Telehomecare allows patients to stay well at home

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Driving to work one September morning in 2001, Iris Foster lost her grip on her morning coffee, spilling it all over her blouse. Annoyed that she would be late, Iris made a quick stop to change at her mother’s house which was luckily en route. When she finally arrived at the Richmond Hill school where she worked as an attendance secretary and realized she couldn’t hold onto the telephone, she anxiously called her doctor, who told her to go hospital immediately.

Iris had suffered a stroke, the first of three and the precursor to a long road of physical health problems that would soon follow.

Today, Iris suffers from a number of chronic diseases, including chronic obstructive pulmonary disease (COPD), heart failure and diabetes. She has endured two open-heart surgeries, had a pacemaker implanted and been hospitalized countless times for congestive heart failure, diabetic shock and fluid retention.  Two years ago, admitted to hospital for heart failure, Iris went in at 180lbs and came out a staggering 50lbs lighter –a result of fluid retention.

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It was during one of these emergency visits that Iris was referred to Dr. Isabella Kogan, a member of the Alliston Family Health team and her current primary care physician. Iris and her husband Wayne couldn’t be more appreciative of the care they’ve received from Dr. Kogan who was responsible for referring Iris to a number health care resources through a Community Care Access Centre (CCAC).

“It’s been a good move,” Wayne says of the transition to Dr. Kogan. It was through Dr. Kogan that the Fosters were also introduced to Telehomecare, a new health care initiative focusing on helping patients stay well at home and empowering them to manage their own care.

Launched in the fall of 2013, Telehomecare is hosted by Southlake Regional Health Centre. Through the program, patients use simple equipment, such as a weight scale and oxygen monitor, to check their vital signs daily, including blood pressure, weight, heart rate and oxygen saturation levels. This information is then transmitted wirelessly to a team of specially trained nurse and respiratory therapist at Southlake. Ana MacPherson, Registered Respiratory Therapist and Catherine Mansour, Registered Nurse, look for trends and health indicators that could be cause for concern. They also provide coaching to patients regarding their health conditions and mentoring on their symptoms and how to manage them. It also teaches the patient how to recognize when an intervention such as medication is needed or when they need to see their doctor or if very ill, when to go to the hospital. The program also provides smoking cessation counseling, weight control, and exercise, to name a few of the interventions. The goal is self management for the patient, the ability to recognize changes in their condition and have the ability to manage their own care. The program is six months long and staff work with the patient and their supports on graduation to self management within that time.

Ana was Iris’s Telehomecare Coach and she monitored Iris’s blood pressure, weight, heart rate and oxygen levels remotely from Southlake and then shares results with Dr. Kogan and any other necessary specialists.

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“I’ve never had any help before,” says Wayne, who was Iris’s primary care giver for the past 14 years. “I felt that I shouldn’t use these services if I could do it myself but now with Telehomecare, I feel like somebody’s got my back.”

As part of Telehomecare’s health coaching initiative, Ana spoke to the Fosters every week about Iris’s results and coached them on ways to improve the outcomes. “When I first started working with the Fosters, Iris was too ill to be involved in managing her own care, so it was Wayne who advocated for her,” says Ana, “but soon after, Iris was able to take her measurements and vitals on her own.”

“Every morning before I would do anything else, I would turn my computer on to Telehomecare,” says Iris. “I weighed myself, checked my blood pressure, did the oxygen count and answered the questions.”

If Ana received any results that concerned her, she would call the Fosters right away to determine the next steps.

As Dr. Kogan explains, health coaching can be difficult to do in a standard 10-15 minute appointment, but Telehomecare allows healthcare workers to build a rapport and trust with patients, making it possible to change patient behavior.

“Telehomecare is an integrated part of the primary care team,” says Dr. Kogan. “This is the future. Community and primary care will be an extended team available for the patient on a daily basis.”

Prior to her enrollment in Telehomecare, Iris was visiting her doctor twice weekly.  Now thanks to the support of the program, she sees Dr. Kogan once every six weeks and hasn’t been to the Emergency Room since her admission fall 2013.

Within the first year of the program at Southlake the program has seen some very positive outcomes.  There has been a reduction of 57 per cent in Emergency Department visits and a reduction of 54 per cent in inpatient discharges.  This is a result of shifting the focus from acute care to preventative care and self-management of chronic disease specifically heart failure and Chronic Obstructive Pulmonary Disease (COPD).

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Iris used to rely so heavily on oxygen that she couldn’t get from her car to the doctor’s office without it. Today, she only uses oxygen at night and hasn’t had to use portable oxygen in more than a year.

“A year ago, Iris was almost completely dependent on me,” remembers Wayne. “Now she’ll sometimes make her own breakfast and has even made breakfast for me a couple times. That wouldn’t normally be a big deal to anybody else, but as things get a little bit better, each small improvement is a push forward.”

The Telehomecare program at Southlake is available to residents in the catchment areas of Southlake and Stevenson Memorial Hospital, including Newmarket, Aurora, Georgina, Bradford West Gwillimbury, East Gwillimbury and New Tecumseth.  There is no charge for the program and the equipment while on the program.

As the six-month enrollment period in Telehomecare came to an end, Wayne and Iris were thankful for the skills and support Telehomecare gave them. Recognizing the symptoms, knowing what to watch out for and understanding what to do with the results, meant that Wayne was able to determine with confidence when and how to manage Iris’ care at home and when medical help is necessary.

With the improvements in Iris’ condition, the Fosters are optimistic for a healthier road ahead. “With the nicer weather now, I take out my scooter and I terrorize the neighborhood on it.” Laughs Iris. “I put the dog leash on the pole on the back and he runs along beside me and we travel all over the place.”

Sounds like things are looking up already.