1. Virtual Clinical Care Home Telemonitoring Service Susan Tappin Associate Member of TSANZ. Registered Nurse. Bth Health Science. Graduate Certificate Health Management CCSM-Flinders. Graduate Certificate Clinical Education. Diploma Population Health. Cert IV Training & Assessment. Winner of the Nursing Excellence Clinical Team Award 2013 for South Australia. ANUM Better Care in the Community Country Health Connect.

2. CHSALHN Virtual Clinical Care (VCC) – Why do we need Virtual Services?
Virtual Services will enable CHSALHN to expand services in a resource poor environment across 1,000,000 square kilometres.
Transforming health!
To address the specific challenges of rural and remote settings, successful models have demonstrated the following features:
a multi-disciplinary approach
integration and coordination
flexibility in design, funding, workforce and resource allocation
sustainability and responsiveness to local need and capacity
culturally safe and appropriate.
National Strategic Framework for Rural and Remote Health 2012

3. Benefits of Virtual Services
Expand availability of services provided in local communities
Potentially reduce transfers to Adelaide for patients requiring specialised intervention
Early detection and management, potentially preventing hospitalisation
Improved self management of chronic conditions
More appropriate utilisation of health services

4. VCC in country South Australia
Supporting clients across country SA who have COPD, Cardiac Failure, Diabetes, hypertension or a combination of these conditions
Patient set up at home with devices to take daily measurements with results linked to a database accessible to members of the healthcare team
Results outside ‘normal’ range for that patient triggers a response from healthcare team
VCC is facilitated by a collaboration between iCCnet (CHSA) and the Better Care in the Community (BCIC) program
Clients are monitored daily for up to 12 weeks.

5. Virtual Clinical Care - Equipment
Home vital sign monitoring
Blood Pressure
Pulse Oximeter
Weight
Glucose (if applicable)
Temperature (if applicable)
Blood
Pressure
Scales
Home Monitoring
Tablet
Pulse
Oximeter
Glucometer

6. Inclusion Criteria Clients with existing chronic condition(s)
3G or 4G mobile network coverage at home, or a home wireless network
Ability to nominate a regular GP
Current ambulance cover
Dependence on medical care and/or a recent exacerbation resulting in hospitalisation OR
Instability of symptom management OR
Unplanned acute admissions of >2 in the last 12 months or >4 in the previous 5 years

7. Exclusion Criteria People who are newly diagnosed with Type l diabetes
Women who are pregnant (including those with gestational diabetes)
Children and/or young people <18 years of age
People with a cognitive impairment, a neuromuscular disease, an intellectual disability or a significant mental illness

8. VCC – innovation in action
18 September 2019
Patient feedback
“I would never have known I had BP issues without VCC. I often felt really ‘crappy’ and didn’t know why. I now know it is because of my high BP and am starting to get on top of it with my GP. So I think the VCC is wonderful.”

9. Monitoring Screen

10. VCC Results

11. VCC Results

12. Service Strengths Clients really value service
Clients report improved understanding of their chronic condition(s)
Clients report improved confidence in managing their chronic condition(s)
Clients benefit from having a current individualised care plan and action plan
Collaborative team approach to effectively and proactively respond to clients’ needs

13. Service Strengths
Clear escalation plan supports action when deterioration detected
Early detection and timely intervention lead to improved client outcomes
Proactive approach to supporting people with chronic conditions
Facilitates engagement of all members of care team
Facilitates communication between members of the care team (clinical notes, reports, trend data etc)

14. Benefits Client centred care
Improved chronic condition self management
Services closer to home and appropriate health service utilisation
More detailed clinical results
Early detection and management
Improved Quality of life for clients
Improved post-discharge services

15. A Case Study - Life for Ross
65 year old man with frequent hospitalisation admissions, poor health outcomes, advised by doctor he was heading for a premature death
Socially isolated T2DM on insulin
Ischemic Heart Disease with stents Hypertension Hypercholesterolemia Obese
COPD Sleep Apnoea Peripheral Neuropathy
Peripheral Oedema Chronic back pain
Post Traumatic Stress Disorder Depression Anxiety
Polypharmacy with non adherence
Minimal mobility due to shortness of breath / chest pain

16. Better Care in the Community Involvement
Virtual Clinical Care Home tele-monitoring
Cardiac / pulmonary rehabilitation
Chronic condition support, motivational interviewing with goal setting
Frequent liaison with GP
Referrals to external stakeholders
Dietician
Credentialed Diabetes Educator
Respiratory General Physician

17. Results at completion of VCC home telemonitoring and rehabilitation
- No hospital admissions!
- Weight loss 11kg
Waistline reduction 7cm
Vast improvement in depression / anxiety score, no longer taking anti-depressants
Blood pressure within target range
Reduction on cholesterol level
Walks to the shops without needing to rest
Taken out full gym membership, attends 3 x week
Currently joining a volunteers community group
Compliant with medications
Goal setting and striving for better health
SMILING 

18. Results at completion of VCC home telemonitoring and rehabilitation
Benefits from VCC
Improved personal Self management of
Medication –use and understanding
Daily contact improved social interaction
Improved social competency
Felt more comfortable with HCW.
Able to voice concerns and be listened to.
Greater understanding of symptoms and how these give signs of condition management
Importance of monitoring his health
SMILING 

19. PIH Trial Data

20. PIH Trial Data

21. PIH Trial Data

22. PIH Trial Data

23. PIH Trial Data

24. PIH Trial Data

25. CHSA VCC to October 2017 Patient Demographics

26. The future of Virtual Clinical Care
Future expansion investigations include:
Opportunities to expand the VCC to include more client groups
Utilising VCC in a variety of settings
Involvement of an expanded workforce to support the VCC model across CHSALHN

27. Virtual Clinical Care

28. Virtual Clinical Care Name: Susan Tappin Phone: 08 88230283
Contact Details
Name: Susan Tappin
Phone: