出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In 2015, a new model of care MoC via telehealth was developed for a community with high rates of chronic disease hospitalisationsand sub-optimal access to health care. Partnership with General Practitioners GPs allowing regular clinical readings at home to transmit to a telehealth co-ordinator through a private telehealth provider, has offered quicker access to patient information and less time out of the hospital for home visits, whilst maintaining that crucial ‘face-to-face’ contact. Practice change : Acknowledge the innovative way to encourage partnerships integrated health care between clients, LHD, GPs and private providers. Patients involved in their own care and over time have better identified their risk status. Aim / theory : Promote wider collaboration between hospital, GPs and private provider to improve a seamless and rapid access to care and coordination for the community, using telehealth technology. Population and stakeholders : As an initiative to streamline access of care for the community in Wollondilly Shire, the telemonitoring project is overseen through the following Governance Structure: Executive Management Group with key representatives of partnering organisations. Care Process Working Group to review MoC and initiatives. Telemonitoring Working Party for day to day operations. Timeline : Implemented from 2015 through to 2017. Highlights : The outcomes included: 1- Wider collaboration Feedback from stakeholders’ surveys reported: Seven GP practices Total of 8 GP Practices locally agreed to participate in the project with 5 Telehealth Clinics established, connecting patients to specialists. Strong relationship with GPs and private provider clinical coordinators and co-design Regular multidisciplinary case conference to support care delivery Empowering patient and carer via ongoing education 2- Improve a seamless and rapid access to care and coordination for the community. Processes for triage and escalation were based on integration of care and provision of services between the patients, GP, telemonitoring nurse clinical coordinator, and private provider. Patient compliance taking required readings as predetermined by GP care plans was very high with only 8% missed readings, which shows willingness of patients to be involved in their own care. 3- Qualitative patient experience “Client who had up to 15 admissions this year, has not presented since clinical intervention and care coordination via telemonitoring”, comment by treating GP. Sustainability : This initiative has transitioned as part of the Local Health District Chronic Disease Management Program and is now sustained within an ongoing service delivery model. Transferability : This MoC has commenced roll-out to other Local Government Areas. The target patients group has also expanded to include other chronic conditions. Conclusions : This proactive approach to chronic disease management has also improved patient self-management capability, patient’s understanding of their chronic condition and reduced presentation to Emergency Department ED, through early recognition and intervention utilising tele-monitoring in consultation with treating GP. Discussion : An outcome based ‘Benefits Realisation’ approach was utilised to confirm current service gaps, identifying potential solutions and implementing the changes. This approach demonstrated greater clinical engagement and ownership across the key stakeholder groups. Lessons : Ongoing gap analysis will be conducted to identify ways to improve compliance rates; education needs, actual interventions and outcomes.
关键词：telemonitoring ; integrated health care ; telehealth ; partnerships ; telecare
