Result card

  • ORG9: What management problems and opportunities are attached to structured telephone support (STS) for adult patients with chronic heart failure?
English

What management problems and opportunities are attached to structured telephone support (STS) for adult patients with chronic heart failure?

Authors: Valentina Prevolnik Rupel, Taja Čokl, Eleftheria Karampli

Internal reviewers: Ulla Saalasti - Koskinen, Elle Kisk, Ricardo Ramos

To answer the questions in the assessment elements we mainly used the basic literature search provided for the whole project. Additionally, two more systematic searches were used: one performed by ORG and ECO domains (described in methodology of ECO domain) and one perfomed by EFF, SAF and ECO domains (described in SAF domain). A qualitative handsearch (google; keywords: structured telephone support, heart failure, telemedicine) was done adding further information for this question.  The results are provided in descriptive way.

The use of RM has improved as a possible way to improve the management of patients with HF by allowing more frequent assessment of patients without the need for FTF clinical reviews {100}. When planning the introduction of a RM intervention in general, there are several questions that need to be addressed concerning: the choice of patients targeted by these programmes; the parameters that will be monitored; the more efficient way to monitor them; the training of patients and healthcare personnel; how to organize the response of the health care professionals to data obtained from monitoring to optimize patient care {1430}{1}. Possibly management will need to deal with (de)employment of new resources, new information systems, new equipment for STS provisions, new administrative leadership and new group culture that promotes quality improvement {15}{40}.

When planning the introduction of a RM intervention in general, there are several questions that need to be addressed concerning: the choice of patients targeted by these programmes; the parameters that will be monitored; the more efficient way to monitor the patients, the training of patients and healthcare personnel; how to organize the response of the health care professionals to data obtained from monitoring to optimize patient care {1430}{1}.

The use of RM has improved as a possible way to improve the management of patients with HF by allowing more frequent assessment of patients without the need for FTF clinical reviews. The technologies and decision systems used vary in their level of complexity. Monitoring can take many forms for a patient with HF: supported self-monitoring, clinic attendance, home visits or RM. Most modern services combine several different approaches, tailoring the care to the needs of the patient and family, and taking account of the local resources and expertise available in both primary and secondary care. Such a tailored approach, matching the model of care to the severity of the condition, is consistent with current healthcare policy in the developed world: most attention is focused on those with more complex needs (case management) built on a platform of good DM in general and with increasingly expert patients who are supported to self-care. {100}

Resources are required to enhance the management of chronic diseases including a clinical information system, a supportive clinical and administrative leadership and a group culture that promotes quality improvement. {15}.

Another parameter to be considered is the cost of the equipment that may be necessary to be purchased by the healthcare provider that is offering the STS programme (for example if the programme includes videophone communication). It can be rented or purchased with advantages and disadvantages in each case {40}.

Another consideration is that provision of these services requires a different approach to the organization of healthcare provision with redeployment of staff being more likely than an increase of the workforce {130}.

With any technology of remote monitoring, the issue of concern is the issue of security and privacy. There is also the question of how to bridge the patient-doctor gap that lies at the root of what telemonitoring strives to solve in the first place. How does one create a product that serves the needs of both the patient, as well as the medical professional, while still upholding a standard of privacy and security? {17}.

Telephonic programs, including the use of home monitoring equipment are the latest approach to improve outcomes for HF patients and several have had acceptable results. To meet this recognized need for improved quality for HF patients, a team of nurses designed a low-cost intervention that was comprehensive and geared toward those who would benefit most (older adults with more severe HF). It was created using the Quality-Caring Model to decrease hospitalization rates while maximize quality of life and satisfaction with services. The Quality-Caring Model indicates that independent (patient-provider) and collaborative (patient-healthcare team) relationships, grounded in specific caring factors, are the foundation for care. In the context of relationship-centered professional encounters, patients and families mutually interact with healthcare providers to advance health. Such relationships promote quality and benefit patients and families, providers, and systems {240}.

The survey results from one Canadian study {210} where clinicians were interviewed in order to expose management barriers and benefits they see from their perspective (Table 1). For example, additional human resources would be required at the clinic, such as a nurse practitioner, to carry out the STS program. Another concern was that there was no method of remuneration for phone interactions with their patients.

Table 1: Perceived benefits and barriers by clinicians {210}

Benefits

Clinical care improvement

 

Clinicians would be able to monitor their patients closely and would be provided with more information than they previously had to base their clinical decisions on. The information would be particularly useful for medication titration, and could help with false high blood pressure seen in clinic (ie. white coat syndrome). The alerts would be beneficial to inform them when their patients needed their help the most.

Benefits

Self-care improvement

Clinicians thought the system would help reinforce the instructions that were given to their patients in clinic (eg. following reduced salt and fluid intake). A lot of information is thrown at the patients and they probably don't get half of it, so STS can serve as a bit of a security blanket.

Benefits

Reduced clinic visits

Clinic visits by some patients could be reduced if they were closely monitored at home.

Barriers

System not suitable for all patients

Clinicians echoed the concerns expressed by the patients that some would have difficulty using the proposed monitoring system. In addition, they were concerned that patients predisposed to anxiety might not be suitable to use it.

Barriers

Clinical workflow challenges

Clinicians are too busy to respond to the alerts. They were concerned about managing the alerts 24/7, including when they were away on vacation. The most common suggestion was to have a nurse practitioner respond to the alerts. They also commented that there should be a way to financially reimburse physicians for calling patients.

Barriers

Medicolegal issues

There could be legal implications if clinicians did not respond to an alert immediately and the patient’s health further deteriorated. They thought that a method to document their actions would be necessary for medicolegal reasons.

Barriers

Security/ privacy

The patient information must be secure, and  appropriate technological measures must be taken to ensure patient confidentiality.

 

Important
Partially
Rupel V et al. Result Card ORG9 In: Rupel V et al. Organisational aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305

References