Telemedicine and Group Programmes for chronic diseases

1
Telemedicine and Group Programmes for chronic
diseases

• Dr Elsie Hui, FRCP
• Division of Geriatrics, CUHK
• Community Geriatric Assessment Team,
• Shatin Hospital

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• Telemedicine is the use of medical information
  exchanged from one site to another via electronic
  communications for the health and education of
  the patient or healthcare provider and for the
  purpose of improving patient care.
• Telemedicine includes consultative, diagnostic,
  and treatment services.

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Telemedicine (telegeriatrics) what is it and
why?
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Tele-geriatrics in residential care home setting

• Direct care
• Physician (geriatrician, primary care)
• Geriatric nursing
• physiotherapy occupational therapy
• podiatry
• Specialist consultation
• Dermatology
• Psychiatry
• Others (neurology, radiology .)

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Our History

• 1998 99
• Pilot study
• SAGE Kwan Fong Nim Chee Care Attention Home in
  Shatin
• Medical, nursing, psychiatry, PT, OT, podiatry,
  dermatology
• Extension of telemedicine network
• To other local residential care homes for elderly
  (RCHEs)
• To other hospitals in New Territories and their
  local RCHEs
• To a Home Care service provider
• 2003 - 04
• Community rehabilitation programmes
• DM, OA, CVA, dementia, incontinence

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NTE Geriatric Service Network

• hospitals
• residential care homes
• social centres
• Broadband or ISDN (remote areas)
• Multi-point Videoconferencing machines
• Also capable of connecting to anywhere in the
  world with an IP address and VC machine (386kbs)

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Shatin Hospital Telehealth headquarters
ELCHK Social Services Network in Shatin
A
B
C
D
E
Day Care HomeHelp Community Clinic
Social Centre Home Help
Social Centre Day Care
Social Centre Community Clinic
Social Centre
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Videoconferencing Hardware

• Polycom ViewStation FX
• (HKD 75 000)
• Hospital and remote sites
• USA
• 512kbps (IP/ISDN)
• Multi-point (max 4)
• max 4 video outputs
• 48o field of view

• Tandberg 880
• (HKD 110 000)
• Shatin Hospital
• Norway
• 768kbps (IP/ ISDN)
• Multi-point (max 4)
• max 4 video outputs
• 72o wide field of view

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Video conferencing link
Broadband Network
1.5Mbps
1.5Mbps
Telemed Fibre IP Link
Telemed Fibre IP Link
CA Home / Community centre
Shatin Hospital
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Pilot study

• Intervention
• Shatin CGAT and a local Care Attention home
  were linked via teleconferencing.
• Services provided via telemedicine wherever
  possible.
• Face-to-face visits were conducted if
  telemedicine inadequate for patient management.

• Outcomes
• Feasibility
• Costs
• Services provided limitations
• User satisfaction

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Geriatrician

• Follow-up of old cases
• Triaging urgent medical problems
• Saves time and increases productivity
• Reduced unnecessary AE visits by 10
• Reduced acute hospital admissions by 11 over 1
  year
• Limitations - new patients, chest auscultation

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Nurse

• Assessment
• swallowing test
• Wounds
• placement
• Educate patients and carers
• use of inhaler,
• checking blood sugar
• Act as liaison between in-patient service and
  residential care home
• More frequent review
• Facilitate earlier discharge
• Limitations - complex dressing procedures,
  clients with communication problems

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• Physiotherapist
• Screening new cases
• Reduces waiting time and shortens follow-up
  intervals
• Nursing home staff able to facilitate assessment
  and supervise rehabilitation
• Limitations
• patients with severe communication difficulties,
  examination e.g. auscultation, neurological,
  musculoskeletal
• specialized treatment modalities e.g. TENS,
  manual techniques

• Occupational Therapist
• Useful for screening - better prepared for site
  visit, reduces inappropriate referrals
• Reduces waiting time and shortens follow-up
  intervals
• Closer monitoring
• Limitations
• assessing range of movement
• activities of daily living in real life situation
• environmental barriers
• prescription of splints, wheelchairs and pressure
  garments

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Podiatrist

• Foot screening - nails, between toes, heels
• Assessment of wounds, footwear, gait
• Advise staff and patients on dressing techniques
  and foot protection
• Triaging referrals according to urgency
• Allows earlier discharge from hospital
• Limitations - cannot perform full neurological or
  vascular assessment

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Telemedicine is Cheaper
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User satisfaction

• Patients - depending on discipline, 82 to 95
  were satisfied with telemedicine.
• Nursing home staff - system was user-friendly,
  boosted confidence, enhanced support from
  hospital services.

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Conclusions

• Telemedicine is an acceptable and useful adjunct
  (but doesnt replace) to conventional outreach
  services.
• It enhances the geriatric outreach teams
  efficiency and improves support to nursing home
  residents.
• Costs can be off-set by involving more
  disciplines, linking up with more homes and
  extending hours of service.

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Latest accessories plug play
Mobile video cart
digital camera
electronic stethoscope
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Telegeriatrics publications
Hui E et al. Telemedicine A pilot study in
nursing home residents. Gerontology
20014782-87. Chan WM et al. The role of
telenursing in the provision of geriatric
outreach services to residential homes in Hong
Kong. J Telemed Telecare 2001738-46. Hui E,
Woo J. Telehealth for older patients the Hong
Kong experience. J Telemed Telecare
20028(suppl.3)S339-41. Tang WK et al.
Telepsychiatry in psychogeriatric service a
pilot study. Int J Geriatr Psychiatry
20011688-93. Corcoran H et al. The
acceptability of telemedicine for podiatric
intervention in a residential home for the
elderly. J Telemed Telecare. 20039(3)146-9.
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Management of chronic diseasesin the community
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Chronic disease group programmes

• Chronic conditions
• Diabetes mellitus
• Chronic obstructive airway disease
• Heart failure
• Fall prevention
• Dementia
• Osteoarthritis
• Stroke
• Incontinence
• Content
• group format
• exercise
• education
• discussion
• peer support

• Outcomes
• objective
• subjective
• Qualitative (focus groups)
• face-to-face or via teleconferencing
• Role of lay personnel
• staff of social centres
• volunteers
• patients

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Program Content
Patient Education disease management
Psychosocial intervention focus group peer
support
Exercises Games
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A community model for care of older persons with
diabetes mellitus

• Features
• 8 sessions
• 1 two-hr session / week
• 6-8 patients / group
• 1-2 facilitators (non-professional)
• Subjects
• Diagnosed DM
• 60 yrs
• Community-dwelling
• Setting
• Community centres for elders
• ELCHK in Shatin

• 3 core components
• Education
• Related to DM
• Self-efficacy
• Exercise
• Aerobic and resistance
• Group home exercise
• Psychosocial interventions
• Share experiences problems
• Find solutions as a group
• Peer support

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Exercise training
30 minute-exercise session starting with a
5-minute warm up
10-minute resistance training using elastic
tubing (Theraband)
followed by a 10-minute aerobic dance

• ending with a 5-minute cool down or progressive
  muscle relaxation training.

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• Outcome measures
• QOL
• Diabetes quality of life questionnaire
• SF-36
• DM knowledge test
• 24-hours dietary recall
• Body mass index
• Blood sugar HbA1c level

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Key Findings

• Significant changes (improvement) were observed
  in the following outcomes
• Diabetes Knowledge Test
• Mean post-prandial blood glucose
• HbA1c
• Blood pressure
• Exercise habit
• QOL
• Diabetes QOL questionnaire
• SF-36

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Falls Management Exercise Program (FaME)

• Features
• 36 weekly sessions
• 1 hr / session
• 4 8 subjects / group
• 1 therapist 1 assistant
• Subjects
• Age 65 yrs
• Hx of 1 fall
• Able to walk aids
• living in community

• Setting
• Community centres for elders
• SAGE in Shatin
• Shatin Hospital

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• Programme structure
• Wk 1 11 Skilling up
• Wk 11 33 Training gain
• Wk 34 36 Maintaining the gains

• Outcomes
• Any falls during study period
• Bergs Balance Score
• 6 Minute Walk Test
• ADL
• Barthel
• IADL

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Conclusions

• Community-based group rehabilitation programs
  incorporating exercise prescription, education
  and peer support can improve patients physical
  and psychological outcomes in various common
  chronic diseases.
• The programs should be part of a comprehensive
  care package offered to patients with chronic
  diseases.
• Community centres for older persons are the ideal
  location for running these programs.

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Community programmes - Publications

• CHF
• Hui E, Yang H, Chan LS, et al. A community model
  of group rehabilitation for older patients with
  chronic heart failure A pilot study. Disabil
  Rehabil 200628(23)1491-1497.
• COPD
• Woo J, Chan W, Yeung F, et a. A community model
  of group therapy for the older patients with
  chronic obstructive pulmonary disease a pilot
  study. J Eval Clin Pract 200612(5)523-531.
• Telemedicine in rehabilitation
• Elsie Hui. In Teleneurology, 2005 Royal Society
  of Medicine Press Ltd. Eds.Richard Wootton
  Victor Patterson
• DM
• Chan WM, Woo J, Hui E et al. A Community model
  for care of elderly people with diabetes via
  telemedicine. Applied Nursing Research
  20051877-81
• OA
• Wong YK, Hui E, Woo J. A community-based exercise
  programme for older persons with knee pain using
  telemedicine. J Telemed telecare 200511310-315
• Stroke
• JCK Lai, J Woo, E Hui, W M Chan.
  Telerehabilitation a new model for community
  based stroke rehabilitation. J Telemed Telecare
  200410199-205
• Dementia
• Poon P, Hui E, Dai D, et al. Cognitive
  intervention for community-dwelling older persons
  with memory problems telemedicine versus
  face-to-face treatment. Int J Geriatr Psychiatry
  200520285-286.
• Urinary incontinence
• Hui E, Lee PSC, Woo J. Management of urinary
  incontinence in older women using
  videoconferencing versus conventional management
  a randomised controlled trial. J Telemed Telecare
  200612343-347

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Chronic Disease Self-Management Programme (CDSMP)
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What is Chronic Disease Self-management?

• In the Chronic Care Model
• Self-management involves (the person with chronic
  disease) engaging in activities that
• Protect and promote health
• Monitor the symptoms and signs of illness
• Manage the impacts of illness on functioning,
  emotions and interpersonal relationships
• Promote adherence to treatment regimes
• Von Kroff et al., Ann Intern Med
  1997127(12)1097-1102.

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The Stanford CDSMP story

• Stanford University School of Medicine / Patient
  Education Research Centre
• Kate Lorig, H Holman, D Sobel
• Started in 1980s as Arthritis SMP
• Program content
• promoting Self-efficacy
• developed from patient focus groups
• Features of CDSMP
• Group format (up to 15)
• Interactive
• 2 group leaders
• Promote self-efficacy
• Action plan
• Problem-solving
• Sharing
• Modeling
• Patients volunteer as leaders
• Re-interpreting symptoms
• Persuasion

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• The definitive study Lorig KR et al., Medical
  Care 199937(1)5-14.
• 1000 patients with chronic diseases
• Heart disease, lung disease, stroke, arthritis
• completed CDSMP
• Followed-up for 3 years
• Improvements in
• Self-efficacy
• Health status
• Health care utilization
• Self-management behaviours
• Extended to other countries
• Canada, Europe, Australia
• Asia
• China, HKSAR, Taiwan, Singapore, Japan
• Internet version
• Generic vs. disease specific

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What is special about the Cadenza Community
Project CDSMP?

• To train up a group of lay leaders as the future
  driving force of the CDSMP movement.
• To demonstrate that lay leaders are just as
  effective as professionals (e.g. social and
  health care workers) in leading CDSMP and
  achieving the desired outcomes.
• To develop a CDSMP delivery model best suited for
  Hong Kong elders, and to pave the way for a
  territory-wide movement.

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Progress of Cadenza Community Project CDSMP

• Commenced December 2007
• Recruited and trained 43 elder Lay Leaders
• 115 subjects completed the CDSMP
• Evaluation still under way
• Compare outcomes between intervention (attended
  CDSMP) and control groups at 6 months
• Compare outcomes of groups led by elder Lay
  Leaders versus staff (social workers)
• Focus groups

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Summary

• In additional to conventional models of health
  care delivery, innovative ways to provide health
  care should be explored and evaluated.
• Some of these innovations were introduced in this
  talk.
• We are grateful to our visionary sponsors who
  helped us realize our dreams.

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Thank you

• huie_at_ha.org.hk