The Quality Scheme of the Spanish Health System supports the use of information and communication technologies (ICTs) to guarantee excellence in healthcare. For that purpose, the regional health systems that compose the National Health System have given priority to the development of courses of action in this field1.

The 2020 Strategy developed by the Health System of Galicia (SERGAS) establishes 20 courses of action, of which the sixth is focused on the promotion of knowledge management and innovation. Based on awareness that polymedicated elderly patients with chronic diseases are the main healthcare users, the SERGAS developed the telehealth platform TELEA2.

TELEA makes it possible for patients to consult their treating physician from home, which enables immediate control and improves disease monitoring. The information obtained is automatically recorded on the electronic medical record of the patient. This technology-based platform reinforces SERGAS commitment to consolidating Telemedicine as another healthcare service.

Patients or caregivers have secure private access to TELEA, where they record the biological measurements, parameters, and questionnaires determined by their medical team. This platform provides a unique opportunity for interaction among patients, caregivers and health professionals. TELEA promotes information sharing, facilitates close monitoring of disease course, and makes it possible to anticipate chronic-disease exacerbations. In addition, this platform allows physicians to update treatments in real time, thereby avoiding unnecessary travels3,4.

The consensus document “SEFH positioning on Telepharmacy: Recommendations for its implementation and development” identifies a set of Telepharmacy activities, including, clinical reporting, drug therapy monitoring, and coordination between intra and extra-hospital health professionals, to name a few (https://revistafarmaciahospitalaria.sefh.es/gdcr/index.php/fh/article/view/11515).

Nursing homes (NHs) have special relevance in the area of health team coordination, continuity of care, and the multidisciplinary management of patients.

Nutrition surveillance is one of the most important aspects of integrated care in frail polymorbid elderly patients. In this age group, malnourishment is a risk factor for the development of dependency and is associated with comorbidity, frailty, and increased mortality5. In February 2021, the Health Area of Vigo set up the first Multidisciplinary Unit of Nutrition Support (UNS) in Galicia, Spain. The initiative was jointly conceived by the Hospital Pharmacy and the Unit of Endocrinology. The mission of the Unit is meeting the nutritional needs of patients with different conditions or health problems and maintaining or attaining an adequate nutritional status, whatever the level of healthcare (secondary or primary care).

In our Health Area, institutionalized patients needing artificial nutrition support (ANS) regularly visit the Unit of Nutritional Support (UNS) of the Hospital Pharmacy Service. During these visits, prior to establishing a nutritional regime and follow-up scheme, an initial nutritional status assessment is performed.

A high proportion of UNS patients are nursing home residents, most frequently dependent, who need to be accompanied by a caregiver and/or require adapted transport to attend their appointments. This led the Hospital Pharmacy to suggest using TELEA for seamless communication between the UNS and NHs. This would eliminate paper-based communication, thereby facilitating coordination of the multidisciplinary team. The SARS-CoV-2 pandemic prompted the development of the project, since workflows had to be adapted to the limitations of the new work environment without compromising the safety and quality of pharmaceutical care provided to UNS patients and outpatient HP users6,7.

The purpose of this study was to evaluate the utility of the telehealth platform TELEA for nutrition surveillance in patients residing in nursing homes.

A multidisciplinary team was created involving NHs, a panel of experts in the implementation of TELEA, specialists from the Unit of Endocrinology and the Hospital Pharmacy, and the Medical Director of the Health Area of Vigo.

Regular work sessions were scheduled to analyze the pathway for referral to the UNS of nursing home residents needing enteral nutrition support, patients at risk of malnourishment, malnourished patients, or patients with dysphagia.

A review of the following UNS processes –from ANS prescription to dispensation– was performed.

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  ANS prescription: all pathways by which the UNS receives new ANS prescriptions.

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  Nutritional status assessment: an evaluation was conducted of all nutritional status assessment tests, food intake records, pressure ulcer control, and laboratory parameters tested by the UNS.

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  Nutrition surveillance: an evaluation was conducted of the periodicity of nutritional status assessments performed to institutionalized patients.

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  ANS dispensation: an evaluation was conducted of the periodicity of dispensations to NH residents.

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  Records and communications with the NH: an evaluation was conducted of electronic and paper-based records and the flow of information between NHs and hospital specialists.

Data of institutionalized patients who already received or needed ANS or beverage thickeners was extracted from the SILICON® electronic prescription system and from the local records of the HP UNS.

The main requirement for inclusion of candidate NHs to inclusion in the telematic nutrition surveillance program was having used TELEA during the COVID-19 pandemic.

Prior authorization from SERGAS was required for the caregivers designed by the center to be granted access to patient profile on TELEA.

In 2021, over 300 institutionalized patients from 28 nursing homes were included in the nutrition surveillance program of the Hospital Pharmacy.

This telehealth nutrition surveillance program for institutionalized patients was implemented as a pilot project in two centers in our Health Area serving a total of 38 users, of whom 13 were on follow-up by the UNS.

Workflow processes before and after the implementation of TELEA are described below.

To the best of our knowledge, this is the first telehealth project addressed at nursing home residents that involves nutrition surveillance. In a literature review, we found studies including telematic nutrition interventions for patients with diabetes mellitus type I8,9; pediatric patients with diabetes, patients on weight control10,11; and patients with cancer12. The telehealth system played a crucial role during the pandemic caused by SARS CoV-2. TELEA enabled the follow-up of patients with active disease at home, close contacts, and patients living in small nursing homes where medical services were not available13. In the context of patient/caregiver education and information interventions, numerous experiences have been reported on the use of telehealth for nutrition surveillance. Arauco Lozada et al.14 assessed the impact of a telematic nutrition education intervention in community-dwelling elderly adults on the risk for depression and malnourishment.

For the purposes of the study, patients were asked to answer the Mini-Nutritional Assessment Questionnaire and Geriatric Depression Scale (GDS-SF) at baseline and at the end-of-study visit. The patients in the experimental group improved their nutrition knowledge, as compared to the control group, although differences were only significant in the area of food safety. Although nutrition knowledge is unlikely to improve in our study population due to their clinical status, it is expected to improve in caregivers and NH staff.

An increasing number of telehealth-based initiatives are being launched and emerge as a useful tool for improving the nutritional status of nursing home residents. Thus, telehealth is effective in helping overcome barriers, improving quality of life, and reducing costs15 related to the transfer of patients from home/nursing home to the hospital, among other. In our case, the use of TELEA for elderly patients using UNS services will reduces travels and result in significant cost savings.

Telehealth platforms facilitate the monitoring of parameters directly measured by NHs, which can be reviewed by the attending physician in real time. Multiple studies have proven that telehealth applied to elderly chronic polymorbid patients improves healthcare quality and relief caregiver burden. A Telemedicine-based multidisciplinary approach was adopted in the one-year follow-up study conducted by Maresca et al.16 in elderly patients. Thus, the nutritional status of patients was assessed based on anthropometric and laboratory parameters, along with factors related to quality of life and depression. This study revealed significant differences between the baseline and final scores obtained on assessment scales, as well as in the laboratory parameters analyzed in some patient subgroups. Although baseline and final data that enable comparison are not yet available in our study, telehealth-based interventions are expected to improve some of the nutritional status indicators established by the UNS.

When a new telematic monitoring platform is incorporated, compliance with key aspects of drug therapy monitoring is essential. The positioning statement of the Spanish Society of Hospital Pharmacy (SEFH) establishes the essential leadership and management activities to be performed in a Pharmacy teleconsultation (https://revistafarmaciahospitalaria.sefh.es/gdcr/index.php/fh/article/view/11515). Our new Telepharmacy program complies with all these recommendations. ANS prescriptions are made by the endocrinologists and hospital pharmacists of the UNS through different pathways (hospital discharges, outpatient units, primary care). All prescriptions are reviewed and validated in accordance with the general recommendations and protocols established by the UNS. The implementation of Telepharmacy represents a step forward in improving patient understanding of their treatment. Communication with NHs (both, with the nursing staff and caregivers/family) was very limited, over the phone or through paper prescriptions. The TELEA platform broadens the range of options available for reporting changes or providing ANS-related information to the NH. Although UNS teleconsultations are focused on nutrition surveillance, other interventions related to drug therapy or patient stratification can be performed. Although these activities are not preferential for the UNS, this experience may be the first step for the implementation of a new integrated care program for elderly polymorbid nursing home residents, with a clear leadership of HPs. For HP physicians, being included in the UNS facilitates the reporting of events, proposing changes and the implementation of drug therapy interventions, while issues are approached from a multidisciplinary approach. This patient-centered approach proves that UNS activity is aimed at demonstrating the role that adequate ANS plays in the treatment and prevention of complications in elderly patients. HP indicators are generally used to assess treatment adherence. In this patient population, nutritional status assessment indicators should also be used.

This project illustrates a new scope of application of the TELEA platform. Thus, in our study, instantaneous messaging and online questionnaires with automatic transfer of responses via e-mail were employed. This opened a new channel that allows direct communication between the UNS and NHs. The UNS established a protocol to report changes in ANS prescription, provide nutrition counseling, and give recommendations about drug administration or the suitability of a formulation. Likewise, NHs use this communication channel to provide requested information, report nutrition/clinical status variations or consult the UNS. Obviously, the use of the TELEA platform is not the preferred or most convenient option but, as the project progresses and more patients are included, an update of this platform is expected.

As the use of TELEA is more generalized, it is necessary that specific nutrition assessment variables can be included on this platform. It would be useful that a specific nutrition profile was incorporated to TELEA that includes anthropometric and laboratory data, scores on Mini-Nutrition Assessment and other scales, intake reminders, or pressure ulcer stage. ANS prescriptions already recorded on the electronic prescription system SILICON® and the electronic medical history system IANUS® should also be included in the TELEA nutrition profile. Thus, all the information generated during the nutrition surveillance process would be recorded on the corporative systems TELEA, IANUS® and SILICON®. This procedure eliminates paper documents and provides access to nutrition-related data of these patients to all their treating physicians.

With regard to NHs, a national healthcare protocol for nursing home residents has not been established due to the different organizational models in Spain (private, state-funded, and public). The diversity of organizational models is a limitation to the generalization of the use of new telehealth surveillance projects.

Future studies are warranted to assess health outcomes in telehealth programs and patient satisfaction with healthcare quality and usefulness of the tool.

TELEA-based nutrition surveillance facilitates the continuity of care by enabling direct communication between NHs and hospital specialists. This model makes it possible to record nutrition-related data on the electronic medical history of patients. This model also eliminates paper prescriptions and medical reports and unnecessary travels. A nutritional status profile should also be made available for nutrition surveillance in patients with chronic diseases. This would be the first step for a new integrated care program for frail/polymorbid elderly patients.

No funding.

We thank all health professionals of the Health Area of Vigo who collaborated in this project.

No conflict of interest.