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1
Telemedicine and Group Programmes for
chronic diseases
Dr Elsie Hui, FRCPDivision of Geriatrics, CUHK
Community Geriatric Assessment Team, Shatin Hospital
2
Telemedicine is the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care.
Telemedicine includes consultative, diagnostic, and treatment services.
3
Telemedicine (telegeriatrics) – what is it and why?
Patient Isolation
Frailty
Health care provider
Limited resources
Traveling time
Hardware I.T. hardware
Broadband
3 G
Telephone/ Fax Traditional consultation
E-mail Photos & X-rays, video clips
Internet Health web sites, on-line assessment / education
Video-conference
Real-time, audio-video link
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Tele-geriatrics in residential care home setting
Direct care Physician (geriatrician, primary care) Geriatric nursing physiotherapy & occupational therapy podiatry
Specialist consultation Dermatology Psychiatry Others (neurology, radiology ….)
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Our History 1998 – 99
Pilot study SAGE Kwan Fong Nim Chee Care & Attention Home in Shatin Medical, nursing, psychiatry, PT, OT, podiatry, dermatology
Extension of telemedicine network To other local residential care homes for elderly (RCHEs) To other hospitals in New Territories and their local RCHEs To a Home Care service provider
2003 - 04Community rehabilitation programmes DM, OA, CVA, dementia, incontinence
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NTE Geriatric Service Network
hospitals residential care homes social centres Broadband or ISDN (remot
e areas) Multi-point Videoconferenc
ing machines
Also capable of connecting to anywhere in the world with an IP address and VC machine (386kbs)
NDH(COST Office)
AHNH(COST Office)
CaritasFWH C&A
石湖墟Cambridge
古洞Nam Fong
TPH
SH x 2 stations(COST & 8/F)
花園城Cambridge
積存街Cambridge
Kwan FongC&A
Caritas C&AHCHW
ELCHK瀝源 ME
ELCHK秦石 DE
ELCHK馬鞍山 DECL
廣福道Cambridge
直街Oi Kwan
PWHCUH
K
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Shatin Hospital
Telehealth headquarters
C A B D E
ELCHK Social Services Network in
Shatin
Day Care
HomeHelp
Community Clinic
Social Centre
Home HelpSocial Centre
Day Care
Social Centre
Community Clinic
Social Centre
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Videoconferencing Hardware
Tandberg 880(HKD 110 000) Shatin Hospital Norway 768kbps (IP/ ISDN) Multi-point (max 4) max 4 video outputs 72o wide field of view
Polycom ViewStation FX(HKD 75 000) Hospital and remote sites USA 512kbps (IP/ISDN) Multi-point (max 4) max 4 video outputs 48o field of view
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1.5Mbps 1.5Mbps
Shatin Hospital C&A Home / Community centre
BroadbandNetworkTelemed
Fibre IP Link
Telemed Fibre IP Link
Video conferencing link
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Pilot study
Intervention Shatin CGAT and a local
Care & Attention home were linked via teleconferencing.
Services provided via telemedicine wherever possible.
Face-to-face visits were conducted if telemedicine inadequate for patient management.
Outcomes Feasibility Costs Services provided &
limitations User satisfaction
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Geriatrician
Follow-up of old cases Triaging urgent medical problems Saves time and increases productivity Reduced unnecessary A&E visits by 10% Reduced acute hospital admissions by 11%
over 1 year Limitations - new patients, chest auscultation
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Nurse Assessment
swallowing test Wounds placement
Educate patients and carers use of inhaler, checking blood sugar
Act as liaison between in-patient service and residential care home
More frequent review Facilitate earlier discharge Limitations - complex dressing proc
edures, clients with communication problems
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Physiotherapist Screening new cases Reduces waiting time and
shortens follow-up intervals Nursing home staff able to facil
itate assessment and supervise rehabilitation
Limitations patients with severe communi
cation difficulties, examination e.g. auscultation, neurological, musculoskeletal
specialized treatment modalities e.g. TENS, manual techniques
Occupational Therapist Useful for screening - better
prepared for site visit, reduces inappropriate referrals
Reduces waiting time and shortens follow-up intervals
Closer monitoring Limitations
assessing range of movement activities of daily living in real
life situation environmental barriers prescription of splints,
wheelchairs and pressure garments
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Podiatrist
Foot screening - nails, between toes, heels
Assessment of wounds, footwear, gait
Advise staff and patients on dressing techniques and foot protection
Triaging referrals according to urgency
Allows earlier discharge from hospital
Limitations - cannot perform full neurological or vascular assessment
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Summary of activities and feasibility of Telemedicine in C&A Home
Discipline Patient-episodes % adequate with telemed
Geriatrician 356 97.2
Psychogeriatrician 149 99.3
Dermatologist 74 74
Nurse 101 88.7
PT 105 87.1
OT 117 59.8
Podiatrist 99 84.9
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Telemedicine is Cheaper
Table 2. Cost comparison between Telemedicine and outreach service or outpatients
Discipline Telemedicine Outreach Outpatients
Geriatrician $40.3 $153 $455
Psychogeriatrician $91.6 $105.9 $455
Dermatologist $117.9 N/A $455
Nurse $22.7 $67 N/A
PT $63.6 $330.4 N/A
OT $54.6 $290.8 N/A
Podiatrist $29.2 $160.8
N/A = not applicable
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User satisfaction
Patients - depending on discipline, 82% to 95% were satisfied with telemedicine.
Nursing home staff - system was user-friendly, boosted confidence, enhanced support from hospital services.
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Conclusions Telemedicine is an acceptable and useful adjunct
(but doesn’t replace) to conventional outreach services.
It enhances the geriatric outreach team’s efficiency and improves support to nursing home residents.
Costs can be off-set by involving more disciplines, linking up with more homes and extending hours of service.
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Latest accessories – plug & play
digital camera
electronic stethoscope
Mobile video cart
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Hui E et al. Telemedicine: A pilot study in nursing home residents. Gerontology 2001;47:82-87.
Chan WM et al. The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong. J Telemed Telecare 2001;7:38-46.
Hui E, Woo J. Telehealth for older patients: the Hong Kong experience. J Telemed Telecare 2002;8(suppl.3):S3:39-41.
Tang WK et al. Telepsychiatry in psychogeriatric service: a pilot study. Int J Geriatr Psychiatry 2001;16:88-93.
Corcoran H et al. The acceptability of telemedicine for podiatric intervention in a residential home for the elderly. J Telemed Telecare. 2003;9(3):146-9.
Telegeriatrics publications
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Management of chronic diseasesin the community
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Chronic disease group programmes Chronic conditions
Diabetes mellitus Chronic obstructive airway
disease Heart failure Fall prevention Dementia Osteoarthritis Stroke Incontinence
Content group format exercise education discussion peer support
Outcomes objective subjective Qualitative (focus groups) face-to-face or via teleconfere
ncing
Role of lay personnel staff of social centres volunteers patients
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Program Content
PatientEducation
disease management
Psychosocial
interventionfocus group
peer support
Exercises &Games
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Features: 8 sessions 1 two-hr session / week 6-8 patients / group 1-2 facilitators (non-professiona
l) Subjects
Diagnosed DM > 60 yrs Community-dwelling
Setting Community centres for elders ELCHK in Shatin
3 core components1. Education
Related to DM Self-efficacy
2. Exercise Aerobic and resistance Group & home exercise
3. Psychosocial interventions– Share experiences & probl
ems– Find solutions as a group– Peer support
A community model for care of older persons with diabetes mellitus
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Exercise training
ending with a 5-minute cool down or progressive muscle relaxation training.
30 minute-exercise session starting with a 5-minute warm up
10-minute resistance training using elastic tubing (Theraband®)
followed by a 10-minute aerobic dance
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Outcome measures: QOL
Diabetes quality of life questionnaire
SF-36 DM knowledge test 24-hours dietary recall Body mass index Blood sugar & HbA1c level
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Key Findings
Significant changes (improvement) were observed in the following outcomes:
Diabetes Knowledge Test Mean post-prandial blood glucose HbA1c Blood pressure Exercise habit QOL
Diabetes QOL questionnaire SF-36
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Falls Management Exercise Program (FaME) Features
36 weekly sessions 1 hr / session 4 – 8 subjects / group 1 therapist + 1 assistant
Subjects Age ≥ 65 yrs Hx of ≥ 1 fall Able to walk ± aids living in community
Setting Community centres for
eldersSAGE in Shatin
Shatin Hospital
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Programme structure: Wk 1 – 11: Skilling up Wk 11 – 33: Training gain Wk 34 – 36: Maintaining th
e gains
Outcomes: Any falls during study period Berg’s Balance Score 6 Minute Walk Test ADL
Barthel IADL
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Conclusions
Community-based group rehabilitation programs incorporating exercise prescription, education and peer support can improve patients’ physical and psychological outcomes in various common chronic diseases.
The programs should be part of a comprehensive care package offered to patients with chronic diseases.
Community centres for older persons are the ideal location for running these programs.
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Community programmes - PublicationsCHF
Hui E, Yang H, Chan LS, et al. A community model of group rehabilitation for older patients with chronic heart failure: A pilot study. Disabil Rehabil 2006;28(23):1491-1497.
COPDWoo J, Chan W, Yeung F, et a;. A community model of group therapy for the older patients with chronic obstruct
ive pulmonary disease: a pilot study. J Eval Clin Pract 2006;12(5):523-531.
Telemedicine in rehabilitationElsie Hui. In Teleneurology, 2005; Royal Society of Medicine Press Ltd. Eds.Richard Wootton & Victor Patterso
n
DM Chan WM, Woo J, Hui E et al. A Community model for care of elderly people with diabetes via telemedicine. Ap
plied Nursing Research 2005;18:77-81
OA Wong YK, Hui E, Woo J. A community-based exercise programme for older persons with knee pain using telem
edicine. J Telemed telecare 2005;11:310-315
Stroke JCK Lai, J Woo, E Hui, W M Chan. Telerehabilitation – a new model for community based stroke rehabilitation.
J Telemed Telecare 2004;10:199-205
Dementia Poon P, Hui E, Dai D, et al. Cognitive intervention for community-dwelling older persons with memory problems:
telemedicine versus face-to-face treatment. Int J Geriatr Psychiatry 2005;20:285-286.
Urinary incontinence Hui E, Lee PSC, Woo J. Management of urinary incontinence in older women using videoconferencing versus c
onventional management: a randomised controlled trial. J Telemed Telecare 2006;12:343-347
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Chronic Disease Self-Management Programme (CDSMP)
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What is Chronic Disease Self-management?
In the Chronic Care Model: Self-management involves (the person with chronic diseas
e) engaging in activities that:
Protect and promote healthMonitor the symptoms and signs of illnessManage the impacts of illness on functioning, emotions and interp
ersonal relationshipsPromote adherence to treatment regimes
Von Kroff et al., Ann Intern Med 1997;127(12):1097-1102.
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The Stanford CDSMP story Stanford University School of Medicine / Patient Education Research Centre
Kate Lorig, H Holman, D Sobel Started in 1980s as Arthritis SMP
Program content promoting Self-efficacy developed from patient focus groups
Features of CDSMP Group format (up to 15) Interactive 2 group leaders Promote self-efficacy
Action plan Problem-solving Sharing
Modeling Patients volunteer as leaders
Re-interpreting symptoms Persuasion
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The definitive study Lorig KR et al., Medical Care 1999;37(1):5-14.
1000 patients with chronic diseases Heart disease, lung disease, stroke, arthritis
completed CDSMP Followed-up for 3 years Improvements in
Self-efficacy Health status Health care utilization Self-management behaviours
Extended to other countries Canada, Europe, Australia Asia
China, HKSAR, Taiwan, Singapore, Japan Internet version Generic vs. disease specific
DM, Back pain, AIDS Leaders movement
Lay leaders Master trainers
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What is special about the Cadenza Community Project: CDSMP?
1. To train up a group of lay leaders as the future driving force of the CDSMP movement.
2. To demonstrate that lay leaders are just as effective as professionals (e.g. social and health care workers) in leading CDSMP and achieving the desired outcomes.
3. To develop a CDSMP delivery model best suited for Hong Kong elders, and to pave the way for a territory-wide movement.
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Progress of Cadenza Community Project: CDSMP
Commenced December 2007 Recruited and trained 43 elder Lay
Leaders 115 subjects completed the
CDSMP Evaluation still under way
Compare outcomes between intervention (attended CDSMP) and control groups at 6 months
Compare outcomes of groups led by elder Lay Leaders versus staff (social workers)
Focus groups
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Summary
In additional to conventional models of health care delivery, innovative ways to provide health care should be explored and evaluated.
Some of these innovations were introduced in this talk.
We are grateful to our visionary sponsors who helped us realize our dreams.