Problem: Significant burden of COPD on health system resources; limited capacity of patients to self-manage COPD symptoms leading to deterioration in their condition and frequent hospital readmissions; weak continuity of care for COPD patients resulting from incompatible electronic medical record systems and fragmentation of providers.
Solution highlights: A pilot programme to test home-based telerehabilitation for COPD patients was designed and implemented by researchers at Aalborg University; a supportive political and legislative environment provided a platform for furthering the development of e-health and telemedicine; partnerships with stakeholders outside the health sector supported the development of telemedicine and helped drive service delivery transformations; patients were given a more active role in care and new collaborative partnerships between patients and providers were developed; success of the initial pilot led to a larger-scale study with greater involvement of regional and municipal actors.
Description of practice
In Denmark, chronic obstructive pulmonary disease (COPD) was ranked the third greatest cause of disability adjusted life years (DALYs) in 2005. COPD placed a significant burden on the health system and consumed a large proportion of health resources, mostly associated with hospitalization. Consistent monitoring and rehabilitation following discharge from hospital is essential for effective COPD management. However, fragmentation between providers resulted in a lack of continuity for patients, increasing their risk of adverse health outcomes and subsequent hospital readmission. This was compounded by the limited involvement of patients in the care process and their inability to effectively self-manage their condition.
Researchers at Aalborg University specializing in e-health and telemedicine proposed an alternative service delivery model for COPD and designed a pilot programme (TeleKat) promoting home-based telerehabilitation. During an initial planning year, patients, health providers, researchers and private technology companies collaborated to design the telerehabilitation intervention. COPD patients were then recruited into the study and were required to self-manage their condition at home for four months supported by telemedicine services. Participating patients received education on COPD self-management and a monitor to collect health data, such as blood pressure, oxygen saturation and lung function. All patient data was uploaded to a common web portal where it could be accessed by both the patient and their providers. District nurses regularly monitored patient data through the portal, provided personalized feedback on results and initiated referrals or treatment when necessary. Positive results from the initial study encouraged its scale up across the Region of North Jutland and both the regional government and all 11 municipal governments signed on to the larger-scale project, now known as TeleCare North. Aalborg University continues to oversee the initiative, but the regional government has assumed operational management. A study on the impact of TeleCare North is due to be completed in 2015 and the results are expected to inform a national model for tele-homecare as part of the National Telemedicine Action Plan.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
Design of the initiative was led by Aalborg University in close collaboration with stakeholders. Researchers provided needed expertise and helped mobilize participants, while private technology companies ensured the focus remained on building a cost-effective solution. Although collaborating with patients was initially seen as challenging by some professionals, eventually they “saw how patients had good ideas and it was worthy to finally listen to them, exchange ideas and develop ideas together”. Once the design was complete, Aalborg University led implementation of TeleKat. The University continues to provide oversight and guidance for TeleCare North, but both regional and municipal governments have taken on an increasing role in the management of this programme.
TeleKat demonstrated that telerehabilitation could have a positive impact on health outcomes for COPD patients and hospital readmission rates were 54% lower with telerehabilitation. Furthermore, interviews held with TeleKat participants showed that patients enjoyed learning about their condition, felt empowered by new knowledge, were secure receiving treatment at home, experienced a greater sense of control over their COPD and were motivated to perform recommended preventive exercises. As one patient said, “seeing my data on the web portal gives me a better understanding of how to exercise and interpret the development of my symptoms”. While the TeleCare North study is ongoing, similarly positive results are expected.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Birthe Dinesen
- Aalborg University