Facilitating Self-Management of

Chronic Disease through Home

Based Tele-Monitoring for Patients

with CCF and COPD

Suzie Hooper

August 2011

Acknowledgement

• Jo McLaren RN

• Emma Boston RN

• Belinda Smith RN

• Sue Rowe RN

• Carmel Bourne RN

Background

• Chronic Obstructive Pulmonary Disease (COPD) and Congestive Cardiac Failure (CCF) are two of the most prevalent chronic disease in Australia

• Difficult to accurately estimate prevalence

• Prevalence is increasing with the aging population

• Both are considered to be major public health issues in all Western countries

AIHW (2005), Abhayaratna (2006)

Project Background

• Funding for the pilot was through the Medibank Private Special Purpose Fund.

• MBP and SJGHC wanted to collaborate to develop a home-based CDM program utilising emerging technology

• SJGHC investigated potential home monitoring systems

• Selected the Intel Health Guide

• Patients with current hospital cover with Medibank Private were eligible for participation in the project.

Target group

Target group for the pilot:

• Patients with a diagnosis of CCF or COPD

• Recent hospitalisation for their condition and / or a history of multiple admissions for this condition

• Potential to reduce the likelihood of hospital admission

• Patients from both metropolitan and regional areas

St John of God Health Care

• Australia’s largest Catholic

not-for-profit private health

care group.

• Established in 1895 in WA by

the Sisters of St John of God.

• 15 hospitals in Australia and

NZ, metropolitan and rural /

regional

St John of God Health Choices

• Established in 2009

• Reduction in hospital admission rates,

bed days and associated hospitalisation costs

• Provides all levels of home-based nursing care:

Community, PAC

HITH

• Branches:

Melbourne, Berwick,

Geelong, Warrnambool, Bendigo,

Ballarat

Perth

Project Aims

• To determine the effectiveness of a home based tele-

monitoring system for patients with COPD and CCF

• Identification of an ‘at risk’ cohort of Medibank Private

members who would benefit from the program,

following an admission to hospital for their condition

• Reduction in hospital admission rates, bed days and

associated hospitalisation costs

Project Aims

• Improved self-management of the disease

• Provision of an integrated program of care between

nurses, doctors, hospital and the community

• Improved member wellness (measured subjectively

and objectively)

Program elements

• Pre-program assessment and recruitment if suitable

• Initial home visit by Health Choices nurse to set up

system

• Daily home-based physiological tele-monitoring for 12

weeks

Program elements• Daily monitoring of vital signs and

physical symptoms

• Web-based data upload to

central monitoring data centre.

• Interpretation of physiologic

parameters by a skilled

registered nurse centrally.

• Appropriate intervention as indicated.

• Weaning over 4 weeks.

• Data collection and analysis.

Equipment

• Intel Health-Guide (home based

monitoring system).

• Peripherals:

Sphygmomanometer

Pulse oximeter (blue tooth)

Scales (blue tooth)

Monitoring System

• Web-based central monitoring system (Intel Health

Management Suite)

• On-line interface that allows nurses to securely monitor

their patient’s condition

• SJGHC developed EXCEL patient data base and

patient record

Monitoring System

Monitoring System

Monitoring System

Possible interventions

• Telephone consultation by the RN

• Home visit by a member of the Health Choices

nursing team (clinical or technical)

• Liaison with patient’s GP/Specialist if indicated

Patient Enrolment

• 62 eligible

• 14 did not continue (no Special Purpose Fund form completed)

– 5 RIP

– 1 doctor refused

– 4 refused

– 4 other

• 46 Enrolled (Special Purpose Fund forms completed)

Patient Enrolment

• 46 approved by Medibank Private Special Purpose Fund

Committee

• 32 Active clients

– 6 patients refused

– 4 RIP

– 4 other reasons

Current Activity

• 32 Active clients (July 2011)

– 9 monitoring daily

– 3 currently weaning

– 20 completed – ceased monitoring

• 2 will be ongoing

Patient Demographics

SJGHC /MPL Tele-monitoring Pilot Program

Age Range

2011

0

5

10

15

20

25

30

35

51-60 61-70 71-80 81-90 91-100 Total

Age range

Nu

mb

er o

f p

ati

en

ts

Patient Demographics

SJGHC /MPL Tele-monitoring Pilot Program

Patient Gender

2011

0

2

4

6

8

10

12

14

16

18

Male Female

Gender

Nu

mb

er o

f p

ati

en

ts

Male

Female

Patient Demographics

SJGHC /MPL Tele-monitoring Pilot Program

Region

2011

0

5

10

15

20

25

Bendigo Berwick Nepean

Region

Nu

mb

er

of

pa

tie

nts

Bendigo

Berwick

Nepean

Patient Demographics

SJGHC/MPL Tele-monitoring Pilot Project

Diagnosis

2011

31%

63%

6%

CCF

COPD

CCF/COPD

Health Service Utilisation

• Number of Admissions to hospital - 6

• Number of admitted days – to be determined

• Days between hospitalisation for the chronic condition –to be determined

• Number of unscheduled home nursing visits

– Clinical - 3

– Technical (system management) - 21

Hospitalisation

• Number of Admissions to hospital - 7

• Reason for admission1. Worsening disease palliative

2. Cardiac complications full time care

3. Chest Infection 10 day stay recommenced monitoring (had commenced weaning)

4. Blood transfusion (leukaemia) 1 day stay recommenced monitoring

5. Back surgery currently in hospital

6. Pneumonia 7 day stay recommenced monitoring (had not commenced weaning)

7. Chest infection 10 day stay – home with PICC line and recommenced monitoring

Clinician Feedback

Successes

- Good system that is very easy for the patients to use

- Currently assessing patient and carer satisfaction

- Comprehensive system of data that provides the

whole picture that usually indicates when intervention

is needed (some exceptions)

- Minimal requirement for phone follow up related to

clinical issues

Clinician Feedback

Difficulties

- Connectivity issues in outer-metro and regional areas

related to wireless internet

- Issues with firewall protection within SJGHC (unable

to use videoconferencing)

- Clinicians need reasonable computer skills

- Complexities related to multiple clinicians monitoring

patients – knowledge of patients reduces necessity

for patient contact

Patient Feedback

• COPD patient who has had 6 hospital admissions in the

last half of 2010 has now stayed out of hospital for 10

months and feels he is in control of his health – remains

out of hospital and wife went on overseas for a holiday.

• COPD / CCF patient admitted monthly prior to

monitoring and rehab program – feels more in control of

her health - remains out of hospital 14 weeks.

Patient Feedback

• COPD / CCF patient – remained out of hospital –

increased confidence – has taken a trip to Sydney to

meet her first great grand child.

• CCF patient – remained out of hospital – severe CCF –

monitoring provides reassurance regarding condition.

• Many patients and carers express general sense of

increased confidence in managing their condition.

Issues for consideration

• Need for broadband internet to facilitate consistent

monitoring and utilise video capability

• Need the formal data analysis to determine quantitative

and qualitative outcomes

• Develop proposals to access funding more broadly

Thanks to our collaborators

• Steve Hall (CEO, St John of God Health Choices)

• Rebecca Redpath (Medibank Private)

• Dianne Paynter (Medibank Private)

• Dr Steve Bunker (Medibank Private)

• Anthony Fanning (Healthe Tech Pty Ltd)

• Scott Moller-Neilson (Healthe Tech Pty Ltd)

• George Margellis (Care Innovations an Intel GE Company)

References1. Australian Institute of Health and Welfare (2005) Chronic Respiratory Disease in

Australia. Their prevalence, consequences and prevention.

2. Abhayaratna, Smith, Becker, Marwick, Jeffery and McGill (2006) Prevalence of heart

failure and systolic ventricular dysfunction. MJA 184(4) 151-154

3. Australian Bureau of Statistics (2001) National Health Survey

4. Krum H. and Stewart S. (2006) Chronic Heart Failure; time to recognise this major public

health problem. MJA 184(4) 147-148

5. Australian Institute of Health and Welfare (2004) Heart, Stroke and Vascular Disease –

Australian Facts 2004

6. Krum H. , Jelinek M., Stewart S., Sindone A., Atherton J., Hawkes A., (2006) Guidelines

for the prevention , detection and management of people with chronic heart failure in

Australia 2006

7. Pfeffer M.,Swedberg K., Granger C., Held C, McMurray J., Michelson, Olofsson B.,

Östergren J., Yusuf S., for the CHARM Investigators and Committees (2003). Effects of

Candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-

Overall programme. The Lancet, Vol 362. 759-766