The Re-ACT Program. Remote Access to Care Technology

w w w.w E C A R E. C A The Re-ACT Program Remote Access to Care Technology January 2011

Introduction Almost 80% of Canadian adults over the age of 65 have some form of chronic disease. Treating and caring for people with chronic disease consumes approximately 70% ($134 billion) of total health care expenditures in Ontario. With our rapidly aging population, it is imperative to find more cost-effective solutions to managing and treating seniors who are living with chronic disease. Using wireless technology, Re-ACT connects seniors living with chronic disease(s) to a Registered Nurse who monitors their vital signs remotely and encourages medication compliance, while providing assessment of vital signs. The Remote Access to Care Technology (Re-ACT ) program is an Aging at Home initiative funded by the Ministry of Health & Long Term Care (MHLTC) through the North Simcoe Muskoka Local Health Integration Network (NSM LHIN) and supported by a partnership with NSM Community Care Access Centre (CCAC) and We Care Home Health Services. Although this three-year project was scheduled to end in March 2011, the funding has been increased and the program extended through 2012. A key focus of the NSM LHIN was to implement strategies that help alleviate Emergency Room (ER) visits, prevent hospitalizations and prevent Alternate Level of Care beds (ALC). Re-ACT has proven to meet these expectations and more. Highlights of Program Results 70% decrease in client falls 96% of clients are able to be maintained in their homes 92% of clients are better informed about managing their chronic health conditions; are able to self-identify and problem-solve 80% of clients believe that Re-ACT made a positive difference in their lives 70% of clients said that Re-ACT helped them learn more about their disease 92% of clients know what signs and symptoms to look for and when to make an appointment with their doctor 68% of clients believe that their home is safer than before 80% of clients feel they will be able to stay at home longer than before Re-ACT 88% of clients are very satisfied with the Re-ACT program Overview Using wireless technology, Re-ACT connects seniors living with chronic disease(s) to a Registered Nurse who monitors their vital signs remotely and encourages medication compliance, while providing assessment of vital signs (blood pressure, pulse, blood glucose, weight and blood oxygen), information about managing their chronic condition and adjustments to their care plan. This service is operated from We Care s Monitoring Centre in Barrie, Ontario during regular business hours. Two hundred and fifty-six clients (256) have been on the Re-ACT Program 153 females and 103 males, representing an age range from 42-97 years. 2

A goal of the Re-ACT program is to help individuals develop skills for healthy living and managing their chronic condition. The program emphasizes the individual and family s role in their health care and encourages them to be an integral member of their health care team. It also engages them in decision making, goal setting, care planning and provides access to education programs and health information. We Care successfully showcased Re-ACT at The Canadian Homecare Association conference, Banff 2009, Ontario Gerontology Association conference, Toronto 2009, Community Health Nurses conference, Calgary 2009. The region of NSM covers 9,200 square kilometres of Canadian Shield and is classified as rural and remote. There are over 1200 lakes and rivers adding to the difficulty in accessing some isolated areas. Demographics The region of NSM covers 9,200 square kilometres of Canadian Shield and is classified as rural and remote. There are over 1,200 lakes and rivers adding to the difficulty in accessing some isolated areas. The following data, graphs and charts reflect information related to 119 clients who have been on Re-ACT over the past five quarters April 2009 to June 2010. During this time frame, the Re-ACT client group included twelve aboriginal clients (Christian Island and Moose Deer Point). Three other client groups shared one unit - two clients living in a mental health outreach group home and two married couples. Figure 1 Locations of Residences of 119 Clients BeloW: Map of the program s service region Re-ACT Geographical Breakdown Township # of Clients Barrie 24 Clearview 4 Collingwood 5 Essa 2 Innisfil 5 Midland 8 Moose Deer Pointe 3 Muskoka 10 Orillia 24 Oro-Medonte 2 Penetanguishene 12 Ramara 2 Severn 5 Springwater 2 Tay 3 Tiny 2 Wasaga Beach 6 Total 119 3

Figure 2 Primary and Secondary Diagnoses of 119 Clients 35 30 25 20 15 10 5 33 17 20 22 22 14 Diabetes COPD CAD Hypert- Stroke/ CHF ension CVA 30 21 8 6 6 12 n Primary n Secondary Data collection using the same questions is repeated quarterly. This information provides We Care with a focus for ongoing client support, teaching and discharge planning. The majority of program participants are living with at least three chronic health conditions. The top three primary diagnostic categories represented by the group are diabetes, hypertension and coronary artery disease. Cardiac diagnoses lead the ranking by over 50%. Assessments and Data Collection Upon admission to the program, each client was interviewed by the We Care e-health nurse and a Baseline Health Profile (BHP) was completed. The client record included: Comprehensive Nursing Assessment Environmental Assessment Falls Risk Assessment Completion of the Baseline Health Profile Identification of Level of Chronic Disease Identification of Clinical Frailty Level (1-7) Management and Prevention Goal Setting and Action Plan The BHP provides crucial data about clients past and present health practices and lifestyle choices. It is the foundation for measuring change. As a retrospective tool, it collects data reflecting the number of visits to the ER and family physician, the number of falls and near misses, the degree of compliance with medication regimen, diet, exercise, and the ability to cope with and reduce risk. Clients rate themselves on a scale of 1-10. When the admission assessment is complete, the nurse assigns each client a level of Chronic Disease Management and Prevention code (ranging from Level A to D) and a number on the Frailty Scale (ranging from Level 1 to 7). Data collection using the same questions is repeated quarterly. This information provides We Care with a focus for ongoing client support, teaching and discharge planning. The client s family physician is informed about the program and asked to provide a target range for each of their respective client s vital signs. Thereafter, a user-friendly, wireless monitoring device is installed at the client s home and the client is trained to use it. Measurements of blood pressure, pulse, blood glucose, weight and oxygen level occur once daily from Monday to Friday*. 4 *Frequency of vital sign monitoring can be increased where indicated by the client s results.

85% of the referrals to Re-ACT came from the North Simcoe Muskoka Community Care Access Centre. The Re-ACT software captures and stores the data on the secure server where the results are subsequently categorized as high-risk alert, moderate-risk alert or normal. Follow up by e-health RNs may involve telephoning a client to gather more information, requesting additional vital-sign readings, visiting a client at home, and/or communicating with a client s family physician or other health care provider regarding the latest findings and revising the care plan. Each client s family physician receives a monthly report, which becomes part of the client s health record. Figure 3 - Referral Sources - represents 119 referrals from the community over the 15 month period. 85% of the referrals came from the CCAC. Figure 3 Referral Sources Community Referral Source % of 119 Referrals Private (Doctor, Consumer) 15% CCAC Community Intake 9% CCAC Hospital Intake 25% CCAC District Case Manager 51% Performance Indicators The following data reflects statistics for the reporting period Q1 2009 to Q1 2010 inclusive, as reported to the NSM LHIN, quarterly. During this time there were 119 clients who came on and off the program, but only those clients who could be reached by the telephone survey s repeated attempts are represented in the table below. Figure 4 Performance Indicator Report, Nsm LHIN Q1 2009 to Q1 2010 Inclusive Performance Indicator Perform. 2009 2010 Indicator Type Target Q1 Q2 Q3 Q4 Q1 Total Clients Surveyed* 81 94 93 93 79 % of clients placed in LTC from program % of clients requiring crisis placement % of clients able to be maintained in community LTC Wait Time < 10% 0.01% 3% 2% 0% 3% LTC Wait Time < 5% 0% 0% 1% 1% 1% ALC > 80% 98% 96% 97% 97% 96% *Number of clients reached during survey data compilation. ADDITIONAL PERFORMANCE MEASUREMENTS The Re-ACT Team also gathers the following subjective information, allowing We Care to track and compare clients levels of chronic disease management and frailty over time. 5

CHRONIC DISEASE MANAgEMENT AND PREvENTION MODEL (CDMP) All clients are assessed according to the Chronic Disease Management and Prevention Model. (Level A-D) This information provides We Care with a focus for teaching and support and also guides plans for discharge. Figure 5 depicts the level of functionality of those with a chronic health problem who are trying to live independently in the community. Figure 5 CDMP Model Level A Level B Level C Level D All clients are assessed according to the Chronic Disease Management and Prevention Model. (Level A-D) This information provides We Care with a focus for teaching and support and also guides plans for discharge. Goals Prevention of disease & promotion of healthy lifestyles Control of disease & empowerment to self-manage Prevention of complications & encouragement of self-management Intensive management to prevent acute episodes & further complications In the past five quarters, 73% remained stable at level B & C, 23% improved, 4% declined (palliative). CLINICAL FraILTy Scale (LevEL 1-7) The Clinical Frailty Scale (which was first used in the BC Interior), helps to define how frail each client is at the time of admission to Re-ACT. This tool helps to plan other necessary supports to prevent falls and promote safe and independent living. It is reviewed quarterly. Figure 6 Clinical Frailty Scale Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7 Definitions Very fit Well Well, with treated comorbidities Apparently vulnerable Mildly frail, some dependence on others for ADL Moderately frail, help needed with IADL Severely frail During the past five quarters, 54% remained at the same level as when admitted to Re-ACT, 41% improved and 5% declined. Conclusion: Re-ACT encourages clients to actively manage their chronic disease(s) and maintain or improve their health status, preventing escalation to the next level of care. Re-ACT is like a health coach that guides them along their chronic disease journey. 6

Financial Savings It is difficult to ascertain the direct and indirect cost savings related to Re-ACT. There are numerous factors that influence whether a person seeks care, is properly assessed, is diagnosed correctly and receives the care required. Figure 7 CCAC Care Requirements for Re-ACT Clients This graph depicts the CCAC care requirements of 119 Re-ACT clients. 76 7 36 The support provided to clients and the knowledge they acquired on the program resulted in the need for fewer CCAC nursing and PSW visits. n No Nursing & PSW visits n Clients requiring Nursing visits n Clients requiring PSW visits ANALysis When clients are admitted to Re-ACT a Baseline Health Profile is completed which reflects their knowledge about managing their chronic disease (medication compliance, signs of complications), their risks (previous falls, ER visits) and their health practices (frequency of visits to their Family Doctor, diet, activity level). These factors are re-evaluated every three months. FALL PREVENTION In this cohort of 119 clients, 21 clients reported a serious fall in the previous 12 months prior to Re-ACT. Since being admitted to Re-ACT only 12 clients experienced a serious fall; a reduction of 43%. Nine of the 21 clients who had a fall did not experience a fall while on Re-ACT. Since coming on Re-ACT the potential cost savings of preventing nine serious falls is estimated to be $77,993.10. This cost saving is based on actual costs as demonstrated in Figure 6. Figure 8 Potential Cost Savings of 9 Re-ACT Clients Service (Direct & Indirect Costs*) Ambulance (5 one-way trip; 4 round trip) For One Client For Client Group $300 per trip $1,500 $2,400 Details (5) (4) 2 ER Visit $138 per visit $1,242 (9) 3 Medical Hospital Bed (3 clients) $532 per day $7,980 (3 x 5 days) 4 Surgical Hospital Bed (4 clients) $910 per day $4,550 (4 x 5 days) 7

5 ICU Bed (2 clients) then Medical Bed $1,930.85/day $532 per day $11,585.10 $5320 (2 x 3 days) (2 x 5 days) 6 ALC days (30% of 9 clients = 2.7 clients X 30 days) Total Cost Savings for 9 Clients $536 per day $43,416 (2.7 x 30 days) $77,993.10 *The direct and indirect costs include: salaries, benefits, med/surg supplies, drugs, laboratory, diagnostics, therapeutics, respiratory, housekeeping, health records, biomed and food services. Nine of the 21 clients who had a fall did not experience a fall while on Re-ACT. Since coming on Re-ACT the potential cost savings of preventing 9 serious falls is estimated to be $77,993.10. Statistical data received from NSM LHIN Susan Plewes, Cindy Webster and Sandra Easson-Bruno Q4 2009/10. Assumptions were made related to LOS and type of bed, based upon NSM data. Cost Savings Based on Expanded Sample A broader sample of patients was monitored over an extended period to measure several key performance indicators: Fall Prevention, Emergency Room Visits, Hospital Admissions and ALC Prevention. Between September 2008 and December 2010, data was collected from a total of 210 clients. Results from this expanded study group provided additional context and validation for the value of the program. Cost justification for Re-ACT is proven by comparing the clients health practices for the above four parameters prior to being admitted to the Re-ACT program and at quarterly intervals during their stay on the program. The above occurrences were analyzed over 6 quarters (April 2009 to March 2010) to provide an average percentage per occurrence for each parameter before and after Re- ACT. By averaging the quarterly data it eliminates the skewing of data from favorable or unfavorable quarters and keeps the process as fair as possible. HOW WAS THE DATA COLLECTED? When clients were admitted to the Re-ACT program, the Registered Nurse conducted a retrospective survey of each client by asking the client a series of questions from the Personal Health Profile (PHP). This PHP provides baseline information about clients health practices - frequency of seeking medical care, lifestyle choices and degree of knowledge and understanding of their chronic diseases. The Registered Nurse asks clients to look back on the previous 3-6 months realistically clients think about what happened in the last 3 months or as their memory permits. We Care telephoned each client at the end of each quarter and asked the clients the same questions and again completed the PHP. 8

Re-ACT helps to level the playing field related to several determinants of health - those living in isolated communities, gender, culture (Aboriginal and Metis groups), income and social status. Figure 9 Cost Savings Based on Expanded Sample Before Re-ACT After Re-ACT Saving FALL PREVENTION Rate of falls in Re-ACT sample 17.65% 10.08% $-7.56% Cost per fall * $8,666 $8,666 $8,666 Total $321,148 $183,513 $137,635 ER VISITS Rate of ER visits in Re-ACT sample 64.36% 29.76% -34.60% Cost per ER visit $138 $138 $138 Total Cost $18,652 $8,626 $10,027 HOSPITAL ADMISSIONS Rate of hospital stays in Re-ACT sample 34.73% 18.56% -16.17% Cost per hospital stay ($532/day, 9 day stay) $4,788 $4,788 $4,788 Total $349,231 $186,631 $162,600 ALC PREVENTION % of clients maintained in home vs ALC 80.00% 97.00% 17.00% Cost per ALC ($536/day for 40 day stay) $21,400 $21,400 $21,400 Total $900,480 $135,072 $765,408 TOTAL $1,075,670 * See Figure 8 ** based on performance targets set by Ministry of Health. A more complete cost analysis can be found in Appendix II. Less: Funding Received Savings to Health Care System $468,064 $607,606 Program Benefits The health status of an individual, organization or society is complex and is influenced by interactions between social and economic factors, physical environment and individual behaviours. Re-ACT represents an approach to health that addresses the root causes of complacency, examines preventative health practices and focuses on individual participation and accountability. Re-ACT helps to level the playing field related to several determinants of health - living in isolated communities, gender, culture (Aboriginal and Metis groups), income and social status. In addition, the following groups have benefited from Re-ACT : CLIENTS: Supports people living with chronic health conditions by increasing their knowledge and confidence in managing their health Empowers people to be more accountable for their own health and health care Promotes healthier choices in diet, physical activity, medication compliance and immunization Reduces accidents and falls in the home Enhances security and prevents social isolation (two suicidal clients changed their course of action with Re-ACT support) 9

Supports hospital discharge and prevents re-admissions to hospital Extends the time people can live in their preferred environment Encourages linkages with community supports The Re-ACT program has proven to have a positive impact on people living at home with chronic health conditions. FAMILy CAREgivERS: Reduces anxiety and stress as caregivers worried less about the health status of their loved one Improves the quality of the relationship with the person cared for Links them with community supports and resources Educates them about signs and symptoms of impending health problems so that they can be addressed earlier than before Travel in general is reduced and safety is enhanced when clients are not required to be on the road for great distances, especially during periods of inclement weather which in NSM can be lengthy THE HEALTH CARE System: Addresses Human Health Resousrces (HHR) by enabling one ehealth RN to care for 100+ clients (the region is short 351 nurses and seven Nurse Practitioners) Unlocks resources and redirects them elsewhere in the system Decreases ER visits and reduces acute hospital admissions Reduces ALC days and allows clients to be transitioned home sooner Decreases re-admit visits to hospital by supporting new post-op clients Improves use of the physicians time by preventing avoidable visits Reduces the burden to the ambulance service, reserving it for other emergencies If an influenza (or other) epidemic/pandemic should occur, care provision would continue and community transmission is limited BENEFITS TO THE NSM CCAC: Provides another option for care at the point of intake and referral Allows clients to be transitioned to discharge earlier Decreases need for some nursing/personal support visits saves HHRs and health care spending Conclusion The Re-ACT program has proven to have a positive impact on people living at home with chronic health conditions. The Re-ACT technology directly fosters active, healthy aging at home and allows people to realize their potential and enjoy a higher quality of life. An investment in the Re-ACT health solution fosters community collaboration, drives seniors wellness, empowers people to be accountable for their health care and decreases the burden of escalating health care expenditures. It represents the next generation of home care and the opportunity to age in place with compassion, dignity and professional care. It s a win-win-win situation for all. 10

A P P E N D I X I APPENDIX I - Client Comments Following is a selection of comments from participants in the North Simcoe Muskoka study. Mr. B 77, lives with wife in Beavercreek Trailer Park - Diagnosis: CHF, COPD, Bladder Cancer is now palliative. - Wife states Re-Act is like a lifeline to us; when Ray is not feeling well, his vital sign measurements help to explain why he feels unwell and so we don t need to call the doctor or go to the ER we check his vital signs again and can see the improvement. Mr. G 82, lives alone - Diagnosis: Diabetes, CHF, Hypertension. - Prior to Re-ACT, client had a long admission for management of congestive heart failure. BP was rising and oxygen level decreased. The nurse told the client to go to the ER - client was seen as an outpatient, given IV Lasix over a course of several hours and returned home the same day. - Client sees this as a success that saved her from a long hospitalization, and credits having the Re-ACT equipment in place for her early intervention. Mrs. L 93, lives alone in the country - Diagnosis: Hypertension, frailty of age, severe arthritis. - Client states It is difficult for me to get out to see the doctor so my doctor wants my vital signs checked so he knows that I am doing OK; Re-ACT and the nurses helpful information about my diseases helps me keep on top of my health so that I can continue to live at home. Mrs. M 81, lives with husband her main caregiver - Diagnosis: CAD, post-stroke, hypertension. - Husband states The vital sign readings from Re-ACT help me to know that a crisis is not likely to happen it gives us peace of mind that everything we are doing is working and when it is not, the nurse keeps us on track. Mrs. L 75, lives alone - Diagnosis: CAD, COPD, Poor Vision. - Prior to Re-ACT client had several admissions to hospital. - Client states When my heart rate went up and my oxygen level went down, the nurse told me to go to the doctor. The nurse faxed all the data to the doctor. The doctor said that it was good thing I came in because I was heading for another crisis. Blood work and x-rays showed fluid in the base of her right lung and prescribed oral antibiotics and a steroid. The client was able to fight off the infection at home. 11

A P P E N D I X I Mr. F. 75, lives at Moose Deer Point (Aboriginal community) - Longstanding diabetes, COPD, obesity, non-compliant with diet restrictions, oxygen use, smoking and activity. - Became acutely aware that his blood oxygen was below the norm. The nurse phoned the client, stressing the need to be assessed further and reinforcing the need for continuous use of oxygen. The client took himself to the ER. The Physician told him he must stop smoking at once, to use oxygen continuously and he was referred on for sleep apnea testing. - Client is using a C-Pap machine during the night, no longer smokes, is using the oxygen on a continuous basis and is scheduled to see a diabetes teacher. He takes pride in taking his measurements and enjoys seeing his blood oxygen levels where they should be. 12

A P P E N D I X I I APPENDIX II - Explanation of Cost Savings* The Re-ACT sample population is 210 clients who were on the program from September 2008 to December 2010. A. FALL PREvENTION The data source is from the NSM LHIN and the Re-ACT clients who experienced falls. Prior to Re-ACT : The estimated rate of falls was 17.65% of the sample population and therefore, at a cost of $8,666 per fall, the total cost on average. $321,148 After Re-ACT : The estimated rate of falls is 10.08% of the sample population and therefore, at a cost of $8,666 per fall, the total cost on average. $183,666 The cost savings realized due to Re-ACT : $137,635 B. EMERgENCy ROOM visits The data source related to the cost of an emergency room visit has been provided by the NSM LHIN and the Re-ACT sample population. Prior to Re-ACT : The estimated rate of ER visits was 64.36% of the sample population and therefore, at a cost of $138 per ER visit, the total cost on average. $18,652 After Re-ACT : The estimated rate of ER visits was 29.76% of the sample population and therefore, at a cost of $138 per ER visit, the total cost on average. $8,626 The cost savings realized due to Re-ACT $10,027 NOTE: The above costs do NOT include the costs of: ambulance trips, medical and surgical supplies while in the ER, drug expenses, medical gases or other primary service expenditures. If these costs were to be analyzed the cost savings to the health care system would be dramatic. * Based on expanded sample; see page 8 for details 13

A P P E N D I X I I C. HOSPITAL ADMISSIONS The data related to the cost of a hospital bed and average length of stay (LOS) has been provided by the NSM LHIN (Q2, 2010) and Re-ACT sample population. Prior to Re-ACT : The estimated rate of hospital admissions was 34.73% of the sample population and therefore, at a cost of $4,788 per stay ($532 per day x 9 day average), the total cost on average. $349,231 After Re-ACT : The average rate of hospital admissions was 18.56% of the sample population and therefore, at a cost of $4,788 per stay, the total cost on average. $186,631 The cost savings realized due to Re-ACT $162,600 D. ALC PREvENTION The Aging at Home Initiative through the MOHLTC set the following minimum performance standard 80% of Re-ACT clients are to be maintained in the community. Over a 25 month period, with Re-ACT support, 97% of the Re-ACT sample population was maintained at home, avoiding ALC days. The data source for the cost and length of stay of an average ALC bed has been provided by the NSM LHIN (2010) which is $536 per ALC day with an average LOS of 40 days (for those over 65 years). While it is unknown the actual percentage of clients over the age of 65 who were able to remain at home, we measured the additional 17% of the sample population greater than the 80% target, to calculate the potential savings. Prior to Re-ACT : The estimated rate of clients maintained at home, at a minimum was 80%. At a cost of $21,440 per ALC stay, the total cost on average. $900,480 After Re-ACT : The estimated rate of clients maintained at home was 97% out of the Re-ACT population sample. At a cost of $21,440 per ALC stay, the total cost on average. $135,072 The cost savings realized due to Re-ACT $765,408 The Total Cost Savings realized from Re-ACT for 210 clients, approximately $1,075,670 14

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