heather sherrard vp clinical services university of ottawa heart institute telehomecare: outcomes...
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Heather SherrardVP Clinical Services
University of Ottawa Heart Institute
Telehomecare:Outcomes and Patient
Experiences
2012
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• 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
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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
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Telehealth Technologies
IVR
Telehome
Telemedicine Broadband connection in the region
Monitoring of patients in their home
Interactive voice response using automated calling to care for patients
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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
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Telehome Monitoring Technology
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Outcome Evidence
Authors Study Outcomes
Goldberg, A. et al
( 2002)
Wharf Trial
RCT n=280
6 month f/u
↓ mortality
↓ ED visits
↑ QOL
Cleland, J. et al (2005) RCT n=426
8 month f/u
↓ mortality
↓ LOS
Antonicelli, R. et al (2008)
RCT n=57
12 month f/u
↓ mortality
↓readmission
↑compliance, BB & statin use, health perception
Woodend, K. et al
(2008)
RCT n=249 ACS & HF
12 month f/u
↓readmission (ACS)
↑QOL & functional status
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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
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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
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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
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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
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Regional Program
MontfortTOH-Civic, OGHQCH
UOHI
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THM
THM
THMTHM
THM
THMTHM
THMTHM
THM
THM
THMTHM
THMTHM
THM
THM
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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
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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