be a burden and a challenge for them. Telehealth has been particularly beneficial for these patients.

Christina: Many of the ways we assess for symptoms of HE through clinical interview can be implemented through telehealth. What is your approach for identifying patients with overt HE?

Sharon: As many emergency departments became overwhelmed with COVID-19 cases, early recognition of overt HE became even more important, and it continues to be an important part of managing patients with HE. The first step in identifying patients with overt HE is recognizing signs and symptoms, as well as risk factors. It’s also important to regularly monitor for neurological manifestations in patients with previous episodes of overt HE to watch for signs of recurrence.

For overt HE, these signs and symptoms may include impaired cognition, confusion, changes in consciousness, personality changes, and impaired memory.

It’s still possible to assess cognitive functioning using telehealth because the patient can participate in answering key evaluative questions. For instance, “Do you know what day it is? Do you know what month it is? Do you know what year it is? Do you know where you are?”

With video conferencing, we can look for physical signs, too, including asterixis, which is a “flapping tremor” that can be seen with hyperextension of the wrists with separated fingers. Signs and symptoms consistent with overt HE should incite high clinical suspicion in patients with chronic liver disease, but it may also be helpful to look for risk factors—such as signs of covert HE, TIPS placement, sarcopenia, renal failure, and diabetes mellitus. Clinical scores such as Child-Pugh class and MELD have been shown to help predict the risk for developing overt HE.

Christina: Sharon, have you encountered any challenges with telehealth? If so, how do you address them?

Sharon: For patients with HE, it can be valuable if a caregiver is present for the visit, but clinicians need to remain attentive to the patient-caregiver dynamic. I’ve sometimes seen coaching from caregivers when I’m asking the patient those cognitive assessment questions, and the caregiver will sometimes answer first—“Hey, honey. It’s 2020”—you know, before even giving the patient a chance to answer.

I think some caregivers, and even some patients, may not fully recognize the role of telehealth visits.

They might have the impression that it’s not a formal consultation, when, in fact, it’s just as important as an in-person clinic office visit.

Not to mention, I think caregivers may not realize that the questioning is actually part of the patient’s cognitive evaluation.

I do also run into some limitations with internet access. Where my office is located in Arizona, I see a lot of Native American patients who live on the reservation, some of whom have inadequate internet access. In those cases, we may need to do an audio-only visit.

Christina: But, as we’ve said, you can still glean information by asking key questions even if you’re restricted to an audio connection. During your conversation with the patient, it’s also important to obtain information about symptoms of infection as well as medication adherence and use of all prescription medications, over-the-counter therapies, herbs, vitamins, supplements, and medications like opioids or benzodiazepines.

Sharon: Exactly. Infections and certain medications—such as sedatives, pain medications, or diuretics—may precipitate episodes of overt HE.

Christina: To your point, the American Association for the Study of Liver Diseases, or AASLD, has outlined some additional recommendations to help preserve quality care during the COVID-19 pandemic. One of these recommendations is to consider evaluating patients with liver disease for COVID-19 if they develop new-onset HE or other complications associated with acute decompensation.

The AASLD has also recommended considering telehealth alternatives in place of outreach clinics and performing a needs assessment prior to patient discharge to determine whether the patient can have follow-up encounters by phone or telehealth. Early monitoring by phone or telehealth is encouraged to help reduce early post-discharge, in-person visits.

Sharon: It is also recommended to ensure patients have refills available for essential medications and to provide prescriptions for 90-day supplies instead of 30-day supplies. Many insurance companies are waiving early medication refill limits, and it may also be possible for patients to have their medications delivered directly to their homes.

Christina: It is our responsibility—whether we specialize in hepatology, gastroenterology, or primary care—to recognize signs of HE and routinely assess patients with cirrhosis for overt HE to help minimize potential delays in care.

Sharon: You are absolutely right, Christina. Optimal care requires coordination among healthcare professionals. When a patient’s care team involves multiple providers, they collectively can offer seamless care despite potential individual limitations with regard to access to the patient. Coordinated care between multiple providers may have potential to help impact hospitalization or readmission rates for our patients with cirrhosis. If a patient is hospitalized, there is also a need for a coordinated transition of care plan post discharge. Studies suggest that early follow-up by any member of the team may result in improved clinical outcomes, which is ultimately the most important goal for all of our patients.

Christina: Sharon, it has been a pleasure speaking with you today and I want to thank you so much for sharing some of your insights around helping adult patients with overt HE through telehealth.

Sharon: Thank you again for having me, Christina!

Christina: And thanks to our audience for tuning in to this episode. You can find more clinical conversations around HE, available in both video and podcast format, on GastroHubAPP.com.