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Telemedicine and Group Programmes for

chronic diseases

Dr Elsie Hui, FRCPDivision 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?

Patient Isolation

Frailty

Health care provider

Limited resources

Traveling time

Hardware I.T. hardware

Broadband

3 G

Telephone/ Fax Traditional consultation

E-mail Photos & X-rays, video clips

Internet Health web sites, on-line assessment / education

Video-conference

Real-time, audio-video link

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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 - 04Community rehabilitation programmes DM, OA, CVA, dementia, incontinence

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NTE Geriatric Service Network

hospitals residential care homes social centres Broadband or ISDN (remot

e areas) Multi-point Videoconferenc

ing machines

Also capable of connecting to anywhere in the world with an IP address and VC machine (386kbs)

NDH(COST Office)

AHNH(COST Office)

CaritasFWH C&A

石湖墟Cambridge

古洞Nam Fong

TPH

SH x 2 stations(COST & 8/F)

花園城Cambridge

積存街Cambridge

Kwan FongC&A

Caritas C&AHCHW

ELCHK瀝源 ME

ELCHK秦石 DE

ELCHK馬鞍山 DECL

廣福道Cambridge

直街Oi Kwan

PWHCUH

K

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Shatin Hospital

Telehealth headquarters

C A B D E

ELCHK Social Services Network in

Shatin

Day Care

HomeHelp

Community Clinic

Social Centre

Home HelpSocial Centre

Day Care

Social Centre

Community Clinic

Social Centre

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Videoconferencing Hardware

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

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

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1.5Mbps 1.5Mbps

Shatin Hospital C&A Home / Community centre

BroadbandNetworkTelemed

Fibre IP Link

Telemed Fibre IP Link

Video conferencing link

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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 A&E 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 proc

edures, 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 facil

itate assessment and supervise rehabilitation

Limitations patients with severe communi

cation 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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Summary of activities and feasibility of Telemedicine in C&A Home

Discipline Patient-episodes % adequate with telemed

Geriatrician 356 97.2

Psychogeriatrician 149 99.3

Dermatologist 74 74

Nurse 101 88.7

PT 105 87.1

OT 117 59.8

Podiatrist 99 84.9

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Telemedicine is Cheaper

Table 2. Cost comparison between Telemedicine and outreach service or outpatients

Discipline Telemedicine Outreach Outpatients

Geriatrician $40.3 $153 $455

Psychogeriatrician $91.6 $105.9 $455

Dermatologist $117.9 N/A $455

Nurse $22.7 $67 N/A

PT $63.6 $330.4 N/A

OT $54.6 $290.8 N/A

Podiatrist $29.2 $160.8

N/A = not applicable

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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 doesn’t replace) to conventional outreach services.

It enhances the geriatric outreach team’s 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

digital camera

electronic stethoscope

Mobile video cart

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Hui E et al. Telemedicine: A pilot study in nursing home residents. Gerontology 2001;47:82-87.

Chan WM et al. The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong. J Telemed Telecare 2001;7:38-46.

Hui E, Woo J. Telehealth for older patients: the Hong Kong experience. J Telemed Telecare 2002;8(suppl.3):S3:39-41.

Tang WK et al. Telepsychiatry in psychogeriatric service: a pilot study. Int J Geriatr Psychiatry 2001;16:88-93.

Corcoran H et al. The acceptability of telemedicine for podiatric intervention in a residential home for the elderly. J Telemed Telecare. 2003;9(3):146-9.

Telegeriatrics publications

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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 teleconfere

ncing

Role of lay personnel staff of social centres volunteers patients

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Program Content

PatientEducation

disease management

Psychosocial

interventionfocus group

peer support

Exercises &Games

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Features: 8 sessions 1 two-hr session / week 6-8 patients / group 1-2 facilitators (non-professiona

l) Subjects

Diagnosed DM > 60 yrs Community-dwelling

Setting Community centres for elders ELCHK in Shatin

3 core components1. Education

Related to DM Self-efficacy

2. Exercise Aerobic and resistance Group & home exercise

3. Psychosocial interventions– Share experiences & probl

ems– Find solutions as a group– Peer support

A community model for care of older persons with diabetes mellitus

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Exercise training

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

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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

eldersSAGE in Shatin

Shatin Hospital

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Programme structure: Wk 1 – 11: Skilling up Wk 11 – 33: Training gain Wk 34 – 36: Maintaining th

e gains

Outcomes: Any falls during study period Berg’s 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 - PublicationsCHF

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 2006;28(23):1491-1497.

COPDWoo J, Chan W, Yeung F, et a;. A community model of group therapy for the older patients with chronic obstruct

ive pulmonary disease: a pilot study. J Eval Clin Pract 2006;12(5):523-531.

Telemedicine in rehabilitationElsie Hui. In Teleneurology, 2005; Royal Society of Medicine Press Ltd. Eds.Richard Wootton & Victor Patterso

n

DM Chan WM, Woo J, Hui E et al. A Community model for care of elderly people with diabetes via telemedicine. Ap

plied Nursing Research 2005;18:77-81

OA Wong YK, Hui E, Woo J. A community-based exercise programme for older persons with knee pain using telem

edicine. J Telemed telecare 2005;11:310-315

Stroke JCK Lai, J Woo, E Hui, W M Chan. Telerehabilitation – a new model for community based stroke rehabilitation.

J Telemed Telecare 2004;10:199-205

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 2005;20:285-286.

Urinary incontinence Hui E, Lee PSC, Woo J. Management of urinary incontinence in older women using videoconferencing versus c

onventional management: a randomised controlled trial. J Telemed Telecare 2006;12:343-347

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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 diseas

e) engaging in activities that:

Protect and promote healthMonitor the symptoms and signs of illnessManage the impacts of illness on functioning, emotions and interp

ersonal relationshipsPromote adherence to treatment regimes

Von Kroff et al., Ann Intern Med 1997;127(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 1999;37(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

DM, Back pain, AIDS Leaders movement

Lay leaders Master trainers

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What is special about the Cadenza Community Project: CDSMP?

1. To train up a group of lay leaders as the future driving force of the CDSMP movement.

2. 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.

3. 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@ha.org.hk