Abstract
Background: Approximately .3 million people in Ireland have one of the 4 main chronic diseases (CVD, Diabetes Type 2, COPD and Asthma) with increasing numbers of patients living with multimorbidity. It is estimated that between % and 5% of patients will require a case management service.People with chronic disease have frequent visits and often present late to the Emergency Department (ED), the Acute Medical Assessment Unit (AMAU) and to both GP day and out of hours service which leads to suboptimal outcomes for patients. The purpose of the project is to reduce episodes of unscheduled care by empowering people with chronic disease to proactively self-manage through the identification and prevention of exacerbations via virtual case management (VCM). VCM is an essential element of the Model of Care (MoC) for the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) in Ireland.
Approach: A cohort of 450 patients (with 2 or more chronic diseases i.e. COPD, Asthma, Heart Failure or type 2 diabetes) were enrolled in the integrated VCM service which was delivered by Caredoc out of hours GP service. Participants were referred (with consent) by GPs, Integrated Care Consultants and Community Chronic disease team staff. Referrals are triaged by nurse triage support team in Caredoc, suitable participants enrolled and provided with monitoring devices including blood pressure monitors, oxygen monitors, weighing scales, and activity monitors based on their requirements.Participants readings are recorded by the devices worn at home and send readings to a specifically designed software program and alerts are monitored and responded to by the telephone triage nurse. If the triage nurse could not resolve the problem they liaised as appropriate with the referrer to agree the appropriate steps to be taken, ensuring integration of the services for the patient. Patient experience feedback was used to continually improve the protocols and operation of the service.
Results: Preliminary data for patients enrolled over 6 months indicate very positive results. Participants report a reduction in unscheduled care episodes, including GP daytime (78.6% of patients), ED attendances/hospital visits (47.6% of patients) 52.5% of patients had a reduction in the bed nights in hospital, compared to .9% of patients who had an increase 79% and 88% of patients engaged months with the technology in the last 3 months 64.3% of patients had experienced symptom stabilisation as demonstrated by the reduction in the number of alerts per patient.Patients reported the following additional benefits: Feeling supported and minded and empowered to managing their condition. Having access to a tablet provides access to other virtual programmes and training including pulmonary and cardiac rehabilitation. Patients can use their watches for counting steps during cardiac rehab. Feeling more educated/motivated when attending rehab classes and more able to benefit from the classes.
ImplicationsThe use of VCM provides increased access to patients with multimorbidity living more rurally to services and prevents deterioration of patients and unscheduled care attendances. Most at risk patients are also enabled and empowered to manage their conditions at home.