Telegeriatrics: delivery of multidisciplinary care to residents of nursing homes

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Telegeriatrics delivery of multidisciplinary
care to residents of nursing homes

• 1Dr. Elsie Hui
• 2Professor Magnus Hjelm
• 2Professor Jean Woo
• 1Community Geriatric Assessment Team, Shatin
  Hospital and 2The Chinese University of Hong Kong

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Background
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Nursing Homes in Hong Kong

• 50,000 of Hong Kongs 0.6 million elderly reside
  in nursing homes.
• Over half live in private, profit-making homes of
  variable standard of care.
• Nursing homes are not supported by general
  practitioners.
• Emergency Department attendance and hospital
  admissions are high.

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CGAT

• Community Geriatric Assessment Team (CGAT) serves
  nursing homes.
• Geriatrician, nurse, physiotherapist and
  occupational therapist.
• Provides multidisciplinary outreach services.
• In Shatin, CGAT supports 20 institutions, 2000
  clients.
• Limitations - infrequent visits, unable to
  respond rapidly to urgent problems.

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Telemedicine in Geriatrics

• Relatively few specialists looking after growing
  numbers of older patients.
• Elderly have difficulty accessing health care
  because of social isolation, poor mobility, low
  awareness, etc.
• Require multidisciplinary input and holistic
  approach, with sequential follow-up, preferably
  in their own homes.

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Objectives

• To explore whether Telemedicine is as effective
  as, or superior to, conventional outreach
  activities in providing a multidisciplinary
  service to elderly patients in nursing homes.

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Methods
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Telemedicine Hardware

• Videophone system - Polycom Viewstation 512K, 30
  frames per second.
• 3 ISDN lines per station.
• Video camera, microphone, colour TV
• Optional - headphones, video recorder, computer,
  stethoscope

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Equipment Costs
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Subjects

• 195-bed nursing home in Shatin
• Current outreach services from CGAT
• ? routine and urgent medical assessment
• ?multidisciplinary input - nursing,
  physiotherapy, occupational therapy
• Specialist clinics participating in study
• ?Dermatology
• ?Psychogeriatrics
• ?Podiatry

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Intervention

• Telemedicine was used to replace all conventional
  outreach activities (CGAT) or outpatients visits
  (derm, psy, podiatry).
• A site visit would be made if telemedicine was
  considered inadequate for patient management or
  decision-making.
• The service was available during office hours,
  five days a week.

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Activities assessed

• Medical
• history taking
• review of case notes/ drug charts
• physical exam
• nursing orders

• Assessment of
• mobility
• ADL
• mental state
• skin and wounds
• swallowing test
• catheter care
• inhaler technique
• home oxygen

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Outcome measures

• 1. Can telemedicine replace previous outreach or
  outpatient activities?
• 2. Can telemedicine increase productivity?
• 3. Is telemedicine cheaper than conventional
  services?
• 4. Does telemedicine reduce utilization of
  hospital-based health services?
• 5. How acceptable is telemedicine to users?

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Findings
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• Telemedicine was adequate in the majority of
  cases and disciplines.
• Areas of limitation
• Geriatrician - new cases, chest auscultation
  essential
• Dermatologist - biopsy necessary
• Nurse - complex procedures
• Physio - chest PT
• OT - measurement for equipment
• Podiatrist - wound debridement

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Telemedicine Increases Productivity

• Geriatrician
• Time savings - 2½ hours per telemedicine session
  compared with 4 hours per outreach visit.
• Increased productivity - number of patients
  increased by 44.4 (from 45 to 65).
• Occupational Therapist
• Waiting time for new referrals shortened from 7
  to 2 days.
• 5 telemedicine sessions were held per month
  versus only 3 visits per month before study.

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Telemedicine is Cheaper
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Savings over One Year (Geriatrician)

• By replacing outreach geriatric clinics with
  telemedicine
• (153 x 45) - (40.3 x 65) x 4
• 17062
• By diverting 20 cases from outpatients to
  telemedicine
• 455 x 20 x 4 36400

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Telemedicine reduces utilisation of
hospital-based services (1)
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Telemedicine reduces utilisation of
hospital-based services (2)

• Compared with same period pre-study
• Emergency Room attendances decreased by 10 -
  Telemedicine was only available during office
  hours whereas 55 of emergency visits were out of
  hours.
• Acute hospital admissions decreased by 11

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Total Savings (Geriatrician)

• Provision of geriatricians services (medical
  follow-up, triaging of urgent cases) via
  telemedicine resulted in savings for the health
  authority amounting to 273,594 over one year.

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User Satisfaction1

• Patients (total 1001 episodes)
• 35 unable to answer (demented, communication
  difficulties).
• Depending on the discipline, 82 to 95 were
  satisfied with this mode of care delivery.

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User Satisfaction2

• Nursing Home Staff
• equipment easy to use
• increased accessibility to CGAT
• workload - 50 increased versus 50 decreased!

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Conclusions

• Telemedicine is an acceptable alternative to
  conventional geriatric services for nursing home
  residents.
• It results in significant cost and time savings,
  increases productivity and decreases utilization
  of emergency and inpatient services by providing
  timely intervention.

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Remarks

• Quality can be improved by availability of a
  stethoscope device
• Cost effectiveness will be enhanced by extending
  the hours of service and supporting more homes.
• Costs will further reduce with rapid advances in
  information technology.