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Title and Description
Telehome Care for chronically ill patients.
Reviewed/ candidate case
Quality reviewed case
Short description
Meavita, a large healthcare company in the Netherlands has 3 years of operational experience in treating patients via internet through their own TV, using a settop box, a camera and remote control.The strategic objective is to improve quality of care, processes of care delivery and HRM using ICT.
Objectives and purpose
Large volumes of chronically ill patients. It will be much too costly to deliver all standard care individually. Meavita wants to create a way to treat more patients per nurse for at least the same quality. Shortage on the labour market of nurses. Meavita wants to be an attractive employer for nurses by raising job satisfaction by delivering modern care. Increasing healthcare costs at a national level. By increasing self management and empowering patients and nurses, Meavita wants to avoid costs in a later phase of the disease and so contribute to affordable healthcare for all.
Detailed description
We treat patients via internet through their own TV, using a settopbox, a camera and remote control.In some projects patients were primarily attended by their own nurses, in other projects they were attended by nurses in a medical call centre.The patients were recruited via nurses of the healthcare delivery company, by the GP or by the specialist.
Objectives addressed until now 1. Creating care-packages for chronically ill patients 2. Finding out if nursing care can be substituted by Telehome Care 3. Making a business case for Telehome Care 4. Scaling the amount of patients using Telehome Care.
Context The application is installed for patients in different categories - vulnerable elderly persons, living at home, needing nursing care - diabetes patients, living at home who are being treated by the GP - diabetes patients, living at home who need to visit ambulatory clinics - CHF patients, living at home who need to be monitored for the specialist - COPD patients, living at home who are being treated by specialist.
All patients can make direct contact with a nurse working for the homecare delivery company for unplanned care. Most patient categories also have planned appointments with nurses or send data, through the application. The services are delivered in three different regions in the Netherlands. At this moment we are moving on to integrated services.
The problem the application is aiming to solve is - substituting care by Telehome Care to reduce costs - treating larger amounts of patients with the same amount of nurses - increasing self management competencies and thus avoiding costs in the future, e.g. rehospitalisation - raising QOL by increasing the feeling of safety and self-sufficiency and thus enabling vulnerable people to remain in their homes.
Through the application several different services were delivered: - delivering nursing care (e.g. attending patients with medication, structuring the day) - supporting self management by sending interactive questions on a daily basis and nurse responded to alerts in a coaching relationship - supporting self management by monitoring vital signs and reacting to alerts - supporting self-sufficiency by delivering unplanned care in response to a patient alert - delivering teleconsults between nurses and patients as a substitute for coming in to the clinic
In all cases nurses were involved. From the medical side GP’s and specialists were involved. In the KOALA project there was also an insurance company and a telecom company involved. In the TVfoon project the same telecom company was involved after the initial producer went broke. The actual users of the service live at home and are either vulnerable or chronically ill (DM, COPD or CHF). Results show: - that it is possible to substitute care by Telehome Care and this saves time of travelling for the nurse. This is especially the case for multi-users - that it is possible to avoid a certain amount of visits to the ambulatory clinics - that nurses enjoy these new ways of working, once they have been properly implemented - that patients feel safer and more self-sufficient with Telehome Care.
Funding
The initial investment was done by Meavita. Retrospectively the investment in hardware at the beginning of the project was too great. There was the promise of funding via regular healthcare reimbursements. In fact the rules and regulations for actually cashing on this income-stream were so bureaucratic that it was not possible to realise the business case until now. There is a structural possibility to fund the hardware. There was extra funding for the initial phase from special government stimulation programmes. (2007-2010) One of the projects received some funds from the EU.
Interoperability and standards
There were several problems in the field of interoperability like no direct link between Meavita and GP/hospital systems, having to translate all the data for television-presentation, no link to mobiles or PC’s. But the choice was made to start up the services anyway as there are many things we need to learn about delivery of care in this way, and if we wait till interoperability is solved, a lot of time will have gone by. The necessity of interoperability to deliver efficient services has become increasingly clear during our processes. The three systems are not interoperable No Dutch EHR to facilitate communication of data, so solutions per group were sought No criteria for interoperability available yet
Timescale
Start of planning
2004
1st milestone
In 2005 Regular funding for Telehome Care delivery and initiation of a national transition programme to fund the experimental phase, was announced.This was an important milestone as it showed the commitment of the authorities to learn about the possibilities of the new forms of care. Meavita and Zuidzorg had been lobbying strongly for the realization of this precondition. Now healthcare delivery companies were confident to take initiatives as a business case seemed possible.
2nd milestone
January 2007: Commercial launch of the TVfoon project. We started the TVfoon project which consisted of reaching out to our patients and employees through their own TV set (their best friend). For patients there were options to support them to remain in contact with important “other”, feel safe at home, enjoy life by being connected to (local) activities and realise self-management. The options for our employees were Meavita-television (communication channel made by employees) and HRM instruments like e-learning, e-planning and e-coaching. We also started developing a channel for young parents.
3rd milestone
January 2007: Merger of four healthcare delivery companies (Meavita, Sensire/Thuiszorg Groningen, Vitras) to one (Meavita Nederland). Time was needed to build a new company and define a new strategy and direction. This made the risk of scaling to a high level at that time too great. Besides, the necessity of integration of the three initiatives within the new company became clear. Meavita still believes Telehome Care will be a precondition to delivering healthcare in the future. Better definition of rolls and responsibilities is necessary, however, to make a restart with a combined initiative.
Start of routine operation
2005
Evaluation
Ongoing
Characteristic of the application
Country
The Netherlands
Part in the healthcare chain
Home-monitoring
Level of Implementation
Country-wide
Technology
Customised solution
Details on Technology
The technology used was different for two of the three initiatives
The hardware used is - a settopbox (partly with hard disc) - a camera, static or movable from the call centre - a remote control - own TV set.
The software used was - developed by ourselves - integrated from Health Buddy - usable for nurses in the call centre or at their own computer. The internet was used, business DSL and cable. Standard safety was observed.
Results
Outcomes
It is hard to give quantifiable outcomes at this moment. For some numbers from the recent KOALA report, see references. Studies show that it is possible to substitute care by Telehome Care but the population that was selected, was chosen very conservatively and the data collection was incomplete. Patients increasingly want to be treated whilst staying in their homes and with flexibility. So with these volumes the proven significance for the business case is practically negligible. An important result is that patients do not perceive the technical side of the systems as difficult. The professionals expect that this will be difficult, but are proven wrong. This means that patient’s experiences should lead future developments. Patients feel safer with a Telehome Care system in their homes, because they experience this as a “presence” of the nurse. In most cases it seems this leads to a lower consumption of care. Patients say that they know more about their disease than before they used the interactive module. This is because the module offered was about knowledge of the disease and self management. They were asked a question and always received explanatory feedback.
Wider impact
The content of the interactive questions has been studied by several universities in the Netherlands and it is plausible to expect the same results in comparable populations. In these studies the chance of hospitalization and the duration of hospitalization decreased significantly for CHF, COPD and DM patients. So this saves avoidable hospitalizations = costs. Meavita shows that it is possible to deliver Telehome Care to a relatively large population. So it is worthwhile to fine-tune the regular funding of this form of care so that it can be easily procured if necessary. It has also shown that several problem areas have to be addressed before Telehome Care can be delivered on a large scale. We have learned that a healthcare delivery company like Meavita is not the stakeholder who should be a full fledged entrepreneur and invest in technical aspects of Telehome Care on a large scale. This is too great a risk for the company. But who will pay for what? In the current system of healthcare it will not be possible to create a healthy business case for Meavita, so change is necessary.
Results expected?
The patient results on the effects of Telehome Care are about what we expected, except that we have to do much more research. We had expected to be able to support our HRM processes sooner via the system. Initially we had expected to include large amounts of patients (6-8000). The complicating factors we encountered were: -difficulties in the decision-making process about investments -cultural barriers within the professional groups - insufficient knowledge about “marketing” -a “language gap” between healthcare companies as sponsor and industrial companies as vendor - small vendors going broke
Success factors
The most important success of our initiative was to make the whole healthcare sector sit-up and realise that change was coming. We set the agenda for the future. A success factor was the feeling for timing at the start of the initiative. The first milestone (funding) was gained because all stakeholders had a feeling that new forms of care were necessary, and healthcare companies started an effective lobby. Another success factor was the choice to formulate the Telehome Care from the point of view of the care-receiver (= client/patient centric approach). At this moment it is a success because it helps us to motivate professionals to work on developing Telehome Care. In the future we hope it will be a success because it actually supports care-receivers to manage their situation in a way that costs will be avoided. A fourth success factor is working with other “players” in the initiative: patient-organizations, different patient groups, different GP’s, specialists, hospitals, healthcare insurance companies, telecom companies, (local) authorities, etc.
Failure factors
Our most important success was also the reason for our fail factors. The concept was too broad to be able to implement as a working technique in a relatively short time for large populations with new forms of care and unclear business cases. Too much at once. The instrument we needed to deliver Telehome Care did not exist so we chose to develop it. This was a very fascinating journey but took too long and cost too much. Also the financial difficulties of the vendor didn’t help. We wanted to deliver evidence-based care. There were not many interventions we could integrate that had been sufficiently evaluated. This brought high costs and long negotiations. Theoretically there were large potential target groups for our companies. But we had insufficient experience with marketing the new forms of care with the professionals and the patients. More time was needed. Unclarity about the right business case supports uncertainty towards investing in these forms of care. We believe Telehome Care will change the way we organize care, not only financially but also the rolls and responsibilities of patients and professionals. But do we make decisions on basis of the reality of today or of the future and taking into account the different perspectives?
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