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House-Calls Telehealth Program Reduction of Hyperglycemic Values

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									Use of Telehealth Modalities to Effect
 Behavioral Changes Required for
    Improved Glycemic Control
                     Presentation to
            American Diabetes Association
                68th Scientific Sessions
                     June 9th, 2008
                Susan Lehrer, RN , BSN
      Director of House Calls Telehealth Program
     New York City Health & Hospitals Corporation
           The New York City Health and
           Hospitals Corporation (HHC)
The largest municipal hospital and health care system in the country

$5.4 billion public benefit corporation that serves 1.3 million New Yorkers and
nearly 400,000 who are uninsured.


 Serves the city’s poorest patients who are most in need of care for
chronic diseases such as diabetes.

11 Acute Care Hospitals
4 Skilled Nursing Facilities
6 Large D&T Centers
A Certified Home Care Agency
A Managed Medicaid/Medicare Health Plan
Over 80 Community Based Health Centers
       Cost of Diabetes in NYC
12.5% of New Yorkers are diagnosed with Diabetes and of those,
59% are black and Hispanic.


Health care costs attributed to diabetes and its complications for
NYC are large and growing. Annual cost of hospitalizations with a
principal diagnosis of diabetes – which reflects only a small portion
of diabetes-related costs – doubled from 1990 to 2003, reaching
$481 million.1


1Kim M, Berger D, Matte T. Diabetes in New York City: Public Health Burden and Disparities.
New York: New York City Department of Health and Mental Hygiene, 2006.
             Priority Areas for National Action:
          Transforming Health Care Quality (2003)
               Quality Chasm report:
At no time in the history of medicine has the growth in knowledge and
technologies been so profound

Research on the quality of care reveals a health care system that
frequently falls short in its ability to translate knowledge into practice,
and to apply new technology safely and effectively

 If the health care system cannot consistently deliver today’s science
and technology, we may conclude that it is even less prepared to
respond to the extraordinary scientific advances that will surely emerge
in the first half of the 21st century

                    (Institute of Medicine, 2001a:2–3).
      The HHC Response:
The Chronic Disease Collaborative

In 2003 HHC launched the Chronic Disease Collaborative to
redesign and improve the care and outcomes for patients affected by
chronic disease.

Collaborative data study showed that majority of diabetic patients
had not met HHC management goals-HgbA1c< 7.0% and that the
gap in treatment outcomes throughout the system was unacceptable
                     A Streamlined Delivery System for
                       Chronic Disease Management
                                             Telehealth
 Improved Safety
        Allows effective, efficient coordination, case management &
        communication between multiple disciplines

 Improved Outcomes
        Have demonstrated significant improvement in diabetic criteria linked
        to decreased complications 1

 Cost Reduction
        Is a fraction of traditional homecare with measurable and dramatically
        improved outcomes 2

1   Dimmick, Susan L., et.al. 2004. Outcomes of a Diabetes Self Management Program Using Home Telehealth. Home
        Health Care Technology Report Vol. 1 No. 5. p.65

2 Bynum,  AB. 2003. The Impact Of Remote telemonitoring On Patients' Cost Savings: Some Preliminary Findings.
        Telemed J E Health. 2003 Winter;9(4):361-7
The Team



  Patients
         Baseline Realities of our Patients
                       (and probably yours)
1. Lack a basic understanding of how to self manage (Avg A1c@9.34%)
2. Are Chronic diabetics (avg. 5-20 yrs) who have learned about their illness
    from a variety of sources
3. Hold on to their “understandings” and fears about their illness until someone
    can demonstrate otherwise
4. Have a poor-at best understanding of the link between carbohydrate intake
    and daily blood glucose levels.
5. Are MOST receptive to information given in non-threatening & familiar
    surroundings
6. Are non “traditional” learners ie: not classroom learners
7. Trust information obtained from people who they perceive “Care about them”
Enter the Telehealth
   “Connection”




                       Push one
                       Button!!
Tabular View
Medication List
Coordination of Care
         Behavior Change Basics
             for Telehealth

Communication Communication Communication

     1. Method
     2. Frequency
     3. Content
     4. Coordination with Care Providers
             Behavior Change Basics
                 for Telehealth

#1 Communication Method = Motivational Interviewing

   Partner with patients: Collaborate & Empower!

   Listen Reflective listening” with open questions to develop
       rapport and trust

   Empathize with their reluctance to change.

   Help patients identify the Discrepancies between what they
      want and what they do

   Elicit most of the talking & teaching from the patients
              Behavior Change Basics
                  for Telehealth
                #2 Communication Frequency
                         (timing is everything!)



   Weekly calls
    Model consistent behavior and build Trust



   Alert response within 2 hrs for BG>300 or <70
    Facilitate Behavioral Conditioning

           “I knew it was you….I knew you’d call”
      Behavior Change Basics
          for Telehealth
       #3 Communication Content


Caution:   Before proceeding in conversation be sure to

            Establish RAPPORT!
      Behavior Change Basics
          REFERENCES
           for Telehealth
          #3 Communication Content (cont.)

   Discuss what’s important to the patient THAT DAY
   “Explore” it’s importance
   Discuss & review readings: Brainstorm with them
   Allow patients to describe their “success strategies” rather than
    their reasons for high BG results. (Discuss the positive)
   Explore their thoughts
   Help them link their behaviors, food choices, portions and meds to
    results
   Ask permission to “Suggest” new foods
   Laugh with them
   Slip vital information into their “comfort talk”
   Count carbs with them, discuss recipes with them
            Behavior Change Basics
                for Telehealth

     Important Points to Remember
COMPLIMENT any improvement or “positive talk”

RECOGNIZE all evidence of self management

Use “Future Talk”
“The next time we talk”…. and… “When your BG is lower….”
                      Recognition
 Recognize their efforts….(no matter how incremental)
 Recognize the challenges of management and our availability to
   partner with them to make it easier.
 Recognize their “success strategies” rather than their reasons for
   high BG results.
 Recognize their testing compliance with the weekly calls and during
   alert response
 Recognize their success publicly with Quarterly Newsletters for all
   patients who demonstrated improvement and those who reached an
   average monthly BG WNL
        House Calls: The Virtual
    “Reach Out and Touch Someone”
        Each patient contact is an opportunity to:
                       Educate
                       Listen
                       Validate
We become “the little voice” that gently encourages and reminds them
  that they can do it.
  Recognizing their efforts and progress keeps them motivated.
                Telehealth Findings
•   “Alert responses” enable patients to “make the connections”
•   Regular conversations allow patients to begin to “normalize”
    discussion of diabetes.
•   Increased comfort with discussing ideas, strategies leads to new
    behaviors
•   Patients are able to absorb & integrate small frequent doses of
    information
•   Patients demonstrate increased problem solving
•   Patients express EMPOWERMENT
•   68% of patients demonstrate improved glycemic control
       Telehealth Patient Outcomes
Patients begin to:
•   Look forward to the weekly calls.
•   Stop “Dreading” discussions about their BG and disease
•   Become more “honest” about their foods & lifestyle and start “hearing
    themselves”
•   Enjoy the personal relationship with the nurse and want to “please” us by
    demonstrating med compliance & glycemic control.
•   “Make the connection” between the food they ate last night and today with their
    current BG due to immediate feedback to alert responses. (behavioral
    conditioning)
•   Look forward to the learning and ask more questions.
•   Look forward to the recognition of their successes and often call us to ask “did
    you see my BG today?”
•   Transfer wanting to please us, to wanting to feel better and please themselves
                   Results of the
              Telehealth Relationship
1. Develop trust through consistency of the weekly calls and follow up.
2. Discussion about DM is normalized” as part of daily life.
3. Patients stop “worrying” about their food choices; they verbalize a reduction in
   their anxiety & “avoidance” of F/U appts
4. Patients begin to become more proactive in their medical care.
5. Patients verbalize feeling more in control of their own lives
6. Patients become more willing to try new foods and make different choices
7. FINALLY...... Monthly BG averages start to trend down and then fall WNL!
8. Patients verbalize excitement with their success and increased
   confidence. They are EMPOWERED to make good informed choices.

         Most people learn their most positive lessons from their
                  successes, Not from their failures…
            What do we really “learn” from our mistakes??
   One Patient’s Success in 2007
SOC: 11/16/06 with A1c 14.3% on 10/27/06
First 2 weeks: average blood glucose = 308
Average BG w/o 10/22/07 = 87
A1c on 9/27/07 = 6.8% (Baseline reduction of 7.5%)

                             15.00%
                                                   14.30%
                             13.00%

                        Hgb A1c
                             11.00%
                                                                                          9.50%
                                  9.00%
                                                                                                                   7%
                                  7.00%
                                                                                                                                     6.80%
                                  5.00%


                                                                               Feb-07




                                                                                                                            Jul-07
                                          Oct-06
                                                    Nov-06
                                                             Dec-06




                                                                                        Mar-07


                                                                                                          May-07
                                                                      Jan-07




                                                                                                                   Jun-07




                                                                                                                                              Sep-07
                                                                                                                                     Aug-07
                                                                                                 Apr-07
               Telehealth Efficacy
                   Response statistics: 1 - 6 months


                     20.55%                      A1c reduction
         1.37%
                                                 no change
                            78.08%               A1c increase



                               A1c Data Averages

      12.00%

      10.00%               9.34%
                                        8.26%       7.78%
      8.00%
A1c




      6.00%

      4.00%

      2.00%

      0.00%
        Baseline                           1
                      1-6 months in Telehealth   6-12 months in Telehealth
Reduction of Hyperglycemic Values
    Percentage of patients on program >30 days with either a decrease
     in monthly average of BG readings or a sustained normal range




                                                                        (101/151)
           Barriers Identified
 Slow buy-in and some        Language & literacy
  resistance by
                              Complexity of chronic
  clinicians (referrals)
                               disease management
 Clinicians concerned
                              Lack of protocols for
  with appearance of
                               use of email in
  decreased productivity
                               coordination of care
 Resistance to change
                              Not all clinicians utilize
  in clinic work flow
                               HHC GroupWise email
 Inability to ‘integrate”     system
  website data and EMR
                 Lessons Learned
 Significant clinical/financial outcomes can be achieved with
  available technology partnered with stringent case management

 Effective patient interactions & interventions can be conducted via
  phone

 Technology enables the immediate feedback that combined with
  expert communication and coordinated case management =
  Dramatic clinical outcomes!

 Chronic Diabetics can learn self management and achieve glycemic
  control with targeted interventions and support.
                        References
                       REFERENCES
Bynum, AB. 2003. The Impact Of Remote telemonitoring On Patients' Cost
Savings: Some Preliminary Findings. Telemed J E Health. 2003 Winter;9(4):361-7


Dimmick, Susan L., et.al. 2004. Outcomes of a Diabetes Self Management Program
Using Home Telehealth. Home Health Care Technology Report Vol. 1 No. 5. p.65


Johnston, B. et. al. 2000. Outcomes of the KaisMedicine er Permanente Tele-Home
Health Research Project. Archives of Family Vol. 9 pp.40-45
Noel, Helen C. et. al. 2004. Home Telehealth Reduces Healthcare Costs. Remote
telemonitoring Journal and e-Health. Jun 2004, Vol. 10, No. 2: 170-183


Shea, S., et.al. 2006. A randomized Trial Comparing Telemedicine Case
Management with Usual Care in Older, Ethnically Diverse, Medically Underserved
Patients with Diabetes Mellitus. Journal of the American Medical Informatics
Association. 13:40-51., DOI 10.1197

Woodbridge, P. Home Telehealth’s Role in Diabetes Case Management. Presentation to
the American Telemedicine Association, April 19, 2005.

								
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