Telegeriatrics: delivery of multidisciplinary care to residents of nursing homes 1 Dr. Elsie Hui 2 Professor Magnus Hjelm 2 Professor Jean Woo 1 Community Geriatric Assessment Team, Shatin Hospital and 2 The Chinese University of Hong Kong

Background

Nursing Homes in Hong Kong 50,000 of Hong Kong’s 0.6 million elderly reside in nursing homes. Over half live in private, profit-making homes of variable standard of care. Nursing homes are not supported by general practitioners. Emergency Department attendance and hospital admissions are high.

CGAT Community Geriatric Assessment Team (CGAT) serves nursing homes. Geriatrician, nurse, physiotherapist and occupational therapist. Provides multidisciplinary outreach services. In Shatin, CGAT supports 20 institutions, clients. Limitations - infrequent visits, unable to respond rapidly to urgent problems.

Telemedicine in Geriatrics Relatively few specialists looking after growing numbers of older patients. Elderly have difficulty accessing health care because of social isolation, poor mobility, low awareness, etc. Require multidisciplinary input and holistic approach, with sequential follow-up, preferably in their own homes.

Objectives To explore whether Telemedicine is as effective as, or superior to, conventional outreach activities in providing a multidisciplinary service to elderly patients in nursing homes.

Methods

Telemedicine Hardware Videophone system - Polycom ® Viewstation 512K, 30 frames per second. 3 ISDN lines per station. Video camera, microphone, colour TV Optional - headphones, video recorder, computer, stethoscope

Equipment Costs

Subjects 195-bed nursing home in Shatin Current outreach services from CGAT:  routine and urgent medical assessment  multidisciplinary input - nursing, physiotherapy, occupational therapy Specialist clinics participating in study:  Dermatology  Psychogeriatrics  Podiatry

Intervention Telemedicine was used to replace all conventional outreach activities (CGAT) or outpatients visits (derm, psy, podiatry). A site visit would be made if telemedicine was considered inadequate for patient management or decision-making. The service was available during office hours, five days a week.

Activities assessed Medical history taking review of case notes/ drug charts physical exam nursing orders Assessment of: mobility ADL mental state skin and wounds swallowing test catheter care inhaler technique home oxygen

Outcome measures 1. Can telemedicine replace previous outreach or outpatient activities? 2. Can telemedicine increase productivity? 3. Is telemedicine cheaper than conventional services? 4. Does telemedicine reduce utilization of hospital-based health services? 5. How acceptable is telemedicine to users?

Findings

Telemedicine was adequate in the majority of cases and disciplines. Areas of limitation: Geriatrician - new cases, chest auscultation essential Dermatologist - biopsy necessary Nurse - complex procedures Physio - chest PT OT - measurement for equipment Podiatrist - wound debridement

Telemedicine Increases Productivity Geriatrician Time savings - 2½ hours per telemedicine session compared with 4 hours per outreach visit. Increased productivity - number of patients increased by 44.4% (from 45 to 65). Occupational Therapist Waiting time for new referrals shortened from 7 to 2 days. 5 telemedicine sessions were held per month versus only 3 visits per month before study.

Telemedicine is Cheaper

Savings over One Year (Geriatrician) By replacing outreach geriatric clinics with telemedicine: [($153 x 45) - ($40.3 x 65)] x 4 = $17062 By diverting 20 cases from outpatients to telemedicine: $455 x 20 x 4 = $36400

Telemedicine reduces utilisation of hospital-based services (1)

Telemedicine reduces utilisation of hospital-based services (2) Compared with same period pre-study: Emergency Room attendances decreased by 10% - Telemedicine was only available during office hours whereas 55% of emergency visits were out of hours. Acute hospital admissions decreased by 11%

Total Savings (Geriatrician) Provision of geriatrician’s services (medical follow-up, triaging of urgent cases) via telemedicine resulted in savings for the health authority amounting to $273,594 over one year.

User Satisfaction 1 Patients (total 1001 episodes) 35% unable to answer (demented, communication difficulties). Depending on the discipline, 82% to 95% were satisfied with this mode of care delivery.

User Satisfaction 2 Nursing Home Staff equipment easy to use increased accessibility to CGAT workload - 50% increased versus 50% decreased!

Conclusions Telemedicine is an acceptable alternative to conventional geriatric services for nursing home residents. It results in significant cost and time savings, increases productivity and decreases utilization of emergency and inpatient services by providing timely intervention.

Remarks Quality can be improved by availability of a stethoscope device Cost effectiveness will be enhanced by extending the hours of service and supporting more homes. Costs will further reduce with rapid advances in information technology.