Vickie de Jong

Project Officer

Acute Care@Home

Metro South Health

Vickie IrvingClinical Health SpecialistTelstra Health

Combining telehealth capabilities to strengthen delivery of home-

based acute care models

What is Remote Patient

Monitoring (RPM)?

• The monitoring of patients remotely – using an app on the patients mobile phone/tablet and Bluetooth equipment for the monitoring of vital signs

• Used in conjunction with normal HITH care and home visits

Photo credit Getty Images/iStockphoto

The Metro South RPM Trial

• A partnership with Telstra Health and the Telehealth Support Unit

• Dual Site 6 month trial – QEII and Redland Hospitals

• Commenced 27th August 2018

• First trial of this kind for HITH patients in Australia

1. Faster response to clinical

deterioration

2. Earlier identification of patient

stabilisation (to support

discharge)

3. Improved patient safety

through real time access to

observation data

4. Improved patient flow,

decreased transfers in &

reduced ED presentations

5. Increased referral rates to HITH

programs in line with improved

clinical decision-making and

provider confidence

6. Increased Diagnostic Related

Group’s and patient acuity

7. Decreased Length Of Stay and

improved service efficiency

8. Decrease in unnecessary travel

for patients and clinicians

9. Increased use of

videoconferencingGoals/Aims

Technology Drivers for HITH

Photo credit Getty Images/iStockphoto

Service Model Intent “Patients who are admitted to hospital substitution services receive care and treatment which is comparable to the services offered in a traditional hospital setting” Qld Department of Health Hospital in the Home Guideline

Safety & Quality Standards “Measurement of physiological observations plays a significant role in detecting clinical deterioration. Abnormal observations may occur at any time during a patient’s admission. Multiple studies and adverse events have shown that patients in acute care settings often go for prolonged periods without having appropriate physiological observations measured. When this occurs it can mean that clinical deterioration may not be recognised, and treatment may be delayed” Safety and Quality Improvement Guide Standard 9: Recognising and Responding to Clinical Deterioration in Acute Healthcare

“The delivery of comprehensive care is based on partnering with patients, carers and families to identify, assess and manage patients’ clinical risks, and determine their preferences for care; and on communication and teamwork between members of the healthcare team” NSQHS 5: Comprehensive Care

Combined capabilities to improve clinical outcomes

✓Care Planning (Engage)

✓Remote Patient Monitoring –

Quantitative & Qualitative data (Identify)

✓Secure Videoconferencing (Respond)

✓Affordable and accessible (Sustain)

Combined capabilities to improve clinical outcomes

üCare Planning (Engage)

üRemote Patient Monitoring –

Quantitative & Qualitative data (Identify)

üSecure Videoconferencing (Respond)

üAffordable and accessible (Sustain)

Client Application

• Cross platform (Android and iOS) on phone or tablet

• Consumer Bluetooth device integration (iHealth TGA

devices)

• Unmetered data usage when connected to the Telstra

network

• Care plan view including ability to track progress and

compliance

• Care plan task reminders (To do list)

• Offline capability

Provider Portal • Secure Web hosted Portal

• Immediate data synchronisation (online)

• Triage dashboard to improve caseload management ‘by exception’

• Coloured “bubbles” show the patient’s risk level -severity

• Automatically sorts patient results according to their risk level

• Configurable and templated health checks

• Simple secure video call initiation

How it works

Patient downloads MyCareManager

application

Patients provided Bluetooth devices

and/or manual data entry

Tasks & reminders pushed through to

patients

MyCareManager triages data

Alerts generated when data is outside parameters or tasks are missed

Trial Participants Key stats from MSHHS pilot patient dataTotal of 68 patients registered as active users of the MCM App (1st November 2018 to 28 February 2019)

64% of patient

participants are male

Average distance from

hospital ~ 7 km

59% of patient

participants are

diagnosed with cellulitis

Average age of patient

participants

~ 46 years old

Average number of

clinic visits ~ 1.7

Average number of

home visits ~ 3.5

Incident data overview –MSHHS pilot patient data and MCM App data

Top Responses – High risk Health Check incidents*Excl Process & Technical Errors

No. of interventions Percentage

Home Visit Scheduled 37 17%

Home Visit Scheduled (Transfer In Avoided) 1 <1%

Clinic Visit Scheduled 17 8%

Additional Observations 15 7%

Phone call to patient 11 5%

Top Responses – High risk Observation incidents*Excl Process & Techniclal Errors

No. of interventions Percentage

Home Visit Scheduled 16 17%

Home Visit Scheduled (Clinic Visit Avoided) 1 1%

Phone call to patient 9 9%

Phone call to patient (Home Visit avoided) 1 1%

Additional Observations 8 8%

Clinic Visit Scheduled 6 6%

Referred to medical officer 1 1%

Patient diagnosis Average no. of incidents per dayCellulitis 4.7Heart failure 5.5Hyperemesis 1.5Hypertension 4.0Infection 5.3Mastitis 9.0UTI 2.0Warfarinization 5.2

All patients 4.7

3 avoided events for high risk incidents (4 in total) – home visit, transfer in, clinic visit

Clinicians are more likely to seek ‘in-person’ review when qualitative data (symptoms) is combined with quantitative data

Incident categories (312 incidents analysed)

54%41%

5%

High Low Medium

Incidents per day by diagnosis (based on data from 32 patients and 466 incidents)

Responses to high risk observation incidents

Responses to high risk health check incidents

Incident data overview –MSHHS pilot patient data and MCM App data

Clinic visit

scheduled

Data entry

error

Home Visit

Scheduled

Incorrect both

are Pulse

Observations

scheduled

Observations

taken

*Patient

dischargedPhone Call

Referred to

medical officer

Technology

IssueTOTAL

Cellulitis29

(10.2%)

9

(3.2%)

62

(21.9%)-

10

(3.5%)

26

(9.2%)

113

(39.9%)

32

(11.3%)-

2

(0.7%)

283

(100%)

Heart Failure -2

(9.1%)

3

(13.6%)

1

(4.5%)

4

(18.2%)

1

(4.5%)

8

(36.4%)-

3

(13.6%)-

22

(100%)

Hyperemesis2

(66.7%)

1

(33.3%)- - - - - - - -

3

(100%)

Hypertension - - - - - -2

(50.0%)

1

(25%)

1

(25%)-

4

(100%)

Infection2

(10.5%)-

5

(26.3%)- -

3

(15.8%)

4

(21.1%)

4

(21.1%)-

1

(5.3%)

19

(100%)

Mastitis - -2

(22.2%)- - -

3

(33.3%)

4

(44.4%)- -

9

(100%)

UTI - - - - - - -4

(100%)- -

4

(100%)

Warfarinization -3

(3.9%)

30

(39.0%)- -

3

(3.9%)

20

(26.0%)

20

(26.0%)-

1

(1.3%)

77

(100%)

TOTAL (including ‘other’)37

(8.5%)

15

(3.4%)

110

(25.3%)

1

(0.2%)

14

(3.2%)

35

(8.0%)

150

(34.5%)

65

(14.9%)

4

(0.9%)

4

(0.9%)

435

(100%)

Further breakdown of actions taken for all incidents (by diagnosis)

Cellulitis, Heart Failure, Infection (all types) and patients undergoing Warfarinization generated the most clinical incidents requiring proactive intervention by the MSHHS Clinical Team.

1 clinic visit and 1 transfer in avoided(high risk incidents)

1 visit avoided(high risk incident)

1 visit avoided (low risk incident)

Patient survey results34/38 participants completed the survey

Happiness:

97% very or mostly satisfied

Ease of use (App):

73% very easy or easy to use

Ease of use (medical equipment):

97% very easy or easy to use

Comfort having observations remotely monitored:

97% very comfortable or comfortable

Preference to be monitored at home in future:

87% definitely or probably would

46% of patients had issues connecting to the internet

Behaviour Change:

93% Care Plan Adherence

“Fantastic Idea, gives reassurance being able to monitor your obs in your own home. Comforting for family members.”

“Great service saves so much time and money”

“Seems like a great system which should save beds in hospital. Best hospital I've been in!”

Outcomes so far – Patient Experience & Behaviour change

Right care, right place, right time

• 44 year old male with upper limb cellulitis

• No co-morbidities

• Admitted to HITH for IVAB’s, enrolled onto trial for RPM

• Observations and Health Checks were scheduled for 8am the next day……

CASE STUDY ONE

CASE STUDY ONE

The next day …

Photo credit: Cristan Lozan on Unsplash

Despite a deteriorating clinical presentation,

this 44 year old patient still didn’t call for

help…

We called him.

Photo credit: Cristan Lozan on Unsplash

CASE STUDY ONE

Outcome• Ambulance transport arranged from hospital

• Accurate clinical assessment made remotely

• Patient deterioration identified early

• Intervention and treatment occurred several hours faster than the standard HITH model

• Clinician did not need travel to the patient’s residence

• Sepsis avoided

• Patient made full recovery

• Paradigm shift from reactive response proactive response

CASE STUDY ONE

• 46 year old female

• Addison's Disease – co-morbidity

• Admitted to HITH - Urosepsis

• Motivated patient – regularly entering observation data into App on ad-hoc basis

Photo credit: Sage Kirk on Unsplash

Patient empowerment

CASE STUDY TWO

CASE STUDY TWO

The next day …Began feeling unwell on evening of 19th Feb so took her BP

Patient noted it she was hypertensive, and self- presented to ED

Outcome• Triage Category X patient

• Diagnosis: Addisonian Crisis

• Admitted to ED for XXX hours

• Discharged back home on HITH

• Continued RPM trial for X days

• Patient made a full recovery

• RPM data was the catalyst in patient’s decision to present to ED

CASE STUDY TWO

• BYOD technology – increased need for first-line technical support but patient’s like it & feel reassured

• Improve access by offering loan pool of provisioned devices – 49 patients had no suitable device

• PAS Integration to automate admissions/discharges/suspensions to support implementation at scale

• Upfront integration to Qld Health Telehealth Network worthwhile to prevent firewall blockages

• A project officer is essential to embed change & secure buy-in from clinicians

• Stage roll out – implement one site at a time

• New data sources – creates new insights to support change management & captures benefits of investing in technology

• Practice changes – ‘usual care’ home visits optimised –more time spent on responding to patients needs then finding out ‘what’s going on’.

Photo credit: Martin Brosy on Unsplash

The Journey So Far…

QUESTIONS?

Photo credit: Camylla Battani on Unsplash