Telehomecare:
Outcomes and Patient Experiences
Heather Sherrard
VP Clinical Services
University of Ottawa Heart Institute
2012
• 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
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
Telehealth Technologies
Broadband connection in the region
Monitoring of patients in their home
Interactive voice response using
automated calling to care for patients
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
Telehome Monitoring Technology
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
↓ mortality
↓ LOS
Antonicelli, R. et al
(2008)
RCT n=57
12 month f/u
↓ mortality
↓readmission
↑compliance, BB & statin
use, health perception
Woodend, K. et al
(2008)
RCT n=249 ACS & HF
12 month f/u
↓readmission (ACS)
↑QOL & functional status
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
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
Innovation Diffusion
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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, 0800-1600 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
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
Regional Program
Montfort
TOH-Civic, OGH
QCH
UOHI
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
THM
Funding
• 75 % of initial equipment funded through grants &
research
• Permanent staff funded through operations
• Leverage to improve bed capacity @ $1000/day,
decrease wait time for admission, improve provider
capacity
• Cost avoidance model
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
Doing the right thing,
at the right time,
in the right place!
cstruthers@ottawaheart.ca