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Results from a care coordination trial for Chronic Heart Failure and how Health Funding Policy can facilitate similar out of hospital collaborative care

Author:

Rajiv Jayasena

Csiro, AU
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Abstract

Introduction:

Objective of this abstract is to present outcomes from a home-monitoring Chronic Heart Failure (CHF) trial coordinated by a hospital community health setting and how these types of care models could benefit from health funding policy targeted at providing hospitals the flexibility to offer patient-services beyond bed-based care.

CHF trial was to examine if an Innovative home-Telemonitoring Enhanced Care Program for CHF (ITEC-CHF) improved compliance to daily weight-monitoring and the impact on self-management and healthcare.

A flexible funding model called HealthLinks Chronic Care (HLCC) trialed in the state of Victoria, Australia will be discussed as an approach to allow health services to develop alternate care-models similar to ITEC-CHF.

Methods:

Technology approach for ITEC-CHF was a zero-touch design where participants provided with a Bluetooth weight scale and measured weights are automatically transferred via a tablet to a cloud server. An application monitored (minimum 6mths) uploaded weights in real-time to detect missing and changes to weights according to guidelines and alerts generated for response by a hospital nurse.

HLCC utilises an algorithm to identify patients who are at high risk of an unplanned readmission to hospital and these patients are enrolled in the program when presented to hospital. Several hospitals in metropolitan Melbourne are involved in this initiative and CSIRO has co-designed the evaluation in partnership with Victorian Department of Health and Human Services (DHHS).

Results:

Results show that the ITEC-CHF program was associated with significantly improved patient compliance with daily weight monitoring (n=91 Test, n=93 Control). ITEC-CHF trial also showed improvements in health maintenance, medication, diet and accepted by patients.

Qualitative perspectives from HLCC hospitals were explored by undertaking focus groups and semi-structured interviews:

(1)       Policy/funder: long lead time before benefits are realised and the need to have shared trust and willingness to participate.

(2)       Implementors/Hospitals: Strong leadership, resourced to deliver new/re-designed care-models and appropriate systems for patient identification.

(3)       Evaluator: data availability, well defined evaluation framework with room for agility and adoptable for changes in a co-design environment.

Discussions & future research:

Proportion of participants in ITEC-CHF achieving weight monitoring was significantly higher than in usual care. Furthermore, ITEC-CHF resulted in significant improvements in health maintenance, medication adherence and diet demonstrating patient benefits. However, the sustainability of these programs is reliant on funding policy for hospitals to deploy them. HLCC is designed to provide this flexibility.

Further research is required to implement care models that have shown evidence of impact to both patient and the health system which can be transitioned to usual healthcare.

Conclusions:

ITEC-CHF program significantly improved patient compliance with daily weight monitoring and was associated with improved self-management related to health maintenance, medication adherence and diet.

Wider implementations of this type of interventions need to be undertaken in a phased manner demonstrating impact and buy-in along the way to achieve long-term sustainability. New funding programs such as HLCC are key to these out of hospital care models and evaluation objectives need to address key sustainability factors such as long-term patient benefits and cost of delivering care.

How to Cite: Jayasena R. Results from a care coordination trial for Chronic Heart Failure and how Health Funding Policy can facilitate similar out of hospital collaborative care. International Journal of Integrated Care. 2021;21(S1):91. DOI: http://doi.org/10.5334/ijic.ICIC20257
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Published on 01 Sep 2021.

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