Transcript Christine Struthers, RN, MScN APN, Cardiac Telehealth
Telehomecare: Outcomes and Patient Experiences
Heather Sherrard VP Clinical Services University of Ottawa Heart Institute
2012
• • • Only tertiary cardiac service provider for the region Over 50 % of our patients come from outside the Ottawa area High disease rates outside of the urban areas
Telehealth Framework
•
Strategies using technology to improve the care delivered to patients
– Enhances care – Improves access – Assists patients to stay in their communities – Improves patient satisfaction – Efficient use of resources
Telehealth Technologies
Broadband connection in the region Monitoring of patients in their home Interactive voice response using automated calling to care for patients
Why home monitoring
• • • • • • • • The majority of patients live outside the Ottawa area Majority of HF care is not in the hands of HF specialists HF is a chronic condition characterized by episodic clinical deterioration interspersed with periods of apparent stability HF remains the most common diagnosis that brings a patient to hospital for medical admission Readmission rates can be as high as 25% at 1 month and 50% within the first year Congestion is one of the main causes of readmission Self-care strategies have a positive impact on decreasing readmission Multidisciplinary approach has produced + outcomes
Telehome Monitoring Technology
Authors
Goldberg, A. et al ( 2002) Cleland, J. et al (2005) Antonicelli, R. et al (2008) Wharf Trial RCT n=280 6 month f/u RCT n=426 8 month f/u RCT n=57 12 month f/u Woodend, K. et al (2008)
Outcome Evidence
Study Outcomes
RCT n=249 ACS & HF 12 month f/u ↓ mortality ↓ ED visits ↑ QOL ↓ mortality ↓ LOS ↓ mortality ↓readmission ↑compliance, BB & statin use, health perception ↓readmission (ACS) ↑QOL & functional status
Outcome Evidence
• • • • • • • Cochrane Review (August 2010)
Structured Telephone Support or Telemonitoring Programs for Patients with Chronic Heart Failure
25 peer reviewed RCT + 5 published abstracts 16 evaluated structured telephone support (n=5613) 11 evaluated telemonitoring (n=2710) 2 tested both interventions Telemonitoring reduced all cause mortality (P<0.0001) Both interventions reduced CHF-related hospitalization, QOL, reduced costs & improved NYHA
Heart Institute Outcomes
• • • Heart failure cohort of 121 patients (2008): 69.4% had 1-2 admissions for HF in previous 6 months prior to THM versus 14.8 % in 6 months post THM (each admission has LOS of 7 days at $1000/day) Case-matched cohort (2009): 91 THM patients matched by EF, age (average 70 yrs.) & gender to usual care showed significant difference in the 6 month readmission rate in THM group (p<0.001) THM & the elderly (2010): 594 HF patients divided into 2 cohorts <75 (n=350) & >75 (n=244) showed no difference in # of medication adjustments, # of calls, monitoring duration, or outcomes (ER visits, admission, death) between the 2 groups
Innovation Diffusion
• • • • • • • • Program started 7 years ago as a research initiative Nurse managed with medical lead available for issues 1 APN + 20 monitors (only from the Institute) 5 day operation, 0800-1600 with support from Nursing Coordinators for off hour coverage No home visits, Greyhound bus used for returns Non physician referrals accepted Intake letter to all HCP Monitoring duration 3-4 months on average with lots of flexibility
Operations now…
• • • • • • 1500 patients have been followed to date 1 RN for ~100 patients/day (40-50 monitors) Monitoring duration 3-4 months with plan to transitional to less intensive HF IVR follow-up (q 2 weekly automated calls) Hub and spoke model for the region 158 monitors & scales, GPRS bridge modems for digital lines or no land lines, 35 pocket ECG, 20 glucose cables, 20 INR units Transitional Care framework adopted
Regional Program
Montfort TOH-Civic, OGH QCH UOHI
THM THM THM THM THM THM THM THM THM THM THM THM THM THM THM THM THM
Funding
• • • • 75 % of initial equipment funded through grants & research Permanent staff funded through operations Leverage to improve bed capacity @ $1000/day, decrease wait time for admission, improve provider capacity Cost avoidance model
Lessons Learned
• • • • • • Using regular phone lines is easy & cost effective Patients are successful at connecting equipment in their homes. Equipment return by bus is feasible. No distance barriers.
The technology is reliable, producing valid patient data & EHR The technology can be adapted to meet individual patient needs: volume, language, frequency of transmissions, clinical questions Infrastructure promotes collaborative care model No billing issues