The Pathways Program “Bridging your way to better breathing” Advocate Health Care, Advocate Home Health Services, Cardio-Pulmonary Rehabilitation, and Physicians collaborating to provide positive outcomes for patients with chronic obstructive pulmonary disease. Connie Polke Advocate Home Health Services

Goals:  Decrease Frequency and Duration of Hospitalizations  Improve Patient Outcomes  Return Patient to Self Management  Improve Patient Satisfaction  Improve Physician Satisfaction  Provide Necessary Home Health Services  Reduce Symptomatic Complaints

Program Activities:  The Pathways Newsletter  Quarterly Patient Support Groups  Respiratory Therapist 1:1 educational sessions  Telehealth via Telephonic Assessments and support  Respiratory Therapist ongoing evaluation of progress and condition  Coordination with other care providers to standardize education  Program Coordinator Case Management and Clinical Interventions

Program Criteria:  Physician order  Pulmonary Diagnosis  Secondary Diagnosis Shortness of breath Deconditioning Decrease in ADL’s Decreased Functional or Neurological Capacity  FEV1 < 60%

Measures:  Dyspnea as measured using Borg and ADL Scales  Strength and Endurance as measured by the Six Minute Walk  Health Status as measured by SF-36 Health Survey  Number and Length of Hospitalizations

Telehealth Phone Monitoring via TouchPointCare, data collected included:  Weight  Shortness of Breath  Sputum Production Color and Amount  Oxygen Change in Liter Flow  Hospitalization Number of Days  Medication

Why We Chose Phone Monitoring:  Focus on the data to be collected, not on methodology  Choose easiest method patients  Patients like real voice connection  Much cheaper than other telehealth approaches

Quality of Life Scale

Results of Six Minute Walk Results of Perceived Exertion and Dyspnea

Weight Change

Number of Days Hospitalized

Data Interpretation  One year data indicative of improvement in the majority of measures  Increase the number of patients in program and continue ongoing assessment  Interpretation of data indicates need for increase in communication and education regarding program goals

Technology Issues for Web Based Phone Monitoring Telehealth:  Hosting eliminates IT hassles  Available 24/7  Secure Server  Robust security  Daily back-ups  HIPAA compliant  Easy to interface

Project Summary:  Telehealth via TouchPointCare phone monitoring facilitates patient data collection  RN not needed for data collection, (only assessment of data)  Improved productivity  Improved patient outcomes  Phone monitoring a cost effective solution

Contact:  Advocate Healthcare: Connie Polke  TouchPointCare: David Anderson