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

2. 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.

3. Telemedicine (telegeriatrics) – what is it and why?

4. 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 ….)

5. 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

6. 古洞 廣福道 Nam Fong Cambridge 石湖墟 Cambridge 直街 Oi Kwan Caritas TPH FWH C&A NDH AHNH (COST Office) (COST Office) PWH CUHK SH x 2 stations (COST & 8/F) Kwan Fong 積存街 C&A Cambridge Caritas C&A 花園城 HCHW Cambridge ELCHK ELCHK ELCHK ME DE DECL 瀝源 秦石 馬鞍山 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)

7. 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

8. 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 Videoconferencing Hardware

9. Video conferencing link Broadband Network 1.5Mbps 1.5Mbps Telemed Fibre IP Link Telemed Fibre IP Link C&A Home / Community centre Shatin Hospital

10. 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 Pilot study

11. 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

12. 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

13. 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

14. 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

16. Telemedicine is Cheaper

17. 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.

18. 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.

19. Latest accessories – plug & play Mobile video cart digital camera electronic stethoscope

20. Telegeriatrics publications 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.

21. Management of chronic diseasesin the community

22. 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 Chronic disease group programmes

23. Program Content Patient Education disease management Psychosocial intervention focus group peer support Exercises & Games

24. 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 A community model for care of older persons with diabetes mellitus

25. Exercise training 30 minute-exercise session starting with a 5-minute warm up ending with a 5-minute cool down or progressive muscle relaxation training. 10-minute resistance training using elastic tubing (Theraband®) followed by a 10-minute aerobic dance

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

27. 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

28. 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 Falls Management Exercise Program (FaME)

29. Programme structure: Wk 1 – 11: Skilling up Wk 11 – 33: Training gain Wk 34 – 36: Maintaining the gains Outcomes: Any falls during study period Berg’s Balance Score 6 Minute Walk Test ADL Barthel IADL

30. 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.

31. 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 2006;28(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 2006;12(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 2005;18:77-81 OA Wong YK, Hui E, Woo J. A community-based exercise programme for older persons with knee pain using telemedicine. 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 conventional management: a randomised controlled trial. J Telemed Telecare 2006;12:343-347

32. Chronic Disease Self-Management Programme (CDSMP)

33. 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 1997;127(12):1097-1102.

35. 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

36. The definitive studyLorig 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

38. 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.

40. 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

41. 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.

42. Thank you huie@ha.org.hk