1. Virtually Ready
Evaluation around use of SmartHealth (HealthTap) in Aged Residential Care
Marie Dickinson, Bridget Killion, Deborah McKellar and Ali Wilkinson
13 October 2017
Introduce ourselves, our background etc.

2. Background Project aim Challenges of an aging population
Alternative models of service delivery
I’m not sure if I’m retiring or SmartHealth training today?!
Project aim: Evaluate the use of SmartHealth (HealthTap) in an Aged Residential Care (ARC) facility
Challenges of an aging population:
65+ age group will increase by 33% by 2026
Multiple co-mobidities – physical conditions such as diabetes, cardiovascular disease, COPD; mental health issues such as depression, dementia; social issues such as isolation, depreviation
Limited resources:
Aging workforce
Difficult to recruit to health
Financial constraints
Physical space
Alternative models of service delivery.

3. Waikato DHB Strategy looking at addressing these issues through offering services:
Closer to home
People centred services
Productive partnerships
Virtual healthcare

4. Virtual healthcare Delivering healthcare through a variety of modes:
Text
Mobile devices
Computers
This aims to be more convenient, effective and resource efficient for both the consumer and health care professionals.
In a Canadian health care setting a virtual programme was set up for rural residents during 2014 that offered 390,000 health care consultations which avoided 260 million kilometres for travel for patients.
Ask audience: What percentage of our community lives in a rural setting?
60% of Waikato residents live in a rural setting. Hence there is comparison to the before mentioned literature.
There is a broader strategy required to ensure infrastructure is available. The wider virtual health project is working in partnership with Spark to address internet connectivity.

5. Out of hours doctor service
Virtual healthcare
Out of hours doctor service
Launch of virtual healthcare by Waikato District Health Board - Timeline:
3 August 2015 – Telehealth – a method of video conferencing between health professionals and within health facilities, i.e. rural Emergency Departments – Waikato to Tokoroa.
Early 2016 – ‘The Virtual DHB’ powered by HealthTap was introduced as a trial and rebranded in late 2016 to SmartHealth
September 2016 – Out of hours doctor service launched
Virtual healthcare targets – aim is to deliver 40% outpatient appointments via virtual health. Tasked with evaluating HealthTap in aged residential care.

6. Virtual Health Terminology powered by
To clarify some of the terms used…
Two products come under the umbrella of Virtual Health – SmartHealth and Telehealth.
SmartHealth is powered by HealthTap, an application the Waikato District Health Board is currently using.

7. Kimihia Home & Hospital
A pilot was established with Kimihia Home & Hospital – Kimihia is a 77 bed ARC facility compromising of rest home level beds, dementia care, hospital level supports and private suites (Kimihia Home and Hospital, 2011). It is located in the north Waikato town of Huntly and is 36 kilometres from Waikato hospital.
Has several local General Practitioner practices, but none of them offer out of hours services to the residents of Kimihia. Therefore when medical services are required outside of business hours, residents need to travel to Waikato hospital emergency department, or a Hamilton based urgent care facility. Kimihia had 42 Emergency Department attendances during Kimihia report that on average they have three trips per week to Waikato hospital for multiple resident outpatient appointments. This can take up to six hours per visit with residents having to wait whilst other residents attend their appointments.
There is evidence that Telehealth has been used overseas to deliver consultations with Aged Residential Care facilities. There is no current literature for HealthTap being used in Aged Residential Care. We are the first to introduce in New Zealand.
Kimihia had been identified as a facility that was enthusiastic to the implementation of SmartHealth (HealthTap).

8. Project delivery using Kotter’s Eight Step Change Model
1. Sense of urgency
2. Building a coalition
3. Create a vision
4. Comm-unicate
5. Remove obstacles
6. Create quick wins
7. Create a momentum for change
8. Rein-forcement
HealthTap Ready
For this project we followed Kotter’s Eight Step Change Model.
For those who are not familiar with the Kotter’s change model it is a systematic approach to change management.
The eight steps are –
Establish a sense of urgency by recognising the opportunity for change
Build a guiding coalition – a group that will influence change within the organisation
Develop a vision and strategy
Communicate the vision
Involve people in the change, empower them to think about the changes
Create some quick wins
Create momentum for change building on the successes – develop people as change agents
Make the changes stick – ensure they become part of the culture of the organisation

9. Project delivery using Kotter’s Eight Step Change Model
1. Sense of urgency
2. Building a coalition
3. Create a vision
4. Comm-unicate
5. Remove obstacles
6. Create quick wins
7. Create a momentum for change
8. Rein-forcement
HealthTap Ready
Some of the steps were completed simultaneously, such as the following –
Instil a sense of urgency, here we
Met with our project sponsors on a couple of occasions to define the scope of the project.
Met with representatives from Kimihia to ascertain their understanding of the project and establish their needs. An initial discussion had already taken place with representatives from the wider virtual health project before it was assigned to us.
Discussed timeframes – limited time as the Capstone project had a set end date.
It was raised by Kimihia that residents did not possess the forms of identification required to sign up to SmartHealth (HealthTap).
Building a coalition
For us, this was not just about project coalition but our group coalition – we worked well together as we come from different backgrounds and have had different experiences, some of us had worked with residential care facilities previously where some had engaged for the first time – we put into practice action learning – having different viewpoints was an advantage for our group.
Maintaining relationships with Kimihia – as Kimihia is not a DHB facility it was important for us to be mindful of the existing valued relationship with the wider DHB and not to compromise this.
It was useful to have the support of the existing links such as the Nurse Practitioner for older people who introduced us to Kimihia management and who was present at our initial meeting.
Create a vision
Kimihia had discussed virtual health with residents and families – specifically having outpatient appointments from the care facility.
We offered the out of hours doctor service as Outpatient appointments were not currently available.

10. OUTPATIENT CLINIC
From initial conversations we recognised we were unable to offer what Kimihia wanted – Outpatient appointments.
Issues raised were –
Identification and creation and the administration overhead this created, for instance:
Residents didn’t have the primary identification type to sign up
Residents didn’t have an address
Limited timeframe to implement during the Capstone project and the moving target for Outpatient services / appointments.

11. Project delivery using Kotter’s Eight Step Change Model
1. Sense of urgency
2. Building a coalition
3. Create a vision
4. Comm-unicate
5. Remove obstacles
6. Create quick wins
7. Create a momentum for change
8. Rein-forcement
HealthTap Ready
Communicate – within this step:
A presentation took place at the November 2016 residents’ meeting to introduce Kimihia to SmartHealth. Due to not having appropriate promotional material the residents lost interest with some leaving – picture residents racing for their zimmer frames whilst some simply fell asleep in their chairs.
Informal interviews took place after the presentation with remaining the residents.

12. From the resident interviews, positive feedback was received, such as:
Less stressful as consultations would take place in the home with familiar staff to support
Reduced travel time to hospital
More convenient
And overall was a good idea

13. However, some concerns were -
Lack of understanding – this could be partly down to the promotional material and initial presentation.
Use of technology – most residents referred to the registered nurses needing to assist them.
Disruption of care – residents didn’t want to change what they were already familiar with. Some thought they would need to change their General Practitioner, this was in reference to the out of hours doctor service.
These concerns are similar to other literature findings.

14. Project delivery using Kotter’s Eight Step Change Model
1. Sense of urgency
2. Building a coalition
3. Create a vision
4. Comm-unicate
5. Remove obstacles
6. Create quick wins
7. Create a momentum for change
8. Rein-forcement
HealthTap Ready
Remove obstacles – to remove some of the obstacles identified a:
Revised list of identification was implemented with the assistance of the wider virtual health project – a secondary list of identification options along with a verification of identity form.
Technology concerns were addressed through development of a consent form – enabling Registered Nurses or designated staff members to assist residents as the HealthTap application is quite complex for some residents.
Promotional material – we identified that there wasn’t currently any promotional material that the Aged Residential Care population could relate to. Working with our Media and Communications team we were able to produce relevant material.

15. Project delivery using Kotter’s Eight Step Change Model
1. Sense of urgency
2. Building a coalition
3. Create a vision
4. Comm-unicate
5. Remove obstacles
6. Create quick wins
7. Create a momentum for change
8. Rein-forcement
HealthTap Ready
Create some quick wins
Some of the quick win benefits for the residents are:
Residents don’t have to leave the care facility
Time effective – timeliness of getting scripts
Saved resources – nurses can manage situations on site and are able to be a part of the consults.
Whilst Kimihia saw the benefits it took some time to move past the administration processes.
By identifying obstacles, a starter pack was developed to give clarity and assist in implementation. This will assist other ARC facilities to implement SmartHealth or become ‘Virtually Ready’ and includes the following:
Promotional video, posters and flyers
Residential Facility Standard Consent Form
Guidelines for implementation into an Aged Residential Care facility
Frequently Asked Questions
Resident Checklist
Spreadsheet for recording usernames and passwords
Step-by-step learning material
Create momentum for change and build on success
Residents and staff from Kimihia are now registered with SmartHealth, however, momentum for change was slow due to:
Uncertainty and competing priorities for Kimihia due to retirement of manager.
Complexity of administration processes and volume for initial sign-up.
Unavailability of virtual outpatient appointments.
Make the changes stick until they are part of the culture of the organisation
Until key Outpatient services are offered via SmartHealth there is not necessarily going to be the culture established. Once the services are in place there will be a good incentive for both Aged Residential Care facilities and the Waikato District Health Board. This will reinforce and create the culture required and the momentum for change.

16. Project delivery: What was achieved
Along with the Residential Facility Standard Consent Form, a poster featuring Maureen, one of the residents of Kimihia was developed.
Also banners have been produced, with one usually located in the main entrance to the OPR building.

17. Project delivery: What was achieved
A flyer was also produced to help promote with prospective residents and their families/whanau.

18. Project delivery: What was achieved
Most exciting for us, Maureen also featured in a promotional video for SmartHealth.
(Play video)
You’ll note that Maureen had the assistance of a nurse from Kimihia, replicating the environment that consults take place for Aged Residential Care residents.
You’ll also note that unlike other SmartHealth adverts, this one features a female voice and version of the SmartHealth character. This was a result of a discussion with our sponsors and it was felt that residents would relate more to a female voice as this is a reflection of their usual care environment.

19. SmartHealth versus Telehealth
Whilst we were asked to evaluate SmartHealth (HealthTap) in Aged Residential Care, it may have been better to look at which virtual health mode is more appropriate in an Aged Residential Care facility.
We questioned whether Telehealth would be of benefit.
An advantage of Telehealth is it is more clinician led, it is already being used to provide face to face consultations, and could easily be established for outpatient consultations. Many studies overseas in Australia and UK have looked at Telehealth as the mode for providing either General Practitioner or rehab consultations through this mode.
A disadvantage is the resident (patient) would not receive immediate information after a consultation takes place, i.e. SOAP Note.
However, there could be opportunities to utilise both modes of virtual healthcare within aged care facilities depending on individual resident needs.

20. ARC Staff benefits
An additional benefit of virtual health within an Aged Residential Care facility is that staff are involved in the clinical decision making which in turn develops their knowledge and expertise.
In the long term the Aged Residential Care facility staff will be able to manage increasing aspects of patient care reducing the reliance on hospital services, but have the back up support as required.
This links to the Waikato District Health Board’s strategy of being more beneficial and a more person centred approach to care, enabling effective community interventions.

21. So what has happened post project.

22. Post project activities
Residents and staff at Kimihia are signed up and ready to use SmartHealth.
Patient/consumer sign up process has been streamlined and other administration tool improvements planned.
Rollout to other aged care facilities and agencies is currently taking place, i.e. Bupa facilities, Hospice and St John.
Community services engaging with patients virtually.
Patients/consumers are driving demand in Outpatient services.
Sign up process has been streamlined – i.e. if patient is known to the Waikato DHB (currently accessing Waikato services), patients do not necessarily need to present ID as this has already been checked; the form has also been simplified and work is underway to create an online form for Minors and those who are unable to manage their own account.
Other administration tool improvements planned to enable facility staff to manage resident accounts more effectively.
Bupa NZ are piloting with 6 of their facilities in the Waikato region before the end of the year – one facility in Hamilton East is up and running. Engagement is also taking place with Hospice and St John – training events scheduled during October.
District and Public Health Nurses along with Clinical Nurse Specialists in the community are engaging with suitable patients virtually for their ongoing care. Also START (Supported Transfer and Accelerated Rehabilitation Team) who provide and promote rehabilitation of patients within their home environment are utilising SmartHealth to connect with their patients where appropriate.
Patients/consumers are now requesting future appointments to be delivered virtually which is encouraging clinicians to offer their services virtually particularly in the Outpatient setting – discussions taking place with individual clinicians as and when these requests occur.
Thank you to Kimihia for their support and patience, the work carried out in their facility has assisted in the rollout to other ARC facilities and agencies.

23. References
Appelbaum, S. H., Habashy, S., MaloJean‐Luc, & Shafiq, H. (2012). Back to the future: Revisiting Kotter’s 1996 change model. Journal of Management Development, 31(8), 764–782. doi: /
Confuscious (n.d.). Retrieved from
Fairhurst, G.T. (2011). The power of framing: Creating the language of leadership. San Francisco: Jossey-Bass.
Grube, M. (2015). Making the case for virtual healthcare. Healthcare Executive, Mar/Apr 2015.
Hex, N., Tuggey, J., Wright, D., & Malin, R. (2015). Telemedicine in care homes in Airedale, Wharfedale and Craven. Clinical Governance: An International Journal, 20(3),
Kazmi, S., & Naarananoja, M. (2014). Collection of Change Management Models – An Opportunity to Make the Best Choice from the Various Organizational Transformational Techniques. GSTF Journal On Business Review (GBR), 3(3).
Kimihia Home and Hospital (2011). A summary of the many services we offer at Kimihia Home and Hospital. Retrieved from
Komives, S. R., Lucas, N. J., & McMahon, T. R. (2013). Exploring leadership: For college students who want to make a difference (3rd ed.). United States: Wiley, John & Sons.
Prosci. (2017). ADKAR Change Management Model Overview. Retrieved from
Sanders, C., Rogers, A., Bowen, R., Bower, P., Hirani, S., & Cartwright, M. et al. (2012). Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study. BMC Health Services Research, 12(1).
Shulver, W., Killington, M., & Crotty, M. (2016). ‘Massive potential’ or ‘safety risk’? Health worker views on telehealth in the care of older people and implications for successful normalization. BMC Medical Informatics And Decision Making, 16(1).
Taylor, A., Wade, V., Morris, G., Pech, J., Rechter, S., Kidd, M., & Carati, C. (2016). Technology support to a telehealth in the home service: Qualitative observations. Journal Of Telemedicine And Telecare, 22(5),
Wade, V., Whittaker, F., & Hamlyn, J. (2015). An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities. Journal Of Telemedicine And Telecare, 21(8),
Waikato DHB (2015). Telehealth Procedure. Retrieved from
Waikato DHB (2015). Waikato DHB Health Profile Retrieved from
Waikato DHB (2016). Healthy People Excellent Care: Waikato District Health Board Strategy. Retrieved from
Webster, P. (2016). Private telehealth foray into public system. Canadian Medical Association Journal, 188(10), E209–E209. doi: /cmaj