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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 and group programmes for chronic diseases

Telemedicine and Group Programmes for chronic diseases

Dr Elsie Hui, FRCP

Division of Geriatrics, CUHK

Community Geriatric Assessment Team,

Shatin Hospital

slide2
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.

tele geriatrics in residential care home setting
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 ….)
our history
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
nte geriatric service network

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)

slide7

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

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

Videoconferencing Hardware
slide9

Video conferencing link

Broadband

Network

1.5Mbps

1.5Mbps

Telemed Fibre IP Link

Telemed Fibre IP Link

C&A Home /

Community centre

Shatin Hospital

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

Pilot study
geriatrician
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
nurse
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
slide13
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

podiatrist
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
user satisfaction
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.
conclusions
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.
latest accessories plug play
Latest accessories – plug & play

Mobile video cart

digital camera

electronic stethoscope

slide20

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.

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

Chronic disease group programmes
program content
Program Content

Patient

Education

disease management

Psychosocial

intervention

focus group

peer support

Exercises &

Games

slide24
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

exercise training
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

slide26
Outcome measures:

QOL

Diabetes quality of life questionnaire

SF-36

DM knowledge test

24-hours dietary recall

Body mass index

Blood sugar & HbA1c level

key findings
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
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

Falls Management Exercise Program (FaME)
slide29
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

conclusions30
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.
community programmes publications
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

what is chronic disease self management
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.

the stanford cdsmp story
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
slide36
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
what is special about the cadenza community project cdsmp
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.
progress of cadenza community project cdsmp
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
summary
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.
thank you

Thank you

huie@ha.org.hk