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Special Consideration Needed for Older Patients Using Telecare

Special Consideration Needed for Older Patients Using Telecare

When most people think about healthcare, the images that come to mind include a trip to their local provider’s office, lab, or hospital for services such as physicals, blood tests, and procedures. However, medical professionals and their patients are increasingly transitioning to more remote services that leverage our advances in communication technologies, resulting in the burgeoning “tele” world of healthcare. But are these services reaching everyone?

Telemedicine, telehealth, and telecare are three examples of remote, interactive services that allow patients to receive healthcare from within their own homes. Although these terms are often used interchangeably, they in fact refer to different aspects of healthcare delivery. Telemedicine applies to physicians who use technology to support the delivery of medical, diagnostic, or treatment-related services. Telehealth is like telemedicine but applies to a broader collection of providers, such as nurses or pharmacists. Telecare (see Figure 1) is generally more consumer-oriented by providing the patient with technology to manage their own care safely from home, such as health apps or digital monitoring devices.

Figure 1. Telecare Slide from MVC Workgroup Presentation

The adoption of “tele” services saw incredible growth in 2020 in response to the pandemic. A report found that Medicare telehealth visits increased 63-fold recently, from 840,000 in 2019 to 52.7 million visits in 2020. However, now that adoption of these services (and the platforms needed to host them) are more commonplace, providers are asking whether it benefits their most vulnerable patients and who may be left behind.

These questions drove the discussion of the most recent MVC workgroup on chronic disease management. Over the course of the session, attendees were particularly interested in how telecare improves elderly care, and whether patients over the age of 65 could adequately access such services. For those older adults utilizing telecare, evidence from the ongoing COVID-19 pandemic identified convenience and affordability as telecare’s primary strengths. In addition, research evidence suggests that the two most effective telecare interventions in this population are automated vital sign monitoring and telephone follow-up by nurses.

Some of the challenges often cited for this population include lack of appropriate internet access or devices, limited digital literacy, medical conditions that may impede participation (i.e., hearing or vision impairments, dementia, etc.), and the need to regularly monitor vitals in very high-risk patients. Although the authors compiling these challenges specifically reference older adults, they could just as easily apply to people experiencing poverty, people with disabilities, and people with more limited language and literacy skills.

Some recommended strategies to address common challenges include tablet delivery services, “mobile medical assistants” who perform video set-up for the patient, assistance from an on-site caregiver, practice or “mock” video visits prior to the appointment date, partnerships with community health workers to support or train patients in their homes, and providing self-monitoring devices. Other simple considerations include the size of the text displayed on the page (use larger text to enhance readability), providing adequate instructions in advance and in multiple languages, and engaging experts in user experience design.

In addition to these considerations, some researchers suggest that, in general, the adoption of new technologies can be predicted in part by Everett Rogers’ Diffusion of Innovation Theory. One study incorporating this theory found that the chances of telecare adoption were highest for three types of older adults: those already receiving long-term or nursing care, those living alone, and those who have fixed daily telecare points of contact.

Increased integration of technology in healthcare is inevitable as advancements continue and we shift to a more digital world. Since the number of people in the U.S. who are age 65 or older will more than double over the next 40 years, it is imperative that older adults are not left behind when transitioning to such services. Rather than fear the challenges, researchers and practitioners are seeking ways to find solutions and help all patients benefit from healthcare access within their own homes.

The MVC Coordinating Center encourages its members to collaborative with one another to benefit from peers’ success stories and lessons learned. If your hospital or physician organization has developed an age-friendly telecare protocol, please consider sharing your story with the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. To catch up on the recent MVC workgroup discussion about telecare, watch the chronic disease management workgroup recording here.

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The Behavior Change Puzzle of Medication Non-Adherence

The Behavior Change Puzzle of Medication Non-Adherence

Non-adherence to a prescribed medication regime for chronic disease management is known to lead to poor health outcomes and higher healthcare costs. A number of studies have shown that adherence is usually around 50% or less, even when medications are provided free of charge. What seems to be less clear is how best to address poor adherence; one study points out that most of the current interventions meant to improve adherence rates are too complex or ineffective, and that the research in this field is rife with weaknesses and bias.

But as with most quality improvement initiatives, understanding the source of the problem is an important first step. In this case, identifying the reasons for non-adherence is an important starting point for reducing barriers and improving patient outcomes. Many factors may affect whether a person takes their medications, including the patient themselves, the disease being treated, the health system and team, and the type of therapy involved. One study’s survey of 10,000 patients found that the most cited barrier to taking one’s medications was simply forgetfulness (24%). This was followed by perceived side effects (20%), high drug costs (17%), and a perception that their prescribed medication will have very little effect on their disease (14%).

The same study illustrated the various patient, provider, and external factors that can play a role in medication adherence using the figure below (Figure 1). If any one of these factors were to present a challenge for the patient, then they are at risk of not taking their prescribed medications on time and any related medical issues.

Figure 1.

While some interventions such as pill box aids and electronic reminders have helped patients when forgetfulness is the issue, these do not address factors such as concerns about side effects and medication-related harm, or uncertainty about the importance of taking long-term prescribed medications. These issues have the potential to be addressed through shared decision-making and education from clinical experts such as pharmacists and nurses.

One review analyzed the impact that social determinants of health has on medication adherence. Disadvantageous circumstances in social and living conditions are associated with an increase in chronic disease, and it is believed that these same challenges impact a person’s ability to manage their health. When an individual is facing food insecurity, unemployment, and unstable living conditions, they are sometimes unable to address their health concerns emotionally or financially. The review found that medication adherence was negatively impacted by food insecurity and housing instability, although few studies identified other specific social determinants that influence non-adherence to medications beyond these two. In fact, education, income, and employment status did not significantly correlate with adherence to a medication regime.

The Michigan Value Collaborative (MVC) would like to hear how your institution is addressing medication non-adherence, especially in the chronic disease patient population. This will be an upcoming topic at a chronic disease management workgroup. Please contact MVC at michiganvaluecollaborative@gmail.com for information about attending.

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Continuous Glucose Monitoring Has Potential in Inpatient Setting

Continuous Glucose Monitoring Has Potential in Inpatient Setting

One of the most prevalent comorbidities in the United States is diabetes; as many as 1 in 10 Americans are diagnosed with this condition, and 90-95% having potentially preventable Type 2 diabetes. It is well documented that unstable blood glucose levels can contribute to increases in morbidity, mortality, and healthcare costs.

In the inpatient setting, the current standard of care for monitoring and testing blood glucose levels in diabetic patients is point-of-care (POC) testing, which combines a specific testing schedule and approved devices to measure blood glucose levels. A recent study involving 110 adults with Type 2 diabetes looked at implementing real-time continuous glucose monitoring (RT-CGM) in order to better manage inpatient glycemic levels. The patients were on a non-intensive care unit (ICU) floor, and received either the standard of care or the RT-CGM with Dexcom G6 monitoring—where a tiny sensor wire is inserted just beneath a person’s skin using an automatic applicator. Data was transmitted from the bedside wirelessly, and monitored by hospital telemetry. The bedside nurses were notified of any abnormal glucose levels or trends and the patients were treated accordingly. The results indicated that patients in the RT-CGM group demonstrated lower mean glucose levels and less time in hyperglycemia.

Another study that evaluated the efficacy of RT-CGM discussed the effect that uncontrolled glycemic levels can have on clinical outcomes and healthcare costs. Currently, hospitals use POC glucose testing in order to monitor and treat hypoglycemia, and it is recommended that POC testing occur four to six times per day. However, this leaves many hours throughout the day where hypoglycemia can go undetected. RT-CGM using a glucose telemetry system (GTS) offers an alternative method to monitor these glucose values. A total of 82 patients participated in this study. Patients in the RT-CGM group experienced 60.4% fewer hypoglycemic events compared to the POC group. Figure 1 below illustrates the number of hypoglycemic events per patient for both the CGM/GTS and the POC.

Figure 1.

RT-CGM has yet to be implemented in inpatient settings for several reasons. The primary reason is the lack of U.S. Food and Drug Administration (FDA) approval. Additionally, institutional challenges may act as a significant barrier. For instance, staff need to be prepared for increased workload and educated on appropriate protocols and procedures. Technological support is required to ensure hardware compatibility and maintain a robust internet network with minimal interference in transmission of results and alerts. Additional factors within the hospital setting include certain medications, procedures, nutrition, acute illness, and any other condition that may affect glucose control. All of these challenges have the potential to impact CGM and its associated workload because of the effect they may have on the patients’ blood glucose levels. Although challenges remain to the implementation of RT-CGM in the inpatient setting, the benefits may outweigh the risks; thus, it is worth considering, especially given the successes in the outpatient arena.

The Michigan Value Collaborative hosts diabetes workgroups where topics such as continuous glucose monitoring are discussed by Collaborative members. If you are interested in attending the next MVC diabetes workgroup, please connect with the MVC Coordinating Center at: michiganvaluecollaborative@gmail.com.

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Henry Ford Health System – Cardiac Rehab

Henry Ford Health System – Cardiac Rehab

At the most recent congestive heart failure MVC workgroup, Dr. Steven Keteyian, Section Head of the Cardiac Rehabilitation/Preventive Cardiology Unit at Henry Ford Medical Group, presented on exercise-based cardiac rehabilitation in patients with heart failure. Dr. Keteyian started out by discussing the importance of cardiac rehabilitation and adhering to a program in order to improve exercise tolerance and disease-specific outcomes. Exercise intolerance is measured and the information gathered can be used to stratify a patient’s future risk. If the measurement improves over time, Dr. Keteyian discussed the potential for a decrease in risk of death and re-hospitalization. This shows a tie to directly improving outcomes and symptoms in cardiac rehabilitation. Also, in the words of Dr. Keteyian, “functionally, the more they don’t do, the less they can do.”

Cardiac rehab is a Class I recommendation from The American College of Cardiology for all of the traditional cardiac disorders. Henry Ford has a 36-visit program that is anchored on exercise training. Between four and fifteen people are in each class and each person receives an individual treatment plan with a focus on bio-behavioral components. Six core components make up the program which include outcome assessments, supervised exercise, dietary/weight management, tobacco abuse, psychological support, and medication adherence. All participants participate in 30-minute behavioral education sessions which cover topics such as nutrition, dining out, proper exercise, medication compliance, and other relevant disease-management self-care activities. These same topics are also available on YouTube and can be found here, all of which are available for use in your cardiac rehab program. Currently, Henry Ford is working on bringing their time to enrollment after hospital discharge to less than 21 days and increasing adherence to the 36-visit program. The goal is to achieve a participation rate of 70% or more in cardiac rehab for Henry Ford’s patient population.

After discussing the program specifics at Henry Ford, Dr. Keteyian discussed the barriers that one may face in relation to participation in cardiac rehab. These barriers include:

  • Demographic
  • Difficulty contacting patient after hospitalization
  • Return to work demands
  • Transportation
  • Co-payment obligations
  • Dependent care responsibilities

Henry Ford is working at a system level in order to increase the percent of patients who gain access to cardiac rehab. This includes increasing the use of electronic medical record (EMR) driven automatic referrals, with an option for users to opt-out if necessary. Additionally, a member of the cardiac rehab team goes to the inpatient setting and talks to patients to establish a touchpoint before they leave the hospital. This five-minute conversation is all some patients need in order to see the importance and benefits of rehab. Lastly, Henry Ford is working to shorten the discharge to start time. Each day after discharge, the chance of getting patients started in rehab decreases by 1% for each day that passes. Henry Ford is working diligently in order to help decrease this risk.

In 2016, Henry Ford launched a hybrid home-based cardiac rehabilitation service. This includes some visits at the clinic and other virtual sessions. Previously being tied to a single visit at a time on their current streaming platform, Henry Ford will roll out a WebEx model in February 2021 that will allow up to six cardiac rehab appointments to occur at one time. This will provide more of a group setting. Currently, a randomized controlled trial is being done on center based cardiac rehab versus hybrid cardiac rehab. Improvements in fitness and the number of sessions attended are being assessed.

If you are interested in watching the entire workgroup, please click here.  If interested in any information about this workgroup, or other MVC workgroups please email michiganvaluecollaborative@gmail.com