Patient Centered Virtual Case Management for People with Multimorbid Chronic Disease – SMILE Project

Background: Patients with multiple chronic diseases (eg. Diabetes, Cardiovascular and Respiratory Disease) often present late and frequently to ED, Acute Medical Assessment Units and Emergency GP Care. Virtual case management of these patients can reduce emergency presentations by empowering them to recognise early deterioration and enable them to better self manage.

 

Approach: 600 patients with two or more chronic diseases are identified by chronic disease specialist teams, GPs and acute staff. On enrolment patients are provided with monitoring devices and daily readings are uploaded to a central patient platform. Alerts are triggered if vital signs go outside patient specific thresholds. Telephone triage nurses review the alerts and provide telephone consults, motivating, educating and supporting patients. Over time the frequency and patterns of alerts stabilise and patients require less emergency care and less hospital admission.

 

 

Clinical staff and patients have been surveyed and interviewed for feedback to shape and improve service. The programme is operational for three years, baseline and annual data on emergency care usage, symptom severity, self status score and patient experience has been collected and analysed. The size of the sustainable service required to meet the need in a population of a half million was estimated and tested.

 

Results: Interim results for the first three years of the project showed a;

55% reduction in ED attendances

75% reduction in nights in hospital

81% reduction in GP urgent visits

72% of patients had a reduction in exacerbations

The final evaluation results for 4 years will be presented at the conference. The required service size was 120 places per 100,000 population.

 

 

Key Learning: The SMILE project leverages technology to provide a proof of concept of virtual case management for people with multimorbidity. It determined the appropriate population size for this type of service as 120 patient places per 100,000 population. The project has developed guidelines for implementation with a view to regional and national implementation. The implication for Health Services is that people with multimorbid conditions who are frequent attenders to hospital, can be empowered to self manage in the community with virtual technology and hence reduce their reliance on unscheduled care. Virtual case management is an integral part of the Enhanced Community Care Programme for Integrated Care in the Republic of Ireland.