Momentum telemedicine service descriptions
Chronic disease management (IL)
Objectives, expected outcomes, main beneficiaries
The multidisciplinary Center for Remote Chronic disease management is a recent expansion (1 July 2012) of an earlier programme that focused on home monitoring for patients with severe congestive heart failure (CHF).
The CHF home monitoring programme was implemented over four years ago. It was for patients suffering from severe congestive heart failure, and who therefore have some level of limitation in mobility. This programme initially began as a research programme. It had an experimental group, receiving telemedicine services, and a control group that continues to receive conventional care. There are 700 patients in each group – 1,400 patients altogether. The objective of the programme is to improve quality of life and patient satisfaction, improve patient security, improve quality of care, and reduce emergency room visits and hospitalisation. It also makes more efficient use of nurse and physician resources.
The main beneficiary is the patient but it also clearly benefits the particular health plan by enabling it to make more efficient use of professional resources. It thus increases clinical benefits without a parallel increase in health manpower. As there is improved quality of patient care and improved efficiency in the delivery of care, it will also potentially benefit the healthcare system in general.
Targeted population, number of patients
The population targeted by this particular service is people with chronic conditions (e.g., who receive long-term monitoring or coaching). The new multidisciplinary chronic disease home monitoring programme includes all of the patients who were a part of the (original) CHF programme. (Indeed, both the experimental and control group from the research phase have been completed.) Thus, the target population includes the following target populations:
• CHF patients Grade 2-4,
• Chronic obstructive pulmonary (COPD) patients Grade 2-4,
• Home care patients (stabilised),
• Patients with new stoma,
• Diabetes patients,
• Patients with chronic wounds,
• Heart rehabilitation patients.
The number of patients receiving this service on a monthly basis is between100-1,000. The estimated size of the targeted population nationally is between 500,000-1,000,000.
Type of telemedicine service
This telemedicine service is a proactive monitoring and case management service. With regard to the general relationship between the key actors involved in the service, the bulk of the interaction is between a call centre nurse and the patient. In parallel, it is also between the patient and his/her primary care physician, as well as between the nurse in the call centre and the primary care physician. There are also relationships for consultation purposes between the primary care and secondary care levels, as well as between the nurse and the secondary care physician.
The multidisciplinary home monitoring service is based on a call centre staffed predominantly by nurses who have been specially trained to manage the care of their target population (e.g. CHF nurses and COPD nurses). Each nurse receives a roster of patients that is his/her responsibility. He or she is expected to be proactive in his/her interactions with the patient and his/her primary caregiver.
In terms of the various technologies involved, each CHF patient has a digital blood pressure measurement device, a pulsometer and a digital scale. The patient takes his or her own blood pressure, pulse and weight each morning: COPD patients have peak flow monitors; diabetic patients have glucometers; and all patients have tablets for video-conferencing. The physiological information is electronically transmitted to the nurses’ call centre and the patient’s electronic medical record. The computerised system in the nurses’ call centre is equipped with computerised protocols that will generate an alert if there is any significant deviation in the patient’s data. In such a case, the nurse will initiate a phone conversation or video conference with the patient. Then, the nurse may (in accordance with the protocols and his/her experience) undertake such activities as change the patient’s care plan (such as medication dosage and diet), set up an appointment for the patient with his/her family practitioner or cardiologist or pulmonologist, contact the emergency room, or call an ambulance. Even if everything is alright, the nurse will proactively initiate communication at least once a week with the patient (the frequency of this contact is determined by the patient’s condition), and the patient may call the nurse as often as he or she likes.
Set-up that was being replaced
The conventional treatment would be more frequent visits to both the primary care and secondary care clinics as well as home visits. The telemedicine service is superior to the conventional treatment in the following three ways:
• Visits to primary and secondary care clinics are predominantly patient initiated. Even in clinics that have chronic disease management nurses, the level of nurse-initiated interaction is low. The call centre is proactive as well as responsive.
• Visits to clinics and home visits take place during conventional work hours. The multidisciplinary call centre, on the other hand, operates 24/7. This means that, when the patient and/or his or her caregiver is in need – at any time of the day or night, they have somebody to contact who can help them.
• The telemedicine service is expected to improve patient compliance significantly. The nurses, using video conference, can actually watch patients taking their medication.
Outcomes and results expected after introduction
The CHF programme has resulted in increased patient satisfaction, sense of security, safety, and quality of life. There has also been increased adherence to medication regimens. As the research part of this programme is nearing completion, it is hoped to have data with regards to emergency room and hospital use, as well as other measures, in the months following November 2012.
The new multidisciplinary call centre is currently caring for over 3,500 chronically ill patients. By mid-2013, it will be caring for 10,000 patients. Based on the CHF experience, first, the service is expected to increase patient satisfaction, sense of security, safety, and quality of life. Second, it is also expected to increase patient compliance to care regimens, reduce emergency room visits and hospitalisations, and enable more efficient and effective use of health carer personnel time and energy. Third, it is expected to enable the service to better empower the patient in managing his or her own care and to involve more actively the primary care giver.
This service is operational and is part of a mainstream service.