Virtual Clinical Care: Telemonitoring for Better Health Outcomes

1. Virtual Clinical CareHome Telemonitoring ServiceSusan Tappin Associate Member of TSANZ. Registered Nurse. Bth Health Science.Graduate Certificate Health Management CCSM-Flinders. Graduate Certificate Clinical Education. Diploma Population Health. Cert IV Training & Assessment.Winner of the Nursing Excellence Clinical Team Award 2013 for South Australia.ANUM Better Care in the CommunityCountry Health Connect.

2. CHSALHN Virtual Clinical Care (VCC) – Why do we need Virtual Services? Virtual Services will enable CHSALHN to expand services in a resource poor environment across 1,000,000 square kilometres.

3. Benefits of Virtual Services • Expand availability of services provided in local communities • Potentially reduce transfers to Adelaide for patients requiring specialised intervention • Early detection and management, potentially preventing hospitalisation • Improved self management of chronic conditions • More appropriate utilisation of health services

4. VCC in country South Australia • Supporting clients across country SA who have COPD, Cardiac Failure, Diabetes, hypertension or a combination of these conditions • Patient set up at home with devices to take daily measurements with results linked to a database accessible to members of the healthcare team • Results outside ‘normal’ range for that patient triggers a response from healthcare team • VCC is facilitated by a collaboration between iCCnet (CHSA) and the Better Care in the Community (BCIC) program • Clients are monitored daily for up to 12 weeks.

5. Virtual Clinical Care - Equipment • Home vital sign monitoring • Blood Pressure • Pulse Oximeter • Weight • Glucose (if applicable) • Temperature (if applicable) Blood Pressure Scales Home Monitoring Tablet Pulse Oximeter Glucometer

6. Inclusion Criteria • Clients with existing chronic condition(s) • 3G or 4G mobile network coverage at home, or a home wireless network • Ability to nominate a regular GP • Current ambulance cover • Dependence on medical care and/or a recent exacerbation resulting in hospitalisation OR • Instability of symptom management OR • Unplanned acute admissions of >2 in the last 12 months or >4 in the previous 5 years

7. Exclusion Criteria • People who are newly diagnosed with Type l diabetes • Women who are pregnant (including those with gestational diabetes) • Children and/or young people <18 years of age • People with a cognitive impairment, a neuromuscular disease, an intellectual disability or a significant mental illness

8. VCC – innovation in action Patient feedback “I would never have known I had BP issues without VCC. I often felt really ‘crappy’ and didn’t know why. I now know it is because of my high BP and am starting to get on top of it with my GP. So I think the VCC is wonderful.”

9. Monitoring Screen

10. VCC Results

11. VCC Results

12. Service Strengths • Clients really value service • Clients report improved understanding of their chronic condition(s) • Clients report improved confidence in managing their chronic condition(s) • Clients benefit from having a current individualised care plan and action plan • Collaborative team approach to effectively and proactively respond to clients’ needs

13. Service Strengths • Clear escalation plan supports action when deterioration detected • Early detection and timely intervention lead to improved client outcomes • Proactive approach to supporting people with chronic conditions • Facilitates engagement of all members of care team • Facilitates communication between members of the care team (clinical notes, reports, trend data etc)

14. Benefits • Client centred care • Improved chronic condition self management • Services closer to home and appropriate health service utilisation • More detailed clinical results • Early detection and management • Improved Quality of life for clients • Improved post-discharge services

15. A Case Study - Life for Ross 65 year old man with frequent hospitalisation admissions, poor health outcomes, advised by doctor he was heading for a premature death Socially isolated T2DM on insulin Ischemic Heart Disease with stents Hypertension HypercholesterolemiaObese COPD Sleep Apnoea Peripheral Neuropathy Peripheral Oedema Chronic back pain Post Traumatic Stress DisorderDepression Anxiety Polypharmacy with non adherence Minimal mobility due to shortness of breath / chest pain

16. Better Care in the Community Involvement • Virtual Clinical Care Home tele-monitoring • Cardiac / pulmonary rehabilitation • Chronic condition support, motivational interviewing with goal setting • Frequent liaison with GP • Referrals to external stakeholders • Dietician • Credentialed Diabetes Educator • RespiratoryGeneral Physician

17. Results at completion of VCC home telemonitoring and rehabilitation • - No hospital admissions! • - Weight loss 11kg • Waistline reduction 7cm • Vast improvement in depression / anxiety score, no longer taking anti-depressants • Blood pressure within target range • Reduction on cholesterol level • Walks to the shops without needing to rest • Taken out full gym membership, attends 3 x week • Currently joining a volunteers community group • Compliant with medications • Goal setting and striving for better health • SMILING

18. Results at completion of VCC home telemonitoring and rehabilitation • Benefits from VCC • Improved personal Self management of • Medication –use and understanding • Daily contact improved social interaction • Improved social competency • Felt more comfortable with HCW. • Able to voice concerns and be listened to. • Greater understanding of symptoms and how these give signs of condition management • Importance of monitoring his health • SMILING

19. PIH Trial Data

20. PIH Trial Data

21. PIH Trial Data

22. PIH Trial Data

23. PIH Trial Data

24. PIH Trial Data

25. CHSA VCC to October 2017 Patient Demographics

26. The future of Virtual Clinical Care • Future expansion investigations include: • Opportunities to expand the VCC to include more client groups • Utilising VCC in a variety of settings • Involvement of an expanded workforce to support the VCC model across CHSALHN

27. Virtual Clinical Care

28. Virtual Clinical Care Contact Details • Name: Susan Tappin • Phone: 08 88230283 • Email: susan.tappin@sa.gov.au