home tele-monitoring · wnswlhd home tele-monitoring trial report_v3 november 2017 introduction...

Home Tele-Monitoring:

Experiences in NSW Western Local Health

District and Bila Muuji Aboriginal Health

Services

Report Version 3

November 2017

A digitally enabled & integrated health system delivering patient-centred health experiences & quality health outcomes (NSW eHealth Strategy 2016-2026)

2 WNSWLHD Home Tele-Monitoring Trial Report_V3 November 2017

We recognise Aboriginal & Torres Strait Islanders as the First

People of this land.

We pay our respects to Elders past and present, and to a culture

rich in history and traditions

This work is copyright. It may be reproduced in whole or part for study or training purposes subject

to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial

usage or sale. Reproduction for purposes other than those indicated above requires written

permission from the Western NSW Local Health District.

© Western NSW Local Health District November 2017

Artwork by Jasmine Sarin Definition of terms used in report: Aboriginal Health Practitioner /Aboriginal and Torres Strait Islander Health

Practitioner - is a person who has completed a Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health

Care Practice (or equivalent as determined by the Board) AND holds current registration with the Aboriginal and Torres

Strait Islander Health Practice Board with Australian Health Professional Registration Agency (AHPRA). Aboriginal

Health Workers have completed training but do not have registration with AHPRA. Trainees are still undertaking their

qualification.


Contents Executive Summary……………………………………………………………………………………………………4

Introduction……………………………………………………………………………………………………………….7

Literature Review………………………………………………………………………………………………………7

Background……………………………………………………………………………………………………………….8

Purpose & Objectives…….………………………………………………………………………………………….9

Method……………………………………………………………………………………………………………………..9

Results………………………………………………………………………………………………………………………12

Discussion…………………………………………………………………………………………………………………16

Conclusion………………………………………………………………………………………………………………..21

Appendix 1: Suggested Integrated Home Tele-Monitoring Model of Care……………….22

Appendix 2: Patient Story - Angus’s Story………………………………………………………………..23

Appendix 3: Patient Story – Kay’s Story……………………………………………………………………24

References……………………………………………………………………………………………………………….25

Authors and/or information for Report supplied by;

Monica Murray – Project Manager – WNSWLHD HITH/Ambulatory Care Rural Sites

Morgan Wilcox – Project Lead, WNSWLHD Integrated Care Project Lead

Kath Skinner – Project Lead Bila Muuji ACCHS

Data interpretation advice provided at end stage of report by Daniel Belshaw, Western NSW Health Intelligence Unit

Document Control

Revision Date By Comments Draft Version 1 10.07.2017 M. Murray Initial draft – HIU, Integrated Care, Bila Muuji

Project Lead Nurse,

Version 2 04.08.2017 M. Murray Draft for consultation to Integrated Care Steering Committee executive (WNSWLHD, Bila Muuji & PHN) HTM Trial Sites, DMS Rural Facilities,

Version 3 November 2017 M Murray WNSW District Executive Leadership Group, Rural & Generalist Clinical Stream,


Executive Summary

Western New South Wales Local Health District’s (WNSWLHD) vision under the fourth Key Achievement

‘One Health Service across Many Places’ is to become Australia’s first digital health region by

implementing eHealth technology and systems with our key community partners (18). Remote home tele-

monitoring allows patient biometric information to be gathered at home so that it can be reviewed in

conjunction with other information held in the patient record or shared collaboration tool.

Recent research (2) suggests that telehealth evaluation can be complex with a great variety of potential

inputs, outputs, outcomes and stakeholders, which may explain the lack of an established telehealth

evaluation protocol and hindering decision-making to implement wide scale initiatives. Systematic review

evidence (3) demonstrates that supporting people with heart failure using information technology can

reduce rates of death and heart failure-related hospitalisations, improve people’s quality of life, knowledge

about their condition and self-care. Telehealth outcomes (4) with Aboriginal and Torres Strait Islander

people recommend that telehealth models of care facilitated through partnerships between Aboriginal

community controlled health services (ACCHSs) and public hospitals have potential to improve both patient

outcomes and access to specialist services for Indigenous people.

In 2016, NSW Ministry of Health provided eHealth funding to enable the testing of remote home tele-

monitoring in four rural Health Districts. WNSWLHD commenced two trials with existing clinicians and

patients across rural and remote sites;

1. WSNWLHD Trial: Hospital in the Home (HITH), Community Health and Integrated Care

2. Bila Muuji Trial: Community Controlled Aboriginal Health Services (CCAHS)

Trial goal was to test implementation of THM technology into rural health workplaces to inform NSW

Health, WNSWLHD and Bila Muuji Executive, Integrated Care Strategy and others doing similar work.

Trial objectives include testing and process evaluation of;

1. Acceptance and relevance of tele-home monitoring with clinicians and patients.

2. Useability of tele-home monitoring within existing service delivery models

3. Improvements in patient knowledge and capacity to self-manage

Guidelines, professional tools and patient resources, training and support strategies were developed, tested

and adapted over a period of eighteen months.

Results

During the WNSWLHD trial period to 30/6/2017, a total of (20) patients were involved in the HTM trial over

twelve months, of which (17) had been discharged and (3) were still being actively monitored in June 2017.

Community outpatients with one or more chronic conditions were the highest enrolments (11), followed by

HITH inpatients (7) and Integrated Care enrolled outpatients (2). The average age of a HTM patient was (68)

years and the average number of days per patient spent enrolled was (32). 20% were referred to community

providers for long term monitoring.

During the later Bila Muuji trial, in the eight month period to 30/6/2017, a total of (25) patient enrolments

occurred across eight ACCHS’s, of which (14) had been discharged and (11) were still being monitored in

June.


Of the WNSWLHD Trial enrolled patients survey respondents;

100% of patients either strongly agreed/agreed that HTM improved their knowledge of symptoms

and 93% of patients felt very confident with using the HTM technology

80% of patients strongly agreed/agreed that they were better able to manage their health condition

73% strongly disagreed/ disagreed that being involved in the daily vital signs increased their anxiety

and 13% agreed that their anxiety was increased.

Overall, 93% of respondents indicated they would like to continue with the HTM and

89% of clinicians believed, as a result of HTM, their patients were better able to identify symptoms

and 94% would recommend HTM for other patients.

During training and in pre and post-trial surveys, WNSWLHS and ACCHS clinicians displayed a highly positive

perception with the concept of remote HTM, both in perceived patient benefits and recommending to

patients – however found the implementation process a challenge. The main challenges identified by

clinicians were maintaining skills to set up patient equipment; double documentation and remote device

reliability (network access, technical glitches and variances of automated equipment). The main limitations

of implementing the HTM service were workforce capacity and procedures. The main themes on benefits of

the service model identified by clinicians were empowerment of the patient, collaboration between

healthcare teams and as a tool for better patient education and management.

The trials indicated that for patients with one or more chronic conditions, the use of HTM provided an

opportunity to undertake patient education and allow patients to be more involved in their clinical

management. The trials have also assisted to identify the barriers, enablers and a better understanding for

how this digital technology might be applied as part of current and future health service delivery in WNSW.

The Bila Muuji Trial will continue until December 2017 and a further evaluation report released early in

2018. As of July 2017, options for WNSWLHD include;

1. Cessation of Tele-Home Monitoring as a service option and return to status quo

2. Continued use of current 37 sets of TeleMedCare equipment for further 2 years, at a cost of $9,000

per annum with targeted projects to increase workforce skills and governance using HTM, with

review in line with directions of Patient Flow Unit patient monitoring.

Barriers

The speed of technological advances is challenging health workforce ability to adapt quickly

Implementation would require significant flexibility, frequent review and adaptation.

Workforce capacity site dependent - number of staff , skills and confidence with technology,

Workforce variable skills to manage and escalate biometrics in the community

Staff comfort/skills with self-management & patient access to additional biometric data

Limited strong evidence to determine HTM cost/benefit contributes to confidence to

implement.

Current vendor’s web-based data not yet compatible with Cerner & Practice software

Enablers

Additional external funding to purchase and trial the technology in a partnership model

Adequately resourced support team with capacity to respond quickly, maintain ongoing training,

coaching support and supervision and develop guidelines and procedures

Local leadership of early adapters, comfort with technology and culture to accommodate change.


Three critical factors for WNSWLHD excecutive and partners when considering options and directions after

the trials are;

If WNSWLHD executive and partners wish to progress to an integrated HTM service model, then as a result

of the trials, a suggested Model is included in Appendix 1 and the following recommendations are provided

for consideration.

Recommendation 1

That WNSWLHD conservatively support remote HTM with current level of HTM equipment for 2017-19 and;

Continue scoping with community partners (Bila Muuji ACCHS and WNSWPHN), Patient Flow & Transport Unit

(PFTU), WNSWLHD Telehealth Strategy and Primary and Community Health Nurses (PaCH) 2020 Framework for

their roles in supporting an integrated, telehealth model of care (Appendix 1).

Further development of how PFTU may in the future provide support and increase access to specialist care for

remote in-home monitored clients

Recommendation 2

That WNSWLHD and community partners establish a HTM Leadership Group to provide ongoing guidance and

advice for remote HTM as part of the broader WNSWLHD Telehealth Strategy including;

Recommending which WNSW patients to most likely lead to improved patient outcomes with HTM.

Review trial draft documents for Guideline and other supporting documents for endorsement, including action

plan, compliance, auditing and evaluation measures and report on same.

Review training to increase accessibility via WNSW My Health Learning

Develop Quick Reference Guide for Community Health Outpatient & Outpatient Care (CHOC) data entry to

improve performance reporting of clinical activity associated with HTM

Review literature with support of affiliated research partners to determine scope and capacity for further ethics

approved research study in HTM for evidence of specific clinical outcomes and/or cost analysis

Make recommendations on features that will meet future needs including electronic medical record (eMR)

compatibility, live stream data, real-time notifications to staff, patient prompts, Dashboard indicators for

improved care team patient management and in-home videoconferencing

Recommendation 3

That WNSWLHD strengthen capacity within its Aboriginal Health workforce and Aboriginal Health Service partners

• Work with WNSWLHD Aboriginal Health Directorate for supported inclusion of Aboriginal Health workforce in

HTM service provision and incorporate as advanced practice into Professional Portfolio of Practice

• Develop a community Clinical Deterioration training module and competency better suited to community and

Aboriginal Health Service workforce and advocate for inclusion on NSW Health state-wide Learning Management

System

1. As the proportion of the population within the region suffering one or more chronic conditions is attributable to

remoteness and Aboriginality, the comparative ease in which clients of the Bila Muuji ACCHSs have been

enrolled in HTM is an early success and should be explored further as a means of better managing chronic

conditions in WNSW

2. Implementing HTM may expose gaps in WNSW workforce skills, capacity and systems and how we detect and

respond to patients in the community who are at risk of deterioration.

3. Implementing HTM will challenge WNSW health professional workforce beliefs and culture about supporting,

enabling and empowering patients to self-manage with additional biometric data


INTRODUCTION

Western New South Wales Local Health District (WNSWLHD) is a large rural/remote District with 38

health facilities covering 250,000 square kilometres. In 2016 WNSWLHD has a population of 279,200

people, of which 11.8% identify as Aboriginal or Torres Strait Islander. Bila Muuji Aboriginal Health

Services Co-operative has eleven member Aboriginal Community Controlled Health Services (ACCHS)

within the District.

WNSWLHD is one of three demonstrator districts for the NSW Integrated Care Strategy. The WNSWLHD

Integrated Care Strategy formed a partnership between the LHD, Western NSW Primary Health Network

(WNSWPHN) and the Bila Muuji Aboriginal Health Services Co-operative with the aim to:

Transform existing services into an integrated Western NSW system of care that is tailored to the

needs of rural and remote communities, and improves access to care and health outcomes, with

particular focus on closing the gap in Aboriginal health. (21)

Under the Integrated Care Strategy, innovative models of care are being developed to improve health

outcomes, patient experience and enhance system inefficiencies. NSW eHealth Strategy is enabling new

technologies like the electronic Medical Record (eMR), telehealth and remote patient monitoring to

support consumers and healthcare providers to better communicate with each other and increase

access to healthcare services. WNSWLHD’s Strategic 2016-2020 plan’s vision is to become Australia’s

first digital health region by implementing eHealth technology and systems with our key community

partner (18)

Remote patient monitoring allows patient biometric information to be gathered remotely or in the home

so that it can be reviewed in conjunction with information held in the patient record or a shared care

tool. Remote patient monitoring regimes may be part of a recommended pathway for managing a

condition, set up as an alternative to hospitalisation, used to track the health of remote patients who

cannot make it to a facility or used as part of a formal care plan (1). Remote monitoring is not an end in

itself; rather it is an enabler in supporting new and innovative models of care. Successful implementation

and realisation of benefits requires remote Home Tele-Monitoring (HTM) to be integrated with other key

factors such as clinical governance and change management.

In WNSWLHD, long-term (HTM) has been available since 2013/14 from non-government organisations

(Integrated Living and Carewest) for people over 65 years with chronic disease. HTM can be delivered as

a single service or under the Commonwealth Home Support Program (CHSP). Clients are trained to self-

measure at home and provided with biometric devices linked via a web portal to the service provider.

Time from referral to connection of patient can take a minimum of 1-2 weeks or under CHSP could be

several months. Services can include monitoring daily vital signs by service nurse provider, video-

conferencing, messaging and providing reports for other members of the patient’s health care team.

Literature Review

Systematic reviews and meta-analyses of HTM programs have differed in scope, analysis and

methodological quality which make it difficult to interpret available evidence (12). Telehealth evaluation

can be complex with a great variety of potential inputs, outputs, outcomes and stakeholders which may


explain the lack of an established telehealth evaluation protocol and hindering decision-making to

implement wide scale initiatives (2). A 2015 Cochrane Systematic review (3) demonstrates that

supporting people with heart failure using information technology can reduce rates of death and heart

failure-related hospitalisations, improve people’s quality of life, knowledge about their condition and

self-care. Most patients, even those who are elderly, are adaptable and can learn how to use the

technology easily and are satisfied with these interventions. Quality of evidence for primary outcomes in

the review was rated as very low for all cause hospitalisation to moderate for all-cause mortality and

heart failure related hospitalisations.

The Australian National Heart Foundation (ANHF) Guidelines (7) makes a Grade A recommendation that

remote management assisted by structured telephone support and tele-monitoring should be

considered for patients who do not have ready access to a Cardiac Heart Failure program. Australian

Guidelines and current expert consensus (20, 8) recommend that home blood pressure (BP) monitoring

offers advantages beyond clinic BP measurements in terms of better evaluation of BP control, better

prognostic indication, greater engagement of patients and improved compliance with drug therapy.

Commencing in 2012, the Australian government funded a number of telehealth pilot projects under the

NBN-enabled Telehealth Pilots Program. One of the larger studies with Commonwealth Scientific &

Industrial Research Organisation (CSIRO) (11) found after one year of home tele-monitoring across

diverse sites there was a 46% reduction in rate of MBS expenditure; 25% reduction in rate of PBS

reduction; 53% reduction in rate of admissions to hospital; 75% reduction in rate of length of stay;

40% reduction in mortality; 83% user acceptance of technology and 89% of clinicians would recommend

HTM to other patients. An economic analysis was undertaken based on these results and applied to an

operational model of one clinical care coordinator managing 100 patients and suggests that;

For chronically ill patients, annual expenditure of $2,760 could generate a saving of between

$16,383 and $19,263 per annum;

LHD’s and PHNs are well positioned to implement and manage tele-monitoring services and clinical

triage call centres and;

People aged over 65 with complex chronic conditions and multiple co-morbidities who are admitted

to hospital at least once each year would benefit from home tele-monitoring.

The report found that success metrics for the deployment of telehealth services relate more to on-site

clinical leadership, capacity to accommodate change and the flexibility of existing processes and

systems (11). This finding is reinforced by experiences of the trials contained in this report.

A systematic review on outcomes with telehealth with Aboriginal and Torres Strait Islander people (4 )

found a predominance of descriptive studies and small sample sizes but recommended that telehealth

models of care facilitated through partnerships between Aboriginal Community Controlled Health

Services (ACCHSs) and public hospitals have potential to improve both patient outcomes and access to

specialist services for Indigenous people.

BACKGROUND

March 2015, the NSW Health Rural e-Health strategy allocated four rural Health Districts $120,000 to

undertake proof-of-concept trials of remote HTM with Home in the Hospital (HitH) patients.


In March 2016, NSW Health HitH directed $230,000 to “develop pathways of care around chronic

disease pathways with Aboriginal people to prevent Emergency Department presentation and

hospitalisation”. With the WNSWLHD HTM trial already underway, the value and opportunity to share

recently developed resources and knowledge with Bila Muuji, one of our key community partners, was

recognised and a second adjunct trial was commenced.

Two options were presented to the Bila Muuji executive – to use the one-off funding to commission a

third party provider to conduct a HTM service on behalf of the ACCHS’s for 1-2 years or build on existing

WNSWLHD/ACCHS relationships to share knowledge, strengthen local capacity and integration over the

long term. The latter was the preferred approach by both partners. Eight of the eleven ACCHS’s of Bila

Muuji are participating in the trial.

PURPOSE AND OBJECTIVES

The initial purpose of the proof-of-concept trials from NSW Health were to test remote HTM in the HitH

setting as an enabler to delivering more in-home care and reducing hospitalisations. However, several

factors limited trial implementation and objectives for WNSWLHD:

Short timeframe for the submission, implementation and evaluation back to NSW Health which

prohibited full exploration of suitable cohorts and models of care;

Limited knowledge with the application of remote HTM with rural health clinicians and patients;

Initial consultations with HITH services revealed considerable apprehension from the workforce.

Therefore, WNSWLHD objectives include testing and evaluation of the following;

Objective Measure

1. Acceptance and relevance of tele-home monitoring with a variety of clinicians and patients.

Demographics of staff and patient uptake,

2.Useability of tele-home monitoring within a range of existing service delivery models

Pre and post-trial staff confidence and usability with the technology, perceived patient benefits and workload impact

3.Improvements in patient knowledge of symptoms and capacity to self-manage

Patient reported experience

METHOD

Planning: Choice of vendor and purchase of equipment was driven by the short-time frame for

expenditure. TeleMedcare was the vendor of choice due to range of equipment available to purchase;

ease of device set up and their partnership with the CSIRO trial in 2013/14.

As HTM is an emerging technology within NSW Health – there was a lack of robust protocol or guidelines

to support trial implementation. Local community providers had not yet developed the policy or

governance documents rigorous enough for guidance of public health facilities and staff. The ACT Health

Home Tele-Monitoring Standard Operating Procedures (9) were adapted for use in WNSWLHD.


Initial consultation with HitH Nurse Managers, Medical staff, Clinicians, PaCH Nurse Consultant,

Integrated Care and Information, and Health Information & Communication Technology (HICT) staff was

conducted via teleconferences and a workshop in October 2015.

Training: WNSWLHD Trial – between March and October 2016, information and initial training sessions

were provided. Target clinicians to conduct HTM were PaCH Nurses across nine sites of Bathurst,

Orange, Dubbo, Parkes, Cowra, Mudgee, Cobar, Molong and Wellington.

Bila Muuji Trial –initial training was held at Wellington and Walgett in October 2016 and mop-up

training or information sessions provided afterwards to those who couldn’t attend initial training or new

staff. Target clinicians to conduct HTM were ACCHS Practice Nurses and Aboriginal Health Practitioners

and Workers.

Trial Design Type: The design was broadly an adaptive proof-of-concept trials. Whilst objectives, project

plans and evaluations were scoped, limited time meant that ethics approval was not sought and the

trials had to take a more quality improvement approach. The main intent of the trials was to test the

process of implementing HTM technology into the rural workplace to inform NSW Health, WNSWLHD

and Bila Muuji Executive, Integrated Care Strategy and others doing similar work.

Evaluation – was obtained via demographics of the patient enrolments; pre and post-trial staff surveys;

post-trial patient surveys and project team observations on the implementation process and interactions

with clinicians and patients.

Site and patient selection: Due to the short-time frame to report trial findings back to NSW Health, the

project team decided to offer supported testing in a range of different sized sites.

WNSWLHD Trial (May 2016-June 2017) Target patients:

1. HitH inpatients (Bathurst, Dubbo, Orange, Parkes)

2. Community outpatients with one or more chronic conditions (all sites).

3. Integrated Care outpatients - outpatients risk stratified and enrolled in local Integrated Care

Program at wave one demonstrator sites (Cowra, Cobar, Molong, Wellington)

Bila Muuji ACCHS Trial (October 2016-December 2017) Target patients: ACCHS outpatients with one or

more chronic conditions at Bourke, Brewarrina, Coonamble, Dubbo, Forbes, Orange, Walgett and

Wellington.

Guidelines and Training: Guidelines, professional tools, patient resources, training and support

strategies were drafted with review points to incorporate iterative changes provided by feedback from

staff and patients during the trial.

Daily Monitoring – local clinicians designated for enrolled patients were responsible for checking their

client’s data once daily Monday to Friday. Both clinical leads for each trial also reviewed the web portal

once daily Monday to Friday and followed up with site staff if patient or technical anomalies were

noticed. Weekend readings were checked on Mondays. An additional safety net during the initial twelve

months of trial included the purchase of remote daily checking by TeleMedcare, who would contact the

LHD or write in the patient’s portal notes if an anomaly was observed but did not contact patients.


Equipment: (37) sets of equipment were purchased for WNSWLHD Trial and (20) for Bila Muuji Trial

from TeleMedCare. Patient Home sets (see Picture 1) included a HUB communications device and an

automated PC-303 Spot-Check Monitor (Shenzhen) with peripherals for blood pressure, temperature,

blood glucose, oxygen saturation, weight and ECG. A hand-held spirometer was included in the set but

withheld during initial trials as many PaCH nurses did not have current competency in spirometry.

Medical equipment adhered to Australian Regulatory Guidelines for Medical Devices Class IIa. All patient

devices, including scales, were also checked by WNSWLHD Biomedical department prior to use to ensure

reliability and precision. Data was transmitted to a secure website via 3G mobile network provider

(Telstra).

Picture 1: TeleMedCare Patient Home Hub (transmitter) and Spot Check Monitor with attachments for

Blood pressure, pulse oximetry, blood glucose and 3 lead electrocardiogram.

Timeline: Figure 1 illustrates the time line of both trials (see below).

Figure 1: Diagram of WNSWLHD and Bila Muuji HTM Trials Timelines


RESULTS

Results will be presented and discussed under the three objectives of the trials; 1. Acceptance and

relevance of HTM; 2. Usability of HTM within existing service models and 3. Patient Knowledge of

Symptoms and Self-Management

4.1 WNSWLHD Trial - Acceptance and relevance of tele-home monitoring.

A total of (54) WNSWLHD staff were involved with the program of which (43) staff attended the

information session with (36) staff completing the training from across 8 sites in WNSWLHD. Note that

some staff attended either the information session and/or the training. Of the WNSWLHD staff that

participated in the program (77.8%) identified as working in the nursing profession, followed by medical

(11.1%) and allied health (7.4%), with both ambulance and Aboriginal Health workers (1.9%) each.

During the WNSWLHD trial period to 30/6/2017 a total of (20) patients were involved in the HTM trial, of

which (17) had been discharged and (3) were still being actively monitored. Patients were more likely to

be located in a regional area (16) and the remaining residing in a remote area (4). Table 1 lists health

facility site enrolments and the number enrolled in each of the three cohorts of HITH (7), Community

outpatients (11) and Integrated Care enrolled outpatients (2). The most common diagnosis on admission

to the HTM was cardiovascular disease followed by respiratory disease, (6) and (5) cases respectively.

Multiple conditions were noted for (5) of the participants and included a minimum of two chronic

conditions (Table 2). The average age of a HTM patient was (68) years old (range 27-89 years); with

females being slightly more represented (12:8). The average number of days per patient spent enrolled

in HTM was (31.9) days (range 5-149 days).

Table 1: WNSWLHD Health Service trial enrolments June16-June 17

Facility Outpatients

HITH Inpatients

Integrated Care enrolled outpatients

Total enrolments Trial to date

Active D/C Active D/C Active D/C

Orange 2 1 0 0 4

Dubbo 0 3 0 0 3

Bathurst 0 0 0 3 0 3

Parkes 0 0 0 4 0 4

Cowra 0 1 0 0 0 0 1

Mudgee 0 0 0 0 0 0 0

Wellington 0 1 0 0 0 1

Cobar 0 2 0 0 0 2 4

Shared Pks/Orage

1

Total 4 8 0 7 0 2 20

Source: Patient data WNSWLHD HTM Trial 2016/17 June Report

Table 2. Primary diagnosis of WNSWLHD patients on entry to HTM.

Primary Diagnosis (n)

Cardiovascular disease 6

Respiratory condition 5

Hypertension 4

Multiple chronic conditions 5 Source: Patient data WNSWLHD HTM Trial 2016/17


Table 3 lists the reasons for patient discharge from the program and as of 30/06/2017, there were 3 patients

actively participating in the program. Hardware issues with the equipment were identified in early stages of

the WNSWLHD trial and (2) participants had to be discharged for this reason. Of the two patients that were

admitted to discharge, one for the continuing management of hypertension and the second due to

deteriorating health status requiring more intensive management. Of the (20) trial patients, (3/17)

discharged patients were referred to community providers to continue long term monitoring and (2/3) of

the active patients will be referred – representing (5/20) 20% referral on discharge to third party providers.

Table 3. Reasons for WNSWLHD HTM patient discharge as of 30/06/2017

Reason for discharge (n)

Completed program 13

Hospital admission 2

Hardware fault 2

Active, ongoing 3 Source: Patient data WNSWLHD HTM Trial 2016/17

4.2 Bila Muuji ACCHS Trial – Acceptance and relevance of tele-home monitoring.

The Bila Muuji ACCHS trial is still in progress and a more comprehensive report will be completed in

December 2017. A total of (38) ACCHS staff have completing a training session from across (8) ACCHS’s. Of

the ACCHS staff that participated in the training (47%) identified as working in the nursing profession,

followed by Aboriginal Health Workers (32%) and Aboriginal Health Trainees (15%) and Medical (5%) and

each. Other information only sessions have been provided at most ACCHS to general staff.

During the period October 2016-June 2017, a total of (24) patients enrolled through an ACCHS as part of the

HTM, of which (2) patients enrolled twice bring the total occasions of service to (25). Of those admitted into

HTM a total of (14) have been discharged by 30/06/2017 with (11) actively being monitored in June. The

most common diagnosis on admission to HTM was for multiple chronic conditions (18), indicating that

Aboriginal clients enrolled in HTM had higher and more challenging co-morbidities (Table 5) than those

enrolled through WNSWLHD (Table 3). The average age was (66) (range 32-87 years) which is slightly

younger than the WSNSWLHD average, with slightly more females (14:10) than males represented in the

cohort. For patients where there was data completeness so far (12/26) the average number of days per

patient spent enrolled in HTM was (30.5) days (range 4-79 days). Patients enrolled through ACCHSs were

more likely to be remotely located (16) with only (8) residing in a regional town. Table 4 below shows site

activity so far. As the trial is incomplete at time of this report - discharge reasons have not been provided

from ACCHSs.

Table 4: Bila Muuji ACCHS HTM Trial Activity in June 2017 Source: Patient data Bila Muuji HTM Trial

Facility Outpatient with chronic disease

Total enrolments Trial to date Active D/C

Bourke 1 3 4

Brewarrina 1 6 7

Coonamble 0 2 2

Dubbo 2 1 3

Forbes 2 0 2

Orange 1 0 1

Walgett 3 0 3

Wellington 1 1 2

Total 11 14 25


Table 5. Primary diagnosis of ACCHS patients on entry to HTM.

Primary Diagnosis (n)

Cardiovascular disease 1

Respiratory condition 0

Hypertension 3

Multiple chronic conditions 18

Diabetes 2 Source: Patient data Bila Muuji HTM Trial Data

4.3 Useability of tele-home monitoring within existing service delivery models

Pre-trial Staff Survey – WNSWLHD and ACCHS clinicians (36) returned surveys at completion of initial

training. Key findings were:

Confidence with HTM after training - (97%) identified as being confident or somewhat confident and (79%-90%) would recommend to other clinicians and eligible patients.

Managing trial in current workload – (52%) believed it would be easy/very easy, with the remaining participants feeling neutral.

Usability – (90%) believed HTM looks easy to use though (69%) indicated that they believed they would need technical support.

Perceived Benefits to Patients – (97-100%) agreed/strongly agreed HTM would improve patient’s knowledge of their condition and allow them to better manage their condition.

Common perceived benefits of HTM included increased patient ability to self-manage their conditions,

reducing presentations to hospital and/or early discharge. Currency of measurements and ability to see

trends over time with graphs supported clinicians being able to monitor chronic conditions. Time saved

by either patient or staff by not having to travel to clinic or as frequent home visits was seen as a key

benefit given the rurality of the region.

Common Limitations or barriers identified included patient /Nurse/GP and/or GP compliance; and the

time required for home visits and the initial setup.; Lack of monitoring after-hours; an adverse impact on

patient anxiety; poor Telstra 3G network coverage in remote areas and changes to workforce could

disrupt continuity of service.

The staff survey conducted after 12 months was not linked to the pre-trial survey as a proportion of the

staff attending training sessions did not actively enrol and manage patients in their workplace.

Post-trial staff survey – WNSWLHD and Bila Muuji ACCHS clinicians who used the equipment with

patients were surveyed in June 2017 with (20) responses from staff received. Of these responses (11)

were from WNSWLHD staff and (9) from ACCHS staff. Key findings were:

Communication amongst the team and with clients – (78-56%) identified communication between staff being very easy or easy, the only staffing groups where staff did not feel it was easy or very easy to communicate with was specialists and GPs (33%) and (47%) respectively.

Use of equipment and website – (31%) of respondents felt that the equipment was difficult/very difficult to use with (71%) indicating that the website was easy/very easy to use.

Patient outcomes – (74%) of respondents believed HTM would provide improved health benefits to clients with (89%) indicating that patients were able to better identify symptoms as a result of HTM.


Health system benefits – (89%) agreed/strongly agreed HTM would provide early detection of a client’s condition, though (39%) agreed/strongly agreed that HTM would result in preventable ED/Inpatient presentations and (44%) agreed/strong agreed that patients admitted would have a reduced length of stay. Yet respondents reported (67%) overall satisfaction with HTM with respondents willing to recommend HTM to clients and other clinicians (94%) and (76%) respectively.

The main challenges of the service model identified by clinicians was attaining and maintaining skills to set

up the equipment with the patient; documenting in two separate places and remote device reliability

(network access, technical glitches and biometric variances of automated equipment).

The main themes identified for limitations of implementing the HTM service were workforce capacity and

procedures. The main themes on benefits of the service model were empowerment of the patient,

collaboration between internal and external team members and as a tool for better patient education and

management.

4.4 Improvements in patient knowledge of symptoms and capacity to self-manage

Client of both trials are asked to complete a survey after discharge from the HTM service. Only WNSWLHD

trial client responses are included in this report. (15) Client responses were received (79% response rate).

Loss to follow up occurred when nurses forgot to provide the survey to the patient in the immediate

discharge period and patients could not be re-contacted at a later date.

Satisfaction with technology – 93% of clients felt very confident with using the HTM technology

Satisfaction with the Service - 100% of clients were satisfied with the HTM service provided by

staff involved in the trial

Improvement in patient knowledge of symptoms and capacity to self-manage - 100% of

patients strongly agreed/agreed that HTM improved their knowledge of symptoms and

80% strongly agreed/agreed that they were better able to manage their health condition.

Anxiety – (11/15) or 73% strongly disagreed or disagreed that seeing their vital signs increased

their anxiety, and (2/15) or 13% agreed that their anxiety was increased. (2/15) were neutral or

unanswered.

During post-trial patient experience interviews patients often stated how they felt the HTM gave them

additional information to make decisions about their own health care. One patient, during the post-trial

interview discussed how she has been monitoring her blood pressure at home for labile blood pressure and

hypotensive episodes and had provided two weeks’ worth of data to her GP. He changed her medication but

reassured her that she didn’t need to monitor her blood pressure so often, as’ doing it too often, would

make her anxious’. When asked by the interviewer if it did make her anxious, she replied “No, if I felt unwell

and my blood pressure was too low then I would just go and lie down. But now, after the GP changed my

medications at my last visit, it’s not happening so often so I won’t need to check as often as I did.”

Overall, 93% of respondents indicated that if required for their health, they would like to continue with the

HTM – the 1/15 patient who did not want to continue HTM stated that she had found it very useful to have

in the immediate period following discharge from hospital whilst still recovering from an acute illness but did

not see the necessity to have HTM all the time.


4.

5.

DISCUSSION ACCEPTANCE AND RELEVANCE

Generally, uptake or enrolments of patients by WNSWLHD PaCH nurses with HTM over the twelve month

period were small. Enrolments with outpatients with cardiovascular disease were the highest cohort in the

WNSWLHD trial (6) and those with multiple chronic conditions in ACCHSs (18). Enrolments in smaller HItH

facility were more sustained and continue to enrol where one HItH nurse gained confidence and was the

lead (Parkes) compared to a large site (Bathurst) where momentum and skills with many nurses was difficult

to maintain. Orange and Dubbo HitH services did not engage in the trial. Enrolments in integrated care sites

were low (n=2) but these small sites had implemented significant changes in the two year period and

possibly were change fatigued. Project team initial training and support capacity to increase momentum was

also limited.

It is important to frame the enrolment results within context. From the four NSW LHD’s who trialled HTM,

WNSLHD had the highest number of enrolments and the most comprehensive evaluation. As a comparison,

another LHD, who commissioned a third party NGO to do HTM on their behalf, with more narrow patient

criteria, enrolled only one patient during the twelve month trial period. NGO’s in WNSWLHD reported small

numbers of enrolments referred from GP’s and PaCH Nurse in the period prior to the trials. Enrolment

uptake may be related to the newness of the technology, Australian health practitioner’s knowledge and

familiarity of the concept, research ambiguity and current marketing, access and integration.

Positive perception with the concept of HTM during training sessions was high and this was reinforced by the

post-training/pre-trial survey. Post-trial staff surveys still showed a highly positive perception with the

concept of remote HTM, both in perceived patient benefits and recommending to other patients – however,

clinicians in both WNSWLHD and ACHHS found the implementation process a challenge. The Bila Muuji

ACCHS staff did progress to enrolling more patients more quickly. This was most likely influenced by;

Initial technical issues with tablets in WNSWLHD trial delayed enrolments and affected staff and

patient confidence;

Resources, knowledge and experience with HTM by WNSWLHD staff in the consultation and

planning stage - WNSWLHD staff were initially more apprehensive with HTM doing more harm or

Case Study 1

An 80 year old gentleman in Orange with

emphysema, heart disease and lung cancer had

multiple admissions to hospital. At the last

admission in January 2017, the Nurse Practitioner

assisted to set him up with home tele-monitoring.

His hospital admissions and ED presentations

reduced as by May, he had still not presented to

Emergency or been admitted to hospital.

“I felt safer – I could check myself if I felt unwell. I

was looking after myself better as I knew what

was going on”

Case Study 2

A 74 year old lady with heart and lung disease and cancer

was admitted to Parkes Hospital for low blood pressure,

shortness of breath and dizziness. The Hospital in the

Home Nurse set her up with home tele-monitoring

equipment on the ward for 24 hours which enabled her

leave the ward and transferred to Hospital in the Home

for 4 days.

“When you are in hospital, you become so reliant on

medical and nursing staff and worry about whether you

are going to cope going home. It was really

comforting…I didn’t want to leave hospital but I didn’t

want to BE in hospital – this was an in-between.”


the unintended outcome of increased anxiety in patients becoming more involved in their clinical

measurements. WNSWLHD staff expressed more concern for liability for missed deteriorations,

adverse patient outcomes and how they were going to manage the data “If we have this additional

biometric data then we have to do something with it”. This was possibly exacerbated by the

WNSWLHD staff being involved in the initial consultation stage, when guidelines and governance

processes were still being sourced and general knowledge was low. By comparison, when the Bila

Muuji ACCHS trial commenced, there was a complete set of draft resources and more positive

patient experiences and knowledge of how to use the HTM with local patients.

ACCHS staff generally did not convey during training that their clients would be more anxious or

unable to participate in HTM whereas this was a concern raised by WNSWLHD staff. ACCHS staff

were more vocal in wanting to support anything which would increase access to services which

might improve the empowerment and health of their communities. (See critical factor 1)

USERBILITY OF HTM WITHIN A RANGE OF SERVICE DELIVERY MODELS

Resources

Tablets initially purchased for the WNSWLHD trial were returned to vendor in July and replaced with hubs

due to ongoing technical issues affecting staff and client faith in trial. As a result, videoconferencing capacity

and patient clinical surveys were not available for trial, however, neither features on the tablets were being

used at that point. Overall, the Hub sets were simple and fast to use, and the web portal was easy to

navigate.

Most selected rural/remote patients could access HTM using the local 3G mobile network service provider;

however, some remote sites required a booster antenna and did experience fluctuations in connection.

Logistics management was significantly underestimated due to the number of devices, limited initial skills

with technical issues and assisting multiple staff over multiple sites. This improved over time as project team

and clinicians became more skilled.

The following table 6 outlines the costs of the equipment and portal.

Table 6: HTM Trial Costs

Equipment Cost per unit (Au $ 2017) Frequency of cost Provider

HTM Hub Set $1,100 Once only NSW Health eHealth Strategy Grant Web portal $240 Annual per device Grant 16/17, Integrated Care 17/18 HTM consumables

$60 Annual WNSWLHD eHealth Strategy Grant

Patients had negligible costs in the trial – they only had to provide an electricity outlet in their home.

Electricity costs for running the HTM equipment was estimated by the vendor at five cents per week. As the

trial funding was external to WNSWLHD and Bila Muuji ACCHS’s, participating facilities did bear any direct

costs in 2016-17.

Critical Factor 1

As the proportion of the population within the region suffering one or more chronic conditions is

attributable to remoteness and Aboriginality, the increased ease in which clients of ACCHSs were

enrolled in HTM is a success and should be explored further as a means of better managing chronic

conditions in WNSW


At time of report, both WNSLHD and Bila Muuji ACCHS have sufficient number of devices and do not require

any additional purchases. The Integrated Care Strategy has met the web portal costs ($8,800) for the 37

current WNSWLHD devices to enable continued use in 2017/18. The initial grant allows Bila Muuji ACCHS to

continue HTM until December 2018 with their (20) devices. Existing project or clinical staff time was

provided in kind and as an indirect cost was not a variable being collected in the trials.

Governance

Interactions with staff in both trials revealed variation with both clinician technique and quality of client

education provided on self-measurement. Subsequent training will require more emphasis on ensuring a

standardised approach to client education.

NSW Health policy PD 2014_004 for Recognition & Management of the Patient who is Clinically

Deteriorating (15) were adapted for the trial for people living at home - both HiTH inpatients with an acute

illness and community outpatients with a chronic condition. Community nurses and ACCHS staff found it

challenging to manage or escalate (according to set criteria) outpatients with chronic disease, who

frequently had measurements in the amber or red zones but otherwise felt well. There are more variances

in the community setting which influences biometric measures and management action. With the exception

of patient activity, variances including patient technique and compliance, patient conditions, limitations of

automated devices, access to a GP, access and compliance to treatment in the community and clinician skill

and confidence with escalation. Variances may be more immediately controlled in the acute setting as

clinicians can do manual measurements more easily, check patient compliance and equipment calibration

and can more quickly consult/escalate to senior staff. This is more challenging to mimic remotely in the

community setting. More work is required in training staff to interpret and action trending of biometric data

rather than one-off measurements. (See critical factor 2)

Initially, both trials experienced gaps in clinician adherence with documentation their daily checks and/or

management actions on the portal in addition to the medical record, when patient measures were not

between the flags; however, this improved as greater understanding of the new procedures were gained by

both project team and clinicians.

Managing HTM did increase workloads initially – both in supporting the patient to use the equipment and

following up if vital signs varied from the set parameters but nurse time was not a measured in this trial.

While not a contraindication, automated monitoring may be limited in some patients including (but not

limited to) those with irregular heart rate and arrhythmias (3) due to equipment using algorithms to

calculate estimated heart rate per minute. Staff need to be knowledgeable of limitations, complete full

manual measurement and assess patient suitability on enrolment. Staff familiar with the clinical history of

the patient would easily be able to factor this in when interpreting vital signs.

Provision of long term HTM is a growing industry and clients who would benefit from this may be referred to

third party providers. To date, NGO provision of HTM is an unregulated industry. At present there are no

community providers in the WNSWLHD who can provide immediate, short-medium term HTM with the

Critical Factor 2

Implementing HTM may expose gaps in our workforce skills, capacity and systems and how we detect and

respond to patients in the community who are at risk of deterioration.


integration that the WNSWLHD and partners would expect. Government telehealth documents have been

dominated by eMedical Records (eMR) and videoconferencing between health professionals and patients.

Remote HTM has been a smaller component and remains an area to be further developed. Therefore, report

Recommendations (1) and (2) for WNSWLHD executive approval include;

Workforce and change management

The project team significantly underestimated the time required for planning, drafting of documents,

logistical management of equipment and consumables, managing technical issues and overall culture change

required to support the WNSWLHD trial. It was assumed that staff would be fully engaged and embrace the

role of HTM as a tool to support both client and health service in the management of chronic conditions in a

community setting. WNSWLHD staff in particular were concerned about the anxiety of patients reviewing

their vital signs which may have impacted on uptake of the trial. This was not observed amongst the staff of

the ACCHSs which were able to enrol more patients and was keen to involve the patient in the management

of chronic conditions.

No additional staffing was provided for WNSWLHD and existing Integrated Care roles were used to

implement the trials. HTM is new and it was a challenge for WNSWLHD to source the right mix of local

people with the skills, capacity or interest within existing roles to sustain a broader implementation group

for the length of the trial. Teleconferences and site visits were used with better effect in the Bila Muuji

ACCHS trial by recruiting 0.6FTE AMS Project Nurse Lead to sustain engagement, momentum and support.

Only PaCH Nurses were targeted initially in WNSWLHD; however, the Bila Muuji ACCHS trial targeted

Registered and Enrolled Practice Nurses and Aboriginal Health Practitioners, Workers and Trainees. The trials

Recommendation 2

That WNSWLHD and community partners establish a HTM Leadership Group to provide ongoing guidance and

advice for remote HTM as part of the broader WNSWLHD Telehealth Strategy including;

Recommending which patients and clinical situations should use HTM that would most likely lead to improved

patient outcomes. Whilst there is scope to test HTM with other patient cohorts – current research indicates that

there may be more potential in the management of patient s with cardiac heart disease.

Review current trial draft documents and make recommendations for final Guideline and other supporting

documents for executive approval, including action plan, compliance, auditing and evaluation measures and

report on same monthly

Review the literature with support of affiliated research partners to determine scope and capacity for further

ethics approved research study in HTM for evidence of clinical outcomes and cost analysis specific to WNSWLHD

Make recommendations on features that will meet future needs including electronic medical record (eMR)

compatibility, live stream data, real-time notifications to staff, patient prompts, Dashboard indicators for

improved care team patient management and videoconferencing

Recommendation 1

That WNSWLHD conservatively support remote HTM by maintaining current level of HTM equipment for 2017-

2019 and;

Continue current scoping with community partners (Bila Muuji ACCHS and WNSWPHN), Patient Flow & Transport

Unit (PFTU), WNSWLHD Telehealth strategy and Primary and Community Health Nurses (PaCH) 2020 Framework

for their roles in supporting an integrated, telehealth model of care (Appendix 1).

Model to develop how PFTU is able to provide future access to specialist support for monitored clients of both

WNSWLHD and Aboriginal Health Services.


identified that the Aboriginal Health Workforce has more potential to participate in HTM, particularly in the

management of chronic disease for Aboriginal people.

HTM is a tool in a suite of health service delivery and like all tools, the potential for clinical benefits will be

influenced by the skills of the people (clients and staff) who are using it – to apply correctly, recognise and

respond to anomalies and escalate care. HTM requires an integrated system of well trained staff wrapped

around the patient. Therefore, a system with role delineation and clinical governance specific to a HTM

service model would require effective clinical training, support and supervision of both patients and

monitoring staff. If WNSWLHD executive and partner facilities wish to progress to an integrated service

model using HTM, then a suggested model and roles are provided for consideration in Appendix 1.

Improvements in patient knowledge of symptoms and capacity to self-manage

After resolution of initial hardware issues, similar to the CSIRO trial, WNSWLHD patients indicated high

confidence and satisfaction with the technology.

A common behaviour observed during the trial was medical and nursing staff unfamiliar with HTM, were

more apprehensive or made a decision on behalf of a client, assuming that because of their age or other

factors, they would not ‘cope’ or would become ‘anxious’ with HTM. Despite 29% of patient respondents

reporting that seeing their vital signs did increase their anxiety, 93% said they would still like to continue. As

one patient stated during their survey interview – her anxiety was more related to her general state of

health at that time rather than the effect of seeing her vital signs. Rather than an assumption that an

unintended outcome of HTM in itself maybe increased anxiety, further research or effort might be required

into the other factors which may influence patient anxiety in HTM. These might include objective

assessment of patient/carer capacity, data/equipment reliability or variance and most importantly the

capacity of the HTM staff to effectively train and support the patient. (See critical factor 3)

Limitations of the trial included short timeframe for implementation which prohibited full exploration of

suitable cohorts and models of care, rapid development of processes and seeking of ethics approval.

Strength of evidence in terms of clinical outcomes as an alternative to usual care is not as rigorous as we

would have preferred. Limited knowledge of application of remote HTM with generalist rural clinicians and

patients; small patient numbers and broad range of patients/staff and sites increases the heterogeneity of

Recommendation 3

That WNSWLHD strengthen capacity within its Aboriginal Health workforce and Aboriginal Health Service

partners in regard to increasing access to HTM training, support and supervision via WNSWLHD and PTFU

specialist staff;

Develop and evaluate a community Clinical Deterioration training module and competency better suited to

community and Aboriginal Health Service workforce and advocate for inclusion on NSW Health state-wide

Learning Management System

Advocate for key community partners (AHS & PHN) access to NSW Health’s Learning Management System

Work with WNSWLHD Aboriginal Health Directorate for supported inclusion of Aboriginal Health workforce in

HTM service provision and incorporate as advanced practice into Aboriginal Health Practitioner Professional

Portfolio of Practice

Critical Factor 3

Implementing HTM may actually challenge our health professional workforce beliefs and culture in

supporting, enabling and empowering patients to self-manage


results. WNSWLHD staff compliance with patient surveys contributed to 20% loss to follow-up. Limited

return of pre and post staff evaluations introduces selection bias.

Conclusion

The trial goal was to test implementation of THM technology into rural health workplaces and provide

information for NSW Health and this is still ongoing with the Bila Muuji trial. Due to the previously stated

limitations, the process measures (number of staff trained, number of patient enrolments and staff reported

experiences) and outcome measures (impact of HTM on the health status of the patient) are able to provide

some useful information in terms of service delivery and potential future models. Whilst clinical trials

provide highest strength of efficacy (does HTM work in a specific patient cohort compared to usual care),

they provide limited information about the effectiveness in WNSW (implementation of HTM in real life) and

efficiency (is HTM a suitable strategy for WNSWLHD to invest in as part of patient management).

Whilst clinical trials continue to evaluate efficacy of HTM in Australia and overseas, the time and numbers of

clients required to achieve power and statistical significance may make it difficult for WNSWLHD to conduct

its own clinical trial. Further discussion on research relevant to HTM in WNSWLHD practice is required and

specifically regarding the qualitative aspect of HTM for patient, staff and the health services.

The success of incorporating telehealth into our existing service model s or service may relate more existing

staff constraints, on-site clinical leadership, capacity to accommodate change and the flexibility of existing

processes and systems (11). Having the evidence and access to digital healthcare technology is not sufficient

– the quality of the data and the workforce practice of using the data as part of holistic assessment to

support, monitor, respond and intervene with community clients is crucial.

The value of the trials in allowing WNSWLHD and Bila Muuji to test current HTM technology in rural NSW

practice has been positive. The trials indicated that for patients with one or more chronic condition, the use

of HTM provided an opportunity to undertake patient education and allow patients to be more involved in

their clinical management. The trials have assisted to identify the barriers, limitations, enablers,

opportunities and better determine ‘our space’ with HTM and move cautiously forward to skill our patients

and workforce with digital technology as part of current and future health service delivery in WNSWLHD.


Appendix 1: Potential Integrated Model for Remote Home Tele-Monitoring

HTM Role Responsibilities:

Role Delivered where

Home Tele-Monitoring Responsibility

1 Client (+ - carer) Home Minimum - Capacity and skills to use HTM equipment correctly, knows how to escalate if concerns Medium - minimum + has a self-management plan, knows how to manage symptoms within plan and escalate if concerned Advanced – medium + may access web portal if desired to see/print own data for self or health professional appts

2 Local Health Team I Aboriginal Health Practitioner/Worker, PaCH EEN/RN, Practice EEN/RN

Home Minimum - Manage equipment, engage, Conduct full manual set of observations and assess patient suitability, quickly initiate HTM, Medium – minimum + participate in daily checking and be competent to detect anomalies or deterioration trends, Advanced – medium + train & support clients, assist in rectifying technical issues and maintain patient engagement for the period of HTM, organise patient for further assessment and escalate to senior health professional, provide data reports

3 Local Health Team II PaCH RN, Practice RN, Nurse Practitioner, GP, THM clinical lead/s

Home, Health Facility or remotely

Provides clinical oversight of patient care, ability to detect and interpret HTM data trends in relation to other available information to assess patient’s overall clinical condition, enable action, change in treatment and/or escalation if required to a more senior/specialist health professional

4 Specialist Team PFTU, Nurse Practitioner, Medical Specialist

Health Facility or remotely

Specialist consultation and intervention

NGO


Appendix 2: Angus’s Story


Appendix 3: Kay’s Story


References:

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