Delivering Long-Term Diabetes Care at Home: A Telemedicine Pilot Project Aims to Improve Quality of Life for Patients with Chronic Disease

This article was previously published in the Summer 2014 issue of The Diabetes Communicator. The Diabetes Communicator is distributed as a benefit of membership to all Diabetes Educator Section (DES) members of the Canadian Diabetes Association. For more information, please visit: www.diabetes.ca/publications-newsletters.

Delivering Long-Term Diabetes Care at Home: A Telemedicine Pilot Project Aims to Improve Quality of Life for Patients with Chronic Disease

Cindy Fajardo RN BScN MScHI
Telehomecare Clinical Practice Manager, Ontario Telemedicine Network, Toronto, Ontario

Patients with diabetes should receive timely diabetes education that is tailored to enhance self-care practices and behaviours (1). Evidence has shown that self-management education is associated with improved outcomes, such as reduction in glycated hemoglobin (A1C), improved quality of life and sustained weight loss (1).

To help, the Ontario Telemedicine Network (OTN) has launched a pilot program in diabetes care which uses technology to give people the self-management support and health coaching they need right in their own homes on a weekly basis. The pilot program extends the reach of Telehomecare, an OTN project that complements the care people with chronic health conditions already receive from their doctors and other healthcare providers. Currently, Telehomecare helps patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF). The service remotely monitors, in his or her home, a person’s vital signs and other signs and symptoms. It also provides self-management support and weekly health coaching through phone calls with a specially trained dedicated nurse or respiratory therapist.

OTN, which designed and oversees Telehomecare, will study whether its diabetes program prevents—and/or improves management of—complications for people living with diabetes, as it does for people with COPD or CHF. The pilot program will assess patients’ participation in self-care and decision-making to manage their diabetes and associated complications. Ideally, a decrease in frequency of hyperglycemic and/or hypoglycemic episodes will be seen.

The pilot program aligns with the Ontario Diabetes Strategy, which works with the diabetes community and all health system partners to improve patient care. OTN will use the results to assess the benefits of expanding Telehomecare to include enrollment of patients with an  established diagnosis of diabetes.

To be selected for the pilot program, patients must be at least 18 years of age and have an Internet or landline connection in their home. They need to have an established diagnosis of diabetes, as well as COPD or CHF. Patients can have type 1 or type 2 diabetes, but those with prediabetes or gestational diabetes are excluded. The pilot began in April 2014, and patients  will be enrolled for an average of six months. There will be a minimum of 40 participants who will be followed until December 31, 2014. Referrals can be received from any member of the patient’s healthcare team, of which diabetes educators would be well-placed to identify potential participants.

Ultimately, the effort is about using Telehomecare to give people living with diabetes the skills and confidence they need to live their lives as optimally as possible. OTN designed Telehomecare to be simple to use, with easy-to-use touch screen tablets and devices that automatically transfer data to the clinician’s patient monitoring management system. Coaching sessions are done by telephone. For the diabetes as comorbidity pilot, eligible participants will receive a tablet computer and standard medical devices to measure their blood pressure, oxygen saturation levels and weight. To keep the technology as simple as possible, the pilot will not use remote glucose metres. Instead, participants will report the patterns of their blood glucose levels by answering a series of daily questions and submitting through their tablet. Each day, patients will submit their vitals, as well as answers to a set of questions to assess changes in how they are feeling or managing their care. Examples include, “Are you more thirsty and urinating more than usual?” and “Yesterday, how many times did you have blood sugar levels above 10 mmol/L?”

The home monitoring protocol has been created with the guidance and approval of the  Telehomecare Clinical Advisory Committee, which includes subject matter experts on diabetes, COPD and CHF. (To learn more about the committee, visit http://rxtelehomecare.ca/clinical-foundations). The clinician will monitor results for changes and conduct weekly check-ins and coaching sessions by phone. Self-management education will include medication management, symptom management, foot and eye care management and lifestyle changes. Telehomecare clinicians work  collaboratively with each patient’s circle of care to ensure continuity and consistency. Progress reports are usually sent on a monthly basis to the patient’s most responsible provider and others in the circle, such as the patient’s diabetes educator. 

OTN’s expectation is that by using standard technology to bring education and follow up right into the home, the pilot program will deliver meaningful improvement to participants’ lives. Telehomecare patients are normally in the program for 6 months. Early studies (2-4) have shown that telemedicine can be an effective tool to help people manage their diabetes. The Canadian Agency for Drugs and Technologies in Health conducted a review in 2008 (5) of telemedicine evidence from 78 international studies. It reported that home telemonitoring provided better glycemic control than traditional care.

In Ontario, Telehomecare is already showing some impressive results (6)—reducing the number of unnecessary emergency room visits and hospital stays among enrolled patients. Between April and September 2013, there was a 43% decrease in emergency room visits and a 71% reduction in in-patient hospital stays among patients in the Telehomecare program delivered by the William Osler Health System in the Central West Local Health Integration Network (LHIN) (6).

Adding diabetes care represents a natural evolution of the service, because it aligns with the self-management model that Telehomecare has already established for mild to moderate COPD and CHF. The focus of that model includes self-monitoring, medication and symptom management,  lifestyle changes, goal setting, problem solving and screening for depression. Moreover, diabetes is frequently a comorbidity of COPD or CHF. Heart failure is twice as common in people with diabetes compared to those without. People with diabetes are 3 times more likely to be hospitalized with cardiovascular disease than those without diabetes (7). In terms of COPD, research has linked hyperglycemia to impaired lung function. As well, COPD medications may worsen hyperglycemia (8).

OTN’s plan is to enroll 40 patients in the pilot program by the end of June. Two healthcare provider groups will host the project: William Osler Health System in the Central West LHIN and the Toronto Central Community Care Access Centre (CCAC) in the Toronto Central LHIN. Telehomecare is funded by the Ontario Ministry of Health and Long-Term Care and Canada Health Infoway.

OTN, which is responsible for managing the clinical protocol development and technology, is expanding the training it provides to Telehomecare clinicians to include the most recent evidence-based clinical guidelines on diabetes management and self-management support. OTN is also a Registered Nurses Association of Ontario Best Practice Spotlight Organization Candidate on behalf of the Telehomecare Program, and relevant best practice guidelines have been incorporated into the curriculum, as well as Telehomecare practices.

The organization is rolling out Telehomecare across the province in partnership with LHINs. The LHINs select the host organizations, which may include hospitals, CCACs or family health teams.
More information about the program and its availability can be found online at http://ontariotelehomecare.ca.

References

1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian  Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2013:37(Suppl 1): S26-S30.
2. Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K. Home telehealth for diabetes management: A systematic review and meta-analysis. Diabetes Obes Metab. 2009;11:913-930.
3. Polisena J, Coyle D, Coyle K, McGill S. Home telehealth for chronic disease management: A systematic review and an analysis of economic evaluations. Int J Technol Assess Health Care. 2009;25:339-349.
4. Polisena J, Tran K, Cimon K, et al. Home telehealth for chronic obstructive pulmonary disease: A systematic review and meta-analysis. J Telemed Telecare. 2010;16:120-127.
5. Tran K, Polisena J, Coyle D, et al. Home telehealth for chronic disease management. Ottawa: Canadian Agency for Drugs and Technologies in Health, 2008.
6. Hospital Utilization Data, William Osler Health System.
7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2013:37(Suppl 1): S1-S3.
8. Respiratory Health Association. Inspiration newsletter, Spring 2010.