1. Telehomecare: Outcomes and Patient Experiences
Heather Sherrard VP Clinical Services University of Ottawa Heart Institute
2012

2. 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

3. 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
Define, give objectives, include knowledge transfer.

4. Telehealth Technologies
Broadband connection in the region
Monitoring of patients in their home
Interactive voice response using automated calling to care for patients

5. 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

6. Telehome Monitoring Technology

7. 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
↓ LOS
Antonicelli, R. et al (2008)
RCT n=57
12 month f/u
↓readmission
↑compliance, BB & statin use, health perception
Woodend, K. et al
(2008)
RCT n=249 ACS & HF
↓readmission (ACS)
↑QOL & functional status

8. 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

9. 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

10. 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, 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

11. 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

12. Regional Program
Montfort
TOH-Civic, OGH
QCH
UOHI

13. THM
THM
THM
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THM
THM
THM
THM
THM
THM
THM
THM
THM
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THM
THM

14. Funding 75 % of initial equipment funded through grants & research
Permanent staff funded through operations
Leverage to improve bed $1000/day, decrease wait time for admission, improve provider capacity
Cost avoidance model

15. 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

16. Doing the right thing, at the right time, in the right place!