Toronto Central CCAC Telehomecare Program. Transforming Chronic Disease Management

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1 Toronto Central CCAC Telehomecare Program Transforming Chronic Disease Management 1

2 Agenda Background Evidence Video Program Development and Engagement Enrolment Numbers Evaluation and Next Steps 2

3 Background Co-funded by Ministry of Health and Long-Term Care and Canada Health Infoway Toronto Central (TC), North East and Central West LHINs were the 3 early adopters North West and Central LHINs part of wave 2 TC CCAC (host organization) Telehomecare program began in late 2012 Telehomecare nursing resources provided through CCAC Program development and technology managed by OTN (Ontario Telemedicine Network) 3

4 Supporting clients with complex chronic conditions COPD, Chronic Bronchitis, Emphysema and Heart Failure to live safely and confidently in home. Self- Management Monitoring to Support Transition Empowering clients to become partners in their own care - right in their own home. 4

5 Evidence TELEHOMECARE IMPROVES Client selfmanagement Medication compliance Clinical outcomes Client and provider satisfaction Collaborative relationships Best practice care for chronic disease Data integration TELEHOMECARE REDUCES Emergency room visits Hospital admissions Primary care utilization Long-term care home admissions Client travel costs Walk-in clinic utilization Client morbidity Based on a growing number of studies and the evaluation of the THC Pilot, we anticipate the positive outcomes listed above.

6 Video The Client Experience 6

7 THC Program Development 7

8 Eligibility Criteria Over the age of 18 Established diagnosis of COPD, Chronic Bronchitis, Emphysema and Heart Failure (with or without comorbid conditions) Active landline or internet connection Informed consent to participate Client lives within the TC-LHIN area 8

9 Improving Health and Preventing Emergencies Nurses promote healthy lifestyle choices and identify potential problems through: Established care plan based on client goals Remote monitoring of vitals Health coaching sessions to educate and motivate Medication compliance and reconciliation Weekday feeds and alerts 9

10 Each weekday, the client sends in their biometric data and answers a series of health questions The nurse has access to this data and is automatically notified if the data falls outside the normal limits that have been set for the client and then decides on appropriate next steps Early identification provides an opportunity for intervention before the client s condition worsens Provide regular reports to PCP 10

11 Clinical Guidelines CCAC Telehomecare Nurses are trained in: Motivational coaching techniques Disease management best practice Modifiable behaviours in chronic disease Telehomecare technology RNAO best practice guidelines have also been incorporated, including: Smoking Cessation Self-Management Hypertension

12 COPD Daily Assessment Are you feeling more short of breath today than yesterday? Has your sputum changed in color, amount, or thickness Do you feel you are starting a cold? Are you feeling more tired than yesterday? Have you missed or stopped taking any of your medications during the last 24 hours? In the past two weeks, have you been bothered by little interest or pleasure in doing things? In the past two weeks, have you been bothered by feeling down, depressed or hopeless? 12

13 COPD Lecturettes Knowing your symptoms (COPD) Medication overview The lungs Understanding your illness (COPD) Activity Anxiety and breathlessness Home oxygen therapy overview Inhaler administration Pharmacotherapy for quitting smoking Relaxation techniques Smoke free environment 13

14 Stoplight Action Plan for COPD 14

15 Teach Back Using Teach Back and health literacy principles is supported by research Teach back is a healthcare competency Asking that clients recall and re-state what they have been told is one of the top 11 patient safety practices based on the strength of scientific evidence. AHRQ, 2001 Report, Making Healthcare Safer 15

16 Engagement Strategy Engagement Lead responsible for establishing contact with organizations and teams across all sectors, i.e., hospitals, family health teams, community health centres, community support services Follow an established implementation process Referral numbers are monitored and evaluated against established targets by organization Regular reporting of volumes at the organizational and sector levels 16

17 Enrolments to Date From January - December 2013, 678 clients have been enrolled (combined COPD and CHF) Currently there are approx. 375 active clients on the Telehomecare program 17

18 THC Enrolment Trend By Sector Source Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total CHC Community CCAC Teams FHT Hospitals Independent Practice Total

19 19

20 Evaluation Currently developing indicators to measure THC service and determine impact on chronic diseases: ED visits Hospital readmissions Length of stay in program # Alerts Interventions Client experience 20

21 Next Steps Continue with engagement strategies across sectors with a focus on FHTs Develop a plan to ensure sustainability of the program and for Telehomecare expansion to other populations and chronic conditions Ensure appropriate supports are available to clients after discharge from THC program Referral to CCAC Care Coordinator to review other available community services and resources Partnering with OLA to link with telephone support line 21

22 Contact Information Carolyn Acton, Engagement Lead, Telehomecare Phone: ext Liana Sikharulidze, Manager, Telehomecare and Rapid Response Phone: ext

23 Questions? 23

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