THE ARRT OF TELEHEALTH

Bringing new age technologies to the eldest of our community

Dr James Hardy - Geriatrician

Therese Jepson - Clinical Nurse Consultant

Aged Care Rapid Response Team (ARRT)

• ARRT is a geriatric outreach service servicing older people who reside on the Lower North Shore, Ryde and Hunters Hill areas

• ARRT is one of three outreach services provided by the Northern Sydney Local Health District.

What Does ARRT Aim to Do?

• Reduce the number of avoidable Emergency Department presentations for older people who become acutely unwell

• Provide rapid geriatric assessment and treatment at home

• Review older persons who are functionally or medically deteriorating and at risk of hospitalisation

Why are we doing this?

Benefits of treatment at home

• 19 % Reduction in mortality

• Reduction in readmission (OR .075)

• Reduction in cost: mean difference, $1567.11

• Improved patient satisfaction in 21/22 studies

Systematic review of burdens of hospitalisation for RACF residents

• 19% of hospitalisations were for new pressure injuries

• 38% of hospitalisations were for delirium

• RACF residents are three times as likely to contract a hospital-acquired gastrointestinal or respiratory infection

• 1-5% of RACF residents will die in ED

• There is up to 34% chance of mortality during hospitalization and 52% mortality within 3 months

• Average cost AUD $5715 per hospital stay

Age and Ageing 2014; 43: 759–766

Conditions ARRT manage

Pneumonia Urinary infections Cellulitis Exacerbation of

COPD

Delirium Heart Failure

Behavioural and Psychosocial Symptoms of

Dementia – BPSD

Cognitive decline

Falls Polypharmacy

Catheter issues: Include PEG/PEJ feeding tube and Urinary catheters

Referral Process without Telehealth

One • Phone Call to ARRT

Two • Phone Triage and Assessment

Three • Plan agreed

Four • Home Visit

Five • Follow Up Care

Digital technology- triage and workflow

• Mobile x-rays with remote access

• Photographs of wounds- Dermatology, Vascular, Plastics

• NSW Ambulance bed board application

• Remote EMR access

Initial Telehealth Implementation

• In November 2017 - Skype for Business was installed however this required the team to have a clinician with the patient

• The local RACFs were unable to access Skype for Business

• The video-calls between ARRT clinicians improved clinical assessment.

NSLHD Telehealth Project

• In March 2019, NSLHD reconvened its steering committee for Telehealth

• The committee has representation from across the district including clinicians and executives. All sites are represented.

• The steering committee ran an EOI process for interested services across the district.

• ARRT submitted an EOI in the first round.

• ARRT were the first service selected to be supported in line with winter planning activities.

Risk Management for implementation Risk Mitigation Strategies

Technology failure Education of RACFs and ARRT team. Selected champion in

RACF. Partnership with eHealth videoconferencing team.

Site visits to test wifi and mobile bandwidth, firewall issues.

Lost or Damaged

iPads

Agreement with facilities regarding financial responsibility for a lost

iPad. Purchase of heavy duty cases and use of passcodes and

Find my iPhone app.

Inadequate

consultation

numbers

Work with ARRT team and RACFs to identify areas which will

benefit from telehealth. Ensure that there is adequate training.

2019 NSLHD Telehealth Pilot

Commenced 1st July 2019

• Preliminary discussion with ARRT and NSLHD Telehealth lead to identify key stakeholders and review video conferencing platform options.

• Pexip was selected due to ability for external stakeholders to join.

• Four Residential Aged Care Facilities were invited to be included in the pilot.

• Onsite training provided to RACF managers and RNs by NSLHD Telehealth Lead.

• Resources were created and provided to pilot facilities.

Use of Telehealth in ARRT

Triage

• The key driver of telehealth was to improve the initial triage of a patient.

Follow Up Care

• In addition to triage, ARRT use video calls to follow up on patients who were seen and require further care.

Referral Process with Telehealth

One • Phone Call to ARRT

Two • Video Call Triage and Assessment

Three • Plan

Four • Home Visit if Required

Five • Follow Up Care by Video Call

Initial Sites for Implementation

Baptist Care North Ryde

Montefiore Hunters Hill

St Peters Lane Cove

James Milson Village Milsons Point

Case Study One: Mrs S

89 years Old

Russian Speaking – No

English

Resident in a high care

nursing home

Retired Journalist

spending a lot of time

reading and researching

on her laptop

• AF

• CCF

• IHD

• Hypertension

• Pulmonary

hypertension

• Chronic renal

failure

• GORD

• Dementia

• Hypothyroidism

• Lower back pain

• Osteoporosis

• Osteoarthritis,

L2#

• Neuropathic

pain

• Urinary

incontinence

• Constipation

• Double

incontinence

• Sciatica

Past Medical History

Mrs S Presenting Problem

• Developed severe neck and shoulder pain past few days

• Seems to be getting worse

• GP cannot review today

OPTIONS:

Send to Hospital by Ambulance

OR

Call ARRT

Mrs S Telehealth

• 10:00: RACF contact ARRT – Initial telephone assessment

• The CNC felt Mrs S was suitable for a telehealth review

• 10:15: Videoconference from facility RN, patient and Russian interpreter to ARRT CNC and ARRT Aged Care Registrar.

Mrs S Assessment

• No obvious neurological abnormality

• Mobile X-ray organised

• Analgesia changed

• Referral to RACF physio for a positioning review

• X-ray reviewed remotely the same day and showed only chronic degenerative changes

Mrs S Outcome

Most likely musculoskeletal pain due to long periods sitting in front of computer screen

• Resident stayed at home

• No onsite visit by ARRT team required

• Triage and clinical judgement were improved by videoconference

Case Study 2: Mrs O

• Phone call from Extended Care Paramedics (ECP) at pilot facility - patient with new onset atrial fibrillation and generally unwell.

• Videoconference with RACF RN, the ECP & patient's daughter, Kate.

• ECP assessed patient to be in Atrial Fibrillation but maintaining BP. Not febrile and well, but drowsy.

• Kate reported her mother had multiple hospitalisations this year with prolonged delirium and admission to a psychiatric facility.

• Did not want mother transferred to hospital and preferred management at the facility if possible.

Mrs O Plan

• Treatment goals discussed with family • Comfort

• Avoid invasive investigations and treatment that may be distressing

• Daughter accepted the risk of stroke with AF and said would not want her mother anticoagulated

• Organised ARRT CNC and Registrar to visit

Mrs O Impression

• Exacerbation of Congestive Cardiac Failure

• Atrial fibrillation

Plan:

• IV Furosemide stat

• Medication review

• Monitor weight daily

• Monitor oxygen saturations and respiratory rate

• Monitor pulse and blood pressure

Mrs O Outcome

• Mrs O remained at home in facility

• Hospital avoided

• Clinical condition improved

• Delirium risk reduced

• Feedback from daughter:

‘the Telehealth call was fantastic for my mother….. without this service my mother would have been admitted to hospital this week’

Benefits of Telehealth for ARRT

• Improved triage – allows us to see patient quickly and decide whether they need to be seen immediately

• Reduced need for some home visits to review patient

• Improved efficiency and capacity to see more patients

• RACF staff who have used the telehealth report: • Increased feelings of support

• ‘Telehealth is convenient’’

• ‘easily accessible’

• ‘timely’

Initial Results July and August 2019

Data Collected

Key Data

• Number of referrals

• Number of visits

• Did telehealth improve triage?

• Did telehealth reduce need for home visits?

• Did telehealth improve clinical judgement?

Results of pilot: July-Aug

Referral source Total

Aged Care Facility 41

HAPOP Team Member 5

GP 3

NSW ambulance/Extended Care Paramedics 2

Grand Total 51

Referral reason

Results: Triage

Results: Impact on Home Visit

Results: Clinical Judgement

Results: Outcome after OOS

Next Steps and Longer-Term Vision

• September- expansion of pilot

• Negotiations with NSW Ambulance to include Extended Care Paramedics in the pilot

• Aim to eventually include all RACFs in the regions

Questions? For further information email: NSLHD-Telehealth@health.nsw.gov.au