Heather SherrardVP Clinical Services

University of Ottawa Heart Institute

Telehomecare:Outcomes and Patient

Experiences

2012

• 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

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

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

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

Telehome Monitoring Technology

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

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

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

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

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

Regional Program

MontfortTOH-Civic, OGHQCH

UOHI

THM

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THM

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THMTHM

THM

THM

THMTHM

THMTHM

THM

THM

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

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

Doing the right thing,

at the right time,

in the right place!

cstruthers@ottawaheart.ca