Evaluation of Northern Patient Watch, a comprehensive care program to keep people well in the community
Northern Health
415 participants
Jul 1, 2020
Interventional
Conditions
Summary
Introduction: People in higher income countries are living longer, with higher burden of chronic disease, disability and psychosocial distress. People affected by this are more likely to present to hospital, where they may receive inefficient and fragmented care. Northern Patient Watch (NPW)was implemented with the aim of better meeting the needs of these patients. This program utilizes trained lay telecare guides, who monitor the patient and health coaches who aid the patient with self-management of their conditions, guided by a rules-based algorithm called the Patient Journey Record. This evaluation will determine whether NPW is effective in reducing acute hospital usage, its effects on participant quality of life, and the quality of the participant’s experience. Methods and Analysis: Emergency department and hospital length of stay will be determined for NPW participants, and compared with these metrics in propensity-matched patients who were eligible for but declined the program. Participant reported outcomes will be measured using EQol-5D-5L, and their experience of the program will be measured using a visual analogue scale and net promoter score. NPW participants and Northern Health staff will be offered the opportunity to participate in interviews and focus groups, to obtain qualitative data regarding the program. Ethics and Dissemination: Patient Watch, and the accompanying collection of hospital usage and patient reported outcome and experience measures, is established as standard care, hence audit-level ethics approval has been obtained. Low-risk ethics approval was obtained for patient/staff interviews and focus groups - see public note below.
Eligibility
Inclusion Criteria1
- Those presenting to the Emergency Department of Northern Health, or being admitted who have been identified by an algorithm (HURT algorithm, Conilione and Gust, 2023) as being at high risk of 3 or more unplanned admissions to hospital, will be offered participation in Northern Patient watch.
Exclusion Criteria1
- People who reside in a residential aged care facility, people unable to consent to participation in the program
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Interventions
Northern Patient Watch (NPW) is similar to Monash Watch. Patients who are at risk of multiple admissions to the Northern Hospital are detected by a machine-learning algorithm developed at Northern Health. Those meeting the criteria are invited to participate in the program. Following induction (where the patient's demographic and health details are collected), participants receive regular telephone calls from trained lay persons, known as Telecare Guides (TCGs), for the purposes of self-rated health monitoring. It provides a script for the TCG to ask the enrollee questions regarding their current health and wellbeing. This involves administration of a standardised set of questions which are used to assess the patients current and anticipated near term state as well as any concerns that the TCG identifies from the responses. The frequency and duration of the calls are set by the smart health platform and are more frequent / longer if the patient has more concerns. If concerns are raised regarding the patient’s health or wellbeing, they are referred to a health coach, who is a senior nurse or allied health practitioner. The health coach will get involved personally, and coordinate interventions as required with the aim of stabilising the participants status and averting a presentation to ED or admission to hospital. The Patient Journey Record (PaJR) is used as an IT platform that guides the frequency of calls and helps alert staff to the need for intervention. The responses drive a proprietary rule-based algorithm which detects near-term hospitalisation risk. This algorithm creates an alert for a health coach to attend to if the patient’s health is deteriorating. The patients are part of the program for as long as they and their health coach feel they are deriving benefit from the program; they graduate out of the program if they are no longer benefiting, or when they can manage their own health issues well. Examples of interventions that a health coach would perform are accompanying patient to GP or specialist, arranging mental health review, and educating patients regarding their medications.
Locations(1)
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ACTRN12623000568617