Monitoring the Chronically Ill Elderly in the Community – User Perceptions and Compliance, and Organisational Challenges

Marlien Varnfield1, Branko Celler2, Jane Li3, Rajiv Jayasena4

 

1 Australian e-Health Research Centre, Level 5 UQ Building, RBWH, QLD, 4029 marlien.varnfield@csiro.au

2 Biomedical Systems Research Laboratory, University of NSW, NSW, 2052, b.celler@unsw.edu.au

3 Australian e-Health Research Centre, Cnr Vimiera & Pembroke Roads, Marsfield, NSW, 2122, jane.li@csiro.au

4 Australian e-Health Research Centre, 343 Royal Parade, Parkville, VIC, 316, rajiv.jayasena@csiro.au

 

Background

One of the major global epidemiologic trends of the current century is the rise of chronic diseases. Australia’s hospital-centric public health system is unnecessarily burdened by the management of these diseases. Telehealth services such as home-telemonitoring have the potential to improve the management of chronic conditions and hence reduce unscheduled admissions to emergency departments and hospitals. The effectiveness of home-telemonitoring, however, may depend on a number of factors such as users’ perceptions and ability to adhere to schedules of monitoring. Furthermore, successful integration of new models of care with long established service models requires substantial change in workplace culture and capacity for organisational change management. This paper draws on the results of a large Australian multi-site Telehealth Trial and reports on user perceptions and compliance, and organizational challenges.

Methods

The study design was a dichotomous, prospective, case matched before-after-control-impact (BACI) trial at each of five sites. Patient selection was based on frequency of hospital admission for a range of chronic conditions to reflect the population realities of the healthcare system. Test patients were supplied with an in-home telemonitoring system to both capture daily vital sign measurements and to complete online questionnaires. Control patients received normal care. Test patients completed an Evaluation Questionnaire at the end of the trial and their compliance with monitoring schedules was evaluated through extracting data from the telemonitoring server. Challenges in capacity to accommodate change and the flexibility of existing processes and systems were documented.

Results

We recruited 114 Test patients (71.1±9.3 years; 64% male) and 173 Control patients (71.9±9.4 years; 56% male) to the trial. Responses to the Evaluation Questionnaire were received from 56 Test patients. Majority of patients found the telemonitoring device easy to use (87.5%) and felt confident in using it (85.7%). Most found that telemonitoring could be incorporated in their daily routine (80.4%), fits in with their daily life (71.4%) and the way they would like to manage their health (76.8%). Compliance with the measurement protocols scheduled was generally high with patients carrying out their scheduled measurements and questionnaires at least once every two days. A strong correlation was found between the level of involvement of clinical care coordinators and patient compliance. We identified that successful deployment of remote telemonitoring requires a new clinical care coordination role, strong support and leadership from the health service management team, the formation of clear clinical governance for the service and strong alignment of workplace culture and values with the objectives of the service.

Discussion

At all trial sites the telemonitoring service was well accepted by patients. Our trial demonstrated high compliance rates, independent of age and gender, suggesting that this could be an appropriate approach for chronic disease management for a large population. Close involvement of clinical carers gives the greatest benefit to patient compliance. The key barriers related to integration of telemonitoring into existing models of care were at the services provider level. These barriers included the capacity to implement/participate in new programs within health organisations.

 

Telehealth in the Bush

Jodie Turvey1

 

1 South West Hospital and Health Service, Po Box 602 St George, Queensland, jodie.turvey@health.qld.gov.au

 

The South West Hospital and Health service is an innovative and diverse rural and remote region. The region expands over an area of 319 870 square km and an estimated population of 26 150. Individuals and communities located within the South West are surpassing the challenges and complexities, often faced when accessing healthcare, through the use of Telehealth.

Telehealth was first introduced in the South West in 2005-06 financial year where a total of 64 clinical consultations were provided. Progressively over time Telehealth has continued grow with 2044 consultations in 2015-16 for Non admitted patients in the South West. For us, Telehealth is simply considered as mode of delivery and should be incorporated into the provision of healthcare on a daily basis. Although Telehealth is progressively becoming an integral part of the healthcare in the bush, we are still faced with many challenges. One of the major challenges for the South West is the change management process and consultation required to enable medical specialist services to be provided via Telehealth. For services that have been identified as appropriate for Telehealth, there is a significant consultation process required. This is predominately due to most medical specialist services being provided from outside our Health Service. It is often challenging to get vital key stakeholders together to discuss and then to understand the importance and the significant positive impact that providing Telehealth consultations can have on individuals, communities, and rural or remote healthcare services. This challenge is also seen at times when dealing with existing services within the South West.

Over time the South West has had numerous lessons learnt. One of the most significant lessons learnt to date is to understand the level of involvement, approval, and interaction that is required from key stakeholders from the providing Hospital and Health Service. Lack of understanding of the level of consultation can detrimentally effect and prolong the establishment of services. Communication and networking is pivotal when engaging and consulting with services. The Telehealth Co-ordinator role has evolved and we now have a strong Telehealth network that has been established with fellow Co-ordinators and the Telehealth Support Unit. Many of the success stories in Queensland are attributable to this strong network.

As Telehealth expands, we continue to investigate clinical opportunities for implementing Telehealth. South West is unique in that we currently have eight medical practices in addition to our 17 facilities. At present we are expanding the scope of practice by enabling Telehealth to be provided into these practices. This is being achieved through the purchasing of Telehealth enabled clinical devices and software.

Telehealth is a mode of healthcare delivery which is assisting individuals and communities within the South West. The future and possibilities of Telehealth looks promising.

Grow Your Own Telehealth

Janet Reid 1Kim Butler 1

1 Warwick Hospital, Darling Downs Hospital and Health Service, Warwick, QLD, Australia

Janet.Reid@health.qld.gov.au

 

Warwick is a rural town that has increased slowly in population over the last 10 years.  The medical services available within the town have not grown in correlation to the increase.  The need for residents to travel for specialist services has been reflected in the high use of Patient Travel Subsidy scheme from the local Queensland Health Hospital.  With this in mind, the Community Health nurses committed to increasing the use of telehealth for the patients.

Since 2009 there had been limited use of this method of consultation, mainly used for preoperative clients review for booked surgery going to be performed Toowoomba.  The Community Health nurses felt that there could be many other specialities that would benefit the client with telehealth use.  They felt this would also lead to decreased patient travel subsidy costs, higher consumer satisfaction and greater efficiency of resource use.  By accepting each discipline that offered telehealth (we now have over 20 specialities performing telehealth consultations) the Community Health nurses now have increased the use from one or two a month to 10 appointments per week.

The next step they are keen to explore is care of chronic disease with the view of keeping people well and in their own homes longer.  The nurses plan to work in collaboration with the GPs and specialists to utilize telehealth for ongoing consultations for the clients.  The nurses will partner with other service providers, including the GP to plan the care.

Telehealth supported rural stroke units – lessons from the pilot

Matt Page1, Jodie Turvey2, Greg Cadigan3

 

1 Queensland Health, GPO Box 48, Brisbane, Queensland 4001, matthew.page2@health.qld.gov.au

2 Queensland Health, GPO Box 48, Brisbane, Queensland 4001, greg.cadigan@health.qld.gov.au

3 South West Hospital and Health Service, PO Box 1006, Roma, Queensland 4455, Jodie.turvey@health.qld.gov.au

 

Background:

Validated evidence (31 RCTs) indicates admission to an acute stroke unit significantly reduces mortality and disability associated with stroke when compared to care in a general ward.  Additionally, reduction in stroke mortality is associated with the prevention and treatment of complications, particularly those related to infection and mobility3.

Queensland has 21 endorsed stroke units, all of which admit >100 stroke admissions per year – however there is a disparity in accessing evidence based stroke care for people living in rural areas due to their remoteness. Thrombolysis, an intervention for treating ischaemic strokes, is only effective if administered within three hours of symptom onset and only in a lysis capable centre.

Excluding thrombolysis, admission to a stroke unit within three hours as opposed to six hours resulted in significantly better outcomes without a statistically significant difference in mortality4.  Interventions such as rapid “door to brain” imaging, thrombolysis, clot retrieval and admission to a stroke unit remain inaccessible for a considerable proportion of Queensland’s decentralised population living in rural areas.

Establishing telehealth supported stroke units in key rural/remote sites has the potential to improve equity of access to specialist and interventionist treatment.  Other potential benefits include reduced emergency retrievals, reduced travel burden for post-acute care, up-skilling of local healthcare teams and improved efficiencies within the healthcare system.

Method:

In collaboration with the Queensland Health Statewide Stroke Clinical Network SSCN a regional “hub” provider with an existing endorsed stroke unit, and a rural recipient site admitting <15 stroke admissions were recruited for an informal telehealth model of care pilot, supporting a rural acute stroke unit.

Pathway development consisted of collaboration across multiple levels/key stakeholders from both facilities.  Initial site visits were complex given the local hospital was not equipped with a CT scanner and support was from a private radiology service located 250 metres away and off campus.  Local Queensland Ambulance Service (QAS) played an important role in the transfer of suspected stroke patients to and from scanning facility.  The local nursing team was provided with in-service education in the model of care and management of the videoconferencing component, and the Emergency Department team received training in the administration of remote thrombolysis via telehealth.

Results:

The pilot program was significantly under-utilised.

Discussion:

We considered potential causes of the low utilisation. The following challenges were considered as contributing factors:

  • Few stroke presentations despite historical data trends, thus difficult for the clinical teams to retain knowledge of the model of care.
  • No stroke presentations were candidates for remote thrombolysis.
  • The model was dependent on the hub site providing specialist telehealth stroke support but with an already over-committed HHS workload, single specialist engagement, and cross HHS medical care, ward reviews were performed on an ad-hoc basis, and for deteriorating patients requiring palliation/transfer decisions.
  • The primary medical lead and enthusiastic clinical champion from the rural recipient site retired.
  • The model was informal and changed significantly across the duration of the pilot.
  • The pilot commenced on a public holiday and included the Christmas/New Year period, meaning there were extensive periods without a providing stroke specialist at the hub site.
  • Despite the site visits and training of local nursing team, the draft procedure was frequently not followed.
  • Other challenges were as a result of cross hospital jurisdiction and determining the responsibilities of each site.

Despite the pilot not achieving the initial business case goals or planned model of care – it can be said that the rural site’s engagement and telehealth support structure retains executive and clinician support. The regional site acknowledges it still has a role to play in providing the best possible care and patient outcome.

References:

  1. (https://strokefoundation.com.au/About-Stroke/Facts-and-figures-about-stroke).
  2. Australian Institute of Health and Welfare 2014, Australia’s Health 2014.
  3. Stroke Foundation, Clinical Guidelines for Stroke Management 2010.
  4. Silvestrelli G, Parnetti L, Paciaroni, Caso, Corea, Vitali, et al. Early admission to stroke unit influences clinical outcome. Eur J Neurol. 2006;13:250–5.

TeleMapping for the Mater Cochlear Implant Clinic a hurdle rather than a sprint to the finish line

Janeen Jardine1, Megan White2,

1 Mater Audiology Department , Mater Hospital Brisbane, Raymond Terrace, South Brisbane , Qld 4101

2 Ambulatory Services Mater Health, ,Level 2 Aubigny Place , Raymond Terrace , South Brisbane Qld 4101

 

Cochlear implantation is well recognised as an effective management option for adults with severe-to-profound hearing loss. There are two established public adult cochlear implant (CI) services in Queensland, both operating from Brisbane. Adults from all regions of Queensland travel to Brisbane to undergo assessment, surgery, rehabilitation and life-long maintenance of their CI. The Mater Cochlear Implant Clinic is the only service to offer outreach services. Where possible a CI audiologist travels to regional communities to provide face-to-face post-operative care, however as the number of implantees in Queensland grows new models of service delivery need to be being considered.

With the emergence of Telehealth as an effective alternative to face-face services in Brisbane, we commenced on the road to offer this service to our growing number of outreach clients. TeleMapping is the use of telecommunication technology to remotely map the cochlear implant recipient and has been shown to be a safe, viable option for providing post-operative “mapping” services. This involves connecting the implantee’s CI device to a remotely located computer with an audiologist located in a main centre controlling the local computer through remote access software. The implantee and audiologist communicate via videoconferencing. The aim of the TeleMapping session (or Mapping session when done face-to-face) is to create and fine-tune an individualised implant program for the implantee. The audiologist does this by presenting different levels of electrical stimulation through the implant to the user who then reports back on the volume and quality of the sound perceived.

Rather than a smooth sprint to the establishment of a TeleMapping service there were many hurdles to jump and finally after 2 years we are able to start rolling out the service state-wide.

This presentation aims to show the challenges that were overcome to provide a TeleMapping service.

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