Utilizing Computer Technology & Data Analytics in Supporting Patients in the Community:

Transcription

1 Utilizing Computer Technology & Data Analytics in Supporting Patients in the Community: A Chronic Disease Management Model to empower patients with Diabetes Mellitus Patty Kwong 16 Oct 2014

2 Introduction Chronic Disease Management Program for Diabetic Patients Integration of Technology Quality Management Program Evaluation A Patient Journey Way Forward 2

3 Diabetes in HK In 2009, 10% of HK population (~700,000) suffered from diabetes By 2025, it is estimated that 12.8% (~1 million) of the HK population will suffer from this disease Source: Diabetes HK,

4 about 20,480 in-patient discharges and in-patient deaths in all hospitals in 2012 about 1.0% of all in-patient discharges and deaths Sources: Department of Health, HKSAR the 10 th commonest cause of deaths in Hong Kong 4

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6 Disease Management Collaborative Self Management Support Traditional Care Coordination Chronic Disease Management Program Source: Home Health Quality Improvement (HHQI) National Campaign Best Practices: Collaborative Self-Management Support & Disease Management, Donna Anderson, PhD, RN, Aug

7 Patient/ Families are ACTIVE partners in the care Provider seeks patients /families preferences Patient/Family- Centered For decision making support Collaborative Self Management Support

8 Patient Education Self-Management Support Teaching Information & Skills Problem Solving Skills Assumes Knowledge yields Behaviours Change Confidence yields Better Outcomes Goal Compliance Increased Confidence Outcome Information Patient Decision Making 8

9 Role of Diabetes Educator Coach & guide patients to understand their diabetes & how it affects personal lives Work with them to set behavior change goals to improve health Achieve their goals at their own pace & upon advice of nurses 9

10 Support CDM patient by Telenurse 10

11 Chronic Disease Management (DM) Program Commenced in

12 Objectives of Service To strengthen self management of chronic disease patients to improve clinical outcomes Characteristics Provide professional advice, health education, medication knowledge & community resources in order to strengthen their self-management for better disease control 12

13 High risk DM patients from Risk Assessment and Management Program (GOPC) HbA1c>7.5% OR HbA1c worsening by 1% from last checking Unable to attend structural education programme at GOPC Good mental state with good hearing & access to phone 13

14 Serving 7 clusters 30 no. of trained Registered Nurses Over 6,200 no. of calls per month 15,991 high risk DM patients served since

15 Dietary advice Home monitoring Risk factor management Exercise Scope of Service Problem solving Coping skills Medication management Reinforce Self Care Behaviour through Empowerment 15 15

16 Structured Telephone Call 1st month 2 nd & 3 rd month 4 th 7 th month 8 th month 9 th month ± ± ± 16

17 User Profile Data Base PSCC System Service Directory Protocol & Guideline Call Logging Data Base epr Outbound Call Target Clients Inbound Call Integrated System 17

18 1. Patient attended GOPC & agreed to join the CDM (DM) Program 2. Doctor or nurse made referral according to patient s DM condition 18

19 Electronic Referral 19

20 Auto-generation of Patient List 20

21 Individualized Goal Contract 21

22 Schedule for Next Call (1) 22

23 Schedule for Next Call (2) 23

24 Service Directory 24

25 Communication with Clinical Team 25

26 Communication with Clinical Team 26

27 SMS Festival Dietary Advice 27

28 Quality Management Protocol Case Sharing Session Audit to evaluate nurse s compliance to standard 28

29 Data Analytics CDM(DM) Program Evaluation By HAHO Statistics & Workforce Planning Department

30 Objective Evaluation period : 1/8/ /3/2013 To evaluate the effectiveness of PSCC on Clinical Outcomes (HbA1c)

31 Goal Selection Total no. of patients* =2,290 % patients 100% 90% 89% 80% 70% 60% 58% 50% 40% 30% 23% 20% 10% 11% 9% 2% 2% 0% Healthy Eating Being Active Home Monitoring Reducing Risk Taking Medication Problem Solving Healthy Coping * Refer to complete the service on or before 31 Mar 2013 P.3 1

32 Behavioral Change Score Score at call #12: Score at call #6: 76% - 90% 71% - 86% Score at call #9: 74% - 88% Score at call #1: 47% - 56% no. of calls P.3 2

33 Improvement in HbA1c Additional 0.23% point* reduction in HbA1c 33

34 Conclusion PSCC is effective in improving knowledge & practice for self-management further reducing HbA1c among DM patients P.3 4

35 A Patient Journey 35

36 M/48 ; Single ; Diagnosis T2DM in 2008 Education: Secondary Occupation: Clerk HbA1c: 9.3% BW: 112.2kg ; BMI: 41.7 Love to eat fast food 36

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38 Assessment - Client s Health Condition Overweight Poor Self Image Poor Motivation Poor Eating Habit 38

39 112.2kg HbA1c 9.3% 1 week 5 week 12 week 23 week 28 week 104.9kg 106.8kg HbA1c 7.5% 39

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41 Better DM Control for CDM Patients It is individualized It is patient engaged It helps people staying healthy 41

42 Way Forward Review the service model & target group of CDM (DM) Program Using computer technology & data analytics to serve different groups of chronic disease patients 42

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