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Telehealth Support for Patients with Long-term Conditions: Evaluation of a Rural Pilot
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Telehealth Support for Patients with Long-term Conditions: Evaluation of a Rural Pilot


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Martin Hefford …

Martin Hefford
Sapere Research Group
(Friday, 10.00, Telehealth/mHealth)
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Congestive Heart Failure and Chronic Obstructive Pulmonary Disease are two chronic conditions that have important impacts on both the quality and length of life of individuals and on utilisation of health services. In the context of limited health funding, workforce restrictions, and an ageing population, there is increasing interest in the use of remote monitoring technologies to improve the quality of life of patients with these conditions, and to reduce unplanned use of hospital services.
In 2009 Lake Taupo Primary Health Organisation (PHO), Lakes District Health Board (DHB) and Healthcare of New Zealand Ltd, entered into a strategic partnership to pilot telehealth devices to support chronic care management in the Lake Taupo community, using a small randomised control trial approach, with ten patients in each arm. Sapere Research Group was commissioned to independently evaluate the 12 month pilot, and found good evidence that the telehealth remote monitoring technology was accepted by both Maori and non-Maori participants; that quality of life was significantly better in the telehealth group than in the control group; and some indications of a trend toward improved survival in the telehealth group. Hospitalisations were reduced in both the control (-19%) and telehealth group (-25%). Results should be considered tentative given the small numbers in the trial, but are consistent with findings of improved survival, quality of life and cost savings from recent international reviews. The impact of the telehealth intervention may have been partially masked by the simultaneous implementation of the Healthright disease management programme.

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  • Telehealth group showed consistent trend towards improved self-reported quality of life on a range of quality of life instruments including the SF36 (16), the St George Respiratory Questionnaire (17) and the K10 (18). Patients in the control group, in contrast, showed no clear trend towards improvement. Telehealth group improved by 20% on the St George score, compared to -2% in control group. Despite the small sample size, the difference in the K10 was statistically significant (p < 0.0199).
  • Telehealth group improved by 29% in the K10 score compared to 6% improvement for the same questionnaire in the control group16% improvement in the SF36 overall score for the telehealth group compared to 5% improvement in control group
  • Transcript

    • 1. Telehealth support for patientswith long term conditions:evaluation of a rural pilotPresentation at HINZ Conference, 25 November 2011
    • 2. 2 Overview of presentation • Background Telehealth The pilot • Evaluation • Findings • Reflections
    • 3. 3 Why Telehealth?• Can‟t afford to build more hospitals:  How do we do a better job of keeping people out?• We need a new venue for care delivery:  By 2015, the home will be the hub of care*  How do we maintain wellness at home?• Better use of doctors and nurses:  New models of care• Patients/clients are expecting more  Increasingly driving their own care * Naomi Fried, VP Kaiser Permanente
    • 4. 4 What is Telehealth?Telehealth technology enables people to monitor theirown heart rate, blood pressure, lung function, weight,temperature, health diary and questionnaires fromhome • Complex patient focus • Individualised trends and alerts setting • Self-management tool • Single, shared or mobile use
    • 5. 5 Clinical Data
    • 6. 6 Setting up the pilot• 2009 partnership between Lakes DHB, Lake Taupo PHO, Healthcare NZ and Freedom Health Technologies• Acknowledgement to Lakes DHB and Lake Taupo as innovation leaders• They took a risk- first to fund, implement and test telehealth in New Zealand• Vision to reduce demand on hospital services
    • 7. 7 Pilot Methodology• Deployed 1 October 2009• Randomised controlled trial structure• 10 patients in trial arm and 10 in matching control• COPD or CHF and enrolled in HealthRight (chronic care programme)• Concluded September 2010
    • 8. 8Series of implementationactivities• Establish legislative & regulatory requirements• Commission Sapere for evaluation framework with Ethics Committee approval• Develop telehealth programme methodology HCNZ, PHO and client requirements Design clinical & technical support framework• Installation and training PHO staff and patients/whānau• Evaluation
    • 9. 9 Legislative & Regulatory requirements• Telehealth is classified as medical device• Manufacturers need to meet their countries requirements prior to export• Australia TGA• NZ Medsafe• Healthcare requirements to both NZ Medsafe/Electricity Act and vendor Telemedcare• Key requirement post market surveillance
    • 10. 10 Clinical Support Guidelines
    • 11. Technical support• Supported Freedom Health Technology• Objective proactive early detection issues and to adhere to post surveillance legislative requirements• Included installation, daily technical support and software upgrades/maintenance• Clients/PHO staff accessed 0800 number• Trained PHO “super-user”
    • 12. Telehealth training• Different requirements for PHO staff, clients and whanau• PHO staff Telehealth monitor Telehealth web support Clinical and Technical support structure• Clients and whanau Telehealth monitor and technical support
    • 13. 13 Change management • Staff Telehealth as enabler (not a stand alone function) • Clients Not an emergency device Self management educator
    • 14. 14 Speed Bumps • Implementation learnings Regulatory „stamina‟: Australian regulatory approval caused ~12 month implementation delay „Be prepared‟: Vendor‟s first implementation in NZ, e.g. initial synchronisation issues
    • 15. 15 From the patients‟ view...• In the words of William Hall...
    • 16. 16
    • 17. 17 Evaluation• Sapere commissioned to independently develop evaluation framework & evaluate 12 month pilot to inform future use of telehealth in NZ• Research questions focused on identifying: 1. Acceptability and usefulness 2. Impact on health outcomes 3. Impact on health service utilisation 4. Impact on clinical practice
    • 18. 18 Important context• Small numbers so data easily skewed• Need 200 to 500 patients for statistical significance• „Supercharged‟ usual care with specialist family nurses (HealthRight)• High threshold for testing telehealth efficacy
    • 19. 19 Data Sources• Telehealth website: patient quality of life and clinical indicator data• Lakes PHO & DHB: service utilisation data• Interviews of patients and healthcare staff: insights on acceptability & usefulness of the telehealth from user perspective
    • 20. Findings: impact on self management„The machine tells me a lot…it changes your whole life‟ Increased awareness, confidence, wellbeing Facilitated self management through better understanding of disease & quick feedback“…helped W notice which foods elevated his bloodsugars and blood pressure”- HealthRight nurse
    • 21. Findings: ease of use„It took only a few hours to become familiar with the unit‟ • Universally reported as easy to use • Most indicated that it took less than a day to learn how to use • Developed a daily routine around monitoring
    • 22. Findings: acceptability to Māori„It‟s like my new security blanket‟• Technology adopted readily• Some reported that whānau felt more confident• Involved whānau in self management through telehealth• Suggested whānau measurements‘A whanau measurement screen would be great for othermembers - other family members all have medicalconditions – asthma, hypertension, diabetes, etc.‟
    • 23. Findings: health outcomes• Substantial but non-significant trend towards reduced mortality in telehealth group• 4/10 in control group died vs 1/10 in intervention group
    • 24. 24 Findings: quality of life• Quality of life significantly better in the telehealth group compared to control group St George COPD (0=best, 100=worst) 60 50 40 Telehealth 30 Control 20 10 0 Baseline Pilot 12
    • 25. 25 Findings: quality of life K10 questionnaire (20=best, 30+= worst) 25 20 15 Telehealth Control 10 5 0 Baseline Pilot 12• Quantitative findings congruent with patients‟ comments
    • 26. Outcomes: clinicalmeasures• Mean blood pressure, FEV1, heart rate, blood oximetry and weight for the control and telehealth group showed no obvious patterns of change
    • 27. Findings: utilisation• Decrease hospitalisations in both groups, slightly greater for telehealth (↓25% vs ↓19%)• Found no impact on ED admissions• Impact on ambulance use at 6 months – but data not available at 12 months• Healthright chronic care programme may have masked impact
    • 28. Findings: GP visits„Saved money by not going to GP so often‟• Most telehealth patients spontaneously reported fewervisits to GP• But data did not support this• Telehealth ↑3%, control ↓19%• Data skewed by one telehealth individual who had 26primary care visits„I used to see doctor every second or third day, nowit‟s every 6-8 weeks‟
    • 29. Process learnings• Reported that telehealth data made earlier detection of exacerbations and trend monitoring easier• Thought it helped patients develop better self- management• Some patients became very concerned about small changes in measurements• Questionnaires felt to be too long and intrusive• Frustrations inherent in the introduction of new technologies• Telehealth portal easy to use
    • 30. Reflections• Telehealth as adjunct to HealthRight• Did not involve substituting face-to-face with telehealth care• But small trial which did not make complete redesign of model practicable, cost effective or advisable• For maximum benefit need change in clinical practice
    • 31. 31 Conclusions• Telehealth can be successfully applied in a NZ community to aid chronic disease management Evidence telehealth was accepted by both Māori and non-Māori participants Clear positive impact on quality of life Impact on health utilisation and mortality less clear• Consistent with results of larger overseas studies- these generally find statistically significant positive impacts from telehealth
    • 32. 32 Postscript • Taking these learnings, we have now implemented telehealth in the Eastern Bay of Plenty • Partnership between HCNZ, EBPHA, Bay of Plenty DHB • Enabler within the broader Te Whiringa Ora service
    • 33. 33 Who is Healthcare NZ? We have more than 40 branch offices • 20 year track record throughout New Zealand and provide home-based support, chronic care • 40 branches throughout NZ management, specialist nursing, training and advanced health technology • 6,500 staff, >17,000 clients services • Services include: – Community Nursing – Home-based support – Complex case management – Telehealth – Mental Health – Intellectual and physical disability support
    • 34. About Sapere Research Group LimitedSapere Research Group is one of the largest expert consulting firms in Australasiaand a leader in provision of independent economic, forensic accounting and publicpolicy services. Sapere provides independent expert testimony, strategic advisoryservices, data analytics and other advice to Australasia’s private sector corporateclients, major law firms, government agencies, and regulatory bodies. Wellington Auckland Sydney Canberra Melbourne Level 9, 1 Willeston St Level 17, 3-5 Albert St Level 14, 68 Pitt St Level 6, 39 London Circuit Level 2, 65 Southbank Boulevard PO Box 587 PO Box 2475 GPO Box 220 PO Box 266 GPO Box 3179 Wellington 6140 Auckland 1140 NSW 2001 Canberra City, ACT 2601 Melbourne, VIC 3001 Ph: +64 4 915 7590 Ph: +64 9 913 6240 Ph: + 61 2 9234 0200 Ph: +61 2 6263 5941 Ph: + 61 3 9626 4333 Fax: +64 4 915 7596 Fax: +64 9 913 6241 Fax : + 61 2 9234 0201 Fax: +61 2 6230 5269 Fax: + 61 3 9626 4231For information on this report please contact:Name: Martin HeffordTelephone: +64 4 915 7593Mobile: +64 272949132Email: 34
    • 35. 35 Questions Further information: or