Telehomecare programs that combine health coaching and remote monitoring are proven effective as an important component of chronic disease care and management.
- Worsening conditions can be prevented through early warning.
- Patient use of the healthcare system, including unnecessary emergency department visits and hospitalizations, is significantly reduced.
- Patient confidence and peace of mind increases as self-management skills are learned.
- Support helps patients retain independence and remain in their own homes.
The burden of chronic disease in Ontario
According to Preventing and Managing Chronic Disease : Ontario’s Framework, as is the case in developed countries throughout the world, in Ontario chronic diseases are the leading cause of death and disability. Almost 80% of Ontarians over the age of 45 have a chronic condition. Of those, approximately 70% suffer from two or more chronic conditions. (CCHS, 2003) Left untreated or managed poorly, chronic conditions can deteriorate and predispose individuals to other chronic conditions.
In Ontario the economic impact of chronic disease is estimated to be 55% of total direct and indirect health costs. As the population ages, without intervention, this trend will escalate unless changes are made.
The number of seniors aged 65 and over is projected to more than double from about 2.0 million, or 14.6 per cent of population, in 2012 to almost 4.2 million, or 24.0 per cent, by 2036. According to the report, evidence from other jurisdictions and innovative practices within Ontario make it clear that what is needed is a fundamentally different way of addressing chronic disease – a systems approach to prevention and management that :
- Is centred on individuals, empowering them to play a greater role in managing their health or illness and to become an integral part of the care team;
- Incorporates prevention at every stage to keep people as healthy as possible for as long as possible;
- Mobilizes interdisciplinary, integrated care teams so that individuals get the right care from the right provider in the right setting at the right time;
- Supports proactive, continuing care with regular follow-up to ensure that care is coordinated and that individuals have help navigating through the system.
Telehomecare answers all of these challenges.
Ontario Telehomecare results
William Osler Health System delivers Telehomecare in the Central West Local Health Integration Network with partners Central West CCAC and Headwaters.
Results for December, 2015 indicate the IP visit rate drops chronologically from 0.98 episodes/pt before enrollment to 0.31 episodes/pt after discharge. The ER visit rate drops chronologically from 1.59 visits/pt before enrollment to 0.66 visits/pt after discharge.
Telehomecare in the U.S.
A letter to the U.S. Congress from Dr. Rashid Bashshur, Senior Advisor for eHealth, The University of Michigan Hospitals and Health Centres, in response to questions about telemedicine.
Can expanded use of telemedicine help lower costs for Medicare and the health care system? If so, how?
The use of telemedicine in chronic disease management (also referred to as telemonitoring, telehome care and home telecare) has been demonstrated to reduce hospitalizations and emergency department visits among chronically ill patients. Such evidence has been published in numerous scientific studies, albeit with minor exceptions. That is, a few studies reported improvements in longevity but no reductions in hospitalization or emergency department visits. However, findings from these studies may not be generalized because they used very sick patients with numerous health problems (comorbidities) and other methodological limitations.
Chronic diseases account for nearly three-quarters of all health care expenditures in the United States. Indeed, “the preponderance of the evidence produced by telemonitoring studies points to significant trends in reducing hospitalization and emergency department visits, preventing and/or limiting illness severity and episodes resulting in improved health outcomes.” (Bashshur, Shannon, and Smith, 2014).
Can the use of technology help treat patients who have chronic conditions, by home health monitoring and “home” telemedicine? Please explain.
I appreciate this question as it points to a critical area where telemedicine interventions would have substantial benefits. Before explaining these benefits, it may be appreciated that chronic diseases: (a) constitute the leading causes of death in the United States; (b) account for nearly 75% of health care expenditures; and (c) are amenable to telemedicine interventions. Again, telemedicine interventions in chronic disease management enable patients to receive appropriate care, at the appropriate time and place, and in the most appropriate manner. It replaces the traditional “revolving door” arrangement for the care of chronically ill patients. The major pillars of telemedicine interventions in the management of chronic illness include patient-centered care, an activated patient, the medical home, and shared decision making. Follow-up visits to the doctor are not arbitrarily determined at set intervals, while exacerbations of chronic conditions can occur any time, and its timing cannot be predicted with any accuracy. Chronically ill patients can be monitored on a continuous basis to detect early exacerbations of symptoms and vital signs; receive prompt responses to identified needs and concerns. Early intervention would result in maximal health benefits and lower cost.
In home health monitoring (also referred to as telemonitoring, telehome health, home telehealth), patients would be provided with: (a) electronic devices that monitor significant vital signs and parameters relevant to specific patients and their particular condition(s); (b) educational materials tailored to their situation, including medication management, symptom recognition, as well as guides and inducements for the adoption of healthy life style and preventive measures; (c) tools for participating in “shared decision making” in terms of available options for treatment together with information on benefits and risks of alternative interventions; (d) ready access to their (electronic) personal health record to see trends in their health data, functional status, symptoms and benchmarks: and (e) ready access to medical advice when they have questions or concerns.
Given your expertise in this field, do you believe that investing in telemedicine technologies to improve chronic disease management will save money over the long run? Please explain.
If I may, I would like to quote the major conclusions addressing this question from a recent literature review that was presented in special briefings to both House and Senate on May 20 and 21, 2014, to wit, “There is a growing and complex body of evidence that attests to the potential of telemedicine for addressing the problems of access to care, quality of care, and health care costs in the management of three chronic diseases [congestive heart failure, stroke, and chronic obstructive pulmonary disease]. Despite some inconsistencies in methodologies, the preponderance of the evidence produced by telemonitoring studies points to significant trends in reducing hospitalizations and emergency department visits, preventing or limiting illness severity and episodes resulting in improved outcomes.”
 Bashshur, R, Shannon, G, Smith, B, et al “The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management,” Telemedicine and eHealth, in press.
A review of Telehomecare programs in other countries
More than 6,000 patients were enrolled in the UK “3 Million Lives” program. Results for 3,230 patients include:
- 45% reduction in mortality rates
- 20% reduction in emergency admissions
- 15% reduction in emergency department visits
- 14% reduction in elective admissions
Reference: BMJ July 2012; 344:e3874. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial
The Veterans Health Administration in the United States has enrolled more than 70,000 patients in its Home Telehealth Program since 2003. Results:
- 20% reduction in hospital admissions
- 25% reduction in number of bed days
Reference: Telemed J e-Health. 2008;14(10):1118-1126. Care coordination/Home Telehealth: The systematic implementation of Health Informatics, Home Telehealth and Disease Management to Support the Care of Veteran Patients with Chronic Conditions.
Partners Healthcare in Boston, Massachusetts, has enrolled more than 1,200 patients since 2006. Results:
- 50% reduction in hospital admissions
Reference: The Commonwealth Fund; January 2013. Partners HealthCare: Connecting Heart Failure Patients to Providers through Remote Monitoring.